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HomeMy WebLinkAboutDP21-007PERMIT # ZVQJ-OcI7.DATE610 aJ( d(p• / o % a1o1 SECTION f '7l , 3 J� BLOrK c� LOT S� TYPE OF WORK er/ D.' e m® JOB LOCATION Q 7S dow,00P �P7�'^r S 7'r7/J /-?Irk%I4ZU. OWNER CONTRACTOR Q I �4a / OfP/SlVy4o 41 faj (9/y)AVc c)975 EST. COST 4 loO FEE Q S V/lcO # Ee4Er FEES 10 ID- DATE TCO # FEE DATE 1l�gPECT10N RECORD DATE FOOTING _ FOUNDATION FRAMING RGH FRAMING INSULATION BI RGH PLUMBI GAS SPRINKLER EL LOW -VOLT ALARM C3 AS BUILT CJ FINAL INSP OTHER APPROVALS ARB BOT 0 ZBA OTHER it44{4 N�J J l9 tt,. 4 s A" annivmaW VILLAGE OF RYE BROOK MAYOR 938 King Street, Rye Brook,N.Y. 10573 ADMINISTRATOR Jason A.Klein (914) 939-0668 Christopher J. Bradbury a ww.ryebrook.org TRUSTEES BUILDING& FIRE INSPECTOR Susan R. Epstein Michael J. Izzo Stephanie J. Fischer David M. Heiser Salvatore W. Morlino CERTIFICATE OF COMPLIANCE June 13,2022 Washington Park Plaza Associates LLC 275 South Ridge Street Rye Brook,New York 10573 Re: 275 South Ridge Street, Rye Brook,New York 10573 Parcel ID#: 141.35-2-51 Demolition Permit#21-007 issued on 10/7/2021 to Demolish Interior Spaces This certifies that the interior spaces,demolished under the above captioned permit have been satisfactorily completed. Sincerely, Michael J. Izzo Building&Fire Inspector /to D BUILDING DEPARTMENT For office use onl 3D PERMIT# 007 APR 2 7 2022 VILLAGE OF RYE BROOK ISSUED: — -3 938 KING STREET,RYE BROOK,NEW YORK 10573 DATE: —c� —Q)a VILLAGE OF RYE BROOK (914)939-0668 FEE: a /0--—PAID$ BUILDING DFPARTMEi\fT wvrw.rvebrook.org 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 tkttt►tt►►►►►►►tt►•tttttk/t/tktkpt►titttktk►kttt►itt/tkt//tttit/tt►tit►ttttktktk►k►lkkit/►ti►►t►►►ttttkktk//tttktkkkkt/tkkttk Address: o�6 cio Occupancy/Use: Comm Parcel ID#: f y I v��— 'L—�I Zone:Off— Owner: (� 9► ri t>�' Address: P.E./R.A. or Contractor: C A-t, i i.D r~ (Z_5 Address: 31 IN g S /y 4 xl y /o b s Person in responsible charge: N I N 0 C= 1 Address: 9/Li 'L e+-) 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: 4 1..b being duly swom,deposes and says that he/she resides at (Print Name of Applicant) (No.and Street) in Ap"A))l 1 �.��' ,in the County of_� in the State of�,that (Ciiyrrown/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:$ /-5-60 ti for the construction or alteration of: .V t L 10 t✓- /J An— — 64ZeA A,, fV C— 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 �� 7 �=�—� Sworn to before me this IL— day of� ,2 day of 14 IL— , 20 L Signature o Property Owner Signature of Applicaid /,[lam Prini ame of Property Owner ;00Print Name of Applicant 4-t) Pu li Notary Pub c CAROLYN MARIE CANNISTRARC xrzro2 Notary Public-State of New York M SUOZZO No.01 CA6177080 NOTE PUBM,STATE OF NEW YOW Registration No.01 SUS070919 Qualified in Westchester County Quallfled In Westch war County My Commission Expires Nov.5,2023 My Commission ExpWw March 11.20M QyE BR(�k, . 19 Q e4t, m "C 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 ryebrook.org - - - - - - - - - - - - - - - - - - - - INSPECTION REPORT - - - - - - - - - - - - - - -- - - - - ADDRESS : �/1 �' DATE: V Z Z PERMIT# 2 " �� ISSUED: SECT:A�BLOCK: LOT: LOCATION: 1 � `� �- 3 %---A -'-> OCCUPANCY: Z ❑ 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 2 ❑ FUEL TANK ❑ FIRE SPRINKLER ❑ FINAL PLUMBING ❑ CROSS CONNECTION ❑ FINAL OTHER i a O = a Q e � ell z N N N t w A A o 04 °• • y p, ,,A W s C a-oi cG �' a C e r� Q 'b tb 0 d•� . � PLOz W . W 3 a � zs o .