HomeMy WebLinkAboutSP21-003PERMIT 1
SECTION
TYPE OF
JOB LOC,
3 DATE:4��7,1s2l
FEE DATE
INSPECTION
RECORD
DATE
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FOOTING
FOUNDATION
FRAMING
RGH FRAMING
INSULATION
PLUMBING
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VILLAGE OF RYE BROOK
MAYOR 938 King Street, Rye Brook,N.Y. 10573 ADMINISTRATOR
Jason A. Klein (914) 939-0668 Christopher J.Bradbury
www.iyebrookny.gov
TRUSTEES BUILDING & FIRE INSPECTOR
Susan R.Epstein Steven E. Fews
Stephanie J. Fischer
David M. Heiser
Salvatore W.Morlino
CERTIFICATE OF COMPLIANCE
June 11,2024
Win Ridge Realty LLC
c/o Alena Hakanjin
24 Rye Ridge Plaza
Rye Brook,New York 10573
Re: 108 South Ridge Street, Rye Brook,New York 10573
Parcel ID#: 141.27-1-6
Sign Permit#21-003 issued on 9/27/2021 for New Sign&Awning
This certifies that the new illuminated accessory wall sign and fabric awning,installed under the above
captioned permit has been satisfactorily completed.
Sincerely,
Steven E. Fews
Building&Fire Inspector
/to
n� For office use oniv:
DD MAY 2 3 2024 BUIL/nliVEPTMENT PERMIT /—�3
VILLAGE OF RYE Bou OK ISSUED: — —ol/
VILLAGE OF RYE BROOK 938 KING STRE I`J(RYEBROOK,,WW YORK 10573 DATE: — —3Ll
BUILDING DEPARTMENT \1914)939-06f8�p FEE: PAtDX
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
\tttttttlii\liiilily!!\+♦!ilTyl♦•!y\!\\\!\!y!lyyy\!i\yt\i♦t♦i+1\\M#\\\\1Mtyyy+l}T\\tttttytt!\\#lMtV yty lM!\wt\yylfIR4\\y\!4!\t*\
Address: 108 SOUTH RIDGE STREET- RYE RIDGE SHOPPING CENTER
Occupancy/Use: BUSINESS GROUP parcel ID#: 141.27-1-6 Zone: C1-9
Owner: WIN RIDGE REALTY LLC Address:
P.E./R.A. or Contractor: SIGNAL SIGN COMPANY LLC Address: 105 DORSA AVENUE, LIVINGSTON NJ 07039
Person in responsible charge: Address:
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 WESTCHESTER as:
LYDIA JIMENEZ.ALL IN PERMIT CONSULTANTS being duly swom,deposes and says that he/she resides at 71 HANRAHAN AVENUE
(Print Name of Applicant) (No.and Street)
in FARMINGVILLE in the County of SUFFOLK in the State of NY that
(Cityrrown/Village)
lie/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 6500.00
for the construction or alteration of: 1 ILLUMINATED WALL SIGN y /N D
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§250-10.A.of the Code of the Village of Rye Brook.
Sworn to before me this `T rµ Sworn to before me this
day of__M q 7 , 20 2—+ day of HA ,20 ;?—q
Signature o Property Agent Signature of Applic
David English LYDIA JIMENEZ,ALL IN PERMIT CONSULTANTS
Pri�amofrty A ent PfName �plican ZIA
Not Notary Public
ALENA NAKANJIN Jean M.Sullivan
NOTARY PUBLIC,STATE OF NEW YM Notary�Public,State of New York
Rsp0lstr�tion No.01NA0013645 No.01 SU6188194 > >
Cusiltisd In Was tcheeler Countyy Qualified in Suffolk County s I, o
My Commission EXPINS 911-,;;
Commission Expires 6=0 2�r
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1982. BUILDING DEPARTMENT
❑BUILDING INSPECTOR
rJ! SSISTANT 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 - - - - - - - - - - - - - - - - - - - -
ADDRESS : 10,9 50 ,41 P ( `7 s T--,Pd DATE:
PERMIT# -se ` ' - O d ISSUED: ''Z%Z SECT: / BLOCK: r LOT:
LOCATION: Vvc�-,� ALkw i OCCUPANCY:
❑ VIOLATION NOTED THE WORK IS... Qr ACCEPTED ❑ REJECTED/ REINSPECTION
❑ SITE INSPECTION REQUIRED
❑ FOOTING
❑ FOOTING DRAINAGE
❑ FOUNDATION
❑ UNDERGROUND PLUMBING NOTES ON INSPECTION:
❑ ROUGH PLUMBING
❑ ROUGH FRAMING
❑ INSULATION
❑ NATURAL GAS �'•: f- }/
❑ L.P. GAS U
❑ FUEL TANK
❑ FIRE SPRINKLER
❑ FINAL PLUMBING
❑ CROSS CONNECTION
FINAL
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D EC IENE
BUIL MENT NOV -4 2021
VIL OF RYE OK
938 K1N EE7 YE B. ,NY 10573 VILLAGE OF RYE BROOK
(914)9 939-5801 BUILDING DEPARTMENT
or �-
ELECTRICAL PERMIT APPLICATION
Westchester County Master Electricians License Required
FOR OFFICE USE ONLY 5/�I—O C EP#: �- a 8 7
NOV - s 2021 Approval Date: Permit Fee: $
Approval Signature: Other:
Disapproved:
(fees are non-refundable)
Application dated, 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 Codes.
