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HomeMy WebLinkAboutBP21-302PERMIT # �J- 30a DATE. IZIJ 9 v1/ EXP: / %9, SECTION 3 BLOCK LOT s L _ TYPE OF WORK .JOB LOCATION c' / Q.e7e OWNER Q /) %�'y'!r r %,SLjQ Cd! ✓u/)/ %. CONTRACTOR geore z�/a C 6%Qi7 EST. COST & FEE vc' CO # EEC JQ .�jgb� DATE 1,2r TCO # FEE DATE.... lNSPECTlON RECORD DATE INSP FOOTING FOUNDATION FRAMING RGH FRAMING INSULATION PLUMBING 0 RGH PLUMBING GAS C1 SPRINKLER ELECTRIC f7 LOW -VOLT 0 ALARM 0 AS BUILT ED FINAL &o 41 &5" 3 7o &/Y)93 7- 91o77 OTHER APPROVALS ARB /Votyn*bf?�7 c)pW BOT PS ZBA QTHER G 4�4.5 JV � :c5.tc yi4C,vt.W y V ° d VILLAGE OF RYE BROOK MAYOR 938 King Street, Rye Brook,N.Y. 10573 ADMINISTRATOR Paul S. Rosenberg (914) 939-0668 Christopher J. Bradbury www.iyebrook.org TRUSTEES BUILDING& FIRE Susan R. Epstein INSPECTOR Stephanie J. Fischer Michael J. Izzo David M. Heiser Jason A. Klein CERTIFICATE OF COMPLIANCE December 29,2021 Lal Jhangimal&Prisha Parvani 4 Bobbie Lane Rye Brook,New York 10573 Re: 4 Bobbie Lane,Rye Brook,New York 10573 Parcel ID#: 135.35-1-32 Building Permit#21-302 issued 11/19/2021 for a New Fence This certifies that the new four foot high black chain link fence and new four foot high white PVC fence, installed under the above captioned permit has been satisfactorily completed. Sincerely, I ( f Steven E. )~ews Assistant Building&Fire Inspector /tg BUILD NT For office use niv: a;8 � !!! Vn, of RYE ox PERMIT# ISSUED: DEC 2 1 2021 KING SIM E YE BROOK, YORK 10573 DATE:tol—a l— 1 �c 9 4 FEE: 1LQ PA11�X VILLAGE O RYE BROOK 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##/ Address: Lr �ji. La Ulf- & ru a 3 Occupancy/Use: Parcel ID#: 1c3V, 3 J-3a Zone: Owner: A wyj Address: T[ j LA P.E./R.A. or Contractor: f%e �NA Address: k� (AMA 11,,u 9 r¢ tksl—Nylo� Person in responsible charge: _Ad fo�,, Z! Address: 14 tyes+ j�ktn AvC At� CA L1W t/ oo� Application is hereby made and submitted to the Building Inspector of the Village of Rye 13rook 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: JA A All 111 r'A� being duly swom,deposes and says that he/she resides at q pojobl c hY1 f'(Trmt Name o Applicant) I I (No.and Street) in Mkt f ,in the County of �� G k S in the State of '`Y 7 ,that (City/Town/Village) he/she has supervised the work at the location indicated above,and that the actual total cost of the work,including all site improvements, labor,materials,scaffolding,fixed equipment,professional fees,and including the monetary value of any materials and labor which may have been donated gratis was:$ ) 7- Q. 00 for the construction or alteration of: 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 0 ` Sworn to before me this day of t--e��e f , 20 a\ day of��Q�� 20_c2L -�l au C4 /(, 110 Signature of P er Signature o Appl ant Q Pratt Name of Property Owne Name of Applicant \A L Notary Public f�ota i 'h f �4r,,v Yoric 1Votary Public, State of h.EewYork Na. 0'ftili 6 i Ci:.Ir 3 kir: t 1 Q,ia':fied i"-"Wtstah_`iBr Colin .',?d .rr Counlif 8/12/2021 Commission Exrtires,!anuanJ 29,2(Q Commission Exnires J?nu ry-3, 20cen QRC�uk • 1982 BUILDING DEPARTMENT ❑BUILDING INSPECTOR _W'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.orR - - - - - - - - - - - - - - - - -- -- INSPECTION REPORT - - -- - - - - - - - - - - - - - - - - E (sobb I e- "(- X DATE: -2- JZ2 -262k PERMIT# � U Y �y�- ISSUED: 2 SECT:n BLOCK: LOT:�L LOCATION: _1 + � � � �I r r v � �(� � OCCUPANCY' ❑ VIOLATION NOTED THE WORK IS... Ql- ACCEPTED ❑ REJECTED/ REINSPECTION ❑ SITE INSPECTION REQUIRED ❑ FOOTING ❑ FOOTING DRAINAGE ❑ FOUNDATION ❑ UNDERGROUND PLUMBING NOTES ON INSPECTION: ❑ ROUGH PLUMBING ❑ ROUGH FRAMING ❑ INSULATION ❑ NATURAL GAS ❑ L.P. GAS ❑ FUEL TANK ❑ FIRE SPRINKLER ❑ FINAL PLUMBING [] CROSS CONNECTION [ 'FINAL OTHER Eta {�■L'� �� Ltl1���1�+ 7':�V�a�V�7!a 7�!������ !'� i�� lad �■ N en I owl r, a 0 b � o � O ; C '� v kn U rr L F FBI Ot tn 14 I•'� F+1 . 'a O14 .. v 2 o u QI .. a U -0 •vCO ) � 0 .0 S a = G� .�. y v O 00 ram, CT �/ a � d � �Z! :.'`� a� •a� � 'ti W m^ .2i > t / F V y iy 3 r1b a w o o—C.Q x x A Z b w v Q a ppa� V. 2 >2 a [EC� ENF BUILD GRTMENT vIL OF RE'� ROOK 938 KIN EET RYE BlR f ,NY 10573 NOV - 8 2021 6 4 9-066$ �'br VILLAGE OF RYE BROOK BUILDING DEPARTMENT FOR OFFICE USE ONLY: Approval Date. NOV 1 8 2021 mit# '30 Application # Approval Signature: M ARCHITECTURAL REVIEW BOARD` Disapproved: : Date: BOT Approval Date: Case# Chairman: CR\- PB Approval Date: Case# Secretary: ZBA Approval Date: Case# Other: Application Fee: S� ermit Fees: FENCE / WALL f GATE PERMIT APPLICATION Application dated: �is hereby made to the Building Inspector of the Village ofRye Brook,NY,for the issuance of a Permit for the installation,construction,repair or replacement of a Fence,Wall or Gate,in accordance with Section 250-6 B.(1)(g),of the Code of the Village of Rye Brook,as perdetailed statement described below. Swimming pool fences must conform to the State Code. 1. Job Address: 4 Bobbie Ln, Rye Brook, NY 14573 2. Occupancy/Use: J�/C�/yf S.B.L.#: 135.35-1-32 Lone: R-10 3. Proposed Fence/Wall/Gate(describe in detail): install approx. 40'of 4'high No.Carolina White PVC fencing on 5"x 5"posts set in concrete with one 5'wide walk gate and one 4'wide wall(gate, All Pests willhave New FiAgland eaps. Alse'Asia!l appfflk. 103'of 4'high blael(ehais link lenemAg along the sides of the property to the retaining wall, using 2"ends, 1.5/8"line posts and 1.3/8"brace posts. Fencing will have#7-gauge top and bottom tension 4. Property Owner: Lai Jhangirnal& Prisha Parvani Address: 4_Bobbie Ln, Rye Brook, NY 10573 Phone# Cell# 201-906-4653 email: LAL.JHANGIMAL@GMAIL COM Applicant:__LaI Jhangimal Address: 4 Bobbie Ln, Rye Brook, NY 10573 Phone# Cell# 201-906-4653 email: LAL.JHANGIMAL@GMAIL.COM Architect/Engineer: N/A Address: Phone# Cell# email: Contractor: Fence By Fabian, Inc Address&Phone: 7 West Glen Ave, Port Chester, NY 114— 7 3 7— 96 77 5. If building is located on a corner lot,which street clues it front on. N/A 6. What is the estimated cost of construction $5.750 (NOTIr,: The estimated cost shall include all site improvements,labor,material,scaffolding,fixed equipment,professional fees,and material and labor which may be donated gratis.) 