Loading...
HomeMy WebLinkAboutBP21-262PERMIT # SL SECTION TYPE OF WORK JOB LOCATION OWNER CONTRACTOR J )/ i Q& co= DATE: /O / ol/ D(P: 136 BLACK LOT s \/cO # c2f C�X' FEE INSPECTION RECORD DATE FOOTING FOUNDATION FRAMING RGH FRAMING INSULATION PLUMBING F1 RGH PLUMBING INSP a6 �ve/7 f vi / 41�P )�57a-�oa3 GAS ED SPRINKLER � - �CU � ELECTRIC L]!I j � �- - j4Q _ &P� -I�� LOW -VOLT Q ALARM a AS BUILT FINAL OTHER APPROVALS ARB BOT PB ZBA OTHER VILLAGE OF RYE BROOK WESTCHEST C©U Y, NEW YORK NO: 22-003 Certif irate of Orrupaurp This is to certify that of, Y 7 having duly filed an application on Derember- requesting a Certificate of Occupancy for the premises known as, 1 NO(Dd f a CC) . Y 1 \�, , Rye Brook,NY, located in a Zoning District and shown on the most current Tax Map as Section: 5. (Q Block: Lot: , and having fully complied with the requirements of the Building Code and the Zoning Ordinance under Building Permit No. Q -C-� issued / C 20 ;2 1, such authority and permission is hereby granted to the property owner to lawfully occupy or use said premises or building or part thereof listed under the New York State Use Classification of: )2- - �`a -'w/J , for the following purposes: &)'3eMCr)4 ree"-k)ya ho - -Td a J'krl)'7 e v6*2 (- Subject to all the privileges, requirements, limitations and conditions prescribed by law, and subject also to the following: FINISHED BASEMENT NOT APPROVED FOR USE AS A SEPARATE APARTMENT OR DWELLING UNIT This certificate does not in any way relieve the owners or any person or persons in possession or control of the premises, building,or any part thereof from obtaining such other permits or licenses as may be prescribed by law for the uses or purposes for which the building or premises is designed or intended. Furthermore, it does not relieve such owners or persons from complying with any lawful order issued with the object of maintaining the premises or building in a safe and lawful condition. No changes or rearrangement in the structural parts of the bui ding or in the exit facilities shall be made, and no enlargement, whether by extending on any side or by increasing in height s all be d L the building be moved from one location to another until a permit to accomplish such change has been bt ' Inspector. Building Inspector,Village of Rye Brook: Date: JAN - 5 2022 D BUILDa NT For office use a PERMIT# /-p2(po� VIL K ISSUED: Q DEC 2 8 2021 8 KING STRE YORK 10573 DATE: ),2 00 FEE: OW r 1�� PAID 0 VILLAGE OF RYE BROOK BUILDING DEPARTMENT APPLICATION FOR CERTIFICATE OF OCCUPANCY, CERTIFICATE OF COMPLIANCE, AND CERTIFICATION OF FINAL COSTS TO BE SUBMITTED ONLY UPON COMPLETION OF ALL WORK, AND PRIOR TO THE FINAL INSPECTION s#t4#4#st#ssi#►i�#�s4##4i#44i4#444►4►s4444is►44i4tiit#ti#tti#►fki##tt4ii►ii4ii4ii#►4►i4k►kit►#4kitk44#k#4k##i44ki44##4#t#t44t44 Address: 18 yVOocfl anA VnVG Rve- BIre NY 1057J5 Occupanc Use: O Wrlerr Parce] ID#: 5e-daon 135. 