1.Address: 108 South Ridge Street SBL: 141.27-1-6 Zone: B
2.Property Owner: Win Ridge Realty Corp Address: 10 Rye Ridge Plaza, Suite 200
Phone#: 914-701-4005 Cell#: email: Pstahl@winprop.com
3.Master Electrician: �Aiarc, _Te -�\V t Address: Lf%Gynd 5�t'� (Ueu�irZcc�neale,VVy 1( 71
Lic.#: 1415 Phone#:"1+Cd` t(JJ D0 Cell#: (41q' 9/9',2707 email:_/Y}&pyY1,e&Cpy61ez y11-iC• GOhi
Company Name: Er An Jec4t is =nC. Address:
4.Proposed Electrical Work/FixtureCount: tin(}Q, L'pr,t A_-Mor\ �;rC One. OS ,e"o'( Mb @Inter+ Carcic,il
S1(1tr(A1?e' on 'e.X tSyi)ns U1rc'Lkkk-.
*****xxxx*xx�xxxxxxxxxxxxxxxxxxxx>xxrxxYxxYxxrYxxxrrxxrxrxxxxxYxxrxxrxxrxxxxrxxYxxxxxxr>xxrr>;:rrxxxxrr<xY
STATE OF NEW YORK,COUNTY OF WESTCHESTER ) as:
Ma-� T-L f, I being duly sworn,deposes and states that he/she is the applicant abo nar�ted,and does further
(print name of individual signing as the applicant) `!1�1}.d ik ay
state that(s)he is the legal owner of the property to which this application pertains,or that(s)he is the
for the legal owner and is duly authorized to make and file this application. (indicate architect,cod ractor,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 ty before me this k
day of ,20 day o 2
Signature of Property Owner S' ture
Print Name of Property Owner Print p t
Notary Public
IANA TROMBACCO
NOTARY PUBLIC STATE OF NEW YORK
Registration No #01TR6348329
OUallfied in Dutchess County
Coin s' E'Pr s Se to 3/21/19
P moer 26.2024
• STATEWIDE INSPECTION
1:1 Main Street,Fishkill, NY 12524 1 emoil:• • . •
SWIS JOB APPLICATION tel8. 1 914.219.1062 •
Office Use Elect.Permit#115— 1 e - Date 1 1
4:
Wdg'Permit# Utility ID#
Final Certificate#
City/Village Zip Township County
Address Cross Street Section Block Lot
Owner Name/Address(If different than above) Contact Number
❑Basement ❑1st Fl. ❑2nd FI. ❑3rd FI. ❑More Than 3 FI. ❑Garage ❑Attic ❑Outside ❑Residential ❑commercial
Receptacles Special Recept GFCI AFCI Switches Dimmers Smoke Alarms Carbon Monox Hood Trash Compact
Amt Amps
Range(s) Cooktop(s) Oven(s) Dishwashers Refrigerator Disposal Microwave Warm Draw
Incandescent Fluorescent
SERVICE
Amperage Voltage 1 P 3P #Meters #Disconnect ❑Underground ❑New ❑Reconnect
❑Overhead ❑Change
❑Visual Re-Inspection ❑ Safety Re-Inspection ❑ Re-Inspection
Additional Information
` -i 0'n-2 C- J \� C �1� �• �,i��f r C'C r f
E
-k 2021
VILLAGE OF RYE BROOK
I BUILDING DEPARTMENT
This application is valid for one(1)year from the date received by SWIS.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 art
authorial to make the inspection and adjust the fee for the additional items Inspected.The applicant declares that there is no open applications for the above address with any other Inspection company.The applicant,owner
or authorized agent agrees to all the above terms and conditions as set forth for the application.
