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HomeMy WebLinkAboutBP21-328PERMIT # ��� / �' � � � DATE: � � of EXP: c% o� �- SECTION ��� o o� � 'BLOCK % LOT TYPE OF WORK �� 1 Q//'C��,,� 1aM/�Liaj'! ��- �7�' %)CIZ. JOB LOCATION �.�t+��, OWNER o �i %i%i%� 1%SS `/Ve%%/ '�/�-S.3 �i/ �j CONTRACTOR t��L��'3 �'�^e �' - LI � �%r1/Gi C9J�%��7 % ��%y� /EST. COST � "'� ��� FEE '-' �/ CO # FEE '�' / ��"" �� DATE �/�-� TCO # FEE DATE,��,_.__. _, INSPECTION RECORD I DATE INSP FOOTI N G FOUNDATION FRAMING RGH FRAMING INSULATION PLUMBING 0 RGH PLUMBING GAS 0 SPRINKLER ELECTRIC 0 LOW -VOLT CI ALARM L� AS BUILT C� FINAL ClTP-IER RPPROVALS � AI�B �'C' L'stl��— /�'� o�l BOT PB ZBA OTHER AS-BUILT/FINAL SURVEY EtEQU1RED PRIOR TO FINAL INSPEC710N .2C�>V'�'d /,/Ju/ dam.. 19 40A anniamaW VILLAGE OF RYE BROOK MAYOR 938 King Street, Rye Brook,N.Y. 10573 ADMINISTRATOR Jason A.Klein (914) 939-0668 Christopher J. Bradbury www.!yebrook.org TRUSTEES BUILDING& FIRE INSPECTOR Susan R. Epstein Michael J. Izzo Stephanie J. Fischer David M. Heiser Salvatore W. Morlino CERTIFICATE OF COMPLIANCE December 12,2022 Robert O'Neill&Melissa O'Neill 4 Loch Lane Rye Brook,New York 10573 Re: 4 Loch Lane, Rye Brook,New York 10573 Parcel ID#: 136.21-1-34 Building Permit#21-328 issued on 12/20/2021 For a New Fence This certifies that the new four foot high black aluminum picket fence,installed under the above captioned permit has been satisfactorily completed. Sincerely, Michael J. Izzo Building&Fire Inspector /to D3BUILq;R MENT For office use onl NOV 3 0 2022 71LYE OK PERMIT#ISSUED:938 KING STREOOK, YORK 10573 DATE:VILLAGE OF RYE BROOK 0 OFEE: g // a^ PA[DBUILDING DEPARTMENT APPLICATION FOR CERTIFICATE OF OCCUPANCY,CERTIFICATE OF COMPLIANCE, AND CERTIFICATION OF FINAL COSTS TO BE SUBMITTED ONLY UPON COMPLETION OF ALL WORK, AND PRIOR TO THE FINAL INSPECTION rasttsrsststsssswres*trsrsrrttttrwtrrrtrsrtttt+srsstssttrtsrrrtsrtr+rrrtststtsssttssstssttrtrrttrtwrtsssrtssttrsrttrrrrsssstt Address: L-1 L-ocN �—�r(E ��� 13RcoK �/ IoS73 Occupancy/Use: I Jf3. Parcel ID#: Aac.K I tor 34 Zone: Q-2.5— Owner: ?,ot33Et2T Ir MELISSL} 0 `1461LL Address: y Lorry) 1-4NE 'eye- A4e04 A/r P.E./R.A.or Contractor: ^1A Address: JY/.4 Person in responsible charge: O w nlc tZ Address: Lf L a C 4l 1_•4N 6_ X yg &*rz!� NY 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: RC QE 127r 0'hJG1 LL being duly swom,deposes and says that he/she resides at (Print Name of Applicant) (No and Street) in RYc a 1zoo K I' in the County of �/EST� gSJL a in the State of IV Y ,that (City/rown/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:S S, <00.00//bo of for the construction or alteration of: Pc Q I M G rt--w- I?L,+CJL �4 t v r 1 N�,•� .,.�cE 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-IO.A.of the Code of the Village of Rye Brook. Sworn to before me this 2 1'�7 Sworn to before me this 2 day of ® b , 2022 day of AWH , 20 22 r Signature of Property Owner Signature of Applicant a cam_t,,L (T_- :✓1r' Atees-F Print Name of Prope Owner Print Name of Applicant C No,ta Public No ub REIKO ARAMO1IO HERRER NOTARY PUBLIC-STATE OF NEW YORK No. 01 AR6280073 Qualified In QueeW26 My Commission Expires �E BRC�v� BUILDING DEPARTMENT /ASSISTANT