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HomeMy WebLinkAboutBP21-275PERMIT #/�( SECTION TYPE OF WOR JOB LOCATIOD r CO N1 �T TCO # FEE _ DATE DATE•w o;�6() I EXP: BLOCK LOT INSPECTION RECORD DATE FOOTING FOUNDATION FRAMING RGH FRAMING INSULATION PLUMBING 71 RGH PLUMBING GAS SPRINKLER ELECTRIC LOW -VOLT O ALARM El AS BUILT FINAL INSP _..9 1 ��* OTHER APPROVALS AR8 BOT PB ZBA OTHER VILLAGE OF RYE BROOK WESTCHESTER COUNTY, NEW YORK No: 22-060 (fertiftcate of ®ccupaucp This is to certify that F / je / of, /mil having duly filed an application on 20�requesting a Certificate of Occupancy for the premises known as, Rye Brook,NY, located in a !z; ""r Zoning District and shown on the most current Tax Map as Section: ' . `"�c.� Block: Lot: and having fully complied with the requirements of the Building Code and the Zoning Ordinance under Building Permit No. , issued /6 L,,-)-6D 20421 , 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 following New York State Classifications, Use: K `31/ Loa- F / Construction: for the following purposes: hi Subject to all the privileges, requirements, limitations, and conditions prescribed by law, and subject also to the following: 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 building or in the exit facilities shall be made, and no enlargement, whether by extending on any side or by increasing in height shall be made,nor shall the building be moved from one location to another until a permit to accomplish such change has been ob ine fro Ilig-a— Inspector. APR 2 6 2012 . Building Inspector,Village of Rye Brook: Date: E C ENE E R For office use oul 2D �J BUILD MENT pERMiT VIL OF RYE K ISSUED: APR 2 5 2022 CING STRE YE BROOK, '1W YORK 10573 DATE: 5- Dora �9 -0 O FEE: PAID 0 VILLAGE OF RYE BROOK w�''� 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 awrrsrrsrsr►*srs►rrrraras•rstw*rawaswst*•ssrra♦sprsssasswsrrsrwss's/wwrassasrrsrrwrtssssrsssasssssrsrrrss•sassssssstrwrsrwrsrsr Address: 3 V�4oAQ�j 5t RXe Ijroo1-� N �� (0 S 2 Occupancy/Use: FaMl Parcel ID Zone: Z- F Owner: t 1 r Sd d e'-'cCi- Address: I✓cl�ems E��Q rya '41 Y D S $o P.E./R.A.or Contractor: / Address: Person in responsible charge: /"t(r)(I X de vo C da Address: Rye Application is hereby made and submitted to the Building Inspector of the Village of Rye Brook for the issuance of a Certificate of Occupancy/Certificate of Compliance for the structure/construction/alteration herein mentioned in accordance with law: STATE OF NEW YORK,COUNTY OF WESTCHESTER as: N(T l r)a cJi A v✓t C u,j being duly swom,deposes and says that he/she resides at (Print Name of Applicant) V // l (No.and Street) in E y p ,in the County of V e S�c�e sl Qr in the State of /J that (Cityrrown/Village) he/she has supervised the work at the location indicated above,and that the actual total cost of the work,including all site improvements, labor,materials,scaffolding,fixed equipment,professional fees,and including the monetary value of any materials and labor which may have been donated gratis was:$ 3 0 .t9 0 , for the construction or alteration of: j lv y yt.,q n S K 7 t'_ 8 r oo I g �(/ Y 1(9 S f o 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 �� Sworn to before\m&4his day of �� , 20 day of �� , 20 Sijnature of Prope per Signature of A7 t tPublok IV(ewt«roperly Owner int Name of Applicant V-J� SHARI MELILLO Notary Public Notary Public, State of New York IVo. 01 P 0 E5160063 s 1, ,„,; Qualified in Westchester County Commission Expires January 29, 20 �E BR(�k, 04 BUILDING DEPARTMENT BUILDING INSPECTOR ASSISTANT BUILDING INSPECTOR VILLAGE OF RYE BROOK ❑CODE ENFORCEMENT OFFICER 938 KING STREET • RYE BROOK,NY 10573 (914) 939-0668 FAX (914) 939-5801 www Uebrook.org - - - - - - - - - - - - - - - - - - - - INSPECTION REPORT - - - - - - - - - - - - - - - - - - - - ADDRESS . DATE: Z Z i PERMIT# ISSUED: SECT: BLOCK: LOT: LOCATION: '4 2 r1 << - OCCUPANCY: ❑ VIOLATION NOTED THE WORK IS... 