3L T 'Block 1- Lot 95 Zone: J2-Q5 Owner: A 1 asta6i1 M al l e-tit Address: IS Wood l ood Dr. }__ye Brook. J n e \A e P.E./R.A. or Contractor: TAlAn [31d1c� g,I)Oj6ljAddress: I&I 1-hQarinre Frond Avg., P.O Box 668' Person in responsible charge: '°t Vaq l yt N Y I it 5$O p g �t�n �Yrnron B� al��•}Address: 5 et Q to c►.tct. Application is hereby made and submitted to the Building Inspector of the Village of Rye Brook for the issuance of a Certificate of Occupancy/Certificate of Compliance for the structure/construction/alteration herein mentioned in accordance with law STATE OF NEW YORK,COUNTY OF WESTCBESTER as: A amps�a G. m CJ 1 eel being duly sworn,deposes and says that he/she resides at 1 9 Y'V d od lan Ch DIr i Ve (Print Name of Applicant) (No.and Street) in Rye- Br0 a V-- ,in the County of we..;f C heS�e r in the State of N Y that (City/Town/Village) he/she has supervised the work at the location indicated above,and that the actual total cost of the work,including all site improvements, labor,materials,scaffolding,fixed equipment,professional fees,and including the monetary value of any materials and labor which may have been donated gratis was:S� for the construction or alteration of: pp rr.S ra n- i rl I S era CA SCMe-ri Deponent further states that he/she has examined the approved plans of the structure/work herein referred to for which a Certificate of Occupancy/Compliance is sought,and that to the best of his/her knowledge and belief,the structure/work has been erected/completed in accordance with the approved plans and any amendments thereto except in so far as variations therefore have been legally authorized,and as erected/completed complies with the laws governing building construction.Deponent further understands that it shall be unlawful for an owner to use or permit the use of any building or premises or part thereof hereafter created,erected,changed,converted or enlarged,wholly or partly,in its use or structure until a Certificate of Occupancy or Certificate of Compliance shall have been duly issued by the Building Inspector as per§250-IO.A.of the Code of the Village of Rye Brook. Sworn to before me this Z r41 H Sworn to before me this day of 0tCX^a ESE' 20 C day of D�en SER ,20 Z. Signature of Property Owner Signature of Applicant AvInsfolsla g�- Kqt�ll Print Name of Property Owner Print Name of Applicant 52ntpol, Qo Ze AT Pr► t/t Notary Public— Aathon Bozeat Notary Public of New York Not�ryttttony I3ozeat y Notary Public of New York I.D.01BO6417066 I.D.0IB06417066 8/12n_021 COMMISSION EXPIRES 05/03/2025 COMMISSION EXPIRES 05/03/2025 �yE DRCI,i,�. O�` tim �982 BUILDING DEPARTMENT ❑BUILDING INSPECTOR �dASSISTANT BUILDING INSPECTOR VILLAGE OF RYE BROOK ❑CODE ENFORCEMENT OFFICER 938 KING STREET- RYE BROOK,NY 10573 (914) 939-0668 FAx (914) 939-5801 www ryebrook.org - - - - - - - - - - - - - - - - - - - - INSPECTION REPORT - - - - - - - - - - - - -- - - - - - - L 6-2-2- . ADDRESS :— l .I ' `w DATE: `� 4� ' PERMIT# ISSUED: AECT: -3 LOCK: LOT: LOCATION: y.mil l-6� 0-0 ;,. c-r C -?)CC PANCY ❑ VIOLATION NOTED z RK IS... C,7� ACCEPTED ❑ REJECTED/REINSPECTION ❑ SITE INSPECTION REQUIRED ❑ FOOTING ❑ FOOTING DRAINAGE ❑ FOUNDATION ❑ UNDERGROUND PLUMBING NOTES ON INSPECTION: ROUGH PLUMBING ❑ ROUGH FRAMING ❑ INSULATION ❑ NATURAL GAS ❑ L.P. GAS ❑ FUEL TANK ❑ FIRE SPRINKLER ❑ FINAL PLUMBING ❑ CROSS CONNECTION Q-FINAL ❑ OTHER a Ln N .. 1 N N oC e N -� 46 tin ON rp `r' CDs Qy �•� ri o F' W O U C S W W F r . U (A - c < G ~ ^ tnen � j CID 00 0-4 pG W w .J W s n ~ ~ x FQ f z rA 96 Q i< 2 3 m $ M w O , U Q w z I%. 