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HomeMy WebLinkAboutBP22-003PERMIT #J/ SECTION TYPE OF WORK JOB LOCATION OW N ERWL CONTRACTOR4 EST, COST CO #_( TCO # l ' DATE, EXP: BLOCK LOT .s re r^risl a 7�Sragen zomloeTl =" d "7 gm OCD" FFF / �' 90 7A4 INSPECTION RECORD i DATE INSP FOOTING FOUNDATION FRAMING RGH FRAMING INSULATION PLUMBING L RGH PLUMBING GAS f SPRINKLER �J �-- ELECTRIC I]Q LOW -VOLT 0 I ALARIVI AS BUILT p FINAL a --of i " "*�' %w QI c LL G OTHER APPROVALS ARB - BOT P8 ZBA OTHER VILLAGE OF RYE BIRO©K WESTCHESTER COUNTY, NEW YORK NO: 22-027 Certificate of (9ccupaucp This is to certify that PCV-ber+ D U+,5 e-h J LA )4h D f(AS G�l of, ,�rc�n &J having duly filed an application on re_b KJAO r V 15,20 <�2Q-requesting a Certificate of Occupancy for the premises known as, Rye Brook,NY, located in a 2' f ff Zoning District and shown on the most current Tax Map as Section: /�?(3•5`7 Block: Lot: and having fully complied with the requirements of the Building Code and the Zoning Ordinance under Building Permit No. (0 d , issued I 20,2� 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 New York State Use Classification of: fG' e - Fal;r?/ / , for the following purposes: S r � cnI 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 hei t shah be made,nor shall the building be moved from one location to another until a permit to accomplish such change has b robt ding Inspector. Building Inspector,Village of Rye Brook: Date: FEB 2 3 2022 For office use only: BUILDING DEPARTMENT PERMIT FEB � 5 2022 VILLAGE OF RYE BROOK ISSUED: 9 38 KING STREET,RYE BROOK,NEw YORK 10573 DATE: VILLAGE OF RYE BROOK (9,t4}9 0668 FEE: b/ PAIe BUILDING DEPARTMENT w 'r r 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 «+rtr•trr+t++rrw«wrrr+rrwtrsrtsrr+tsrrr+srtt++r«wwrr«t++««r+srrrr«stt«r«srrtsssrsrrssstrsa+rssrrrrsrs«r+t+r►rrr+«rt«ss«rsrr«s Address: 19 Boxwood Place Rye Brook, NY Q Occupancy/Use: Residential parcel lD#: �e1 9. �7 r��—�y _ Zone: 4a-�S Owner: Mr. Herbert Deutsch Address: 19 Boxwood Place Rye Brook, NY A,--n,'A or Contractor: Ralph lamiceli Address: �►�c4 i�co� GCS x h�� 1-'y Person in responsible chargc: Ralph lamiceli Address: S-A 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: Ralph lamiceli being duly swom,deposes and says that he/sho resides at gft l5, s V (Print Name ofA15plicant) (No.and Strectl in 0 S S I bj A ,in the County of Westchester in the State of NY ,that Wliyrlow V ilk%0 he/she has superviscdVje work at the location indicated above,and that the actual total cost of the work,including all site improvements, labor,materials,scaffolding,fixed equi ent,professional fees,and including the monetary value of any materials and labor which may have been donated gratis was:5 4 p G d for the construction or alteration oC 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 structureiwork 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.ofthe Code orthe Village of Rye Brook. Sworn to before me this Sworn to before the this 2-3 day WN ^ 0a-1 day of De"Cp W Signatu c of Propc O ncr Signy) kk Fkk pp t-am Pr' t Name of Property Owner Print Name of Ap \�'�I�L e- � 7AAAA y.J�+ No-W6 Public ��Public SHABI lv1E NOIA Yf��,8'011EOFNEWY'OIIK Notary Public, Statee o of f N New York ; � • ,,,,� N1c. 011A0 616C°^S3 R0910rokeNo.OISSM306 Oualified in Westch; ter County ., QuM06dtn1A 'Cw* Commission Exoires January 