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 ❑,,ACROSS CONNECTION V FINAL U OTHER f s tn r s N N OL v o 3 O U • O > U • Z 'UX Fw- 3 o` °• W = Cr rr > G d a O fl1 � v f h�l fag -Ono Zo I�Mn oc p v o c VD W > ... A o0-0 � u oc Q.12 .2 rA a. c Q"" E- vac c :nEa� .o u A V1 za � a� UO ° a � �h HW Z C M, 4x •° U w ry M x E3 w BUILDING MPARTMENT 2 VILLAGE OF RYE'BROOK I A OCT 2 1 2021 938 KING 5TUET RYE Bnom,NY 10573 (914)939--0668 VILLAGE OF RYE BROOK w"xyebropk.ore BUILDING DEPARTMENT INTERIOR BUILDING PERMIT APPLICATION FOR OFFICE USE ONLY: '"] Approval Date: 0 C T 2 5 20, Permit#: /' / Application Fee:$ Approval Signature: Permit Fees:$ Disapproved: Other: ********************************************************,►**********�,�*�.****,�****max**,�********************** Application dated: /Q"C) is hereby made to the Building Inspector of the Village of Rye Brook,NY,for the issuance of a Permit for the interior alteration of an existing building,or for a change inuse,as per detailed statement described below. a p 1. Job Address: � (A-y U, t, S / P7 e 13 r00 k,Q SBL:/'q�•7 3 '�' / Zone: J_ 2. Proposed Improvement.(Describe in detail): d l v I Y a c w S 0 w e t_- ©,9 o t d �f d2 /Jlclln el,01C ' J l9.c1 fOV_t d ea, �a a s S: + (l- r e i a C l• e.J 9 L" 040 0 r Ck 1 r✓ �,, �,r�c Lc ht„�rlca� 3. Does the proposed improvement involve a Home-Occupation as per§250-38 of the Code of the Village of Rye Brook? No: Yes: If yes,indicate: TIER I: TIER II: TIER III: 4. Will the proposed project require the installation of a new,or an extension/modification to an existing automatic fire suppression system(Fire Sprinkler,ANSL System,FM-200 System,Type I Hood,etc...) :No: Yes: (If yes,please submit a separate Automatic Fire Suppression System Permit application&2 sets of detailed engineered plans) 5. Occupancy;(1 fam.,2 farn.,comm.,etc...)Prior to Construction: 7 1�&v— After Construction: S'-&tom i, 6. NX State Construction ClAssification: N.Y. State Use Classification: 7. Property ppOwner: 1 rs �e wt e mil' Address: wy k,6 h S/ Ate/e 0--0,3 t e Phone#,1,Z9—,2Zf— �19Y2 Cell# 9z9-22$-�9q.1mai1: �/(1utd " ewlr i s� , at c0" 8. Applicant: Address: Phone# Cell# email: 9. Architect: Address: Phone# Cell# email: 10. Engineer: Address: Phone# Cell# email: 11. General Contractor: Address: Phone# Cell# email: 12. Estimated cost of construction $ (NOTE:The estimated cost shall include all labor,material,scaffolding,feed equipment,professional fees,and material and labor which may he donated gratis) 13. Job Timetable:Start: Finish: (1) 8/12/2021 BUILDING DEPARTMENT VILLAGE OF RY ,'OkOOK OCT 2 1 2021 T 938 KING SET RYE BR9 ,NY 10573 VILLAGE OF RYE BROOK BUILDING DEPARTMENT AFFIDAVIT OF COMPLIANCE VILLAGE CODE §216 • STORM SEWERS AND SANITARY SEWERS THIS AFFIDAVIT MUST BEAR THE NOTARIZED SIGNATURE OF THE LEGAL PROPERTY OWNER AND BE SUBMITTED ALONG WITH ANY BUILDING OR PLUMBING PERMIT APPLICATION. ANY BUILDING OR PLWBING PERMIT APPLICATION SUBMITTED WITHOUT THIS COMPLETED AND NOTARIZED FOR11 WILL BE RETURNED TO THE APPLICANT. STATE OF NEW YORK, COUNTY OF WESTCHESTER ) as: r / _, residingat, �Ldev') ��d pYe. (Print name) (Address where you live) being duly sworn, deposes and states that(s)he is the applicant above named, and further states that(s)he is the legal owner of the property to which this Affidavit of Compliance pertains at; Rye Brook,NY. (Job Address) Further that all statements contained herein are true, and that to the best of his/her knowledge and belief,that there are no known illegal cross-connections concerning either the storm sewer or sanitary sewer, and further that there are no roof drains, sump pumps, or other prohibited stormwater or groundwater connections or sources of inflow or infiltration of any kind into the sanitary sewer from