7. Estimated date of completion: l 81120021 Please note that this application must include the notarized signature(s) of the legal owner(s) of the above-mentioned property, in the space provided below. Any application not bearing the legal property owner's notarized signature(s) shall be deemed null and void, and will be returned to the applicant. #*#*R*****#RRR*R***R*****#R*******#**R***#*#*RR#**#**R***#*R*RRR#*R*****#*#*RRRRR**R##RRRRRR**********##** 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. Swom to before me this � Sworn to before me this r� day of n1 �, � z -�? 20a�_ day of 120 Signature ofPrope Owner Signature of Applicant -, " k �q_V4 V • Print Name of Property Owner Print Name of Applicant A4L." rlyc�_Z� Notary Public Notary Public SHARI MELILLO Notary Public, State cf NeW York 0,ml'r";ad In Wostoh:: ter County <) ,? Commission Exoires January 29.20. 2 8/12/2021 Building Permit Check List&Zoning Analysis Address: SBL: 3 S r " Z Zone: —1 D Use: 2 rJ Cont.Type: Other. Submittal Date: 3 Revisions Submittal Dates: Applicanc��51A w6 l Nature of Work: '�-� r 'zLACE2 ('.4A g s-_ ^Ltj '� - ' W 4L11 TV i✓ i�NC�eJG Reviews:ZBA: NOV 9 2021 PB: BOT: Other. NEED/ OK ( { ) FEES:Filing. ?.K-- _/42,�n-I3P: C/O: Legalization: ( ) (,�/APP: Dated: ✓� Notarized: y/ SBL: L--Truss I.D. Cross Connection: `f H.O.A.: { ) ( ) Scenic Roads: Steep Slopes: Wetlands: Storm Water Review: Street Opening. ( ) ( ) ENVIRO:Long Short: Fees: N/A: { ) ( ) SITE PLAN:Topo: Si a Protection: S/W Mgmt.: Tree Plan: Other. SURVEY:Dated 3 Z Current: ✓ Archival;- Sealed: Unacceptable: ( ) ( ) PLANS:Date Stamped: Sealed Copies: Electronic: Other. ( (Jj License: ✓Workers Comp: ie""Liability:_(GComp.Waiver. Other. ( (. CODE 753#:11 ;�,9/—00/ —16 7­00 Dated—, -77`c3 9—Q/ N/A: ( ) ( ) HIGH-VOLTAGE ELECTRICAL:Plaza: 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 Surve)r Final Topo: RA/PE Sign-off Letter. As-Built Plans: Other. ( ) ( ) BP DENIAL LETTER: C/O DENIAL LETTER Other. O O Other: (v ARB mtg.date: 1 I t 1 approval• notes: ( )ZBA mtg. date: approval: notes: ( )PB mtg.date: approval• notes: UOUiRED EXISTING PROPOSED NOTES APPROVED Am: Circle: Fron�tate Fr= Front: S aw. Main Cov Acts.Cov - Ft.H Sd.H/Sb: -GEA: To Ft. P Hcght/Stories: notes: ME BUILD MENT � � `=' E VIL OF RY OOK NOV DD - $ 2021 938 KING ET RYE BR ,NY 10573 4 9 9-0 ��� VILLAGE OF RYE BROOK 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: 4 Bobbie Ln, Rye Brook, NY 10573 Date of Submission: Parcel 1D#: 135.35-1-32 Zone: R-10 Proposed Improvement(Describe in detail): Install 4'white PVC fence on the front left and right side of APPLICANT CHECK LIST: the property, with a 5'wide walk gate on the left side and one Nl E s 1 BE: COMPLETED Bl TIIE APPLWANT 4'wide walk gate on right side.. Install 4' black chain link The following items must be submitted to the Building fence along both sides to the retaining wall in the back. Department by the applicant-no exceptions. Property Owner: Lal Jhangimal 1. (L) Completed Application 2. (k) Two (2) sets of sealed plans. (one tell size In,axnnnm Address: 4 Bobbie Ln, Rye Brook NY alloN%able plan sirs 36- x-42* ; and one I I"x17") Phone# 201-906-4653 3. (17 Two(2)copies of the property survey. 4. ( ) Two(2)copies of the proposed site plan. Applicant appearing before the Board: 5. (R—) One electronic/disc copy of the complete Lal Jhangimal application materials. 6. (,[) Filing Fee. Address: 4 Bobbie Ln, Rye Brook, NY 10573 7. (jC) Any supporting documentation. Phone # 201-906-4653 8. ( ) HOA approval letter. (if applicable) 9. ( Photographs. Arch itect/Engineer: NSA 10.