29,20 My C.aatelid�ion F.xpi+et Dwm6a%2023 �E BR(�k. igir. BUILDING DEPARTMENT '0�UILDING INSPECTOR y &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.or - - - - - - - - - - -- - - - - - - INSPECTION REPORT - - - - - - - - - - - ------ - - - ADDRESS: DATE: Z Z Z Z PERMIT#rl'�ZZ ISSUED: �*Z ECT: ��7 - BLOCK: LOT:Z LOCATION: -T� � �� „�-'�- OCCUPANCY: Z I O ❑ 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 ❑ FUEL TANK ❑ FIRE SPRINKLER ` C� ❑ FINAL PLUMBING ❑ ;ROSS CONNECTION ❑,/FINAL C v o OTHER BR(�v�. O 2m w � BUILDING DEPARTMENT ❑4UILDING INSPECTOR /ASSISTANT BUILDING INSPECTOR VILLAGE OF RYE $ROOK �/ 11 CODE ENFORCEMENT OFFICER 938 KING STREET • RYE BROOK,NY 10573 (914) 939-0668 FAx (914) 939-5801 www.Uebrook.or� - - - - - - - - - - - - - - - - - - - - INSPECTION REPORT - - - - - - - - - - - - - - - - - - - - ADDRESS• DATE` I PERMIT# a r ISSUED: 'SECT: BLOCK: LOT: LOCATION: OCCUPANCY: ❑ VIOLATION NOTED THE WORK IS... ❑ ACCEPTED ❑ REJECTED/REMSPECTION ❑ SITE INSPECTION � �� �.�i REQUIRED ❑ FOOTING l ❑ 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 Q�E BRC�k 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 : DATE: PERMIT# 1 " ISSUED: SECT: BLOCK: LOT:" r LOCATION: ` ��r- J'`' 1 ' �� \ OCCUPANCY: ❑ VIOLATION NOTED THE WORK IS... ❑ ACCEPTED ❑ REJECTED/REINSPECTION ❑ SITE INSPECTION REQUIRED ❑ FOOTING ❑ FOOTING DRAINAGE ❑ FOUNDATION UNDERGROUND PLUMBING NOTES ON INSPECTION: ROUGH PLUMBING 0 ROUGH FRAMING ❑ INSULATION ❑ NATURAL GAS ❑ L.P. GAS ❑ FUEL TANK ❑ FIRE SPRINKLER FINAL PLUMBING ❑ CROSS CONNECTION ❑ FINAL ❑ OTHER s a o N O y • C)' � N ad ■ N In o r. o ■ • Qy � •`i W • :: y 8 : W r`] Ri .Vr .r p � rn ■ ■ d --i O w ~ V 0 Cl) M Q 0 —0 oo- w z U A � A p u n ov � � L n ;L, w zi 00 -0 eE ■ o � y v . `n uy� .v 70 Zca° s= vvw^ W `n d 00 � •• '-� O W W � 5 a 5 0. BUILDING DEPARTMENT VIL 411/ E BROOK DEC 2 8 2021 938 KING ROOK,NY 10573 68 VILLAGE OF RYE BROOK k: BUILDING DEPARTMENT INTERIOR BUILDING PERMIT APPLICATION FOR OFFICE USE ONLY: h Approval Date: J AN — 4 Permit#: 46A Application Fee: S Approval Signature: Permit Fees:S Disapproved: Other: Application dated:/e� a 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. 1. Job Address: 19 Boxwood Place, Rye Brook, NY SBL: 129.59-1-24 zone: R-15 2. Proposed Improvement.(Describe in detail): Restore finished basement for storage use only damaged by flood. 3. Does the proposed improvement involve a Home-Occupation as per§250-38 of the Code of the Village of Rye Brook? No: X Yes: If yes,indicate: TIER 1: TIER Il: TIER III: 4. Will the proposed project require the installation of a new,or an extcnsion/modification to an existing automatic fire suppression system(Fire Sprinkler,ANSL System,FM-200 System,Type I Hood,etc...) :No: X Yes: (If yes,please submit a separate Automatic Fire Suppression System Permit application&2 sets of detailed engineered plans) 5. Occupancy;(I fam..2 fam.,comm..etc...)Prior to Construction: One family Aftcr Construction: One family 6. MY State Construction Classification: Residential N.Y.State Use Classification: 7. Property Owner: Mr. Herbert Deutsch Address: 19 Boxwood Place, Rye Brook, NY Phone# Cell# 914-417-5015 email: herbert1819a@gmeil.com 8. Applicant: Ralph lam€cell Address:E4 9ptN�l( l)C.a ,/�oSs'�✓ % c �- Phone# Cell#914-557-6703 email: erotonpilot@gmaiFcom 9. Architect: Demasi Architect PC-Luigi Demasi Address: 105 Smith