the subject property in accordance with all State, County and Village Codes. r , (Signature of Property er(s)) ' l r fib� jl�e (Print Name of Property Owner(s)) Sworn to before me this da of owy Public) CAROLYN MARIE CANNISTRARO Notary Public-State of New York (2) No.01CA6177080 Qualified in Westchester County My Commission Expires Nov.5,2023 8/12/2021 This form must be properly completed &notarized by the Design Professional of record and the Property Owner. Failure to provide this completed form with your permit application will delay the permitting process. Notice of Utilization of Truss Type, Pre-Engineered Wood, or Timber Frame Construction. Title 19 Part 1264 & 1265 NYCRR To: The Building Inspector of the Village of Rye Brook. From: MC U Subject Property: Zone: Please take notice that the subject; &(One or Two Family; ❑ Commercial, ❑ New Structure ❑ Addition to an Existing Structure Ws Rehabilitation to an Existing Structure to be constructed or performed at the subject property will utilize; ❑ Truss Type Construction(TT) - uond Construction(PW) ❑ Timber Construction(TC) in the following locadon(s); Floor Framing, ' (F) ❑ Roof Framing(R) ❑ Floor Framing and Roof Framing(FR) Please note that prior to the issuance of the Certificate of Occupancy, the subject dwelling or building utilizing truss type, pre-engineered wood, or timber construction must be posted with a Truss Identification Sign, installed in conformance with NYCRR§1264 for Commercial Buildings, and NYCRR§1265 for One&Two Family Dwellings. Date Design Professional Date Property Owner Date Notary Public (3) 8/12/2021 This application must be properly completed in its entirety and must include the notarized signature(s) of the legal owner(s) of the subject property, and the applicant of record in the spaces provided. Any application not properly completed in its entirety and/or not properly signed shall be deemed null and void and will be returned to the applicant. Please note that application fees are non-refundable. STATE OF NEW YORI ,COUNTY OF WESTCEESTER ) as: /V I I-J a� e w.c u-A ,being duly sworn,deposes and states that he/she is the applicant above named, (print name of individual signing as the a cant) and further states 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,contractor,agent,attorney,etc.) 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. By signing this application,the property owner further declares that he/she has inspected the subject property, and that to the best of his/her knowledge there are no roof drains, sump pumps or other prohibited stormwater or groundwater connections or sources of infiltration into the sanitary sewer system on or from the subject property. Sworn to before me this Sworn to before me this day of .20 2-1 day of , 20 Signature of Property Own Signature of Applicant ✓(st't v, (L (2Vt.,Ca Print Name of Property Owner Print Name of Applicant otary Public Notary Public CAROLYN MARIE CANNISTRARO Notary Public-Stale of New York No.01 CA6177080 Qualified in Westchester County My Commission Expires Nov.5,2023 (4) 811 212 02 1 AFFIDAVIT IN SUPPORT OF FEE WAIVER RELATED TO HURRICANE IDA STATE OF /✓ COUNTY OF W(?5 T G4-'e S T C r e &d Idem Ca (insert name), being duly sworn, deposes and says 1. I am the applicant for a Cuildin Per ' / ertificate of Occupanc /Demolition Permit Electrical Permit lum ing Perm' /Fence & Wall Permit Mechanical Permit Pod Permit (circle all that apply) 2. I am the legal owner of property located at 3 1—"Xm Li s � � y� 191-00�eC Rye Brook,New York (insert street address) OR I am the (Architect/Contractor/Engineer/Attorney) (circle one) for the legal owner of property located at , Rye Brook,New York and I am duly authorized by property owner 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 refsult of Hurricane Ida: tt p f 01J � e t�a (0 51�PQ rot � ao�_ IMP �aC� C ahf 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 t before me this o ary ublic -.