Inspector Date Finalized Inspector#
Company Name Date 1 1 i Signature `" v
Address City/State , -Zip Code
License# Phone# f
D rCIE �WI
State Wide Inspection Services
CAC FEB 16 2024 1080 Main street
Fishkill, NY 12524
S"Vork"0 ts VILLAGE OF RYE BROOK 845 202-7224 Phone
BUILDING DEPARTMENT 914-219-1 Fax
STATE WIDE INSPECTION SERVICES Email. oI I iCe\_/rJwiSn sny y.Com
Website: www.swisny.com
Service With Integrity
BY THIS CERTIFICATE OF COMPLIANCE STATE WIDE INSPECTION SERVICES
CERTIFIES THAT:
Upon the application of: Upon Premises Owned by:
ECNY Electric, Inc. Win Ridge Realty LLC
Marc Terilli 108 South Ridge Street
48 Grand Street Rye Brook, NY 10573
New Rochelle, NY 10801
Located at: 108 South Ridge Street, Rye Brook, NY 10573
Section: Block: Lot: Electrical Permit Number: EP 21-287
141.27 1 6
Certificate Number: 2024-1120 Building Permit Number: SP 21-003
A visual inspection of the electrical system was conducted at the Residential occupancy described
below.The electrical system consisting of electrical devices and wiring is located in/on the premises
at: 108 South Ridge Street, Rye Brook, NY 10573
The Exterior was inspected in accordance with the NYS and NFPA 70-2017 and the detail of the
installation, as set forth below,was found to be in compliance on the 26Th Day of February 2024.
Name Quantity Rating Circuit Type
Exterior Commercial Sign 01
Officer: Frank J. Farina
This certificate may not be altered in any way and is validated only by the presence of a seal at the location
indicated.This certificate is valid for%vork performed on the date of inspection only.
Building Permit Check List & Zoning Analysis OB & C ONLY
�� Address: O S —IZ 3- -ST• SBL: 1 1 • ZZ L - (o
Zone: (✓ Use: Cont.Type: Other.
Submittal Date: Z� Z�( ReZisions Submittal Dates:
Applicant: W 1 N L2'-_C>S r-
Nature of Work L'%J %t- AGGE SSoa!pt WAL L� S le- I,4 `4-
T:;as:a:2 c c_ AW N t o l„ � r
Reviews:ZBA: PB: BP: Other.
OK
( ( ) FEES:Filing.3:YY�• BP: Z7.S' � C/O: Legalization:
( ) ( L�/APP.: Date Stamped: ✓ Properly Signed SBL Verified H.O.A.Approval•
( ) ( ) 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.
( ) ( ) rSURVEY:Dated: Current Archival: Sealed: Unacceptable:
PLANS:Date Stamped Sealed; ✓ Copies:,e '2--Electronic: Other.
( (l� License: Workers Comp:_x�Liability: %- Comp.Waiver. Other.
( ) ( ) Code 753#: Dated: N/A:
HIGH-VOLTAGE ELECTRICAL:Plan: Permit: N/A: Other.
( ) ( ) LOW-VOLTAGE ELECTRICAL:Plan: Permit: N/A: Other.
O O FIRE ALARM/SMOKE DETECTORS:Plans: Permit H.W.I.C.:_Battery:_Other.
( ) ( ) PLUMBING:Plan: Permit: Nat. Gas: LP Gas: N/A/: Other.
( ) ( ) FIRE SUPPRESSION:Plan: Permit: N/A: Other.
( ) ( ) H.V.A.C.: Plan: Permit: N/A Other.
( ) ( ) FUEL TANK: Plans: Permit: FUEL TYPE: Other.
O O 2020 NY State ECCC: N/A: Other.
( ) ( ) Final Survey. Final Topo: RA/PE Sign-off Letter. As-Built Plan: Other.
( ) ( ) BP DENIAL LETTER: C/O DENIAL LETTER: Other. _
( ) ( ) Other.