- 11 F- oc O C� O o~o W o�U c o o `. o ETaw w M p _ c � � L W oa � A a ¢ F z � o-'a" � u W z Q Q d y v W C v C x '�;; 0-4z V z oo f T U U o WW U d � — y •- � OOr v� w z0 C r° •� .a ,� oQ ' wb-d a O w w �"� � G4 U � d pE�" •� o. aa BUILDING DEPARTMENT !BUILDING E (C E O V E VILLAGE OF RYE BROOK 938 KING STREET RYE BROOK,NY 10573JUL 2 1 202� (914)939-0668 FAx(914)939-5801 AGE OF RYE 0 BROpK PARTMENT DEMOLITION PERMIT APPLICATION JUL 2 1 2021 DU 7 Application Fee:S At Permit Fees:$ Other. *rw****,►******+r**�,r,e*e***,rr�:*****t*****:*f*.;�***t*:rt�t�:�tw*****�t,e:**«*+r***w:***,�*,e*,k*wt,t,ttt******,►•**�**** 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 existing building,or for a change in use,as per detailed statement described below. / f^- .J S � r SBL: / 1j 3, —sk 5/ Zone: ( ''s 1. Job Address: .. 2. Proposed Demolition. C V E x� s - f CtE21E�j "lJ� 3. Property Owner:WJ b-P O 'P L A', A Address: Phone# Cell# 11'1 l'I 3+' b email: Applicant: ` L' WI Address: Phone# Cell it l `?' �' email Architect/Engineer: Address: Phone# Cell# emaiil: General Contra i ! �r r--tor Q�o%ixt-1 l.�//C 1c .1 .. � re3 :,3 l, ,0es r , /Q �5/T Lnt2 f ..r.. Phone# �11#t �7 7'c�J 7S owwr S44 l A- 30/ ,��Al Y 0,r� � J /OU/� 4. Estimated cost of construction S V A P n �MQ Y-q r- 5. Type of construction:( masonry,steel,etc...) 6. Method(s)of Demolition; 7. Number&Location of Fuel Oil Tanks to be Removed: 8. Number of Stories: 1 Height to Highest Ridge: To Highest Chimney. 9. Estimated date of completion: g r_� r'L - — CIL 1 3/21/19 STATE OF NEW YORK,COUNTY OF WESTCHESTER ) as: n L-C:-74'y , 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 -M/1 A',, :Z , ��=/L�'i 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 ail other applicable laws,ordinances and regulations. Sworn to before me this 11�—/ Sworn to before me this day of 0'22 day of , 20 Si of Property Owner Signature of Applicant �U Print Name of Property Owner Print Name of Applicant Notary Public Notary Public SHARI MELILLO Notary Public, State of New York No. 01 ME6160063 Oualified in Westchester County Commission Exnires.lane tgry 99 20 a 3121/19 Mike Izzo From: Mike Izzo Sent: Wednesday, April 13, 2022 4:23 PM To: 'Brothers Hima' Cc: 'martha7087@aol.com'; Steven Fews; 'Tara Orlando'; Laura Petersen Subject: RE: 275 s ridge st Attachments: CO - CC Application 8.2021.pdf Dear Mr. Ahmetaj, Thank you for the email. After reviewing your permit file for the subject address, I find a number of outstanding items which must be addressed before we can schedule any final inspections. You have three open construction/demo permits and one open sign permit. The oldest one is Demo Permit #DP21-007 issued 10/7/21 to demolish interior finishes. You must file for a C/O to close this permit and remit the appropriate C/O fee. The fee is based on the final cost of the demo work which must be provided by you on the C/O Application. A copy of the C/O Application is attached hereto for your convenience. Next is BP22-007 issued 1/19/22 for the interior renovation of the restaurant. The file indicates that not one of your trades called for any inspections for anything during the renovation work including plumbing, FIVAC, fire sprinkler, fire alarm, line voltage or low voltage electrical. Neither do we have a copy of the approval from the NY State Liquor Authority for the new bar. Once these items are resolved you must file a C/O application and fee as previously described, then you can request a final inspection. Next is BP22-012 issued 1/24/22 for the storefront renovation. Again, the file indicates no inspections requested or performed, and no C/O application or C/O fee. Finally, SP22-002 issued 3/25/22 for the new roof sign: no inspections, no C/O application, and no C/O fee. Please arrange to resolve these open issues to the satisfaction of the code. To schedule an inspection, please contact one of our Office Assistants by telephone, Monday through Friday between the hours of 8:30am and 4:00pm at (914) 939-0668. Thank you. AW011(7, /zzo Building& Fire Inspector Village of Rye Brook, NY (914) 939-0668 From: Brothers Hima<himabrothers@gmail.com> Sent: Monday, April 11, 2022 2:37 PM To: Mike Izzo<Mlzzo@ryebrook.org> Subject: 275 s ridge st Mike good afternoon I hope this email finds you well I be ready for final inspection in this 2 days is any way you can stop by please I have done Fire alarm report Striker system Report Fire suppression system Report Fire extinguisher report Hood cleaning report Emergency lights test and report Greas trap report Please let me know if I need anything else And when is a good day for you to come in. Thankyou Edin Ahmetaj 2 Mike Izzo From: Mike Izzo Sent: Friday, October 8, 2021 3:38 PM To: Brothers Hima Cc: Laura Petersen; 'Tara Gerardi'; Steven Fews; martha7087@aol.com; Lanny Lerner Subject: RE: 275 s ridge Blackstones Mr. Ahmetaj, Since you now hold a valid Demolition Permit you may proceed with painting, sanding, and other similar ancillary work which does not rise to the level of requiring a Building Permit, Electrical Permit, Plumbing Permit, HVAC Permit, or any other kind of permit. Thank you. Ac47e,1(7, Izzo Building & Fire Inspector Village of Rye Brook, NY (914) 939-0668 From: Brothers Hima<himabrothers@gmail.com> Sent: Friday,October 8, 2021 1:31 PM To: Mike Izzo<Mlzzo@ryebrook.org> Subject: 275 s ridge Blackstones Michael good afternoon I received an email I will get everything done But meanwhile can sand and repair the floors and do painting work Please and thank you Thank you Edin Ahmetaj Building Permit Check List&Zoning Analysis Address: 7-7�� s AA' �S 1�_- S-1 • SBL: Zone O 11-S Use: Const.Type: �`T Other. Submittal Date: I Z l Z l Revisions Submittal Dates: Applicant: W AS 11-c d2 A A S S o c Nature of Work: V-JT�.rL, D evi ws:ZBA: J U L 2 1 2021 PB: BOT: Other. ( ( ) ES:Filing: Z SP• BP: i7 S', C/a - .w,o, ( ) (�P: Dated: ✓ Notarized: `-' 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 Seale Copies: Electronic: Other. ( (�License: Workers Comp:V Liability Comp.Waiver. Other. ( ) ( ) CODE 753#: Dated: N/A: (� ( ) HIGH-VOLTAGE ELECTRICAL:Plans: Permit: N/A: Other. ( ) ( ) LOW-VOLTAGE ELECTRICAL:Plans: Pen-nit: 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: REQUIRED EXM ING PROPOSED NOTES APPROVED A=& nafs. JUL 2 1 2021 Front: Froru: 1� Main C AccL Coo Ft H/Sb: Sd.H/Sb: spa: HHig /hx.s ram• Laura Petersen From: Laura Petersen Sent: Friday, July 23, 2021 11:47 AM To: MARTHA7087@AOL.COM Subject: Demolition Permit Application - 275 South Ridge Street Good morning, The building permit application has been approved by the Building Inspector. Before I can issue the building permit the following items must be submitted to our office, " 1. General contractor's contact name (first and last) :/ 2. General contractor's valid liability insurance (the Village Of Rye Brook must be the certificate holder) /3. General contractor's valid workers compensation on a NY State Board form (C105-2 or U26.3) This information can be emailed to me. Thank you and have a good day! Laura Laura Petersen Office Assistant Village of Rye Brook 938 King Street Rye Brook, New York 10573 Phone(914)939-0668 1 Fax(914)939-5801 1 IpetersenCcDryeb rook.org &P <3LoA11(2A-6 ai - Gd e s�7 �lQve �o� recei�ral_�i� .e so ion S dieo azwa-) S Q// k.