- - CAROLYN MARE CANNISTRARC Notary Public-State of New York LL= V l �L� No.01CA6177080 Qualified in Westchester County My Commission Expires Nov.5.2023 O C T 2 1 202-1 I VILLAGE OF RY'E- BROOK BUILDING BFR"RTfL^EN T �o in i 3 O C €y � G. y 0 C. F u 'v � 8 W m 16 W 3 L� > •o P. 14 ; 40 F' O OEM tn 0° � � H � aei OF ry1 O o � W °� N �o � ` � ° g ` • � � � � •us O O00 Q Q , ot itI co ., �\ W °o q cv ~~ C7 M z Q > Eci z; ` Ca " M.y Vf 00 W U U iy > ° � � e �i M a Q ..l g 6 Z W." E u � h�I z CA _ FF.. N U � x � y � w Q' z � r.: 0 o o W o „it-� a °� i B c--.o is C" co � 3 TE E M G Fr W Z O on uoo " BUILDING DEPARTMENT DiD VILLAGE OF RYE BROOK OCT 2 1 2021 938 KING STUET RYE BROOK,NY 10573 (914)939-0668 VILLAGE OF RYE BROOK BUILDING DEPARTMENT APPLICATION FOR PERMIT TO INSTALL AND/OR REMOVE HEATING, VENTILATION AND/OR AIR CONDITIONING EQUIPMENT FOR OFFICE USE ONLY: 7`5 PERMIT#: / OCT 2 2021 Approval Date: Permit Fee: $ Approval Signature: Other: A)a/ye Disapproved: (fees are non-refundable) ******************************************************************************************************* REQUIREMENTS FOR RELEASE OF PERMIT&CERTIFICATE OF COMPLIANCE: 1. Properly completed& Signed Application. 2. Site/Staging Plan if Required by the Building Inspector. 3. Copy of Licensed Contractor's Liability Insurance. (Village of Rye Brook must be listed as certificate holder)&Workers Compensation Insurance on a NYS Board form(Form#C105.2 or Form#U26.3/or NY State Workers Compensation Waiver) 4. Payment of Fees/Unit: RESIDENTIAL=$100.00/unit•COMMERCIAL=$350.00/unit. 5. Inspection by the Building Department for removal and/or installation.(48 hour notice required 6. Electrical work requires a separate Electrical Permit&Electrical Inspection. 7. Plumbing/Gas work requires a separate Plumbing Permit&Plumbing Inspection. t,r,t*,r*,r,r*,r,r*********rr***,r**,►*****+r**,t*+r+r********,t+r*,r*****,t*,t,r********,r***,r******,t**********,r*,t*w* Application dated, is hereby made to the Building Inspector of the Village of Rye Brook for a permit for the installation and or removal of the HVAC equipment as listed below.The applicant and property owner,by signing this document agrees that said equipment will be installed and/or removed in conformance with all applicable Local,County,State&Federal laws, codes,rules and regulations. / Q Q �^ 1. Address: 'SBL:���. 7 3--1— / Zone:A-cO 2. Property Owner: Address: Phone#: q���, 2 �� — �Q�2 Cell email: ab 3. Contractor: L Address: Phone#: Cell#: email: ` .C1N 4. Applicant. Address: Phone#: Cell#: email: 5. Scope of Work:New n lla ' n( �Replacement( •Removal( )•Oth 6. List Equipment: 7. Location of Equipment: 8. Method of In tallation/Removal(list au equip eat needed to perform job): .S n ` 8/12no21 ST OF NEW YORK,COUNTY OF WESTCHESTER ) as: ,being duly sworn,deposes and states that he/she is the applicant above named, t name f dividual signing as the applicant) an tates 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. (' cate arc4iteft,contractor,agent,attorney,etc.) That a '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. /sf Sworn to before me this Sworn to before me this 1 day of 0(ff tLk, ,20 2 day of r Signature roperty Owner gnatur of Ap c .'�l r,d j -XJe v, c OIL Print Name of Property Ov er Print Name o pplicant Notary Publi Al H.MARSHALL z�—gotary RA H. SHAII Notary Public,State of New York Notary Public,State of New York No.01FR6363711 No.01FR6363711 Qualified in Westchester County. Qualified in Westchester County Commission Expires August 28,20 Commission Expires August 28,20 This application must be properly completed in its entirety and must include the notarized signature(s) of the legal owner(s) of the subject property, and the applicant of record in the spaces provided. Any application not properly completed in its entirety and/or not properly signed shall be deemed null and void and will be returned to the applicant. 