GARB mtg.date: •' Z( approval• notes:
( )ZBA mtg.date: approval: notes:
( )PB mtg.date: approval: _notes: APPROVED
REQUIRED EXISTING PROPOSED NOTES A U G 1 9 2021
Area: Date:
Circle:
F%tave _
Front:
Front:
Sides:
Rear.
F.A.R•:
en Sae:
Hecht:
Stories:
notes:
ECENE
BUILDING DEPARTMENT R
VILLAGE OF RYE BROOK JUL 2 3 2021
938 KING STREET RYE BROOK,NY 10573
(914)939-0668 Fax(914)939-5801 VILLAGE OF RYE BROOK
N%".4-.aebrook.orgy I BUILDING DEPARTMENT
ARCHITECTURAL REVIEW BOARD CHECK LIST FOR APPLICANTS
This form must be completed and signed by the applicant of record and a copy shall be
submitted to the Building Department prior to attending the ARB meeting. Applicants
failing to submit a copy of this check list will be removed from the ARB agenda.
Job Address: 108 SOUTH RIDGE STREET Date of Submission:
Parcel ID#: /`L7 1,017 J—4p Zone: C 1-P
Proposed Improvement(Describe in detail): APPLICANT CHECK LIST:
ERECT ILLUMINATED 30SF ACCESSORY WALL MUST BE COMPLETED BY THE APPLICANT
The following items must be submitted to the Building
SIGN&SUNBRELLA FABRIC AWNING FOR Department by the applicant-no exceptions.
CITY MD 1. ( )Completed Application
2. ( )Two(2)sets of sealed plans. (one titll size ;maximum
Property Owner: WIN RIDGE REALTY LLC allocable plan size=36"x 42"1 and one I 1-x 177')
Address: 10 RYE RIDGE PLAZA,#200 Rye Brook,NY 10573 3. ( )Two(2)copies of the property survey.
4. ( )Two(2)copies of the proposed site plan.
Phone# 914-468-7300 5. ( )One electronic/disc copy of the complete
application materials.
Applicant appearing before the Board: 6. ( )Filing Fee.
LYDIA JIMENEZ,ALL IN PERMIT CONSULTANTS 7. ( )Any supporting documentation.
Address: 71 HANRAHAN AVE FARMINGVILLE 11738 8. ( )HOA approval letter.(fopplicable)
9. ( )Photographs.
Phone# 631-320-3880 10.( )Samples of finishes/color chart.(a sample board or
Architect/Engineer:
SALVATOR CARADONNA PE model may be presented the night of the meeting)
Phone# 631-320-3880
By signature below, the owner/applicant acknowledges that he/she has read the complete Building Permit
Instructions&Procedures,and that their application is complete in all respects. The Board of Review reserves the
right to refuse to hear anyapplication not meeting the requirements contained herein.
Sworn to before me this Sworn to before me this �v2
day of 3 V` , 20 Z day of `.L` , 20
t�
ature of Proper eom ci Signatu aaof Applicant
D1S.Y I D e ) L,164— U�v'\
Print Name of Property 6wmr A l r Prin Nam f Applicant
� s
a
Notary Pu lic Notary Public
MARfA MARTINS REI
KELLY SANDLER Notary Public,State of New York
Notary PUbiiC, State of New York No.01PEr-70388
No. 01 SA5003882 Qualified in Suffolk County
Qualified in Westchester Count Commission Expires Dec 16,20,�Z
Commission Expires March 9, 20• 'Z ,I 11)
` VILLAGE OF RYE BROOK
BUILDING DEPARTMENT
938 KING STREET, RYE BROOK,NY 10573
(T) 939-0668 (F) 939-5801
ARCHITECTURAL REVIEW BOARD
Tuesday, August 17, 2021
NAME&LOCATION TYPE OF APLLICATION MOTION SECOND APPROVED REJECTED
22 Highview Ave One Story Side Addition 5244
(Saunders/Del- w/Finished Basement
Rosario)
90 S. Ridge St(RSP) New Illuminated Sign 5245
Group "Walk In Care Center"
6 Jacqueline Lane New Rear Deck, Patio, 5246
(Gasparino) Windows, Siding & Front
Door
108 S. Ridge St New Sign & Awning For 5247
(Win-Ridge) (City M.D.) �c�1 p� C)
9 Charles Lane Legalize 2nd Fl Bedroom, 5248
(Straus) & Install 2 New Casement
Egress Windows
2 Jennifer Lane 2nd Floor Addition, New 5245
(Bien LCC) Rear Patio & Renovations
33 Talcott Road Rebuild Rear Deck 5249
(Selzer)
11 Whippoorwill Rd 2nd Floor Dormer 5250
(Aspis) Addition
68 Windsor Road Replace Rear Exterior 5251
(Perry) Stairway
134 S. Ridge St(Win New Sign 'Buff City 5252
Ridge) Soap"
ML NM
MR SE
JM f SF
AC M I
KC _ -.