( ) Samples of finishes/color chart. (a sample board or Phone# NIA model may be presented the night ofthe meeting) 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 any application not meeting the requirements contained herein. Swom to before me this Sworn to before me this day of 'nl OQ ���—Qa , 20_0� day of , 20 Signature of Property ter signature of Applicant Lai Jhangimal Lal Jhangimal Name of Property Owner Print Name of Applicant V\_&� Notary Public Notary Public SHARI MELILLO Notary Fublic, State cf",dew York No u'dvi fit_ 3 Wasfch-.a::rer Courty Commission Exnires Jantivry 29.20,�& 9/12/2021 • VILLAGE OF RYE BROOK BUILDING DEPARTMENT 938 KING STREET, RYE BROOK,NY 10573 (T) 939-0668 (F) 939-5801 ARCHITECTURAL REVIEW BOARD Wednesday, November 17, 2021 ANNOUNCEMENT: PER THE GOVERNOR'S EXECUTIVE ORDER THIS MEETING WILL BE HELD VIRTUALLY THROUGH THE ZOOM PLATFORM. THE PUBLIC CAN ACCESS THE MEETING THROUGH THE FOLLOWING LINK: https://us02web.zoom.us/i/81417970741 OR BY OPENING ZOOM AND ENTERING THE MEETING ID: 81417970741 NAME & LOCATION TYPE OF APPLICATION MOTION SECOND APPROVED REJECTED APPL.# 22 Valley Terrace New Partial 6ft High Consent 5640 (Camacho) Privacy Fence In Rear Agenda Yard 1 Mohegan Lane Roof Top Solar Array Consent 5641 (Daraio) Agenda 11 Candy Lane Legalize Existing Patio w/ Consent 5642 (Gordon) Alterations Agenda 26 Beechwood Blvd 4ft High Black Chain Link Consent 5643 (Elkins) Fence In Rear Agenda 4 Bobbie Lane 4ft Black Chain Link Consent /� 5644 (Jhangimal) Fence& White PVC Agenda (� Fencing 3 Lincoln Ave ( Roof Top Solar Array Consent 5645 Paniagua) Agenda 17 Wilton Circle Re- Appearance 2nd Story 5638 (Tabakhov) Addition, Front Portico, Rear Patio &Interior Alterations 17 Rye Ridge Plaza New Sign For Tenant 5646 (Sign Design) "Jett" 42 Lawridge Drive Egress Window for 5647 (Altman) Basement Legalization ML {� NM MR SE JM SF AC MI KC �. �. � a - � "s�- �,� _' 1f Y�L �.. 4- �t a � L e u O � i r u LLl c� L C soL. 0 160 v Q y � C •am O u �- .00 ce a p C � •= a� N u W y I Vj E Q Z W �i 7 le. G > LU 16 m C7 = 3 r ` t �o L U w U ll t_ Gi w ci c L c C') 3 y � s ACO d CERTIFICATE OF LIABILITY INSURANCE F o2118=1 THO CORTI VA12 0 ISSUED AS A MATTER OF lIFORl1AT101i ONLY AM CONIFERS NO RIOHTIZ UFONI THE CERTIFICATE HOLDER.THIS CERTIFICATE DM NOT AF"WATNTELY OR NDOATNELY AMEND,EIf MD OR ALTER THE COVERAGE AFFORDED IiY THE PMXWS SELOW THIN CERTVWATE OF INMRANCE DOES NOT CONSTITU E A CONTRACT SETWEEN THE IiWW IISURERIS),AUTHOIUZED REPRESENTATNE Ott FRODUCER.AND THE CERTIFlCATE FOLDER I111110ORTAMT: if**CifwCies 11olAp Is M1 ADDITIONAL INSURED,On pa6"Wa)must Ilsrs ADDITIONAL INSURED provisions or be aidofssd. N MINWOATION D MANED.1ublM to the ft"m end eondbom of the policy,esrtell p@Ndw my rwWks an andsrSomnl A stMMHHMIt NMI DUM owSka4a doss not confer Vft is the cwditob haidw In Rw of Muth• NlGoucw COM Dien Do" MAML Rani Parews Inmfwxn Agency (II14)93W7b00 (414)4074M 287 Sawro l Avenue OOm Suit 40E Nvor OMIa OOSABAa! RA10 e Purdrw NY 10577 MIMtA�A HMNted Ur10MMrNMe M+Ncrrrloa Ca PWW 70104 �� MIRMISR s: MGM bnunrros Ca isany 14M Fence By Fabian Inc. WALWd R c. 7 W'Glen Ave ONPJ R 0: MMLEIet E: Pon