00 G7 4 G7 6 a (A U G wcc a � C=q w _ � e a e a BUIL Do ENT VEL E OK OCT 19 2021 938 ICIIv E NY 10573 14)939-5801 VILLAGE OF RYE BROOK BUILDING DEPARTMENT ELECTRICAL PERMIT APPLICATION Westchester County Masten Electricians License Required FOR OFFICE USE ONLY B P#: — �P �- E P#: C�y Approval Date: QC g 02 Permit Fee: $_ �+� tr ve U Approval Signature: Other: Disapproved: (fees are non-refundable) Application dated, 1011 1I a t is hereby made to the Building Inspector of the Village of Rye Brook NY, for the issuance of a Permit to install and/or remove electrical equipment,wiring,fixtures,or to perform other high or low voltage electrical work as per the detailed statement described below. The applicant & property owner, by signing this document agree that all electrical work performed will be in conformance with all applicable Federal, State,County and Local Coddess.• 1.Address: ( j b/I a Atj fl 'N U� SBL: /35.*349 �-o�s Zone: �S 2.Property Owner: Ak)A 5 TA ra M(A U e-to Address:S{� rr_Q Phone#:9 1 t{ -cn,) -t 1 n ci Cell#: email: 3.Master Electrician:M�h L r-,,2t.P_c C' Address: 6 S CP m i5;� Q_6 r-,4. au r,� PA c,o k 103�I� Lic.#: 9 5 act—Phone#:cal1/- 9 a 5 U a I Cell#:! J 4'�7`1 5 ya 9 email: 40 Company Name:ti Q QS` NINO &C !E j r�c.Y9-t c_ Address:E.S(flU(;C " a_T 63 9-WC 1J q I0 L23 4.Proposed Electrical Work/Fixture Count: a r,-t i" D-o r ctiti J STATE OF NEW YORK,COUNTY OF WESTCHESTER ) as: ,T-Cl�b G 2t e c f, ,being duly swum,deposes and states thgr /she is the applicant above named,and does further (print name of individual signing as the applicant) state that(s)he is the legal owner of the property to which this application pertains,or that(s)he is the L'0 CrAA---6 2 for the legal owner and is duly authorized to make and file this application. (indicate architect,contractor,agent,attorney,etc.) The undersigned further states that all statements contained herein are true to the best of his/her knowledge and belief,and that any work performed,or use conducted at the above captioned property will be in conformance with the details as set forth and contained in this application and in any accompanying approved plans and specifications,as well as in accordance with the New York State Uniform Fire Prevention&Building Code,the Code of the Village of Rye Brook and all other applicable laws,ordinances and regulations. Sworn to before me this Sworn to befor m this � day of 20 day f ,20 Signature of Property Owner S• ature of Applicant Print Name of Property Owner Name of AppI' t Notary Public Notary Public SHARI MELII_LO Notary Public,State of New York No.01 ME6160063 Qualified in Westchester County Commission Exoires Januanr 29 20 3/21/19 Westchester Rockland Electrical Inspection Services, Inc. ` Phone: 914-347-3595 DO NOT WRITE HERE-FOR OFFICE USE ONLY 43 North Lawn Avenue � ir Fax: 914-347-3596 Elmsford, NY 10523 � BUILDING PERMIT NO. 1 T7 P# DATE // l � D CITY OR VILLAGE ZIP CODE TOWNSHIP COUNTY STREET AND NO,OR ROAD pp POLE NUMBER C. A BETWEEN WHAT TWO CROSS STREETS IS PREMISES LOCATED? SECTION BLOCK LOT >t OCCUPANT'S NAME BUILDING OCCUPANCY OWNER'S NAME AND ADDRESS HOME TELEPHONE NUMBER CURRENT SUPPLIED BY FROM THEIR OFFICE WORK TELEPHONE NUMBER LIST BELOW ALL EQUIPMENT WHICH YOU INSTALLED NUMBER OF OUTLETS NO.OF FIXTURES& MOTORS HEATERS OFFICE USE LOCATION LAMP RECEPTACLES ONLY SIDEWALL SWITCH INCADE FLUORE NO. H.P EACH NO. WATTS EACH INSPECTION OUTSIDE BASEMENT I'FL. OCT 1 2021 2n°FL. „I 3—FL. UUIC REMARKBI LtBT OTHER ELECTRICAL DEVICES NOT SET FORTH ABOVE: [[ THIS APPLICATION IS INTENDED TO COVER THE ABOVE LISTED ITEMS TO BE INSPECTED.IF AT ANY TIME OF