_ ^
�
ALL U U �� PERMIT U ��
�� u~ u. o n� v- x~ n� mm n n
CONSULTANTS
VILLAGE OF RYE B OK
BUILDING DEPARTMENT
July 22, 2021
Village of Rye Brook
Building Department
938 King Street
Rye Brook, NY 10573
RE: Sign Permit &ARB Application
OtyMDSi0n &Awning
l08 South Ridge Street
Rye Brook, NY 10573
Dear Building Inspector and Architectural Review Board Members,
Please find enclosed si0na8e application package for submittal.
(1) 4rchitectura| Review Board checklist
(I) Sign Permit Application
(2) sets ofsi0ned/sea| renderings with proposed signa0e superimposed on existing building facade
(Z) site plans for Rye Brook Shopping Center with proposed space indicated
(l) Red & Black Perforated acrylic samples
(l) Flash drive with electronic copies
(l) Filing Fee check
If you have any questions or require additional information/materials, please contact me directly at
(63l)'3Z0'3880orby email at .
Thank
Lydib Jimenez
All In Permit Consultants
A ~ IN PERMIT CONSULTANTS VILLAGE OF RYE BROOK
BUILDING DEPARTMENT
September 21' Z021
Village of Rye Brook
Building Department
938 King Street
Rye Brook, NY 10573
RE: Sign Permit&ARB Application
CityMD5i8n &Awnin0
I08 South Ridge Street
Rye Brook, NY 10573
Dear Building Inspector and team,
Please find enclosed outstanding items required for the sign and awning permit referenced above.
(I) Permit Fee check#S34J for$J7S.O0
(1)Worker's Compensation Exemption Form
(1) General Liability-AcnrdForm
(1) copy of Westchester Consumer Protection Home Improvement License
If you have any questions or require additional information/materials, please contact me directly at
(6]1)'320'3880 or by email at .
Thank You,
ydia Jimene+z ,--��3
All In Permit Consultants
Laura Petersen
From: Laura Petersen
Sent: Thursday,August 26, 2021 11:46 AM
To: bruce@signalsign.com
Cc: David English
Subject: Building Permit Application - 108 South Ridge Street - Sign Permit
Good morning,
The building permit application has been approved by the Building Inspector. Before I can issue
the building permit the following items must be submitted to our office,
A. General contractor's contact name (first and last),y01i 407n ene Z
General contractor's valid liability insurance (the Village Of Rye Brook must be the
certificate holder)
3. General contractor's valid workers compensation on a NY State Board form (C105-2 or
U26.3)
4. Building permit fee $275.00 (due once permit is issued and ready for pick-up)
P
This information can be emailed to me. Thank you
Laura
Laura Petersen
Office Assistant
Village of Rye Brook
938 King Street
Rye Brook, New York 10573
Phone(914)939-0668 1 Fax(914)939-5801 1 1petersenarvebrook.org
1
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SIGNSIG-02 DDEGROOT
A�O�RO CERTIFICATE OF LIABILITY INSURANCE DAT14/2DIYYYY)
9l1412021
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 endorsement(s).
PRODUCER CRNPAME:CT_Deborah DeGroot
N
,KRA Insurance Agency,Inc. PHONE -- -- FAX -
871 Mountain Avenue (A/C,No,E)a973)850-49641337 Afc Nol:(973)232-2833
Springfield,NJ 07081 Miss.DeborahD@krainsumnce.com
_ IN URERISIAFFORDINOCOVERAGE _NAICN
INSURER A_S011901ve Insurance Commpanny of New England i11887
INSURED INSURERS:SeiectiVO Insurance Company of America- 12572 _-
Signal Sign Company,LLC -INSURERc
105 Dorsa Ave, INSURER D:
Livingston, J 07039 INSURERE:
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.