Ave, Mt. Kisco, NY 10549 Phone# 914-666-3858 Cell# email: lou@demasiarchitects.com 10. Engineer: Address: Phone# Cell# email: 11. General Contractor: Ralph lamlcell Address: Phone# Cell#914-557-6703 email: crotonpilot@gmail.com 12. Estimated cost of construction $ 42,000.00 (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: Finish: (1) 8 1212021 rr BUILD bikRTMENT 2 8 20 r 21 VIL E OF RYE BROOK _� 938 KING ET RYE BROc 4,NY 1©573 VILLAGE J RYE BROOK jc BUILDING DEPARTMENT k.org AFFIDAVIT OF COMPLIANCE VILLAGE CODE §216 • STORM SEWERS AND SANITARY SEWERS THIS AFFIDAVIT MUST BEAR THE NOTARIZED SIGNATURE OF THE LEGAL PROPERTY OWNER AND BE SUBMITTED ALONG WITH ANY BUILDING OR PLUMBING PERMIT APPLICATION. ANY BUILDING OR PLUMBING PERMIT APPLICATION SUBMITTED WITHOUT THIS COMPLETED AND NOTARIZED FORM WILL BE RETURNED TO THE APPLICANT . STATE OF NEW YORK,COUNTY OF WESTCHESTER ) as: Mr. Herbert Deutsch , residing at, 19 Boxwood Place, Rye Brook, NY WI-ittt name) here 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; 19 Boxwood Place Rye Brook, NY , Rye Brook, NY. 1.11,I, 1,1':1,"I 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 conceming either the storm sewer or sanitary sewer, and further that there are no roof drains, sunup 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. (Si,naiture ol'Pr erl% �'n ;I k- ZAZA2L , y OLIUA'T 3C (Print Name of Propeily Owner(s)i Sworn to before me this �41 ay ofDCe f. `� , 203\ (Notary Public) SHARI IVIELILLO I'lotary Public, Stato of New York No. Q�ialified in Westcin Ater Courof � (2) Commission Expires.January 79.2f�,..? 9-1 z/zuz 1 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: Ralph larniceli ,being duly sworn,deposes and states that h&sfic 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 Contractor 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 stonnwater or groundwater connections or sources of infiltration into the sanitary sewer system on or from the subject property. Sworn to before me this Sworn to before me this 2-7+-", day , ,20 day of O W_VA t'LQ ( , 20 2- Signature of Proper Ow Signa i' �Q Q GJLt 0 W t� C 2� Print Name of Property Owner Print V Pelican IN Votary uhlic Notary Pubtic SHARI MELILLfJ Notary Public, State of New York ` MAUR1Ct0 ESPINOIA No. 011':Lff6160C63 NOTARY pumX,STATE OF NEW YORK 0,_ialified in Westch-ster County Registration No.01ES6401306 Commission Expires January 29,20 Qualified in Westchester County My Commission Up m December 9,2W3 (4) -2021 ry N 0 w � Ln a L w x �-1 i`nn a��o ° H + M fA GO i ; .-. Ln p� �' Z 2 V N v, zo © A � � N A CZ pm 00 o ZLno W z c c� MCI eel � Z °0 v vUi z cn A � � a a o z H A oc H ig BOIL, D M ENT C) � ' 7' VILLAGE OF RYE tOOK 938 KING S'lRt-Lr RYEL3 ,NY 10573 ------------- Spy 2 1 2 2 (914)9 _ A {g939-5801 VILLAGE OF RYE BROOK N-•1`V __. wr BUILDING DEPARTMEi`T ELECTRICAL PERMITAPP'LICATION Westchester County Master Electricians License Required / / FOR OFFICE USE ONLY BP#: �� Z2 Qn3 _ EP#: c> 0/ I Approval Date: Permit Fee: $Approval Signature:Signature: Other: Disapproved: > (fees are non-refundable) Application dated, is hereby made to the Building Inspector of the Village of Rye Brook NY, for the issuance of a Permit to install an r r move electrical equipment,wiring, fixtures ,or to perform other high or low voltage electrical work as per the detailed statement described below. The applicant & property owner, by signing this document agree that all electrical work performed will be in conformance with all applicable Federal, State,County and Local Codes. 