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HomeMy WebLinkAboutBP21-282PERMIT # 6) Q d.C) DATE. o� EXP;� SECTION 13 `'32 l / BLOCK LOT ,� TYPE OF WORK .3J"0 1 5l w' 46 P,�OJQ0&e/ JOB LOCATION cam: OWNER US-5el/ FEE INSPECTION RECORD DATE INSP FOOTING FOUNDATION FRAMING RGH FRAMING INSULATION PLUMBING 0 RGH PLUMBING GAS 0 SPRINKLER ELECTRIC C) LOW -VOLT L ALARM CJ AS BUILT O FINAL d rJC-sowss �aY 9 (9/97/s OTHER APPROVALS ARB BQT PB ZBA OTHER B 4 1 t'GL S4�j\JJ V . 19 VILLAGE OF RYE BROOK MAYOR 938 King Street, Rye Brook,N.Y. 10573 ADMINISTRATOR Paul S.Rosenberg (914) 939-0668 Christopher J.Bradbury www.ryebrook.org TRUSTEES BUILDING& FIRE Susan R. Epstein INSPECTOR Stephanie J. Fischer Michael J. Izzo David M. Heiser Jason A. Klein CERTIFICATE OF COMPLIANCE January 24, 2022 Russell Tenenzapf&Michele Tenenzapf 279 North Ridge Street Rye Brook,New York 10573 Re: 279 North Ridge Street, Rye Brook, New York 10573 Parcel I D#: 135.27-1-18 Building Permit #21-282 issued on 10/29/2021 for Replacement Windows This certifies that the six new windows,installed under the above captioned permit have been satisfactorily completed. Sincerely, Michael J. Izzo Building& Fire Inspector Ag V BUILDING DEPARTMENT Far office use only:i_ PERbf1T 4 aj? p2/-,QZ0L VILLAGE OF RYE BROOK ISSUED: �'�iN 1 2 2022 1NG STREET, RYE BROOK,NEVI'FORK 10573 DATE: f— l a—a*Z1 (914)939-0668-FAx(914) 939-5801 FEE: (Q PAID 0-- VILLAGE OF RYE BROOK , ebroak.or BUILDING DEPARTMENT h' rl: 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 ffiti;;;;#R;;tYtt}};;;#}};;RRtii;i;ifttt4tiRWi;tiRRttt}}}#;.i.....itt;;tiiR;R;;ii+tiiY;it#};};;};}}};Y;;;};;;;►iit}f tiRiii}t} Address: t U 10, 7 Occupancy/ Use: �—F mid Parcel ID #: —� �- Zone: MI,ck A 11-�then 2v eU. d,7e e�+W Owner: Address: ,Q,_ P.E./�A. or Contractor: 7 NC` Address: I)L5 AL 17-D " IL r a c!-Ksr(�c IL l OS73 Person in responsible charge:micAt k t A. _T'eo R_�agpf_ Address: e1-7 Cj NpgQ jA j�� ,B a� A, Application is hereby made and submitted to the Building Inspector of the Village of Rye Brook for the issuance of 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: 41MOP being duly sworn,deposes and says that he she resides at (Print Name of Appfl licant) -� _— — /) (No and Street) in _ Of 1 n)* in the County of W'�.ts���[t(� in the State of � that (City Town!village) he she has supervised the tivork at the location indicated abo,.e,and that the actual total cost ofthe,.%ork,including all site impro:emerts,labor. material,, scaffolding. fixed equipment,professional fees. and including the monetary value of any materials and labor which may have been donated gratis was $ f L�/ U 00, t / l for the, Ai _,_c_m _of R 0_T" &b-yv '1 T 0 F 10 W t�� C! D L+� 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 approNed plans and any amendments thereto except in so far as%ariations 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 am 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 ha%a been duly issued by the Building Inspector as per §250-10.A ofthe Code ofthe/Village of Rve Brook Sworn to/before me this / Sworn to before me this /3 day of J/�'�/�/ , 20 Z day of jh-h'I✓A-1/ 20ZZ- Ite �. Signature of Property f) Der f' Signature of Applicant Print Name o p )wn Pnnt Name of plic t Notary'Public SCOTT GOWE Notary Public SCffTT GOWE NOTARY PUBLIC OF NEW YORK NOTARY PUBLIC OF NEW YORK I D.