INS --LTRTYPE OF INSURANCE ADDL SUBR IN D pOVCY NUMBER POLICY EFF POLICY EXP LIMITS
A X COMMERCUIL GENERAL LVU3ILRY EACH OCCURRENCE $ 1,000,000
CLAIMS-MADE X OCCUR S 23830" 7/25/2021 7/25/2022 DAMAGE
AMA SETO RENTED
PREM500,000
MED EXP(Any on
e : 15,000'
P_ERSONAL&ADVINJURY_ 3 1,000,000
GENT AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE 2,000,000
POLICY X Pppf CX LOC 2,000,000
—_ � PRODUCTS=COMPlOP ACiG i_ —__-_.
OTHER
A AUTOMOBILE LIABILITY COMBINED tSINGLE LIMIT S 1,000,000
X ANY AUTO S 2383048 112021 7/25/2022 BODILY INJURY(Per parson,__E
OWNED SCHEDULED
AUTEO�S ONLY AUTOS BODILY
p pBOODILY INJURY Per ac"V)_
AUTOS ONLY AUOTOS ONLY PMPERjY_ AMAGE E
A X UMBRELLA UAB _X OCCUR EACH OCCURRENCE $ 7,000,000
EXCESS LIAB I CLAIMS-MADE S 2383048 7125/2021 7/25/2022 AGGREGATE = 7,000,000
- - -- -
DED X RETENTIONS 0
B AND EMPLOYERSEN1A8 COMPENSATION X PSTAMM ER ER TH-
WC 9066626 7/25/2021 7/25/2022 E.L.EACH ACCIDENT 3 _ _
ANY PROPRIETOR' A BILITYEXECUTIVE YNN NIA 1,000,000
OFFICERIM%V EXCLUDED
(MMandatory In NH) E L.DISEASE-EA EMPLOYE 1,000,000
i yes,describe under E L.DI EASE-POLICY LIMIT
DESCRIPTION OF OPERATIONS below OOO,OOO
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required)
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
e Village of R Brook THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
g Ry
e
938 King Street ACCORDANCE WITH THE POLICY PROVISIONS.
Rye Brook,NY 10573
AUTHORIZED REPRESENTATIVE
ACORD 25(2016/03) 01988-2015 ACORD CORPORATION. All rights reserved.
The ACORD name and logo are registered marks of ACORD
Workers' Certificate of Attestation of Exemption
Compensation from New York State Workers' Compensation and/or
Board Disability and Paid Family Leave Benefits Insurance Coverage
"This form cannot be used to waive the workers'compensation rights or obligations of any party.**
The applicant may use this Certificate of Attestation of Exemption ONLY to show a government entity that New York State
specific workers'compensation and/or disability and paid family leave benefits insurance is not required. The applicant
may NOT use this form to show another business or that business's insurance carrier that such insurance is not required.
Please provide this form to the government entity from which you are requesting a permit,license or contract. This Certificate will
not be accepted by government officials one year after the date printed on the form.
In the Application of Business Applying For:
(Legal Entity Name and Address): Building Permit
Signal Sign Company,LLC
105 Dona Ave From:Village of Rye Brook
Livingston,NJ 07039-1002
PHONE:973-535-9277 FEIN:XXXXX7090 The location of where work will be performed is
Rye Ridge S/C,Rye Brook,NY 10573.
Estimated dates necessary to complete work associated with the building
permit are from June 1,2021 to September 30,2021.
The estimated dollar amount of project is $0-$10,000
Workers'Compensation Exemption Statement:
The applicant is NOT applying for a workers'compensation certificate of attestation of exemption and will show a separate certificate of
NYS workers'compensation insurance coverage.
Disability and Paid Family Leave Benefits Exempition Statement:
The above named business is certifying that it is NOT REQUIRED TO OBTAIN NEW YORK STATE STATUTORY
DISABILITY AND PAID FAMILY LEAVE BENEFITS INSURANCE COVERAGE for the following reason:
The business MUST be either: 1) owned by one individual; OR 2) is a partnership(including LLC,LLP,PLLP,RLLP,or LP)under
the laws of New York State and is not a corporation; OR 3) is a one or two person owned corporation,with those individuals owning
all of the stock and holding all offices of the corporation(in a two person owned corporation each individual must be an officer and own
at least one share of stock); OR 4) is a business with no NYS location. In addition,the business does not require disability and paid
family leave benefits coverage at this time since it has not employed one or more individuals on at least 30 days in any calendar year in
New York State. (Independent contractors are not considered to be employees under the Disability and Paid Family Leave Benefits Law.)