2 8/12no21 I Building Permit Check List&Zoning Analysis W Address: c� V 4t j _� • SBL: Zone:'12 Use: Cont.Type: Other. C e4 N �- Submittal Date: O 2l Revisions Submittal Dates: Applicant ►V I F—y G A.S Nature of Work: l 1-rT CZ LD f�— Reviews:zBA: OCT 2 5 2021 PB: BOT: Other. p OKK ( ) ( FEES:Filing._ BP: 9(" C/O: Legalization: APP: Dated:_s.,� Notarized s_/ SBL: ✓Truss I.D. Cross Connection: ✓ H.O.A.: ( ) ( ) Scenic Roads: Steep Slopes: Wetlands: Storm Water Review: Street Opening. ( ) ( ) ENVIRO:Long. Shore Fees: N/A: ( ) ( ) SITE PLAN:Topo: Site Protection: S/W Mgmt.: Tree Plan: Other. ( ) ( ) SURVEY:Dated Current: Archival;- Sealed Unacceptable: ( ) ( ) PLANS:Date Stamped Sealed Copies: Electronic Other. License Workers Comp: Liability. Comp.Waiver.Z Other. ( ) ( ) CODE 753#: Dated N/A: (vY ( ) 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: yermit: N/A: Other. ( ) (Jf 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: ( )PB mtg.date: approvaL notes: REQUIRED EXISTING PROPOSED NOTES APPROVED- OCT 2 5 2021 Cir Fr n Ems Erse l� Main Ft.H HS : GEATot.imp paddug: Hag Storms notes: A Berkshire Hathaway HOMEOWNERS POLICY : Insurance DECLARATIONS G UARD Companies AmGUARD Insurance Company — A Stock Company 39 Public Square • Wilkes-Barre, PA 18703-0020 Issued: 08/13/2021 Policy No.: MIH0274885 Renewal of: NEW POLICY INFORMATION PAGE [1] Named Insured and Address Named Insured: Mirsad Memcaj & Bahri Kopliku Residence Premises: 3 Wyman St, Rye Brook, NY 10573-3429 Mailing Address: 29 Gilbert Pl, Port Chester, NY 10573-4788 [2] Agency SIMON AGENCY, 14 Front Street, Suite 201, Hempstead, NY 11550 [3] Policy Period From August 11, 2021 to August 11, 2022, 12:01 AM, standard time at the residence premises [4] Coverage This policy consists of the Coverage Forms listed on the Schedule of Forms and Endorsements. Coverage is provided where a premium or limit of liability is shown (below) for the coverage. Section I Limits of Liability A. Dwelling $ 483,000 B. Other Structures $ 48,300 C. Personal Property $ 241,500 D. Loss of Use $ 144,900 Section II E. Personal Liability $ 500,000 Each Occurrence F. Medical Payments to Others $ 5,000 Each Person [6] Premium Basic Policy Premium $ 1,350.00 Additional Premium Charges Related to Other $ 197.00 Coverages or Endorsements This amount is the total of the premium for all additional optional charges;the individual coverages and charges are shown on the next a e. Total Premium $ 1,547.00 In return for your payment of premium, and subject to all terms of this policy, we agree with you to provide insurance as stated in this policy. HO DEC NY 07 18 Page 1 of 8 HOMEOWNERS POLICY DECLARATIONS Issued: 08/13/2021 Policy No.: MIH0274885 Effective Date: 08/11/2021 Deductible: Section I: $ 1000 Other: Same as All Peril Windstorm (All) Same as All Peril Catastrophe N/A ADDITIONAL PROTECTION ELECTED COVERAGE LIMIT PREMIUM Additional Amounts of Insurance Options Coverage A Only Additional Amount Options 25% Animal Liability Aggregate sublimit(exclusions still apply) 100,000 Business Property Off-Premises Limit 1,500 On-premises Limit 2,500 Coverage C -Other Residences Limit 24,150 Coverage C -Self-storage Facilities Limit 24,150 Coverage C -Special Limits of Liability Jewelry, Watches and Furs Limit 1,500 Money Limit 200 Securities Limit 1,500 Silverware, Goldware & Pewterware Limit 2,500 Firearms Limit 2,500 Portable Electronic Equipment in or upon a motor 1,500 Vehicle Limit Credit Card, Electronic Fund Transfer Card or Access Device, Forgery and Counterfeit Money Coverage Limit 1,000 Damage to Property of Others Limit 1,000 Debris Removal Limit 5%/1,000 Fire Department Service Charge Limit 500 