INSPECTION ADDITIONAL ITEMS HAVE BEEN INSTALLED,YOU ARE AUTHORIZED TO MAKE THE INSPECTION AND ADJUST THE FEE FOR THE ADDITIONAL ITEMS INSPECTED AS PROVIDED BY THE APPLICANT THE APPLICANT DECLARES THAT THERE IS NO OPEN APPLICATIONS FOR THE ABOVE WITH ANY OTHER INSPECTION COMPANY.WREIS,INC. IS NOT LISTING,LABELING,UNDERWRITING OR CERTIFYING ANY EQUIPMENT, MATERIALS OR DEVICES WHICH ARE PERFORMED BY OTHER CERTIFIED TESTING AGENCIES OR INSPECTION COMPANIES.THE APPLICANT,OWNER,OR AUTHORIZED AGENT AGREES TO ALL THE ABOVE TERMS AND CONDITIONS AS SET FORTH FOR THE APPLICATION. SIZE OF SERVICE FEEDERS I jI• CHARACTER OF WORK NEW❑ ADDITIONAL❑ EXPOSED❑ CONCEALED❑ MUST ENTER APPLICANTS IDENTIFICATION NUMBER SERVICE ENTERS BUILDING OVERHEAD❑ UNDERGROUND:T AVOID DELAYS BY GIVING FULL AND ACCURATE INFORMATION.ALL SPACE MUST BE FILLED IN OR APPLICATION MAY BE RETURNED. NAME OF COMPANY DATE OF APPLICATION SIGNATURE OF APPLICANT S.M.Abblum TELEPHONE NO. CITY OR PORT OFFICE f ZIP CODE LICENSE NO.WHEN APPLICABLE 9 AFFIDAVIT IN SUPPORT OF FEE WAIVER RELATED TO HURRICANE IDA STATE OF L W COUNTY OF UC�'T :��y'U &—t C c d (insert name), being duly sworn, deposes and says 1. I am the applicant for a B grin/Certificate of Occupancy /Demolition Permit Electrical Permit Plumbing Permit/ Fence & Wall Permit Mechanical Permit/Pod Permit(circle all that apply) 2. I am the legal owner of property located at Rye Bro ew rk (insert street address) OR I am the (Architell<ontractor ngineer/Attorney) (circle one) for the legal owner of property located at 1$ WO Qctf-4,,�-1 Q , Rye Brook, New York and I am duly authorized by property owner AtiO,-: TA.c, ,4 n411 ("La-. to make and file the accompanying application. 3. The following is a description of(1)the work to be performed under the permit for which I am applying; and (2) how the work arose as a direct result of Hurricane Ida: 4. The work described herein arose as a direct result of Hurricane Ida and does not include Work which was not caused by Hurricane Ida. Sworn to before me this '� Day of Oc-,I e , 20 �1 Notary Public SHARI MELILLO Notary Public, State of New York No. of ME61 secs3 0 C T 1 9 2021 Q!ialified in Westchester County Commission Expires January 29 20 WESTCHESTER ROCKLANO ELECTRICAL INSPECTION WREIS,,,,,,,,,INC. BY THIS CERTIFICATE OF COMPLIANCE THE Westchester Rockland Electrical Inspection Services 43 North Lawn Ave, Elmsford, NY 10523 914-347-3595 (Office) 1 914-347-3596(Fax) CERTIFIES THAT Upon the application of: Upon premises owned by: Westmore Electric Anastasia Malley fi Sunset Road NY,Rye Brook 10573 Located at:18 Woodland Dr Rye Brook,NY 10573 Certificate Number: 1032293 Section:135,36 Block:1 Lot:25 BDC: Permit Number:EP:21.265-BP:21.262 A visual inspection of the electrical system at this premise described as a Residential occupancy,wherein the premises electrical system consisting of electrical devices and wiring,described below,located inton the premises at: 18 Woodland Dr Rye Brook,NY 10573 12 Basement 1st Floor 2nd Floor 3rd Floor Garage Attic Outside Other: Inspection was conducted in accordance with the NYS and NFPA 70-2017 International Electrical Code and detail of the Installation,as set forth below,was found to be in compliance therewith on 12/15121 Name Type Quantity Replace Receptacle(s)Convenience --- 14 Replace Fixture(s)Incandescent ---- 9 Switch Single Pole --- 1 This Certificate has been approved by Westchester Rockland Electrical Inspection Services. This certificate may not be altered in any way. This certificate is valid for work performed before date of inspection only. f/ (+Y1 Llf7 Building Permit Check List&Zoning Analysis Address: SBL: �• ��� — L Zone ?