I,Bruce J.Fish,am the Member with the above-named legal entity. 1 affirm that due to my position with the above-named business I have the
knowledge,information and authority to make this Certificate of Attestation of Exemption. I hereby affirm that the statements made herein are true,that 1
have not made any materially false statements and I make this Certificate of Attestation of Exemption under the penalties of perjury. 1 further affirm that
I understand that any false statement,representation or concealment will subject me to felony criminal prosecution,including jail and civil liability in
accordance with the Workers'Compensation Law and all other New York State laws. By submitting this Certificate of Attestation of Exemption to the
government entity listed above 1 also hereby affirm that if circumstances change so that workers'compensation insurance and/or disability and paid
family leave benefits coverage is required,the above-named legal entity will immediately acquire appropriate New York State specific workers'
compensation insurance and/or disability and paid family leave benefits coverage and also immediately fumish proof of that coverage on forms approved
by the Chair of the Workers'Compensation Board to the government entity listed above.
SIGN Signature: Date:
HERE
Exemption Certi sate tuber Received
2021-029325 May 11, 2021
NYS Workers'Compensation Board
t'
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- eN�eR Bowman Avenue
lNTE R %
Parking
26 4424
R 27 23 UPPER
R PLAZ •22 LEVEL
i LEVE
f 28 i1-►Rye R.idg 21
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60
GROUND LEVEL 4 ,61
•4lR.DIM� V !s NTEl
44 ANDREW BRONIN,M.D. 162 ;oW ►
59 BLUM CENTER 63 r
FOR HEALTH 64
46 COCO NAIL SPA RYE RIDGE SHOPPING CENTER RYE RIDGE SHOPPING CEtMR OUth � 1
55 F.FREDERIC KHOURY, (PLAZALEVEL) 65 �
M.D, 3 BALDUCCI'S FOOD LOVERS 66
47 HOTT BLOW DRY BAR 42 8ONNIE RUSIN AUDIOLOGY MARKET f9 t
BEAUTY LOUNGE OF RYE RIDGE,PLLC 5 CERSONE'S BAKERY 4.67
49 LEARNING EXPRESS 25 BUDDHA 1 CHASE SAND 68, �
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fW Yo��TOYS 27 CAS►°A� 25 CHIPCTLE �
53,54 LESTER'S ?+, 4k 4
EAST POINT'E DANCE,LLC 1'� CHQPT CREATIVE SALAD CO.'
51 LESTER'S BOYS&MEN'S 39 EYE LEVEL LEARNING CEWMR 21 CITYMD(OPENING SOON)
45 ILLUMINATION PR 34 GREEN&TONIC 5 COMPASS d
58 RYE RADIOLOGY 37 MENDEL OPTICAL INSIGHT 24 CUSTOMERS BANK a � w
ASSOCIATES.LLP 40 PORT CHESTER TEACHER'S 19 DIG INN Q z
48 SALT+SWEAT IrEOERAL CREDIT UNION 18 DUSTY ROSE
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29 RC)STNET 8 I~C}RTINA
32 ENTRANCE C30 SLT 10 LANDSBERG JEWELERS ��, NQ. �4t �
TO ELEVATOR E so '#r
32 STRETCH D 15 MIXOLOGY CLOTHING C+D
24 MANAGEMENT OFFICE � YOGURT
WIN RIDGE REALTY 38 SOUL+C'CLE _3 RED MANGO :�39 BfKRAMC1FGA R -
a3 TOTALLY NOTT SALON a SMOOTHIES 67 CIS
10 RYE RIDGE PLAZA 43 WESTCHESTER LASER 13 RUGBY&JENNA 68 ELEVATION SURGE
OFFICE ENTRY
ASSOCIATES,LLC 11 RYE RIDGE DELI
14 RYE RIDGE PLAZA .� +5# EURGPEAN�fAK C..
OFFICE ENTRY 2 RYE RIDGE PHARM ;SS LENN'Y"S BAGELS
E E 22 SHOE-INN SHOES
'8G MASSAGE ENVY.
12 SPORT"ECH ,BUST 4U NAILS
16 STARSUCKS 43 WESTCI`#ESTER EYE DOCTORS,
14 THE WINE CELLAR
so4*AY#V-CUB 20 VANILLA SKY
TAM 7 Z LIFE
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