ILDING INSPECTOR BUILDING INSPECTOR VILLAGE OF RYE BROOK DE ENFORCEMENT OFFICER 938 KING STREET • RYE BROOK,NY 10573 (914) 939-0668 FAx (914) 939-5801 www ryebrook.org - - - - - - - - - - - - - - - - - - - - INSPECTION REPORT - - - - - - - - - - - - - - - - - - - - ADDRESS l I_eC L(►�ngp DATE: PERMIT# 1 J>� I � ISSUED SECT BLOCK:LOT: 7(/ /f 1 LOCATION: �[ "1 �C V�� �0 PANCY: ❑ VIOLATION NOTED THE WORK IS... ACCEPTED ❑ REJECTED/REINSPECTION ❑ SITE INSPECTION REQUIRED ❑ FOOTING i ❑ 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 r c a N rl N N o a - a m O � • A �, u �� .� � E �3 W m i.•� > i C 22 y "b s V W cv w 0. M � M ono 3 -0 ,0 O O y F M y O C {+ •� F O W > > 15. 31 O z N Q 6 r•� �4 � � �■y I--t � " � a� — 'o a r7 a oc z WCrA ~ CN U Z LW7 >d t. ` p U CD w M„■� MM A ppqq ' _ y ce U N Fy � W �� ■ CIN La A x F o q o � x ce. z dc. a, U U U z i T E �i w Z a d . o a a >CO Uj az rni3r. � �I OQ C� W 2 9 r � BUILDING DEPARTMENT [ECIEO V ILLA V OF RYE BROOK D 938 Ki EET RXE B h,NY 10573 DEC _ 7 2021 4 9- �$ :or. VILLAGE OF RYE BROOK FOR OFFICE USE ONLI': 21 G1� Approval Date: DEC 2 O Z i # /rs Application # Approval Signature: ARCHITECTURAL REVIEW BOARD: Disapproved: Date: BOT Approval Date: Case# Chairman: PB Approval Date: Case# Secretary: ZBA Approval Date: Case Other: Application Fee: Permit Fees:IN lJye FENCE / WALL / GATE PERMIT APPLICATION Application dated:December 7 2021 is hereby made to the Building Inspectorof the Village of Rye Brook.NY.for the issuance of a Permit for the installation,construction,repair or replacement of a Fence,Wall or Gate,in accordance with Scction 250-6 B.(1)(g),of the Code of the V illage of Rye Brook,as per detailed statement described below. Swimming pool fences must conform to the State Code. I. rob Address: 4 Loch Lane, Rye Brook, NY 10573 2. Occupancy/Use: 1 family residential S B L#: Section 136.21, Block 1, Lot 34 Zone: R-25 3. Proposed Fence/Wall/Gate(describe in detail): Install black aluminum fence around perimeter of back yard as show_ n on attached plans. Fence is to terminate at the rear exterior corners of the house. LV- i 4 `FL 4. Property Owner: Robert & Melissa O`Neill Address:4 Loch Lane, Rye Brook, NY 10573 Phone# 917-418-5341 cell# 917-418-5341 email: rponeill@gmail.com Applicant:.Robert O'Neill Address: 4 Loch Lane, Rye Brook, NY 10573 Phone# 917-418-5341 Cell# 917-418-5341 email: rponeill@gmail.eom Architect/Engineer: N/A _ Address: Phone# Cell# email: Contractor:_Fence Installer: Fences by Fabian 91y-937-9(07%rveyor:W.E.James Engineering and Land Surveying Address&Phone: 7 West Glenn Ave, Port Chester, NY 10573 8 Cheanda Lane, Wallkill, NY 12589 5. If building is located on a corner lot,which street does it front on: N/A 6. What is the estimated cost of construction $3,500 (NOTE: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: Pending acceptance of ARB Application-6 to 8 weeks after acceptance by ARB. i 1212021 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. STATE OF NEW YORK,COUNTY OF ) as: _Robert O'Neill , 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 Notapplicable] 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. 