-_ Use: Const.Type: Other. Submittal Date 0 "2. Revisions Submittal Dates: Applicant: Nature of Work C+•�-[�..j r :�� T��N l'�.� 1 2�-� RARI=.o~- Reviews:ZBA: OCT 1 2 2021p$: BOT: Other. NEED QK ( ) (� FEES:Filing. 91 BP: C/O: Legalizati? ( } (,-y APP: Dated Notarized: SBL; L- russ I.D. Cross Connection: H.O.A. { } ( } Scenic Roads: Steep Slopes: Wetlands; Storm Water Review: Street Opening: ( ) ( ) ENVIRO: Long. Short: Fees: N/A: ( ) ( } SITE PLAN:Topo: Site Protection: S/W Mgmt.: Tree Plan: Other: ( ) ( ) SURVEY:Dated: Current: Archival Sealed: Unacceptable: ( ) (�PLANS:Date ed Sealed Copies: Electronic. Other. (�License: Workers Comp: Liability Comp.Waiver. Other; ( } ( ) CODE 753#: Dated: N/A: HIGH-VOLTAGE ELECTRICAL:Plans: Permit N/A: Other. ( ) ( ) LOW-VOLTAGE ELECTRICAL:Plans: Permit: N/A: Other. ( ) ( ) FIRE ALARM/SMOKE DETECTORS:Plans: Permit: H.W.I.C.:_Battery:_Other. ( ) ( ) PLUMBING:Plans: Permit Nat.Gas: LP Gas: N/A/: Other: ( ) ( ) FIRE SUPPRESSION:Plans: Permit: N/A; Other: ( ) ( ) H.V.A..C.: Plans: Permit N/A: Other. ( ) ( ) FUEL TANK:Plans: Permit: Fuel Type: Other. ( ) ( ) 2020 NY State ECCC; N/A: Other: ( ) ( ) Final Survey Final Topo: RA/PE Sign-off Letter. As-Built Plans: Other. ( ) ( ) BP DENIAL LETTER: C/O DENIAL LETTER Other. ( ) ( ) Other: ( )ARB mtg.date: approval: notes: ( )ZBA mtg. date: approval:- notes: ( )P$mtg.date: approval• notes; APPROVLU REQUIRED E?QSTING PROPOSED NOTES oat..OCT 1 2 2021 cir Froze Front: From: sue: R.cgr Mn C�v Accs,Co F S S .HS • a& Tot : EL-IMP: Hei /Stories notes: Laura Petersen From: Joe Viger <joe@ ryebuilder.com> Sent: Tuesday, October 12, 2021 4:33 PM To: Laura Petersen Cc: joe@ryebuilder.com; malleynyc@aol.com Subject: Licence and Insurance- RE: Malley, 18 Woodland Drive Attachments: License Westchester Cnty exp 10-28-21.pdf; INS Cert Liability 21-22 Rye Brook.pdf; INS Workers Comp 21-22 Rye Brook.pdf To The Rye Brook Building Department: Regarding the building permit application for Stacey Malley, 18 Woodland Drive, Rye Brook, please see attachments for license and insurance documents.Thank you. Joe Viger Town Common Building& Development, Inc. 129 Theodore Fremd Ave. PO Box 668 Rye, NY. 10580 (914) 572-4023 JOE@RYEBUILDER.COM 1 f 06 CD a Y, Eca w O ► ! LU Z W ' Ci r••� IJJ O `oteetioq 4+ w+J C COLO „ �4 •�� z c a NBM v�Rr LU C Q 3 c 0 4 w co `ae5 C* � w f ; 0 O) ' 0 z t f F.$0 PW ,y r ! TOWNC-1 AC©RO CERTIFICATE OF LIABILITY INSURANCE DATE(M MID DIYYYY) �� 10/08/2021 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsements. PRODUCER 845-638-2206 VDIACT Ellen Yoskowitz Robert Alan A enc Medlicott PHO 115 North Main Street WC,No,Ext;845-638"2206 (VC,No New City,NY 10956 L Ellen.YoSkowft ro erta anagency.com RAA New City INSURE 8 AFFORDING COVERAGE NAIL O INSURER A:Wee First Ins,Co. 15326 SURE INSURER B: own 8ommon Building& Development,Inc. INSURER C: _ 129 Theodore Fremd Ave Rye,NY 10580-2827 INSURERD: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES,LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE Of INSURANCE DDL UBR POLICY NUMBER POLICY