Grave Markers Limit 5,000 Home Systems Protection Coverage 30.00 Limit 50,000 Landlord's Furnishings Limit 2,500 Service Line Coverage 30.00 Limit 10,000 Supplemental Loss Assessment Coverage Residence Premises Limit 1,000 HO DEC NY 07 18 Page 2 of 8 HOMEOWNERS POLICY DECLARATIONS Issued: 08/13/2021 Policy No.: MIH0274885 Effective Date: 08/11/2021 Trees, Shrubs and Other Plants Limit 5%/500 Water Backup& Sump Overflow 137.00 Limit 10,000 Workers' Compensation Endorsement Limit Included HO DEC NY 07 18 Page 3 of 8 HOMEOWNERS POLICY DECLARATIONS Issued: 08/13/2021 Policy No.: MIH0274885 Effective Date: 08/11/2021 SCHEDULE OF FORMS AND ENDORSEMENTS Form Number Title HO P 004 05 11 LIMITED HOME DAY CARE COVERAGE ADVISORY NOTICE TO POLICYHOLDERS HO P 063 10 15 ADVISORY NOTICE TO POLICYHOLDERS HO PRIV POL PRIVACY POLICY IL P 001 01 04 U.S. TREASURY DEPARTMENT'S OFFICE OF FOREIGN ASSETS CONTROL ('OFAC') ADVISORY NOTICE TO POLICYHOLDERS HO DEC NY 07 18 HOME OWNERS POLICY DECLARATIONS - NEW YORK HO 00 03 05 11 HOMEOWNERS 3 - SPECIAL FORM HO 131 01 03 20 New York Special Provisions HO 04 20 05 11 SPECIFIED ADDITIONAL AMOUNT OF INSURANCE FOR COVERAGE A- DWELLING HO 04 43 05 11 REPLACEMENT COST LOSS SETTLEMENT FOR CERTAIN NON-BUILDING STRUCTURES ON THE RESIDENCE PREMISES HO 04 46 10 00 INFLATION GUARD HO 04 53 10 00 CREDIT CARD, FUND TRANSFER CARD, FORGERY AND COUNTERFEIT MONEY COVERAGE HO 04 90 05 11 PERSONAL PROPERTY REPLACEMENT COST LOSS SETTLEMENT HO 06 53 02 17 HOME-SHARING HOST ACTIVITIES AMENDATORY ENDORSEMENT HO 23 85 05 15 Limited Water Back-up and Sump Discharge or Overflow Coverage - New York HO 23 95 05 02 Off Premises Theft Exclusion - New York HO 24 93 05 02 Workers' Compensation Endorsement HO 34 02 02 17 AIRCRAFT LIABILITY DEFINITION REVISED TO REMOVE EXCEPTION FOR MODEL OR HOBBY AIRCRAFT HO 99 83 08 17 PROTECTIVE DEVICES HO 99 89 06 17 SERVICE LINE COVERAGE HO 99 90 06 17 HOME SYSTEMS PROTECTION HO FCRA Notice of Consumer Rights Under the Fair Credit Report Act IL 99 00 08 13 Authorization and Attestation HO DEC NY 07 18 Page 4 of 8 HOMEOWNERS POLICY DECLARATIONS Issued: 08/13/2021 Policy No.: MIH0274885 Effective Date: 08/11/2021 SECTION II — LIABILITY COVERAGES (of the policy): OTHER INSURED LOCATIONS Address(es) MORTGAGEE(S)/LIENHOLDER(S) Name Address Loan Number LoanDepot.com, LLC PO Box 7114, Troy, MI, 48007-7114 600273956 I SAOA/ATI MA, LOSS PAYEE(S) — PERSONAL PROPERTY (Name and Address of Loss Payee and Personal Property Involved) Name Address Personal Property HO DEC NY 07 18 Page 6 of 8 HOMEOWNERS POLICY DECLARATIONS Issued: 08/13/2021 Policy No.: MIH0274885 Effective Date: 08/11/2021 PROTECTIVE DEVICES As a condition of this insurance, you MUST maintain the protective devices or services shown below and discussed on form HO 99 83 attached to your policy. You should also be prepared to supply proof of proper maintenance upon request. Name of Device Fire Alarm: Local/Smoke Detector HO DEC NY 07 18 Page 6 of 8 HOMEOWNERS POLICY DECLARATIONS Issued: 08/13/2021 Policy No.: MIH0274885 Effective Date: 08/11/2021 RATING CHARACTERISTICS Construction: Frame Year Built: 1940 Number of Stories: Square Footage: 2300 Roof Age: 12 Protection Class: 04 Roof Type: Composition -Architectural Shingle Number of Losses Last three years: 0 Burglar Alarm Type: none Fire Alarm Type: Local Sprinkler System: No Occupancy Type: Owner Occupied HO DEC NY 07 18 Page 7 of 8 HOMEOWNERS POLICY DECLARATIONS Issued: 08/13/2021 Policy No.: MIH0274885 Effective Date: 08/11/2021 RECAP OF UNDERLYING POLICY INFORMATION PROVIDED TO US Your coverage with us has been written based on the following information provided by you either directly or through your authorized representative: Information about the Residence Year built 1940 Square footage 2300 Type occupancy Owner Occupied Number of families accommodated 2 Owner