1.Address: IcL u:ct:�:'l QIQaQ, SBL: J2q,,�C{ - l -2y Zone: &I 2.Property Owner: � Q,(�p �,,� ,�.i,L P.J-f�� Address: 60 qjpnve__ Phone#: A—'//7- 0��' Cell#: email: 3.Master Electrician: tiek__ VAU,JdA Address:. L61021 U j Lic.#: (501 Phone#: Cell#:1$2-$SI email: nic" —,e(er,J-Yz�r_ ,1127A Company Name: e e,�-vz c- Address: 61,8 abo w 4.proposed Electrical Work/Fixture Count: i 6-e—J', w++++++w+++w+wwwwww++ww++www++++w+w++++++w++wwwwww+www+++++w+++rwwwwwwwwww+w++w+wwwwwwwwwwww+wwwwww+wwwww STA,,�LT��""E OF NEW YORK,COUNTY OF WESTCHESTER ) as: K) L'l _. V_�al s w'o' ,being duly sworn,deposes and states that he/she is the applicant above named,and does further (print name of individual signing as the applicant) state that(s)he is the legal owner of the property to which this application pertains,or that(s)he is the_G�PCyGt Qd� for the legal owner and is duly authorized to make and file this application. (indicate architect,contractor,agent,attomev,etc.) The undersigned further states 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. Sworn to before me this Sworn to before me this �J day of ,20 day of--3t'k�v���(�-,, ,20 a-.). Signature of Propert er Signature of Applicant iC,r- 'k—,4 L y vet S Print Name Property Owner Name of Applicarg tl MEL NotaTfublic V yr u rc, StateIof New York 01m4fied in Westch;-,Eter County Commission Expires January 29,20� 6/1/18 INSPECTIONSTATEWIDE 4F Service With Integrity 0:0 SWIS JOBAPPLICATIONi. Office Use Elect. Permit# 0� I Date � � 1 4� lJ©J ! Bldg Permit# Utility 1D# /�/- - 00 Final Certificate# City lVillage yc a !Zip h . J Township l2 r/& Q ��k CountyV. Address p 0 X (Voo Q 110L Cross Street S diop , Q Block r F Owner Name!Address(If different than above) 4 .lIJ Contact Number 9� Z Basement ❑ 1 st Fl. ❑2nd Fl. ❑3rd Fl. ❑More Than 3 Fl, ❑Garage ❑Attic ❑Outside ❑Residential ❑Commercial Receptacles Special Recept GFCI AFCI Switches Dimmers Smoke Alarms Carbon Monox Hood Trash Compact Amt Amps L Range(s) Cooktop(s) Oven(s) Dishwashers Refrigerator Disposal Microwave Warm Draw Incandescent Fluorescent SERVICE Amperage Voltage 113 3P #Meters #Disconnect ❑Underground ❑New ❑Reconnect ❑Overhead ❑Change ❑Visual Re-inspection ❑ Safety Re-Inspection ❑ Re-Inspection Additional Information `ME� E N 21 202? t_.J fi VILLAGE OF rti`r'E BROOK BUILDING GE1='A TMEINT This application is valid for one(1)year from the date received by SWtS.This application is intended to cover the above listed items to be inspected,if at any time of inspection additional items have been installed.you are authorized to make the inspection and adjust the fee for the additional items Inspected.The applicant declares that there is no open applications for the above address with any other inspection company.The applicant,owner or authorized agent agrees to all the above terms and conditions as set forth for the application. Inspector Date Finalized Inspector# Company Name Date ! /2 L Signature Address S� A j/y�/ fT City!State�I�7 fin/ v� � t�AlJ.