� cue Q6 S/7e final T cz/ le -1- /es Clow_, Ac" CERTIFICATE OF LIABILITY INSURANCE °A08��312021"' 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 cerdflcate holder Is an ADDITIONAL INSURED,the pollcy(les)must have ADDITIONAL INSURED provisions or be endorsed. H 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 certfficate holder in lieu of such endorsement(s). PRODUCER NAMEACT Virginia Lars BNC Insurance Agency PHONE (914)937-1230 AAX IC (914)937-1124 90 South Ridge Street E-MAIIEss vlara®bncagency.com ADOR INSURER(S)AFFORDING COVERAGE NAIL a Rye Brook NY 10573 INSURER A: Colony Insurance Company 39993 INSURED INSURER B: AmGUARD Insurance Company 42390 Cardinal Builders,Inc. INSURER C 315 West 39th Street INSURER D Suite 301 INSURER E New York NY 10018 INSURER F COVERAGES CERTIFICATE NUMBER: CL20111298842 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 LTR TYPE OF INSURANCE INSD WVQ POLICY NUMBER YMR)oP/rrr MMDWYYYY LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE S 2=000 CLAIMS-MADE F%_;� DAMAGE TO RENTED N OCCUR PREMISES S 100'000 MED EXP one S 5,D00 A X Contractual Liability Y 600GLOO26253-02 10/30/2020 10130/2021 PERSONAL d ADV INJURY S 1.000.000 GENL AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE S 4•000•000 POLICY R PRO- JECT LOC PRODUCTS-COMP/OP AGG S 4,000•D00 OTHER: S AUTOMOBILE LABILITY COMM6BINEDSINGLE LIMIT S 1 000 D00 n ANY AUTO BODILY INJURY(Per person) S g SCHEDULED AUTOS ONLY AUTOS CAAU108241 10/30/2020 10/30/2021 BODILY INJURY(Per scddem) $ AUTOS HIRED NON-OWNED S AUTOS ONLY AUTOS ONLY Per aCClOsnl S LS ELIA LW OCCUR EACH OCCURRENCE S 3,000.000 A EXCESS LUS CLAIMS-MADE AR4237795 02/23/2021 10/30/`2021 AGGREGATE S 3,000.000 DED I I RETENTION S S WORKERS COMPENSATION PER E ER AND EMPLOYERS'LIABLLRY Y I N ANY PROPRIETORIPARTNER/EXECUTIVE ❑ N/A E.L.EACH ACCIDENT S OFFICERIMEMBER EXCLUDED? (Mandatory In sm) E.L.DISEASE-EA EMPLOYEE S If yes,describe under DESCRIPTION OF OPERATIONS bslow E.L DISEASE-POLICY LIMIT S Excess Layer Liability Each Occurrence S2,000,000 A AR4237796 02/23/2021 10/30/2021 Aggregate $2,D00,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Addltlonal Remarks Schedule,may be attached I1 mom space Is rspulrsd) Village of Rye Brook Is Included as an additional insured when required under written Contract or Agreement CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN Village of Rye Brook ACCORDANCE WITH THE POLICY PROVISIONS 938 King Street AUTHORIZED REPRESENTATIVE Rye Brook NY 10573 ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD NYSIF New York State Insurance Fund 199 CHURCH STREET,NEW YORK,N.Y. IW07-1100 nysif.com CERTIFICATE OF WORKERS' COMPENSATION INSURANCE (RENEWED) m *Jw 'O ^^ ^^^ 455565677 e BNC INSURANCE AGENCY 90 S RIDGE ST 0 .m •. RYE BROOK NY 10573 SCAN TO VALIDATE AND SUBSCRIBE POLICYHOLDER CERTIFICATE HOLDER CARDINAL BUILDERS, INC. VILLAGE OF RYE BROOK 315 W 39TH ST#301 938 KING STREET NEW YORK NY 10018 RYE BROOK NY 10573 POLICY NUMBER CERTIFICATE NUMBER POLICY PERIOD DATE M2370 847-2 745419 09/04/2021 TO 09/04/2022 8/3/2021 THIS IS TO CERTIFY THAT THE POLICYHOLDER NAMED ABOVE IS INSURED WITH THE NEW YORK STATE INSURANCE FUND UNDER POLICY NO. 2370 847-2. 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:/NVWW.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. PRESIDENT NAZMI AHMETOVIC 1OF1 FOR CARDINAL BUILDERS INC THE POLICY INCLUDES A WAIVER OF SUBROGATION ENDORSEMENT UNDER WHICH NYSIF AGREES TO WAIVE ITS RIGHT OF SUBROGATION TO BRING AN ACTION AGAINST THE CERTIFICATE HOLDER TO RECOVER AMOUNTS WE PAID IN WORKERS'COMPENSATION AND/OR MEDICAL BENEFITS TO OR ON BEHALF OF AN EMPLOYEE OF OUR INSURED IN THE EVENT THAT, PRIOR TO THE DATE OF THE ACCIDENT, THE CERTIFICATE HOLDER HAS ENTERED INTO A WRITTEN CONTRACT WITH OUR INSURED THAT REQUIRES THAT SUCH RIGHT OF SUBROGATION BE WAIVED. 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 DI RECTOR,INSURANCE FUND UNDERWRITING VALIDATION NUMBER 736475578 U-26.3 7/19/2021 Mail-edin EDDY ahmetaj-Outlook EXIT EXIT ARE 8 T=.1 0 EXIT n u UFFER FLOOR o EVACUATION PLAN �o FILE Copy PERM AP l-0 SB ec �� DATE APPR JUL v/t�� ? ?0?i BUIWING INS CT R,Village of lty��r�pok,�jry DING F RYE B -- �FpgRT�_ _EIOT https://outlook.live.com/mail/0/inbox/id/AQQkADAwATNiZmYAZC05MTcwLTU5MjAtMDACLTAwCgAQAD%2F6%2Ficx25dMs6cG%2B ErQDOM%3D/s... 1/1