17 Sworn to before me this Sworn to before me this day of , 20 day of t�fL� , 20 - Signature of Property Owner Signature of Applicant Robert O'Neill Robert O'Neill Print Name of Property Owrter Print Name of Applicant Notary Public Notary Public LETITIA O'BRIEN NOTARY PUBLIC, State of New York No. 01OB4975928 Qualified in Queens County Commission Expires Dec. 26, 202 8n212o2t Building Permit Check List&Zoning Analysis Address:��� a - sBL ► 6 .Z L Zone:-2 Z-5- Use. Z Const.Type: 1. Other. Submittal Date: l Z Revisions Submittal Dates: Applicant: l L_L_ Nature of Work: L4 LD 'l !Ll 4 L A G1L vi w :ZBA: C 2021 PB: BOT• Other. OK ( ( ) FEES:Filing. / BP: A c/O: Legalization: ( ) (vY APP: Dated ✓ Notarized: -,-"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: ( ) ( ) ITE PLAN:Topo: Si Protection S/W Mgmt: Tree Plan. Other. ( ) (� VEY:Dated 4 ( L IL ( Current: ✓ Archival• Sealed:T Unacceptable: ( ) (• LANS:Date Stamped: Sealed Copies: Z Electronic ': � Other (J� ( License: ✓Workers Comp:_x/- Liabili ._jGComp.Waiver. Other. ( (J CODE 753#: /��O/ -'Do/—03 --00 Dated/.4 36-- *:),I 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 LEVER Other. ( ) ( ) Other: (4166 mtg.date: t Z 125- 7-1 approval• notes: ( )ZBA mtg.date: approval• notes: ( )PB mtg.date approval• notes: `` REQUIRED EXWfING PROPOSED NOTES \\ DEC 2 0 2011 Ate. Cirde: FronW Front: Front: Sides: &Mr. Main Cov Accs.Cov F S : Sd.H/Sb GGFA: Tom: Ft LW: Pin Hight/Stories: notes: p C CSC NE BUILDING DEPARTMENT VILLAGE OF RYE BROOK DEC - 7 2021 938 KING STREET RYE BROOD:,NY 10573 (91,4) 9-0668 VILLAGE OF RYE BROOK �ti��w.ry rooko'r_ 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 Loch Lane, Rye Brook, NY 10573 Date of Submission: Parcel ID#: 1,�>6 Z.l —1 -3 Zone. R-25 December 7, 2021 Proposed Improvement(Describe in detail): Install black aluminum fence around perimeter of APPLICANT CHECK LIST: back yard as shown on attached plans. Fence is MUST BE COMPLETED BY THE APPLICANT The following items must be submitted to the Building to terminate at the rear exterior corners of the house. Di.-partment by the applicant-no exceptions. Property Owner:_Robert & Melissa O'Neill 1. (X)Completed Application 4 Loch Lane Rye Brook, NY 10573 2. (x)Two(2)sets of sealed plans. (one full size ;maxinium Address: y aIlowahlc plan size= 36"x 42-1 and one l I-x 17") Phone# 917-418-5341 3. (X)Two(2)copies of the property survey. 4. (X)Two(2)copies of the proposed site plan. Applicant appearing before the Board: 5. (X)One electronic/disc copy of the complete Robert O'Neill application materials. 6. (x) Filing Fee. Address: 4 Loch Lane, Rye Brook, NY 10573 7. (X) Any supporting documentation. Phone# 917-418-5341 8. ( ) HOA approval letter. (ifopplicable) - 9. (X) Photographs. Architect/Engineer: N/A 10.(x) Samples of finishes/color chart. (a sample board or Phone# N/A model may be presented the night of the 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. / Sworn to before me this 6O Sworn to before me this S0 1� day of 20 Z/ day of 20 Zrpdk� 4--r� Signature of Property Owner Signature ooff Applicant g� Print Name of Property Owner Print Name of Applicant Notary Public Notary Public LETITIA O'BRIEN NOTARY PUBLIC, State of New York No. 01OB4975928 Qualified in Queens County Y Commission Expires Dec. 26, 20z 8/12/2021 r I'lie New Standard of Quality b- -Jnphasis on Detail S7 - Horizon — S 10 - Derby A This Horizon has a view in mind with its cl Issic The simplicity of this basic two rail smooth top dPcipn, smooth rail on top and picket space F. of with enclosed pickets is ideal for pool applications • between pickets is built for harmony the and is also excellent for balconies and decks. landscape. 