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HomeMy WebLinkAboutDP20-006PERT SEC1 TYPE JOB OM CON EST. .to/c O TCO # FOOTING FOUNDATION FRAMING RGH FRAMING INSULATION PLUMBING CO RGH PLUMBING GAS 0 SPRINKLER ELECTRIC LOWVOLT L� ALARM AS BUILT CD FINAL FEE INSPECTION RECORD DATE INSP DATE J OTHER APPROVALS ARB BOT PB ZBA OTHER �y BR t'i Sub j Q Jal�L,,c,uSJ A`C VILLAGE OF RYE BROOK MAYOR 938 King Street, Rye Brook,N.Y. 10573 ADMINISTRATOR Paul S.Rosenberg (914)939-0668 Christopher J.Bradbury www.ryebr000hora TRUSTEES BUILDING& FIRE Susan R. Epstein INSPECTOR Stephanie J. Fischer Michael J. Izzo David M. Heiser Jason A. Klein CERTIFICATE OF COMPLIANCE November 17, 2021 Valenti Communications Corp 111 South Ridge Street Rye Brook,New York 10573 Re: 111 South Ridge Street, Rye Brook, New York 10573 Parcel ID#: 141.27-1-29 Demolition Permit#20-006 issued on 7/20/2020 This certifies that the partial 2"d floor demolition,under the above captioned permit has been satisfactorily completed. Sincerely, Michael J. Izzo Building& Fire Inspector Ag 1/ UILD 0, ENT For oMee use only: PERMIT# Pao—Gala VIL OF RYE K ISSUED: '7 3G-3k0 JUL - 9 2021 8 KING STREE tr"E BROOK, YORK 10573 DATE: (914)9 939-5801 FEE: ,& 6 /0— PAIDAi VILLAGE OF RYE BROOK c.o BUILDING DEPARTMENT jf 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 ssssxsissssisssissesssisssssssxsasssessssssxsisiissiiissiiiisssssssssx+sssssss***ss**sass:assssiisi*iisiiiisssitssssssssssssx Address: I I l S.RIDGE STREET Occupancy/Use: UNOCCUPIED Parcel ID#: 141.27-1-29 Zone: C-1 Owner: VALENTI COMMUNICATIONS CORP. Address:I I I S. RIDGE STREET-STE 100,RYE BROOK,NY P.E./R.A.or Contractor: J. A. VALENTI DEVELOPMENT,INC. Address: I I l S.RIDGE STREET-STE 100,RYE BROOK,NY Person in responsible charge: CHARLES J,VALENTI Address: 72 FENIMORE ROAD,NEW ROCHELLE,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: CHARLES J.VALENTI being duly sworn,deposes and says that he/she resides at 72 FENIMORE ROAD (Print NameoiApplicant) ('No and Street) in NEW ROCHELLE in the County of WESTCHESTER in the Stateof NY that (City/Town Viliagel he/she has supervised the work at the location indicated above,and that the actual total cost ofthe 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:$ 18,000.00 for the construction or alteration of: Partial 2nd Floor Demolition 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 am 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 Bui iding Inspector as per §250-10.A.of the Code of the Village of Rye Brook. Sworn to before me this 6th Swam to before me this 6th day of , 20 21 day of Ju IN' , 20 21 A A . I r o r r gnawreof`ApThi ai[ CHARLES J.VALENTI JOHN-ANTHONY VALENTI Print Name of Property Owner Print Name of Applicant 4 d ltt „M n PLlblle Na 'ublic JE90ME A. VALENTI JEB E A. VALENTI' NOTARY PUSLIC-STATE OF NEVI YORK NOTARY PUBLIC-STATE OF NEW YORK No.01VA62U5161 No 01VA6205161 Qualified in'L Westchester County Qualified in Westchester County hAy Commission Expires 06-01-2025 ,My Commission Expires 06-01-2025 Iow ' 19132•��� 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 Uebrook.or - - - - - - - - - - - - - - - - - - - - INSPECTION REPORT - - - - - - - - - - - - - - - - - - - - ADDRESS :— t f V `I DATE: PERMIT# !�t f O ISSUED:2 ECT: BLOCK: LOT: LOCATION: OCCUPANCY: ❑ 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 _ f� ❑ NATURAL GAS Sib ❑ L.F. GAS FUEL TANK FIRE SPRINKLER ❑ FINAL PLUMBING ❑ CROSS CONNECTION FINAL OTHER �E DRC��. w � BUILDING DEPARTMENT ❑BUILDING INSPECTOR 11 ASSISTANT BUILDING INSPECTOR VILLAGE OF RYE BROOK ❑CODE ENFORCEMENT OFFICER 938 DING STREET • RYE BROOK,NY 10573 (914) 939-0668 FAx (914) 939-5801 www.aebrook.org - - - - - - - - - - - - - - - - - - - - INSPECTION REPORT - - - - - - -- - - - - - - - - - - - - ADDRESS : t so, \� V-\ � � � 2D� zo �f DATE: -2� PERMIT#' � � ^� ISSUED: ��'� SECT: BLOCK: LOT: LOCATION: - +. 