Chester NY 10573 COVERAM CEItTIICATE NUMsIR: 21-22 cart REVNION NuMRER; THIS a TO CERTIFY THAT THE POLICED OF INSURANCE LISTED BELOW HMIE SEEN ISSUED TO THE INSURED NAMED ABOVE FOR TIME POLICY PERIOD INDICATED. muTwumwmNDmANY REOl111RAENT.TEHVM OR CONDITION OF ANY COqTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFIG1TE MAY BE IBBUED OR MAY PERTAIN.THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN d 51111LECT TD ALL THE TERMLS. EXCLUSI INS AND CONDITIONS OF S"POLICIES.LANTS SHOWN MAY HAVE BEEN REDUCED BY PAD CLAMS. MINN LTR TV"a7 EINIwMCR POLOT suesw Lam 0•�LLL*AKM Fi1L7�OCCIAtlRFJILtc i 1,OOD,O00 nJIARdI40E [g Opaq r i 1.000:ODO i®ExP Om I i 10.000 A 16 SBAAK4WMK 02115=1 02il5R022 POINOWL 4 WV KAyry 1.000,000 00ftA010REUTE LaaT APPLIED PER aEJNERAL ADOME011TE i 2.000.000 POLICY®� LLOC PROOtJCT7 W P1WADO f 2,000,000 OTHER I AUrOUOfILJ!UAMAITY I. I.000,000 ANY AUTOYMNNH'r Aas*! I B ovvMw adsrrrcn B1V1577D 02115R021 0211512022 StIRpBYSNfAreder+l A AI/TOE 0,**, AUT04 HIM NOM401N D f ALL=OrLY AViOa ONLY i IMF LUS 00" wh OC ACM LM LLAMLL4M0E i METanIaN alowoslS a0lMIYEnM PER AM!►4yom UAMRIIY V f Y AOFFIllIMMISISlIM W XECUTM 0 OtGtIJOE O7 MIA EL EACH AtJCoOE.NT f ` won EleTEl1 DE-EA E!lLOYt� a QIf91AT10r r� El uall E-POLICY LINT t COMM"=OF aPRRATIONS I LOCAT01011 1 VEHICUM MNIo1O M.ArINwrM Munow McMaer.espy w arena a es>ra seems r Merle, CERTIFICATE HOLDER LISTED AS ADDITIONAL INSURED AS PER WRiTTH31 CONTRACT CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCifEWID POLIpO AB cAncri.L.So aE/gRE THE EXPOtATION DATE THE REOP.NOTHCF WILL BE OELIVNiAB r Vft"of Rye SMOK ACCORDANCE TITTHH THE POLICY PROV MONL 93S Km0 Street AUTOS®iBReRM[ATM Rye Smok NY 10573 _ Aor —� 01898-Ml ACORD CORPORATION. AN r1oft n seN v ACORD 29(MGM) The ACORD name and logo N ruglslsrad marks of ACORD Z4Workers' Compensation CERTIFICATE OF Board NYS WORKERS' COMPENSATION INSURANCE COVERAGE 1a. Legal Name and address of Insured(use street address only) 1b. Business Telephone Number of Insured FENCE BY FABIAN INC. 1c. NYS Unemployment Insurance Employer 7 W.GLEN AVE. Registration Number of Insured PORT CHESTER NY 10573 1d. Federal Employer Identification Number of Insured or Work Location of Insured (Only required if coverage is specifically Social Security Number limited to certain locations in New York State, i.e. a wrap-Up Policy) 204803377 2. Name and Address of the Entity Requesting Proof of 3a. Name of Insurance Carrier Coverage(Entity Being Listed as the Certificate Holder) Property and Casualty Insurance Company of The Village of Rye Brook New York Hartford 938 KING ST 34690 RYE BROOK NY 10573 3b. Policy Number of Entity Listed In Box"1a": 76 WEG JX2517 3c. Policy effective period: 03114/2021 to 03/14/2022 3d.The Proprietor, Partners or Executive Officers are ❑ Included.