or tenant occupied Owner Type electrical box Circuit Breaker Most recent plumbing update 2017 Number of losses in last three years 0 New Home Buyers Only) Date of Inspection — N/A for Not Applicable N/A Roof Date of last update 2009 Shape Gable Primary covering used Composition -Architectural Shingle Hail resistance class Unknown Heating Primary Type Natural Gas Other Secondary T e s /A liances Used N/A Pets Pets No Number of dos N/A Breed(s) includes one of the following -- pit bulls, Rottweilers, N/A Wolf Hybrids, or a mixed breed that includes one of these. History of Biting N/A Exotic N/A Description N/A Further Details Yes No N/A Purchased within the last six months X Primarily used for residential purposes X Seasonal/secondary dwelling X Dwelling will not be unoccupied for more than 30 days X Mobile home, trailer home, or house trailer X Underground oil tanks on property X Swimming pool X Swimming pool within area enclosed by a fence X Diving board for swimming pool X Trampoline X Trampoline in enclosed area X Use of drones X Any residents with a history of smoking X Used as a farm X Structure is a rowhouse/townhouse X Features log home constructions X HO DEC NY 07 18 Page 8 of 8 Affidavit of Exemption to Show Specific Proof of Workers' Compensation Insurance Coverage for a 1, 2, 3 or 4 Family, Owner-occupied Residence **This form cannot be used to waive the workers'compensation rights or obligations of any party.** Under penalty of perjury, I certify that I am the owner of the 1, 2, 3 or 4 family, owner-occupied residence (including condominiums) listed on the building permit that I am applying for, and I am not required to show specific proof of workers' compensation insurance coverage for such residence because (please check the appropriate box): ® I am performing all the work for which the building permit was issued. ❑ I am not hiring,paying or compensating in any way,the individual(s)that is(are)performing all the work for which the building permit was issued or helping me perform such work. ❑ I have a homeowners insurance policy that is currently in effect and covers the property listed on the attached building permit AND am hiring or paying individuals a total of less than 40 hours per week (aggregate hours for all paid individuals on the jobsite) for which the building permit was issued. I also agree to either: ♦ acquire appropriate workers' compensation coverage and provide appropriate proof of that coverage on forms approved by the Chair of the NYS Workers' Compensation Board to the government entity issuing the building permit if I need to hire or pay individuals a total of 40 hours or more per week(aggregate hours for all paid individuals on the jobsite)for work indicated on the building permit,or if appropriate,file a CE- 200 exemption form; OR ♦ have the general contractor, performing the work on the 1, 2, 3 or 4 family, owner-occupied residence (including condominiums)listed on the building permit that I am applying for,provide appropriate proof of workers'compensation coverage or proof of exemption from that coverage on forms approved by the Chair of the NYS Workers' Compensation Board to the government entity issuing the building permit if the project takes a total of 40 hours or more per week(aggregate hours for all paid individuals on the jobsite)for work indicated on the building permit. (Signap& of Homeowner) (Date Signed) Ar�(d /�t°M CckA Home Telephone Number (Homeowner's Name 'nted) o- • ♦ Sworn before me thls dwy of Property Address that requires the building permit: O , C9 04_, Cler F` e bro qt ON tyNotary Public,State of New York No.01 ME6160063 Qualified in Westchester County S O Commission Expires January 29,20 �� Once notarized,this BP-1 form serves as an exemption for both workers'compensation and disability benefits insurance coverage. BP-1 (12/08) NY-WCB