✓ �' Zip Code License# ? / I Phone# //t,;K— z 7J — 21 7- 2— State Wide Inspection Services 1080 Main Street Fishkill, NY 12524 ® 845 202-7224 Phone 914-219-1062 Fax STATE WIDE INSPECTION SERVICES Email: office@swisny.com Website: www.swisny.com Service With Integrity BY THIS CERTIFICATE OF COMPLIANCE STATE WIDE INSPECTION SERVICES CERTIFIES THAT: Upon the application of: Upon Premises Owned by: NK Electric LLC Herbert&Judith Deutch Nick Kalyvas 19 Boxwood Place P.O. Box 171 Rye Brook, NY 10573 Croton-on-Hudson, NY 10520 Located at: 19 Boxwood Place, Rye Brook, NY 10573 Section: Block: Lot: Electrical Permit Number: EP22-011 129.59 24 Certificate Number: 2022-0310 Building Permit Number: BP22-003 A visual inspection of the electrical system was conducted at the Residential occupancy described below.The electrical system consisting of electrical devices and wiring is located in/on the premises at: 19 Boxwood Place, Rye Brook, NY 10573 The Basement was inspected in accordance with the NYS and NFPA 70-2017 and the detail of the installation, as set forth below,was found to be in compliance on the 17th day of February 2022. Name Quantity Rating Circuit Type Receptacles 06 GFCI 02 Switches 03 Luminaires 06 Officer: Frank]. Farina This certificate may not be altered in any way and is validated only by the presence of a seal at the location indicated.This certificate is valid for work performed on the date of inspection only. Building Permit Check List&Zonin Anal sis Address. `1� -W 0 0:> ::�:L . SBL I Zone: :a "' Use: z 'J Const.Type: Subnttal Date: t�- 2 Z Revisions Submittal Dates: Applicant:ul SL4A Nature of Work� �f D�— 1pj�ti° S 4R_t. �'-�r�"' �-0 2 Z e7 E vi ws:ZBA: JAN — 4 2021 PB: BOT: Other. NMP OK ( ( ) FEES:Filing. 7-5 � BP: &�2 • r C/O: Legalization: ( ) (�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: { ) ( ) SITE PLAN:Topo: Site Protection S/W Mgmt: Tree Plans Other. ( ) ( ) SURVEY:Dated: Current: Archival: Sealed: Unacceptable: ( ) {✓� PLANS:Date tamped: ✓ Sealed: -� Copies: Electronic: Other. License: Workers Coampi./ Liability Comp.Waiver. Other. O O 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: REOUiRED EXLSUNG PROPOSED NpTES APPROVED Ate: Date: ,BAN - 4 202& Circle: FroaW Front Front: sid5u: �r Main Cov Accs.Cov HS : S .HSb: Tot,Imp Ft.I : Parking Height/Stories: notes: ..• a a �•- '�\ .�ao�ru'� �-�taf�� a I ��ft, tt)� ��. � .•. Irk , r� l 1IIe1 � 11 • 1 ♦♦ � { 11 r 1. 11 � � r Y � ,� 4j Hl: lJJ nnn N Wqut l��)► :+� d etl eti CV y w� O ��• •O CV 1: r` C• r'; C v O CV 1 t(ss)i�AO;ra as 'E If1l �• ,�� �1 � "! ate+ � '.i. N i;p. i(�u's)� rrinv� � •^I C OCJ"' rtiltc 04 ction LO w O u �Q Lu �' O � �Ga a aQ Lo t(o)D wuu h+l r5 w z {uu Kss)> /f h • -4w i V O � i tt•--� � r a6 N` k 04 Via• J ra O Lo o Sr: V •• N N N ge 1 f 1 / 1 ► 1 "in"i o alIb � .. } I�CtON, :, ie1e+ deeN ►eeN +eeli+ ►NI+ •: • 1. 17 /r A�'tk•��1♦ y� ? � (,t� �!1• 1 I Amg ,i ♦4 yl. A t r, •• 1 A 4 1� p A r /♦ l�i .4, Yo 1na u o . o ra � ` o . o ' a it/1 V SY `4 /• k•�r�� '�'fs:;fir�,,,,v� �I,i�eY �� �� 'i�� l�Y�' �1 AcoRLJ►" CERTIFICATE OF LIABILITY INSURANCE pATE(MMOOmrrl 12128l2021 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' COMMERCIAL LINES TEAM GEICO INSURANCE AGENCY PHONE Gt): 800.841.1621 BBB-953-6966 ONE GEICO BLVDL s RICOMMCLU®GEICO.COM FREDERICKSBURG.VA 22412 NSURE APPORoedoeoveRAoe P"v INSURER A: UTICA FIRST 15326 INSURED INSURER B. RAFAEL IAMICELI oi$URER C: _ 54 POND VIEW CT 9IwRER0: OSSINING,NY 10562 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 REOUIREMENT.