'f,Vw.„� � Lai I I S8 - Falcon _ _ S I I - Privacy Panel With every other picket thrusting a spear- point This aluminum board on board privacy design through the top rail and with I%:" picket spacing, offers a unique alternative to wood or vinyl this fence was created to make the vision of your privacy. landscape soar r S9 - Storrs Doggie Panel Modification The height of simplicity, this fence with smooth top Any standard panel maybe modified to incorporate rail has been modified so that pickets do not extend a Doggie Panel in lower third section. This will keep through the bottom rail. smaller pets in or add detail to any design. .v- T �t �yt f • A Indicates available also in our patented MINATEa screwless design in all grade. / • ELSOL �Iv�W� A ; al;'.Al��1s�� ���/�r�r �� G1,•\ e;��i*�1 }';J1 �li � ,yeti� y+t�)+. � J 1 �/ �>� � ° ��I;►1� t��iR>ti� tLzo .t `v S ter• '.a T z A �t ddlk M. l _ � r��;: y�- ? d• ,.a �-�r...:P i t- .cYfr s -:-^k, :,�''''.-# -s !! � ,� li� •. fir. :r,, fes. /. '� fir, a. Laura Petersen From: R O'Neill <rponeill@gmail.com> Sent: Thursday, December 30, 2021 3:15 PM To: Laura Petersen Subject: Re: Fence Permit for 4 Loch Lane Hi Laura, The fence installation company is going to be Colony Fence, not Fences by Fabian. Colony Fence Co. 744 West Hartsdale Road White Plains, New York 10607 Can you please let me know what else is needed to make this change on the permit. Happy New Year. Best, Rob O'Neill 917-418-5341 On Dec 20, 2021, at 3:02 PM, Laura Petersen<LPetersen@ryebrook.org>wrote: Good afternoon, The building permit for the fence at 4 Loch Lane is ready for pick up. The permit fee is $100.00 (check made payable to the Village of Rye Brook). Our office is open Monday — Friday 8:30am to 4:00pm (closed Friday 12/24/21 for Christmas Eve). Please provide the ticket number from DIG Safe NY prior to picking up the permit. Thank you 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 Ipetersenaryebrook.or4 1 Laura Petersen From: R O'Neill <rponeill@gmail.com> Sent: Thursday, December 30, 2021 4:16 PM To: Laura Petersen Subject: 4 Loch Lane - Fence Permit - Contractor Documents Attachments: Colony Fence Village of Rye Brook C105.2.pdf; H.I. License 2022.pdf Hi Laura, In follow-up to my earlier email—please see attached documentation for Colony Fence Co. to change the Contractor listed on the approved fence permit. We have decided to use Colony Fence Co, not Fences by Fabian. Best, Rob O'Neill 917-418-5341 Begin forwarded message: From: Ruben Colonia <colonyfence@gmail.com> Date: December 30, 2021 at 3:42:37 PM EST To: rponeill@gmail.com Subject: Requested documents Good afternoon. Attached are the requested documents needed for your permit. Please feel free to contact us if there is anything else