(Only check box if all partnerslofficers included) Z all excluded or certain partners/officers excluded. This certifies that the insurance carrier indicated above in box "3" insures the business referenced above in box "1a"for workers'compensation under the New York State Workers' Compensation Law. (To use this form, New York (NY)must be listed under Item 3A on the INFORMATION PAGE of the workers' compensation Insurance policy). The Insurance Carrier or its licensed agent will send this Certificate of Insurance to the entity listed above as the certificate holder in box"2". The insurance tamer must notify the above certificate holder and the Workers' Compensation Board within 10 days IF a policy Is canceled due to nonpayment of premiums or within 30 days IF there are reasons other than nonpayment of premiums that cancel the policy or eliminate the Insured from the coverage indicated on this Certificate. (These notices may be sent by regular mail.) Otherwise, this Certificate is valid for one year after this form is approved by the Insurance carrier or Its licensed agent, or until the policy expiration date listed In box"3c",whichever Is earlier. This certificate is issued as a matter of information only and confers no rights upon the certificate holder. This certificate does not amend, extend or alter the coverage afforded by the policy listed, nor does it confer any rights or responsibilities beyond those contained in the referenced policy. This certificate may be used as evidence of a Worker's Compensation contract of insurance only while the underlying policy is in effect. Please Note: Upon cancellation of the workers' compensation policy indicated on this form, If the business continues to be named on a permit, license or contract issued by a certificate holder,the business must provide that certificate holder with a new Certificate of Workers' Compensation Coverage or other authorized proof that the business is complying with the mandatory coverage requirements of the New York State Workers' Compensation Law. Under penalty of perjury, I certify that I am an authorized representative or licensed agent of the insurance carrier referenced above and that the named Insured has the coverage as depicted on this form. Approved by: Danielle Clausen (print name of authorized representative or licensed agent of insurance carrier) Approved by: , �,�Ifo.( ! .,.�� 05/03/2021 (Signature) (Date) Title: Operations Manager Telephone Number of authorized representative or licensed agent of insurance carrier (866)467-8730 Please Note: Only Insurance carriers and their licensed agents are authorized to issue Form C-105.2. Insurance brokers are NOT authorized to issue it. C-105.2(9-17) Form WC 88 31 21 F Printed in U.S.A. www.wcb.ny.gov Page 1 of 2 Laura Petersen From: Dig Safely New York Exactix <tickets@exactix.digsafelynewyork.com> Sent: Thursday, December 2, 2021 8:01 AM To: Mike Izzo Subject: Message from Dig Safely New York, Inc. (DSNY) ** *LATE**** DIG REQUEST from DSNY for: VIL RYE BROOK Taken: 12/02/2021 08:00 To: VIL RYE BROOK PRIMARY Transmitted: 12/02/2021 08:01 00008 Ticket: 11291-001-169-01 Type: Late Previous Ticket: ------------------------------------------------------------------------------ State: NY County: WESTCHESTER Place: RYE BROOK Addr: From: 4 To: Name: BOBBIE LN Cross: From: To: Name: Offset: ------------------------------------------------------------------------------ Locate: WORKING IN THE REAR YARD, REAR PROPERTY LINE NearSt: N RIDGE ST & ROCK RIDGE DR Means of Excavation: HAND TOOLS Blasting: N Site marked with white: N Boring/Directional Drilling: N Within 25ft of Edge of Road: N Work Type: INSTALLING FENCE Estimated