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 INSR TR ADOLaV611 TYPE OF INSURANCE POLICYNUM R POLM QuCILYYYY LIST{ COMMERCIAL OENERALLIABILRY EACHOCCURRLNCE f 300,000 CLAIMS-MADE X OCCUR _DAMA(A rU RLN I LID >• 5oow PREMISES;Ea oocwranw) _ MEo EXP(An aw won) s 5,00D A N N ART 512677002 030512021 03/2512022 PERSOW&ADVINJURY f 300,000 DENTL AGGREGATE LIMITLpIMpIIT.APPLES PER, OENERALAGOREDATE 5 600,000 F JE LOG PRODUCTS COMPIOP AGG f 600,000 OTTER --- AUTOMOIIILE UAa1LITY f ANY AUTO ODDLY INJURY{Par Parallel) OWNED LED AUTOS ONLY �O ODDLY INJURY IPW a idaM) S HIRED ry NON-OWNED : AUTOS ONLY _AUTOS ONLY (P4AtAAC"E s UMSRELLALWS OCCUR EACH OCCURRENCE f EXCESS LUIB CLAIIAS,MAOE AGGREGATE f ULU RL'LNI IONS : WORKERSCOMPENSATION AND EMPLOYERS'UASILT'Y YIN T _. ANvPROPRIETOR PARTNERIEXECUTNE EL EACH ACCIDENT f O=FICERAWNIBER EXCLUDED? r MIA -- iManddesv'wory NH) E.L DISEASE•EA EMPLOYE f I1 yye,,desaive uraler DESCRI PT ION OF OPERATIONS b 1. E.L.DISEASE-POLICY LMT DESCRIPTION OF OPERATIONS I LOCATIONS 1 VEHICLES IACORO I01,Addlbonsl Remarks Schedule,maybe imsched it more space Is requlredl JOB LOCATION HERBERT DEUTSCH 19 BOXWOOD PLACE RYE BROOK NY 10573 VILLAGE OF RYE BROOK BUILDING DEPARTMENT IS NAMED AS ADDITIONAL INSURED. 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- BUILDING DEPARTMENT 938 KING ST, 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 COMMERCIAL LINES TEAM Page 2 K Workers' Certificate of Attestation of Exemption 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 part),.** 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.contram This Certificate 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 Rafael Ia View Ct 54 Pond View From;Village of Rye Brook Ossining,NY 10562 PHONE:914-557-6703 FEIN:XXXXX9472 The location of where work will be oerformed is 19 Boxwood Place,Rye Brook,NY 10573. Estimated dates necessary to complete work associated with the building permit are from January 1,2022 to January 31,2022. The estimated dollar amount of project is S0-S10,000 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 applicant is a homeowner serving as the general contractor for a primary/secondary owner-occupied residence.The homeowner has ONLY uncompensated friends and family working on his/her residence or is hiring individuals a total of less than 40 aggregate hours per week and has a current homeowners insurance policy that covers the property. 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 applicant is a homeowner serving as the general contractor for his/her primary/secondary personal residence. The homeowner 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.) 1,Rafael famiceli,am the Homeowner 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 Workers'Compensation Board to the government entity listed above. SIGN HERE Signatur ( `T Date: (� � l ( Exemption Certificate Nutll er Received 2021-080399 December 29, 2021 NYS Workers' Compensation Board CE-200 01/201 R auou asouM uos- ^n�c au =_I7�o�a p pun a,, papas pun pau is rul uo ssajun q p Joj piJrn, quo,)-sj-)aq!g,)jVIsvwaa@no7 :INOHcl MAN�p / o - 9 bt�S01>,�10,l MAN'OOSI>1NnOW'�nN�3�V H11WS Sol N I 41 N N 1L I Is) be uo�quawasog pag5iul� Q { oz 0 LLJ Cz m1-I o Wwf CNJ� oo >-<! a-i a�ndslHro.r�6W}�Ix311TO W 0 Z' 13 nnn W ry `m m 1mvig o�,see')7y O luul `_0 u� �� J_ lwpl�Hj Meg jam � J� jm N L _ yy Y ■I-�zlQ .'b YQ-��7 .S 1 /�/� N m _l �. 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