Loading...
HomeMy WebLinkAboutBP21-296PERMIT SECTION TYPE OF JOB LOC. BEST. y c0 i TCO 93 7--/ck3P 6���o C9/y)9�o- 963a fEE DATE INSPECTION RECORD � DATE INSP FOOTING FOUNDPTION FRAMING RGH FRAMING INSULATION PLUMBING RGH PLUMBING GAS O SPRINKLER _- ELECTRIC LOW -VOLT O ALARM O AS BUILT 0 FINAL Z OTHER APPROVALS ARB BOT PB 28A OTHER _ VILLAGE OF RYE BROOK WESTCHESTER CouiO Y, NEW FORK NO: 24-07 i Certificate of Occup ucp L This is to certify that Of, having duly filed an application on V�y1 e �o2y 20 429 requesting a Certificate of Occupancy for the premises known as, A01) A&T/7 A04W �!/"�e� , Rye Brook,NY, located in a P�—/ Zoning District and shown on the most current Tax Map as Section: 5. Block: 0? Lot: �Cy and having fully complied with the requirements of the Building Code and the Zoning Ordinance under Building Permit No. _0"2(?(0a , issuedb,;;2 20�, 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: 12 311)l7el6�1ZL1Construction: for the following purposes: l k- 11-7 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 shA the building be moved from one location to another until a permit to accomplish such change h in r the ing Inspector. Building Inspector,Village of Rye Brook: Date: J UN 1 3 2024 DV Il V L r�' For office use onI BUILDING DEPARTMENT PERMIT# e'0 �U` N ' 2�2�24 VILLAGE OF RYE BROOK ISSUED: — 938 KING STREET,RYE BROOK,NEW YORK 10573 DATE: — —,) VILLAGE OF RYE BROOK (914)939-0668 FEE:, �/0 PAID Id BUILDING DEPARTMENT y1NNi,ry"etlt'1+(J1C.UI'�� 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»»sssss»ssssssssssssssssssssssssssss»ssssssssssssrssssssssssssssssssssss»ssssssssssssssssssssssssssresssssssssssssessssssss Address: c,P af, On -b Occupancy/User Parcel ID#: 13 S _ Z _ C (o , C-)— Zone: Owner: M- NC I ( 1�1 np ('� t I n 0 Address: P.E./R.A.or Contractor: �` � (� i la Address: �r Person in responsible charge: �,h n 6 L) i n ) Address: It�U' Application is hereby made and submitted to the Building Inspector of the Village of Rye Brook for the issuance of a 1061— 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: � being duly sworn,deposes and says that he/she resides at �(�P?NaMC-ot�Ilcantl�,� � �0.��3 (No and Street) � in ,in the County of V V�S �� � in the State of�that ICitv'1oti,ti Vill�gel 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:$ i aO''U for the construction or alteration of: � k f'o o m 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. ,1 rh Sworn to before me this J p� Sworn to before me this day of , 20 day of lr�I>� , 20 2 5Z A�4A Si of Property owner \� Si Applicant \11 coLi;d� ()h V1 6LA I int a of Property Owner Print Name of Apnt &L— Nota—ry-Pubfic Notary PubKc SHARI MELILLO SHAREEDA KAVUM Notary Public,State of New York Notary Public-State of New York No.01M E6160063 NO.01 KA6154557 Qualified In Westchester County, Qualified in Westchester County Commission Expires January 29,20��� My Commission Expires Oct 23, 2026 QyE BR�k, '9a2 BUILDING DEPARTMENT ❑.,BUILDING INSPECTOR 2J 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 ryebrook.org - - - - - - - - - - - - - - - - - - - - INSPECTION REPORT - - - - - - - - - - - - - - - - -- - - ADDRESS : / 6 1 (&Q 2 /21 eke S 7lucr DATE: L PERMIT# 9/ 21 - Z* ISSUED: 11"/4' Z SECT: j-S J-} BLOCK: Z- LOT: .SX•L LOCATION: EA T/H f 0U OCCUPANCY: ❑ Violation Noted THE WORK IS... [a-'f�ASSED ❑ FAILED / 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 ,a4INAL ❑ OTHER a i a s to cyl x N .