needed. Happy New Year, Best Regards Colony Fence Company Inc. 744 Hartsdale Rd White Plains, NV 10607 Phone 914 497-3442 Fax 914 468-1229 colonyfence@qmoil.com www.colonyfence.com http://www.angieslist.com/review/311906 1 Laura Petersen From: Dig Safely New York Exactix <tickets@exactix.digsafelynewyork.com> Sent: Thursday, December 30, 2021 4:30 PM To: Mike Izzo Subject: Message from Dig Safely New York, Inc. (DSNY) ****REGULAR**** DIG REQUEST from DSNY for: VIL RYE BROOK Taken: 12/30/2021 16:28 To: VIL RYE BROOK PRIMARY Transmitted: 12/30/2021 16:29 00003 Ticket: 12301-001-036-00 Type: Regular Previous Ticket: ------------------------------------------------------------------------------ State: NY County: WESTCHESTER Place: RYE BROOK Addr: From: 4 To: Name: LOCH LN Cross: From: To: Name: Offset: ------------------------------------------------------------------------------ Locate: REAR OF PROPERTY NearSt: KING ST Means of Excavation: HAND TOOLS Blasting: N Site marked with white: Y Boring/Directional Drilling: N Within 25ft of Edge of Road: U Work Type: FENCE POST INSTALLATION Estimated Work Complete Date: 01/12/2022 Depth of excavation: 2 FEET Site dimensions: Start Date and Time: 01/12/2022 07:00 Must Start By: 01/27/2022 ------------------------------------------------------------------------------ Contact Name: RUBEN COLONIA Company: COLONY FENCE COMPANY INC., WHITE PLAINS Addrl: 744 HARTSDALE ROAD Addr2: City: WHITE PLAINS State: NY Zip: 10591 Phone: 914-497-3442 Fax: Email: colonyfence@gmail.com Field Contact: RUBEN COLONIA Alt Phone: 914-497-3442 Email: colonyfence@gmail.com Working for: HOME OWNER ------------------------------------------------------------------------------ Comments: Lookup Type: PARCEL ------------------------------------------------------------------------------ Members: ALTICE USA CONED MCI SUEZ WTR WESTCHESTER VIL RYE BROOK WESTCHESTER CTY SWR 1 Ail O � C L ? 'J O too a - = l O J W h�c r. r ^ . s CO C rn 1.� L W < LU cum Cb J i K N x J b a3i COLOFEN-02 LCANDELA ACORO CERTIFICATE OF LIABILITY INSURANCE DAT 5/4/2 D/YYYI) 5/4/2021 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 NAME: _ World Insurance Associates,LLC PHONE Est).(845)279ti5151 FAX 3 Starr Ridge Rd ( ( •�► Ste 100 E-MAIL Brewster,NY 10509 ADDRESS: INSUR AFFORDING COVERAGE NAIL t INSURER A:Selective Insurance CO of South Carolina 19259 INSURED INSURER B. _ Colony Fence Company Inc. INSURER C: 744 West Hartsdale Rd INSURER D: White Plains,NY 10607 INSURER E• INSURER F: 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 SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. qLTR BR I TYPE OF INSURANCE ADOL OM POLICY NUYBER POLICY EFP POLICY EXP LEfrH A X COMMERCIAL GENERAL LIABILRY EACHCURRENCE 2,000,000 CWMS41ADE �OCCUR DAMAGE TO RENTED S 2440908-00 2/1/2021 2Hr2022 500.000 MED EXP oneperson) 10r000 PERSONAL 3 ADV INJURY 2r000r000 GEN'L AGGREGATE pa LIMIT APPLIES PER: GENERAL AGGREGATE 4,OW,WO POLICY�X JECT D LOC PRODUCTS-COMP/OP AGG S 4,WOr000 OTHER: 3 A AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT 1r000r000 X ANY AUTO S 2440908-00 2+•1/2021 2M/2= BODILY INJURY Per arson OWNED SCHEDULED AUTOS ONLY AUTNOOSW ED BODILY INJURY Per accident ORS