EFF POLICY EXPLTR LIMBS A X COMMERCIAL GENERAL LIABILITY 11000,000 EACH OCCURRENCE CLAIMS-MADE OCCUR TS16178500 09/17/2021 09/1712022 DAMAGE TO RENTED 500,000 X Business Owners 10,000 MED EXP(Any oneperson) PERSONAL&ADV INJURY S 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE 2,000,000 X POLICY❑z9f LOC PRODUCTS-COMPIOP AGO 2,000,000 OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ma Mcident) ANY AUTO BODILY INJURY Per eraw OWNED SCHEDULED AUTOS ONLY ONLY AUTOS BODILYBODILY INJURY(Per acddent AUTOS ONLY AUTOS ONS O m AMAGE UMBRELLALJAB OCCUR EACH OCCURRENCE EXCESS LIAR CLAIMS-MADE AGGREGATE DED I I RETENTIONS WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY Y I N ANY PROM IMTORIEXCLUDED4ECUTNE NIA Q� E g�� E.L.EACH ACCIDENT (Mandatory In NH) IP yyas,describe under E.L.DISEASE-EA EMPLOYE ESCRIPTIDN OF OPERATIONS below DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES (ACORD 101,Additlonal Remarks Schedule,may be attached If more apace la requlred) Village of Rye Brook is listed as Certificate Holder CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Village of Rye Brook ACCORDANCE WITH THE POLICY PROVISIONS. 938 King St Rye Brook,NY 10573 AUTHORIZED REPRESENTATIVE / ACORD 25(2016/03) O 1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD 4 NYSIF New York State Insurance Fund WESTCHESTER ONE,44 SOUTH BROADWAY, 10TH FLOOR,WHITE PLAINS,NY 1 060 1-44 1 1 1 nysi#.com CERTIFICATE OF WORKERS' COMPENSATION INSURANCE (RENEWED) 0 0 ^^^"^^ 133930914 TOWN COMMON BUILDING& DEVELOPMENT INC PO BOX 668 RYE NY 10580 SCAN TO VALIDATE AND SUBSCRIBE POLICYHOLDER CERTIFICATE HOLDER TOWN COMMON BUILDING& VILLAGE OF RYE BROOK DEVELOPMENT INC 938 KING ST. PO BOX 668 RYE BROOK NY 10573 RYE NY 10580 POLICY NUMBER CERTIFICATE NUMBER POLICY PERIOD DATE W1239 814-5 798743 09/17/2021 TO 09/17/2022 8/24/2021 THIS IS TO CERTIFY THAT THE POLICYHOLDER NAMED ABOVE IS INSURED WITH THE NEW YORK STATE INSURANCE FUND UNDER POLICY NO. 1239 814-5, COVERING THE ENTIRE OBLIGATION OF THIS POLICYHOLDER FOR WORKERS' COMPENSATION UNDER THE NEW YORK WORKERS' COMPENSATION LAW WITH RESPECT TO ALL OPERATIONS IN THE STATE OF NEW YORK. EXCEPT AS INDICATED BELOW, AND, WITH RESPECT TO OPERATIONS OUTSIDE OF NEW YORK, TO THE POLICYHOLDER'S REGULAR NEW YORK STATE EMPLOYEES ONLY. IF YOU WISH TO RECEIVE NOTIFICATIONS REGARDING SAID POLICY,INCLUDING ANY NOTIFICATION OF CANCELLATIONS, OR TO VALIDATE THIS CERTIFICATE,VISIT OUR WEBSITE AT HTTPS:INVWW.NYSIF.COM/CERT/CERTVAL.ASP.THE NEW YORK STATE INSURANCE FUND IS NOT LIABLE IN THE EVENT OF FAILURE TO GIVE SUCH NOTIFICATIONS. THIS POLICY DOES NOT COVER CLAIMS OR SUITS THAT ARISE FROM BODILY INJURY SUFFERED BY THE OFFICERS OF THE INSURED CORPORATION. JOSEPH VIGERIPres. TOWN COMMON BUILDING&DEVELOPMENT INC THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS NOR INSURANCE COVERAGE UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICY. NEW YORK STATE INSURANCE FUND DIRECTOR.INSURANCE FUND UNDERWRITING VALIDATION NUMBER: 125387777 U-26.3 PERMIT DATE APPR i r �• r /UILDEfiEG IN$PE TOR, illage of Rye Brook„NY L _ , � p j J a tI p q � 1 i m � > i { c ! z � s •�r Y- � � I � I - � � r1 �- Ir I A t ! > I � I p FILE COPY OCT -8 2021 ! I VILLAGE OF RYE BROOK BUILDING dEPARTMENT CI , h G. DARCY okasaN, ARCHITECT q L3 U r ` T y (w� qA 7�4r0Y 4�n• ROrlh AYE, R.■ York A * (, h 5 E P1 a 11 j" 10 ( - A 4