7 c)`_ I t-'!` `r OCCUPANCY: i ❑ VIOLATION NOTED THE WORK IS... D ACCEPTED REJECTED/REINSPECTION ❑ SITE INSPECTION I REQUIRED FOOTING W FOOTING DRAINAGE ❑ FOUNDATIONS'' ❑ UNDERGROUND PLUMBING NOTES ON INSPECTION: ❑ ROUGH PLUMBING ❑ ROUGH FRAMING ❑ INSULATION � ❑ NATURAL GAS l ❑ L.P. GAS ❑ FUEL TANK ❑ FIRE SPRINKLER ❑ FINAL PLUMBING ❑ CROSS CONNECTION Q FINAL 'd OTHER t �i O N{� N 04 33 1 ��j 't u 6. �Tw ... Q, cco Q Q N C: `� it how o ' ON _ �:+ U 1 O � T�+ �N E.... r 7 .. Z aR r+ ® 81; in VIEW 6Q FEN _D $UIL EX MENT ff� VIL E OF RYE OK OCT Z 2 ?OZQ 1 938 KIN ET RYE B ,NY 10573 j (914)9 1 939-5801 VILLAGE OF RYE BROOK h ar BUILpING pEPARTMENT ELECTRICAL PERMIT APPLICATION Westchester County Master Electricians License Required ,,//� f� FOR OFFICE USE ONLY O EP#: �V � [•�� Approval Date: ()CT 1) rb qwe _ _ Permit Fee: $ C1 Approval Signature: `, Other: Disapproved: (fees are non-refundable) ****#*##****##*r**# **#* Application dated, !Q ; Qs hereby made to the Building Inspector of the Village of Rye Brook NY, for the issuance of a Permit to install and/ r remove 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. TIl 1 1.Address: 1 '/ de—t SBL: �y�. � �'- r � 2� Zone: 43 II 2.Property Owner: ll , r Address: Phone#: Cell#: email: 3.Master Electrician. Af/L tt e/! Address: Lic. #: /z7 ",/I_Phoned�#; 92'y tell#: ! email: Company Name: !A1j_ WCeU r_ja +CGIl 60nfr0C:�'rnC1 Address: F5? s• ��f_ol ✓I/" r1m,71U' T- r 4.Proposed Electrical Work/Fixture Count: f trr ra a I �,ieocc, r t Edwardne6. STATE OF NEWYORK,COUNTY OF WESTCHESTER ) as: _ ,/,'i 4r f. {1AL•nC J[ ,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 for the legal owner and is duly authorized to make and file this application. (indicate architect,contractor,agent,attorney,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 worn to before me this v2 day of acre Signature of ProperW<vner Signatide p r 47. Print Name o ro erty Owner Pri ame of Applican No tar ublic Notary Public DEN15E SCOTT Notary Public, State of New York No. 01 SC613B237 Qualified in Westchester Countwr Commission Expires Dec. 19, 2Q! 3/21/19 r Westchester Rockland Electrical Inspection Services, Inc. ` , Phone: 914-347-3595 DO NOT WRITE HERE-FOR OFFICE USE ONLY 43 North Lawn Avenue Fax: 914-347-3596 Elmsford, NY 10523 BUILDING PERMIT NO. TEMP Jl DA7TE �1 ` '-' CITY OR VILLAGE I _ ZIP COPE TOWNSHIP COUNTY J 1f.. STREET AND NO.OR ROAD J C(r POLE NUMBER BETWEEN WHAT TWO CROSS STREETS IS PREMISES LOCATED? SECTION AYI 2 7 BLOCK LOT 29 OCCUPANT'S NAME �l 11 d G d G BLI0.DIIK3 OCCUPANCY cc OWNER'S NAME AND ADDRESSr � �� n I !G! HOME TELEPHONE NUMBER en-CURRENT SUPPLIED BY FROM THEIR OFFICE WpgK TELEPHpNE NUMBER, , LIST BELOW ALL EQUIPMENT WHICH YOU INSTALLED NUMBER OF OUTLETS NO.OF FIXTURES& MOTORS HEATERS OFFICE USE LOCATION LAMP RECEPTACLES ONLY SIDEWALL SWITCH 1NCADE FLUORE NO, H.P.EACH NO. WATTS EACH INSPECTION OUTSIDE BASEMENT 1i"FL Zulu FL VIL. LA E OF R E BROOK 3'FL NT REMARKS:LIST OTHER€LECTRICAL DEVICES NOT SET FORTH ABOVE:. THIS APPLICATION IS INTENDED TO COVER THE ABOVE LISTED ITEMS TO BE fNSPECTED.IF AT ANY TIME OF INSPECTION ADDITIONAL ITEMS HAVE BEEN INSTALLED,YOU ARE AUTHORIZED TO MAXE THE INSPECTION AND ADJUST THE FEE FOR THE ADDITIONAL FTEMS INSPECTED AS PROVIDED BY THE APPLICANT THE APPLICANT DECLARES THAT THERE IS NO OPEN APPLICATIONS FOR THE ABOVE WITH ANY OTHER INSPECTION COMPANY WRENS,INC.IS NOT LISTING.LABELING,UNDERWRITING OR CERTIFYING ANY EOUIPMENT, MATERIALS OR DEVICES WHICH ARE