#01 G 06357188Z, I.D.#01 GO6357188 MY COMMISSION EXPIRES!,/2,zoZ!� MY COMMISSION EXPIRES ' 1/7/2a,f' QyE BRC��. BUILDING DEPARTMENT ❑BUILDING INSPECTOR ['ASSISTANT BUILDING INSPECTOR VILLAGE OF RYE BROOK �0 CODE ENFORCEMENT OFFICER 938 KING STREET + RYE BROOK,NY 10573 (914) 939-0668 FAx (914) 939-5801 www.ryebrook.or - - - - - - - - - - - - - - - - - - - - INSPECTION REPORT - - - - - - - - - - - - - - - - - - - - ADDRESS : DATE: t i PERMIT# IV ISSUED: f l SECT: BLOCK: LOT: LOCATION: `--- ri\ l OCCUPANCY: ❑ VIOLATION NOTED THE WORK IS... ACCEPTED ❑ REJECTED%REINSPECTION ❑ SITE INSPECTION REQUIREQ. 4 ,_.•.X�""r ❑ FOOTING ❑ FOOTING DRAINAGE ❑ FOUNDATION i ❑ UNDERGROUND PLUMBING NOTES ON INSPECTION: ❑ ROUGH PLUMBING ❑ ROUGH FRAMING ❑ INSULATION ❑ NATURAL GAS ❑ L.P. GAS ❑ FUEL TANK ❑ FIRE SPRINKLER ❑ FINAL PLUMBING ❑ C320SS CONNECTION INAL 1,• OTHER N OD • N �. 1 o N o N N Q` w 3 a 55 w a Ja .2 � ti $ O m y ° o.o a U co6 > ■ t00 �° oz O hil ~ Z C) Yz � pwv : �■t� G=i ai o too 00 � a l ~ C4 er 14. b �' co _ a V � o v> v _ 4 00 � cm o ■ W O 0 O Z Y ° '2 � o _ CP*A V gz t 11 z� I1 Q Q q�q I 0 E ►Y+ .a N M 00 W Z � d o aCi CZ G z W H x 4 It Z E• O z a d o 0 0 F w w oQ :Y N o a w �� c°G • 7. O O ram. t1 1J. > �; BUILDING DEPARTMENT D VILLAGE OF RYE BROOK 938 KING STREET RYE BROOK, NY 10573 OC T 2 1 2021 (914) 939-0668 FAX(914) 939-5801 _ WWW+ryeb rook.or2 VILLAGE OF RYE BROOK BUILDING DEPARTMENT ADMINISTRATIVE EXTERIOR BUILDING PERMIT APPLICATION FOR EXTERIOR WORK WHICH DOES NOT REQUIRE VILLAGE ARCHITECTURAL REVIEW BOARD APPROVAL FOR OFFICE USE ONLY: APPROVAL DATE: 2 5 "O PERMIT#:�J �� P APPLICATION FEE: APPROVAL SIGNATURE: PERMIT FEES: H.O.A. APPROVAL: ---------DATE:, + DISAPPROVED: _OTHER: Application dated: 0 ':wfV-16N is hereby made to the Building Inspector of the Village of Rye Brook,NY,for the issuance of a Permit for the construction of buildings,structures,additions,alterations or for a change in use,as per detailed statement described below. { r� . JobAddress: ! C1 617jZ]11 k L;'-&()D k A-) V j J 2. Parcel ID#: 3 S4 x 7 —/ —/ Zone: 3. Proposed Improvement(Describe in detail); C► 12 F mC iv i'f h f a U S /e- 4. Property Owner: ch-e-L fT 4 RO,�.LL T—(?i4 ea z&i?F Address: a/ , q�2 0 Phone#9 I`7 "1 J7 yN 1# /`7 D(oo' b —+ MINA � List All Other Properties Owned in Rye Brook: Applicant: Address: Ip Y2 A j'a�e- Phone# .� I 4R o Cell# pl&a.(�yM e-mail �p�,pM —T IL:, Architect: Address: Phone# Cell# e-mail Engineer: Address: } Phone# Cell# e-mail General Contractor: i• MAhzkyo, JW e�- tZ 4- l I.) (rO`V 1�1­04 s Address: s A L--7Z7 A'wP )e Poar Z +,ed-r o 7 3 Phone 4/L4 V`f —-2 Cell# e-mail-f- /l A ' j)a Lad,00 9 cll 3121/19 5. Occupancy,(1-Fam.,2-Fam.,Commercial.,etc...)Pre-construction: Post-construction: 6. Area of lot: Square feet: Acres: 7. Dimensions from proposed building or structure to lot lines: front yard: rear yard: right side yard: left side yard: other: 8. If building is located on a corner lot,which street does it front on: 9. Area of proposed building in square feet: Basement: i g`fl: 2°d fl: 3`d fl: 10. Total Square Footage of the proposed new construction: 11. For additions,total square footage added:Basement: I51 fl: 2"d fl: 3rd fl: 12, Total Square Footage of the proposed renovation to the