Work Complete Date: 12/09/2021 Depth of excavation: 30 INCHES Site dimensions: Length 110 FEET Width 18 INCHES Start Date and Time: 12/02/2021 08:00 Must Start By: 12/16/2021 ------------------------------------------------------------------------------ Contact Name: FABIAN DORAZIO Company: FENCE BY FABIAN Addrl: 7 WEST GLEN AVE Addr2: City: PORT CHESTER State: NY Zip: 10573 Phone: 914-469-7081 Fax: Email: fencebyfabian7l@yahoo.com Field Contact: FABIAN DORAZIO Alt Phone: 914-469-7081 Email: fencebyfabian7l@yahoo.com Working for: HOMEOWNER ------------------------------------------------------------------------------ Comments: Lookup Type: PARCEL ------------------------------------------------------------------------------ Members ALTICE USA CONED SUEZ WTR WESTCHESTER VIL RYE BROOK : WESTCHESTER CTY SWR i Laura Petersen From: Dig Safely New York Exactix <tickets@exactix.digsafelynewyork.com> Sent: Monday, November 29, 2021 12:40 PM To: Mike Izzo Subject: Message from Dig Safely New York, Inc. (DSNY) ****REGULAR**** DIG REQUEST from DSNY for: VIL RYE BROOK Taken: 11/29/2021 12:39 To: VIL RYE BROOK PRIMARY Transmitted: 11/29/2021 12:40 00004 Ticket: 11291-001-169-00 Type: Regular Previous Ticket: ------------------------------------------------------------------------------ State: NY County: WESTCHESTER Place: RYE BROOK Addr: From: 4 To: Name: BOBBIE LN Cross: From: To: Name: Offset: ------------------------------------------------------------------------------ Locate: WORKING IN THE REAR YARD, REAR PROPERTY LINE NearSt: N RIDGE ST & ROCK RIDGE DR Means of Excavation: HAND TOOLS Blasting: N Site marked with white: N Boring/Directional Drilling: N Within 25ft of Edge of Road: N Work Type: INSTALLING FENCE Estimated Work Complete Date: 12/09/2021 Depth of excavation: 30 INCHES Site dimensions: Length 110 FEET Width 18 INCHES Start Date and Time: 12/02/2021 08:00 Must Start By: 12/16/2021 ------------------------------------------------------------------------------ Contact Name: FABIAN DORAZIO Company: FENCE BY FABIAN Addrl: 7 WEST GLEN AVE Addr2: City: PORT CHESTER State: NY Zip: 10573 Phone: 914-469-7081 Fax: Email: fencebyfabian7l@yahoo.com Field Contact: FABIAN DORAZIO Alt Phone: 914-469-7081 Email: fencebyfabian7l@yahoo.com Working for: HOMEOWNER ------------------------------------------------------------------------------ Comments: Lookup Type: PARCEL ------------------------------------------------------------------------------ Members: ALTICE USA CONED SUEZ WTR WESTCHESTER VIL RYE BROOK WESTCHESTER CTY SWR i < m U O I W p = • � ,�� v E c � � R / }y 13 L o s O y e E $ ZLu ? € S $ a 8 ppMryry 7 3 3 E w a s �ry \S4 /1too rl �JlsmOr � � W lJj a grw >$ Q d (deWpai[dpio-ajadM'0'a,09) � �°`a g � s� c�¢`s s+ `Y. £a= g }P W 3Nm�V� 8s<er1a�s8_ o8w.es08 s $ Y$ at Y{W gFE `ag�� Z amaW&W W. p Z AO OO -00*00L AAZO OS S © 11VM3NOiS w ? � a ogo<u- n LLI wwa - a — J o any - o cop vi I� fm I PF��jj ff � J.rSMI # SBL# t 3,5,3 S-— l DATE APP D ga s en H BUILDING INS ECT R,Village c f Rye Brook, _ 7lbM 3NOLS W NOV - $ 2021 Z 8 VILLAGE OF RYE BRC OK BUILDING DEPARTM T 100,006 --- -- _-- .00'00L 3.00M.091\1 3,M.M.09 N o S Vill grttwye Bruoc, w Archit c � � .vie Bo N Z Approval Date: 31-ig\ Chairman:till 1