PERFORMED BY OTHER CERTIFIED TESTING AGENCdFS OR INSPECTION COMPANIES,THE APPLICANT,OWNER,OR AUTHORIZED AGENT AGREES TO ALL THE ABOVE TERMS AND CONDITIONS AS SET FORTH FOR THE APPLICATION SIZE OF SERVICE FEEDERS CHARACTER OF WORK NEW ADDITIONAL C EXPOSED CONCEALED❑ MUST ENTER APPLICANTS IDE,rNTIFICAT10N NUMBER(`} SERVICE ENTERS BUILDING OVERHEAD UNDERGROUND 1 d r ,} jo f, Y� 3 AVOID DELAYS BY GIVING FULL AND ACCURATE INFORMATION.ALL SPACE MUST BEFILLED IN&R0PLICATION MAY BE REETURNIEDD, NAME OF CGMPNNY 1 DATE OF APPLICATION SIGNATURE OF APPLICANT \ t°�WG /ec tTj CL 60/1 !(o C: rI i Ic 2 y X STPAEF TELEPHONE NO.✓ �. Cmf OR Posy OFFICE / � ZIP CODE�� LICENSE NO.WHEN APPLICABLE V 4 WESTCHESTER ROCKLINO WRE I ELECTRICAL INSPECTION SERVICES,INC. BY THIS CERTIFICATE OF COMPLIANCE THE Westchester Rockland Electrical Inspection Services 43 North Lawn Ave, Elmsford, NY 10523 914-347-3595 (Office) 1 914-347-3596 (Fax) CERTIFIES THAT Upon the application of: Upon premises owned by: Belway Electric Valenti Communications Corp 66 South Central Avenue Elmsford NY 10523 Located at: 111 S Ridge St, Rye Brook, NY 10573 Certificate Number: 749336 Section: 141.27 Block: 1 Lot: 29 BAC: Permit Number: EP:20-205 BP:20-006 A visual inspection of the electrical system at this premise described as a Commercial occupancy,wherein the premises electrical system consisting of electrical devices and wiring, described below, located in/on the premises at: 111 S Ridge St, Rye Brook, NY 10573 ❑Basement ❑1st Floor ❑X 2nd Floor ❑3rd Floor ❑Garage ❑Attic ❑Outside Other: Inspection was conducted in accordance with the NYS and NFPA 70-2017 International Electrical Code and detail of the installation, as set forth below,was found to be in compliance therewith on 11/3/2020 Name Quantity Rating Circuit Type Demolition 1 Removal of existing electrical This Certificate has been approved by Westchester Rockland Electrical Inspection Services. This certificate may not be altered in any way. This certificate is valid for work performed before date of inspection only. Building Permit Check List&Zoning Anal sis I C Andress: 1.1 __c 11 � th a _ (� , S13L: -- Zone G se Cons t Type Z Other: Submittal Date: 4 1 2� Revisions Submittal Dates: Applicant: `r%, (f©.r-,, �,�.. tom► Nature of Work A L1 Reviews:ZBA: J U L 1 4 2020 PB: BOT: Other. OK ( ( ) FEES:Filing. Z�` � BP: L{.O 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 Plan: Other. ( } ( ) SURVEY:Dated Current Archival• Sealed Unacceptable: ( ) (.,�'PLANS:Date Stamped Sealed ✓ Copies: —2i Electronic Other. License: Workers Comp:_ Liability: f Cornp.Waiver. Other. ( ) { ) CODE 753#: Dated N/A: HIGH-VOLTAGE ELECTRICAL:Plans: Permt: N/A: Other. ( ( ) LOW-VOLTAGE ELECTRICAL:Plans: Permit: N/A: Other. {✓}� ( ) FIRE ALARM/SMOKE DETECTORS:Plans: Permit: H.W.I.C.:_Battery:_Other. LP Gas• N/Af: Other. ( I :Plans: e Eer OerH.V.A.C.: Plans: Permit N/A ( ) ( ) FUEL TANK:Plans: Permit: Fuel Type: Other: ( ) ( ) 2017 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: BEOUIRED EXISTING PROPOSED NOTES APPROVED AMP Cir . a Frp E= Fm= - - main CoP Acm FL H Sd.H/5b: a& TRIM Ft.Imp Plug: HH /stories notes: Laura Petersen From: Laura Petersen Sent: Thursday,July 16, 2020 10:33 AM To: 'JOHNANTHONY@VALENTIPROPERTIES.COM' Subject: 111 South Ridge Street - Demolition Permit Application Attachments: Fire Suppression Full 61.2020.pdf 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. Fire inkler application & fee ($275.00 application fee and permit fee $25.00 per ,000 or a minimum of$275.00) Fir prink contractor's valid liability insurance (the Village Of Rye Brook must be the rtifi a holder) 3. Fi sprinkler contractor's valid workers compensation