existing structure: 13. N.Y. State Construction Classification. N.Y.State Use Classification: 14. Construction Type&Location:()Typical Western Lumber Frame;()Timber Frame[TC];()Wood Truss[TT]; ()Pre-engineered wood[PW];Located;{) Floor Framing[F];() Roof Framing[R];()Floor&Roof Framing[FR];Other: 15. Number of stories: Overall Height: Median Height: 16. Basement to be full,or partial: finished or unfinished: 17. What material is the exterior finish: 18. Roof style;peaked,hip,mansard,shed,etc: Roofing material: 19. What system of heating: 20. If private sewage disposal is necessary,approval by the Westchester County Health Department must be submitted with this application. 21. 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...)Yes:_No:_ (f yes,applicant must submit a separate Automatic Fire Suppression System Permit application&2 sets of detailed engineered plans) 22. Will the proposed project disturb 400 sq. ft.or more of land,or create 400 sq. ft.or more of impervious coverage requiring a Stormwater Management Control Permit as per§217 of Village Code? Yes:—No:—Area: 23. Will the proposed project require a Site Plan Review by the Village Planning Board as per§209 of Village Code? Yes: No: (f yes,applicant must submit a Site Plan Application, &provide detailed drawings) 24. Will the proposed project require a Steep Slopes Permit as per§213 of Village Code Yes: No: (if yes,you must submit a Site Plan Application,&provide a detailed topographical survey) 25. Is the lot located within 100 ft. of a Wetland as per§245 of Village Code? Yes: No: (if yes,the area of wetland and the wetland buffer zone must be properly depicted on the survey&site plan) 26. Is the lot or any portion thereof located in a Flood Plane as per the FIRM Map dated 9/28/07? Yes : No: (rf yes,the area and elevations of the flood plane must be properly depicted on the survey&site plan) 27. Will the proposed project require a Tree Removal Permit as per§235 of Village Code?Yes: No: (ifyes,applicant must submit a Tree Removal Permit Application) 28. Does the proposed project involve a Home-Occupation as per§250-38 of Village Code? Yes: No: Indicate:TIER I: TIER I1: TIER III: (ifyes,a Home Occupation Permit Application is required) 29. What is the total estimated cost of construction: $ M , T12 Note:estimated cost shall include all site improvements,labor,material,scaffolding,fixed equipment,p ofessional fees, including any material and labor which may be donated gratis.!f the final cost exceeds the estimated cost,an additional fee will be required prior to issuance of the C/O. 30. Estimated date of completion: —S�/1'lYY7 0,/, C) a` (2) 3121/19 BUILDING DEPARTMENTVRLOCT VILLAGE OF RYE BROOK 21 2021 938 KING STREET RYE BROOK, NY 10573 (914)939-0668 FAX(914)939-5801 VILLAGE OF RYE BROOK wwwxvebrook.org 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 PLUMBING PERMIT APPLICATION SUBMITTED WITHOUT THIS COMPLETED AND NOTARIZED FORM WILL BE RETURNED TO THE APPLICANT. STATE OF NEW/� YORK, COUNTY OF WESTCHESTER ) as: 31, M I c ke I e- 'k re4 0Il-274Pf- , residing at, C 0" 'q 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; 11!D&yg pl> GB �s k e t oDk /�% , Rye Brook, NY. 