ONLY A�TOS ONNLY s�a�rd AMAGE A X UMBRELLA LIAB X OCCUR EACH OCCURRENCE 2,000,000 FEXCESS LIAR CLAMS-MADE S 2440908-00 2/1=1 2/11MM AGGREGATE 210001000 —DED X RETENTION E 10r000 WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY Y/N STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE (actin Erin EXCLUDED? N/A E.L.EACH ACCIDENT 11fMyes describe under E.L.DISEASE-EA EMPLO DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT I DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101 Additional Remarks Schedule,maybe attached if more apace is requ Ired) Certificate Holder is Additional Insured with respects to taeneral Liability as required by written contract subject to the terms and conditions of the policy. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Village Of Rye Brook THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 938 Kings Street ACCORDANCE WITH THE POLICY PROVISIONS. Rye Brook,NY 10573 AUTHORIZED REPRESENTATIVE ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD 5/4/2021 Certificate of NYS Workers'Compensation Insurance Coverage NEW CERTIFICATE OF O K Workers' NYS WORKERS'COMPENSATION INSURANCE COVERAGE STATE Compensation Board Insured Detail Is.Legal came and address of Insured(Use street address only) lb.Business Telephone Number of Insured Colony Fence Company Inc 845-279-5151 744 Hartsdale Road White Plains,NY 10607 lc.NYS Unemployment Insurance Employer Registration Number of Insured Id.Federal Employer Identification Number of Insured or Social Security Number Work Location of Insured(Only required if coverage is specifically limited to 454912167 certain location in New York State,i.e.a Wrap-Up Policy) 2.Name and Address of the Entity Requesting Proof of Coverage 3a.Name of Insurance Carrier (Entity Being Listed as the Certificate Holder) AmTrust Insurance Company Village of Rye Brook 938 King Street 3b.Policy Number of entity listed in boa"la": Rye Brook,NY 10573 KWC 1246469 3c.Policy effective period: 4/l/2021 to 4/1/2022 3d.The Proprietor,Partners or Executive Officers are: included(Only check box if all partners/officers included) 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"la"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 carrier 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 Workers'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: Henry C.Sibley (Print name of authorized representative or licensed agent of insurance carrier) q* " '"0 Approved By: 5/4/2021 (Signature) (Date) Title: Underwriting Manager Telephone Number of authorized representative or licensed agent of insurance carrier:CarrierPhone Please Note:Only insurance carriers and their licensed agents are authorized to issue the C-10S.2 form.Insurance brokers are NOT authorized to issue ii. https://wc.amtrustgroup.com/ANAWC/PolicyNYCertificateOfWclns.aspx?lndexld=338982&lnstanceld=1 a76422b-4ald-4158-8al3-d605c8e9eec4 1/2 b Oo v rn W N W CD m 3 O 0 CO D *O D D� 0(n (n ;U 0 .r ;b z m c N z =Zr Z= Dc c m2 Z p -n co o-� 0 r r 0 m �co � 0� r f+7^� M D M�m �0r rTl�m �p Dn o-0 ►--' =�,� Z=DZD� �� �o -N r �n � ova _ .. D Q << O �• a 0 a° ��!� rv�'0 �oD ooz nD zN O c O - — ®. 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