on a NY State Board form (C105-2 or U26.3) Laura Fetersen Office Assistant Village of Rye Brook 938 King Street Rye Brook, New York 10573 Phone(914)939-0668 1 Fax(914)939-5801 1 ipetersen ri ryebrook.org 1 ACQ or CERTIFICATE OF LIABILITY INSURANCE DATE'M1a�zoza 12020YY) THIS CERTIFICATE 15 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: Adam Antoinette BNC Insurance Agency,Inc PAHON o (914)937-1230 FAX Arc Nc. (914)937-1124 90 South Ridge Street EMAIL aantoinette@bnca en oom ADORE SS: g INSURER(S)AFFORDING COVERAGE NAIL N Rye Brook NY 10573 INSURERA: Selective Insurance Company of South Carolina 19259 INSURED INSURER B J.A.VALENTI DEVELOPMENT INC. INSURER C: 111 South Ridge Street INSURER D: Suite 100 INSURER E Rye Brook NY 10573 INSURER F: COVERAGES CERTIFICATE NUMBER: CL2071097288 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 IN SD VND POLICYNUMBER MMNDNYYY) (MMI LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE ® DAMAGE TO RENTED OCCUR PREMISES Ea occuM!ce S 500000 MED EXP(Any one person) $ 15,000 A S 2204321 0111712020 01/1712021 PERSONAL&ADV I NJURY 5 1,000,000 GEN'LAGGREGATE LIMIT APPLIES PER. GENERAL AGGREGATE $ 2,000,000 POLICY EljE0. ®LOC PRODUCTS-COMPIOPAGG S 2,000,000 OTHER' S AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000 Ea acc".nt ANY AUTO BODILY INJURY(Per person) $ A OWNED SCHEDULED S 2204321 01117/2020 01/1712021 BODILY INJURY(Per amdentl 5 AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE S AUTOS ONLY AUTOS ONLY Per aeadertt S A IUMBRELLA LAB OCCUR EACH OCCURRENCE $ 10.000,000 EXCESS LIAB CLAIMS-MADE S 2204321 01117/2020 01/17/2021 AGGREGATE $ 10.000,000 DED I X1 RETENTION S 10,000 5 WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY YIN STATUTE I IER ANY PROPRIETORIPARTNERIEXECUTIVE ❑ NIA E.L.EACH ACCIDENT $ OFFICERIMEMBER EXCLUDED? (Mandatory In NH)If yes,describe under E.L.DISEASE-EA EMPLOYEE 5 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT 5 DESCRIPTION OF OPERATIONS r LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Re: Building Permit The Village of Rye Brook is named as Additional Insured. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF 7HE 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 ORK Workers' STATE Compensation CERTIFICATE OF Board NYS WORKERS' COMPENSATION INSURANCE COVERAGE In.Legal Name&Address of Insured(Use street address only) I b.Business Telephone Number of Insured (914)633-9700 J.A.Valenti Development,Inc. 1 I 1 South Ridge Street Suite 100 Ic.NYS Unemployment Insurance Employer Rye Brook,NY 10573 Registration Number of Insured Work Location of Insured(On1y required ifcoverage is specifically Id.Federal Employer Identification Number of Insured limited to certain locations in New York,i.e.,a Wrap-Up Polic.0 or Social Security Number 131849941 2.Name and Address of the Entity Requesting Proof of 3a.Name of Insurance Carrier Coverage(Entity Being Listed as the Certificate Holder) Selective Insurance Company of America Village of Rye Brook 3b.Policy Number ofentity listed in box"la" 938 King Street WC 9024453 Rye Brook,NY 10573 3c.Policy effective period 1117/2020 to 1/17/2021 3d.The Proprietor,Partner or Executive Officer are ❑ included.(only check box if all partners/officers included) El 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"1 a"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: Paul Sohipian (Print name of authorized representative or licensed agent of insurance company) Approved by: 711 012 0 2 0 (Signature) (Date) Title: Vice President Telephone Number of authorized representative or licensed agent of insurance carrier: (914)937-1230 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) www.wcb.ny.gov