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 crass-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. V Sworn to before me this Q day of C C,DAY , 20 2_< KELLY L FORD Notary Public-State of New York No.01 F06277613 Qualified In Dutchess County (3) My Commission Expires March 11,2025 3/21/19 This application must be properly completed in its entirety by a N.Y. State Registered Architect or N.Y. State Licensed Professional Engineer & signed by those professionals where indicated. It must also 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 YORK, COUNTY OF WESTCHESTER ) as- 1 C f /t e/1A� rbeing duly sworn, deposes and states that he/she is the applicant above named, (print name of individual signing as the applicant) and further states that (s)he is !be IggaL owner_of the property to which this application pertains, or that Lghe 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 ()+') _0 d Sworn to before me this day of D , 20 2 day of 0 obe`( , 20 Q Signature of Property Owner Signature of Apphcant Print Name of Property Owner Print Name of Applicant Notary Public Notary Public KELLY L FORD Notary Public-State of New York No.01 F06277613 KELLY L FORD Qualified in Dutchess County Notary Public'State 01 New York My Commission Expires March 11,2025 No,01F06277613 Qualified in Dutchess county My Corittrta ion Expires March 11,2025 (4) 3121/19 m o a a o a)x to v o w aR °= c a — o rn Q LLI 47 Ors 0) O CL a N U r " i < < a o a pi va aj Q p _� a) `�° m in in c 0 .0 ` c ` O Cl) co CD U') ' N E CD ai0i O 'a a U)c x �' 2 V m w Z iD sn � c � - p C c '0 a 0 W CO N y_ to 0) w 0 ¢ a 13) OL p 0 E h a E c c oin e (=j Z cEo 3 U rl. aD c .a = I o D U c o x 6 w cc o a E 3 U) CD ar L J cn a d n L a3 W N L O CN H co m W lL f/3 a) a 7 CL D O -0 - m Q v rM c r 'r CD c ` CN Or o G w 7 E T NO N V c c Q t 7 a' W O O C a) c Z m m m co H ;J (U c � -7 d Q 4i N V ' 3 .a o a �_ l c C U) = Q Lo N a+ •_V H d Q D E q) (D a c L LL > x x CL �; c 9 w LU a d w > m ai c a ar Cn O c •- .O Q " O O U C0 x Q C c W a +' Lu N U O �+ 4@ n `h o�- cx o O G� Z Z � x Nc c Env v � 5 Q Q C) wQ � c w e4 U) - o0a a � O r o o _ U a' e�E jo O LL 00 a) cv LL Q r 0 w } v Eya Z� co c E E O a Q n m .CL rov a C � 'q N LL D B `o ai c CD c O n� El a c 6co a � p " .a a) Y� d Cl cD 6 .p C2 3 U c m c x oQ °= o m xz x E Uci � U � _ — wc1 w [ r) co (%? - _ U1 i 4 CD C) D V W Cn W i Cn 3 a Q Z ,, a O i > W C Z } 7 y v s CO i m 0) r U)F. Z Q` CC �` g LL i CN CN _ © W W 0 o d CV Q 0 'ze.r re i d = a YLC it'3h � I c i r CV Q D I QQ Building Permit Check List&Zoning Analysis Address: �� SBL: I TS r Z-7 LES Zone: 2` !S� Use: Z to Const.Type: Other. Submittal Date: 10 2 l -Z( Revisions Submittal Dates: Applicant: Nature of Work V-4.S t�L--L— l 6 I �4G ti✓��o l� Reviews:zBA: OC T 2 5 2021 PB: BOT: Other. QK ( ( ) FEES:Filing. 7S BP: I� . C/O: Legalization: APP: Dated ✓ : SBL:Notarized ✓Truss 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: Unacceptably ( ) ( ) ,PLANS:Date Sramped: Sealed Copies: Electronic. Other. ( ) (, License: ✓ Workers Comp: Liability. Comp.Waiver. Other. O O CODE 7S3#: 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.Ca_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 Surve)r 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 mrg.date: approval: notes: APPROVED >zEouuiED Exisrrrro PROP NOTFS OCT 2 5 2021 �: Date:cirdv FWAW l= E= sides: Bar. Mein S Aces.Cov Ft.H/Sb: sd.H/Sb: SFA: EL Imp Tot