--i 0 i O N � i 04 N N W C 41 .a i rA Fi LC 0 v a �p ? 0- �0 •- � � � � a"" W C"'"' !V `fY chi o >, c p > •� � m In u.� � � c c a. � y � ■ C6 cam � Q w oCocoo + A ■ col r* O 00 - 00 H i - � O MCI U GG a °�" . c4'° �, :: a� E■ 'Q � o °c � � '� u C/� A V C U v EE A _ �--I A uarl z � d o o � `� -v•v i a BUILDING DEPARTMENT R ENE VILLAGE OF RYE]BROOK N�� -$ 2�2� 0 938 KING STREET RYE BROOK,NY 10573 (914)939-0668 VILLAGE OF RYE BROOK ivvvtn.r,*6brotlk.og,,, BUILDING DEPARTMENT INTERIOR BUILDING PERMIT APPLICATION FOR OFFICE USE ONLY: / Approval Date: NOV _ Permit#: / — Application Fee: $ ��^r 1> Approval Signature: Permit Fees:$ Disapproved: Other: Application dated: 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 existin buildin or for a change in use,as per detailed stateTgnt described bel 1. Job Address: Q Q_ I SBL: /3.Ti 7 — �a►c_j�-Zone: 2. Proposed Improvement(Describe in detail): 2. l r e 3. Does tl�e proposed improvement involve a Home-Occupation as per§250-38 of the Code of the Village of Rye Brook? No:Z/ Yes: If yes,indicate: TIER I: TIER II: TIER ill: 4. Will the proposed project require the installation of a new,or an extension/modification to an exisqng automatic fire suppression system(Fire Sprinkler,ANSL System, FM-200 System,Type I Hood,etc...) : No:LZ Yes: (If yes, please submit a separate Automatic Fire Suppression System Permit application&2 sets of detailed engineered plans) 5. Occupancy;(1 fam.,2 fam.,comm.,etc...)Prior to Construction:C-on d U After Construction: 6. N.Y State Construction Classification: N.Y.State U,A,s++e Classification: ff 7. Property Owner: MC(V I Q �f ��t 0 Address: Iy c,r- in R i d a64 U Phone#q G D $ Cell# I R b 1 1 C1 email: 8. Applicant: 'T—Ga �-{ /&U l 0 Address: : � �. -s Phone# D b, Cell# �► ('} q�3 email 1 L a 9. Architect: Address: Phone# Cell# email: 10. Engineer: Address: Phone# - „► � v 'Cell# email: _ 11. General Contractor: c� �/ Add�ess: ' mil �7le,? e �4�S�C44e s I c y Phone# 91_l-9 4O 0-9?&3a Cell# email: /0709 12. Estimated cost of construction $ 1 Q� , (NOTE The estimated cost shall include all labor,material,scaffolding,fixed equipment,professional fees,and material and labor which may be donated gratis-) 13. Job Timetable:Start: AS A_P Finish: {l) 8/1212021 J I BUILD' MENT VIL E OF RYE. OOK 938 KING"ET RYE BRO NY 10573 -0 AFFIDAVIT OF COMPLIANCE VILLAGE CODE §216 • STORM SEWERS AND SANFTARY 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 YOM COUNTY OF WESTCHESTER ) as; �p 31, MCk r l CL V1 Y)Q, G V 1 ID , residing at, (n �O r+1 �t 4 c e's+ 1 lob (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; j V O �`�`�'► ! Ci �TU Vil T (o 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. (Signature„ yOwner(s)) t / �, �l � r G C3 (Print Nam- 'Properly(?wncr(s)) Sworn to before e this day of ✓ , 20�_ (Notary Public) (2) S/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 YORK,COUNTY OF WESTCHESTER ) as: being 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 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 O Sworn to before me this day /VUIl' d-'1 , 20_eZL day of ,20 A:�L� of Property Owner si ofApplicant J r &a' d& Print N e of Property owner —Print Name of Applicant Notary Public Notary Public (4) 3/21/19 KOHLER® Rely 60" x 30" shower base K-8642 0" (1524 mm) r 11.1/4" 11-5/8' =1 (286 mm) 1(41 mm) I I ------ 14 1/4" � Flange Detail ----- (362 mm1 3/8" 10 mm 30" - —Li� 3/8"(762 mm) (10 mm) r2-5/8* (67 mm)'1 