Imp Height/Stories —o notes: -wry } -SIL A t Au A r S. A ti -:.." A �"�. ::i } t n• A J fir il vm ki I +z s css 04 �t� o O t 1I O ¢ N •? L LO � o O OLn O Pm UJ gg ui r1 Lo <co)► �yyggyyo>►�"n;'�' �..... � ICI f'- a �.. � z �� �(�1T`/. O N , �a4 L) _ c� 'C c3co co o q� i! 04 � 1 1 ``-- Ac o® CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDIYYYY) 1161 � 10/18/2021 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 endorsement(s). PRODUCER CONTACT John M. Glover Agency PHONE Tylor osueh FAX P.O. Box 700 AIc No •860-288-4898 A/C No):860-_62.3-0061 Norwalk CT 06852 ADDRESS: tosuch@johnmglover.com INSURERS)AFFORDING COVERAGE NAIC# INSURER A:AmGUARD Insurance Company 42390 INSURED THOMPAL-02 INSURERS: Thomas Paladin0 Inc. DBA Pyramid 25 Alto Ave INSURER C: Port Chester NY 10573 INSURERD: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:1412555984 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. I POLICYEXP LTRR TYPE OF INSURANCE A DL SU R POLICY NUMBER MMIDDY� MM DDIYYYY LIMITS A X COMMERCIAL GENERAL LIABILITY THBP206206 1/1/2021 1/1/2022 EACHOCCURRENCE $1,000,000 CLAIMS-MADE �OCCUR DAMA E T PREMISES Ea occurrence $50,000 MED EXP(Any one person) $5.000 PERSONAL BADV INJURY $Included GEML AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE S 2,000,000 )( POLICY J PECTRO- 7]LOC PRODUCTS-COMP/OP AGG $2,000,000 OTHER: $ A AUTOMOBILE LIABILITY THAU206263 111I2021 11U Ea accident 2022 MBINEDSINGLELIMI $1,000,000 ANY AUTO BODILY INJURY(Per person) $ OWNED X SCHEDULED AUTOS ONLY AUTOS BODILY INJURY(Per accident) $ XI HIRED X NON-OWNED PROPERTY DAMAGE AUTOS ONLY AUTOS ONLY Per acc dent $ I $ UMBRELLALUIB OCCUR EACH OCCURRENCE $ EXCESS LIAB Ll CLAIMS-MADE AGGREGATE $ LIED RETENTION$ $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY YIN STATLITE ER ANYPROPRIETORIPARTNERIEXECUTIVE E.L.EACH ACCIDENT $ OFFICER/ME M BE R EXCLUDED? ❑ NIA (Mandatory In NH) E.L.DISEASE-FA EMPLOYEE $ If es,describe under DESCRIPTION OF OPERATIONS below E.L DISEASE-POUCY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,maybe attached it more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERER IN ACCORDANCE WITH THE POLICY PROVISIONS. Village of Rye Brook 938 King Street Rye Brook NY 10573 AUTHORED REPRESENTATIVE ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016iO3) The ACORD name and logo are registered marks of ACORD NYSIF New York State Insurance Fund WESTCHESTER ONE,44 SOUTH BROADWAY, 10TH FLOOR,WHITE PLAINS,NY 10601-4411 1 nysif.com CERTIFICATE OF WORKERS' COMPENSATION INSURANCE f' 0 A A A A A A 133867878 JOHN M GLOVER INSURANCE AGENCY } PO BOX 700 NORWALK CT 06852 SCAN TO VALIDATE AND SUBSCRIBE POLICYHOLDER CERTIFICATE HOLDER THOMAS J PALADINO INC VILLAGE OF RYE BROOK T/A PYRAMID CONTRACTORS 938 KING STREET 25 ALTO AVENUE RYE BROOK NY 10573 PORT CHESTER NY 10573 POLICY NUMBER CERTIFICATE NUMBER POLICY PERIOD DATE W1304 852-5 18980 09/14/2021 TO 09/14/2022 10/1$/2021 THIS IS TO CERTIFY THAT THE POLICYHOLDER NAMED ABOVE IS INSURED WITH THE NEW YORK STATE INSURANCE FUND UNDER POLICY NO. 1304 852-5, 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://WWW.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, THOMAS J PALADINO-PRESIDENT THOMAS J PALADINO INC ONE PERSON CORPORATION 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: 185570012 U-26.3