I I I 13-1/2' — I (89 mm) Front Lip Detail 4-11/16" (119 mm) Technical Information Notes All product dimensions are nominal. Measure your actual product for rough-in Installation: Three-wall alcove details. Drain location: Right Install this product according to the installation instructions. Weight: 59 Ibs (26.8 kg) Subfloor must be within 1/2" (13 mm)of level. This receptor has a front lip. This should be taken into account when installing a shower door. 1-800-4KOHLER (1-800-456-4537) THE BOLD LOOK Kohler Co. reserves the right to make revisions without notice to product specifications. OF KOHLER For the most current Specification Sheet, go to A .kohler.com. 5-29-2021 22:57- US/CA KOHLER. Re'y° 60" x 30" shower base K-8642 Features Low-threshold design for easy entry and exit. Molded-in textured floor. Water containment bead incorporated into threshold design provides an optimum barrier, preventing water from escaping from shower space. Single threshold for alcove installation. Coordinates with Choreograph®shower walls and other KOHLER@ collections. Material • Acrylic. Installation • Right drain. Codes/Standards Recommended Products/Accessories CSA B45.5/IAPMO Z124 K-23726 Drain treatment ASTM E162 K-23732 Tub & shower cleaner ASTM E662 K-9132 Shower Drain KOHLER@ Plastic Baths and Shower Bases Lifetime Limited Warranty See website for detailed warranty information. Available Colors/Finishes Color tiles intended for reference only. Color Code Description 0 White 96 Biscuit NY Dune 95 Ice TM Grey G9 Sandbar 1-500-4KOHLER (1-800-456-4537) THE BOLD LOOK Kohler Co. reserves the right to make revisions without notice to product specifications. OF KOHLER. For the most current Specification Sheet, go to www.kohler.co_m. 5-29-2021 22:57- US/CA Building Permit Check List&Zoning Analysis Address: 'L Sti SBL: l 3 ,?s — Z - 5' 6 . Z Zone .1—�Use: t 1�t`� Const.Type: -�� Other. Submittal Date: Revisions Submittal Dates: Applicant: Nature of Work: :: 7I_ 1.c c Fi-34ZP G 1,A y! ITS4 tVAA L.Z -1 tJ Reviews:ZBA: N'V - 2021 PB: BOT: Other. OK ( ( ) FEES:Filing S BP: I 0.2, fj � C/O: Legalization ( ) ( %Y APP: Dated: Notarized. c/ SBL %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: Unacceptable: ( ) ( ) PLANS:Date Stamped: Sealed Copies: Electronic: Other. ( ) License: Workers Comp: Liability. o( n p.Waiver. 77' 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: ( )PB mtg.date: approval• notes: APPROVED REQUI EXIST RED ING PROPOSED NOTES A Circle: IvVy — FrQntQ Front: Front: Sides: &W.. Main Cov Accs.Cov Ft.HS : S .HS • T ! : EL!W P rku Haight/Stories: notes: Onto..t. :W' O � �.'�••. �.'_ J -'O 7!. O � O "3 � �t.Y" O 'A�-� •1 > .. 's�► - ♦• r P !♦ ♦ �► 1!f fit: n f1♦t • ♦Nf rg ♦♦f �I s �= � b ticill ►ci cill �� cl4�d {��_ Illci'/cili � Ihcll/cl�l � ;yyl�c�, �i ,1cl�cp, „' �.i .�,�:- =•=�ti 111�=-ate s 1111/ _ �1/1_�t,.' �-',41/1d =..''rl 1�.-,. - -.:-1 + 1�,:,. ��- ��<O) r � 'i3 •. -4`:z%: 11 1/ .g:11 �. r."s=:.1��11��'�.�e����0)!�•, a . . .. . . . . . . .. . . . . . ." .. ,yam �•. •� s~ ice•�� � � n tt N _ < ,cs = •i L R 0 0. o t( k N wa: )>� R yO R n N y Q CD ' 4 • rA O co cn W p oction w cc vj cc E co LLJ CO Z5y o LLJ W o i A v — N (o) --► C� ?•w Q 1Cj f O w F— N p e a w � •mod S� `v y, '. ��, 02 Gn «o» o A 72 co =•� 1 _ 0 .p ccCO y N r #' \ w .i Orb Sr =• (�[a))1i ��. -•11 11 �sti� _ _ 1 1'� o .." wo ;iLl1 ��� 0� L Yy'vo�.�/ 'W4= a�1'✓ v�oy�''� ^�� � �_. 0 �• \1\ ���'iL�W i \NOp ! Ac oRne CERTIFICATE OF LIABILITY INSURANCE DA,E1f15 ,ri' 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(les)must have ADDITIONAL INSURED provisions or be ondomed 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). CONTACT y;F I L A DIROM171U NAME RateFafm 1HE LANZA INSURANCE AGENCY � -tt 91435.6C00 � me) 914-835.6996 �• 18 HAt SIEAU AVENUE r-MIAA S1ELLACiVtANLAINSURANCE COM ADDRESS I-WiRIS(7N.NY 10528 INSU14"131"FUNDING COVERAGE INSURER A Stall.Fdfm Fue and(:asuagy Company MSURI D wYURCR e , GLEN ROAD ENTERPRISES INC WsuAfR C GO JOHN GUIDO wwRfaO 42 GLEN ROAD wSUIIER E F.ASTCHESIEK,NY 10709-3169 ^- MyuaEaF_— — C_OVE_R_AGES _ _C_E_R_T_IFIC_ATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE PQI ICIES NF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INOWAMD NOTWITHSTANDING ANY REQUIREMLNT TFRm OR CON(,ITIUN OF ANY CCNirRAc7 OR OTHER LX)CUMCNT WITH RESPECT TO WHICH THIS CERTIFICATE MAY at ISSUED OR MAY PERTAIN Crlt INSURANCE AFFORDED BY THE POtICIFS DESCRIBED HEREIN IS SULUFrT TU AIL THE TERMS EXCiAISIONS AND CONDITIONS OF SUCH POLICES LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. ~� TYPE Of wSURANfE AM SLAB. POLICY Efr Vot1CY r" LIA a1SD Mf1fO• POLILY NLY41eEA �Y rYYYj Yy 11111M _ CWWEACIAL GENERAL LAAMIRMY EACHOCAlkREW't I, 1.000.000 DAMAGF T(5 REK1ED r CLAALCMADk x OCCLAI �EwSEs.IEsaLw ei f 300,000 Mt D t.P rArry utia Doreen) A Y 9"V-W799-2 F 12f 012020 12120rd021 ;f RSONAL A Aalr vuuRY = 1000.r,}(A) AM AGGAEGATE LIMIT APPIIESPER GEMiM ACiGREGATE = 2,000,000 P0t1Cr PJRLTT Loc I'R00U(:T5.cOMvroaAnt1 f 2.000.000 _ n•HER s AUTOYOeks uAellmr ------------ -----+— l.A/91IIED SW.At LIMIT s ---�-- {tr,xvoe•r) AKY ALRO RQ1�71 r.hJtJRY(Ear T.erecn) >: AWNED AUTOSU ALJIOSLxEO WAAN WIURYIPwaa.awr)�1 rar ADIOS _ HOED Nt)r*0VAED � PfiWERTY DMAACA _ AUTOS ONLY AU105("Y 1/'or�coeenri -- UUGMLLA LIM --_ OCCUR EACH OCCURRENCE S -- "CESS LIAtl CUUAC:MAJE; ^41MIEGAlf -- -'f _ CEf1 -RE rr N!IUN'j —_� S WORKERS COWEISSATION - 'PER OrH AND EM►t OYE RS LIABILITY VIM STATY TIt ER ANr PW44-rf"OR4PAMNF"_XECl71NF r' EL tAp/ACtfDFM f 4EK7.+E MD£N CxCil.OEO� , NIA' 104ra0atorY N NRt L' E I. DISEASE EA T:MPLOYVE 1 D(lAlPWTK)H C4 Of ERATKWS below, —� '— 1 EL M%EASE-P(X K:Y L M T S i DESCRIPTION OF OPERATIONS r LOCATIONS I VEIeCLES fACORD 101.AddK1aW Its-me a Scrrdla.eery be atisceW I mnm space be ) Addltw%al Intiured Vdiage of Rye Brouk I CERTIFICATE HOLDER CANCELLATION_ �`✓ »� SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF. NOTICE 1MLL BE DELIVERED IN Vd41ge of Ryo Brook ACCORDANCE WITH THE POLICY PNOVISIONS- 938 King Street Rye Brook.NY 10573 AUTMORIIED REPRESENTATT1ft � 0 1988-201S ACORD CORPORATION. All rights reserved. ACORD 25(201&03) The ACORD name and logo are registered marks of ACORD raolw 1]r114912 0116:0/6 Ari✓Rd CERTIFICATE OF LIABILITY INSURANCE FDATE'" 1 uDaZ._ THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER ' CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIf' 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 ttw caltt scats holder Is an ADDITIONAL INSURED,the policy(iss)must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED,subject to the terms and condrdons of the policy, certain policies may require an endorsenwnt. A statsm rtt an this certificate does not confer rights to the certificate holder In lieu of such andorsenwn a. FROD CM STELLA DIDOMIZIO tarp.:_-_ StateFarnl THE LANZA INSURANCE AGENCY 914 g �pOp i 9t4 833-0806 18 IiALSTEAD AVENUE .STELLA�IANZIVNSURANCECOM HARRISON,NY 10528 —._ eaumers±A�r+ncovalAoe NAIL matow r__ — - — — --, Stale Farm Fire and Qmmky CaWwV 25143 GLEN ROAD ENTERPRISES INC. s+EtffiFt . _ aslaretCc CIO JOHN GUIDO aawRFA o: 42 GLEN ROAD paURER E EASTCHESTER,NY 10709.3169 patlRElt p 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 SUI IECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED B LAIMS. DLTR ISK TYPE OF NWRAIICE — --- - -— POLICY La/ra COMMERCIAL GO(IMALLIAwury OCCURRENCE t 1,000,000 . CWMSMAOE ®OCCUR _ t 300,000 EXP1N�er a 5,000 A Y 96CUPW118-7 F 1?110ft021 1?/20/Z07Z a ACV INAMY It 1.000.OD0 Gan AGGREGATE LIIaT APPLIES PER PRO. S 2 000.000 �n� ❑LocAGGREGATEAGGREGATE�DairO.Aoo s 2.000.-000 � R • AUTW10�E U 1TY Aea w__ • ANY AUTO WOOLY nAIRr(ter Pwai S OWNED SCIiEDIILEO ODDLY PCJURY Mwsouortll S HIRED NLY saomo AUTOS ONLY AUTOS ONLY PROPERTY Nu"*__ (IIIeAELLA u" EACH otcEas LtAB CLAIu!~afIADE AGGREGATE_ >{ DEO R WORICM COMPENSATION AND EMPLOYER:'LW LLrry AW PROPRIETORJPARTNERIEXECLgM YfN EI EACNACCa)fNT,Or-FICE"EAIBER EXCLUDEIr NIAJ 1 (MlwWdeva s�cf<w In NH)urtOr ILL01 6EASE.EA rail S tl e RAC I-L OISEAR•POLICY Loa S T OE MM"' N DF OPERAIM4I L.00A?V4 f VEISCLES(ACORO 1".A&AIMM FAMMfla Ogb$ddM,MW be Meaebd Room vpm w rtlptltlq Additional Insured: Vfte of Rye Brook CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED N V illage of Rye Brook ACCORDANCE WITH THE POLICY PROVISIONS. ing Street rook NY 10573 A REPRESENTATIVE © 988-20 ACORD CORPORATION. All rigttta reeer"d. 31 The ACORD trams and logo are registered marks of ACORD +00148e 13284 12 osTetots NEW Workers' Certificate of Attestation of Exemption YO STATE 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 CertiScate 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 Glen Road Enterprises Inc DBA:Jeanco From:Village of Rye Brook 42 Glen Road Eastchester,NV 10709 The location of where work will be performed is PHONE:914-960-9632 FEIN:XXXXX0121 16 North Ridge Street,Unit 16 D,Ryebrook,NY 10573. Estimated dates necessary to complete work associated with the building permit are from November 8,2021 to November 22,2021. The estimated dollar amount of project is $0-$10,000 Workers'Compensation Exemption Statement: The above named business is certifying that it is NOT REQUIRED TO OBTAIN NEW YORK STATE SPECIFIC WORKERS'COMPENSATION INSURANCE COVERAGE for the following reason: The business is a one person owned corporation,with that individual owning all of the stock and holding all offices of the corporation. Other than the corporate owner,there are no employees,day labor,leased employees,borrowed employees,part-time employees,other stockholders,unpaid volunteers(including family members)or subcontractors. Disability and Paid Family Leave Benefits Exemption 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,1ohn P.Guido,am the President with the above-named legal entity. I 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 I have not made any materially false statements and I make this Certificate of Attestation of Exemption under the penalties of perjury. I 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 I 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 furnish proof of that coverage on forms approved by the Chair of the Worke ompensatio Board to the government entity listed above. HERE Signatu e: Date:ry i I y I y 1 Exemption a cate Number Received 2021-069955 November 7, 2021 NYS Workers'Compensation Board CE-200 01/2018