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HomeMy WebLinkAboutRP22-009PER MIT # c� � — OC�� DATE; 'Y c�-c� ExP; '� SECTION � BLOCK LOT _ TYPE OF WORK — J %J U/� %� � JOB LOCATION � � P/I Q � e/)l,/+v OWNER 6%4 'C�e � _ �Ar aiCv 1-ISE i'' CONTRACTOR QrJ e�.� � V�IO .MIP�7� _ _ %EST. COSnT ��' �/ OOt� -- FEE � �% — 1� � ✓ CO # G � ��' i FEE .�'� �i� �',�� DATE / TCO # FEE DATE INSPECTION RECORD 1 DATE I NSP FOOTING FOUNDATION FRAMING RGH FRAMING INSULATION PLUMBING 0 RGH PLUMBING GAS SPRINKLER ELECTRIC 0 LOW -VOLT C� ALARM Q AS BUILT 0 FINAL 0 � (��y� ��o- f�a 7 Spy°u��lo C �q�/las�aca 1� ' OTHER APPROVALS ARB BOT P8 ZBA �JTHER _ �.__.�. Qy DA L lea t V 4 tt� � . 19 40A annit�( VILLAGE OF RYE BROOK MAYOR 938 King Street, Rve Brook,N.Y. 10573 ADMINISTRATOR Jason A. Klein (914) 939-0668 Christopher J.Bradbury wFww.ryebrook.org TRUSTEES BUILDING& FIRE INSPECTOR Susan R. Epstein Michael J. Izzo Stephanie J.Fischer David M. Heiser Salvatore W. Morhno CERTIFICATE OF COMPLIANCE November 7,2022 Gerardo R. Paico Eusebio&Libia P. Declet 493 Ellendale Avenue Rye Brook,New York 10573 Re: 493 Ellendale Avenue, Rye Brook,New York 10573 Parcel ID#: 141.28-1-9 Roof Permit#22-009 issued on 4/4/2022 to Re-Roof Existing Building& Garage This certifies that the new roof,installed under the above captioned permit has been satisfactorily completed. Sincerely, Michael J. Izzo Building&Fire Inspector /to DD "`' For office use niv: BUILDING DEPARTMENT PERMIT M—&� AUG 19 2022 VILLAGE OF RYE BROOK ISSUED:VILLAGE OF RYE BROOK 938 KING STREET,RYE BROOK,NEw YORK 10573 DATE: BUILDING DEPARTMPJT 1 (914)939-0668 FEE: A //Q-- PAID;% wwW,ryj&r00k ore 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 rr►rrr►►►p►►►►►►se►►►►r►►r►►►►►r►►►►►►►►►rerrrrrrr••r•r►►rr►►rrrr►rrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrr►rrrrrrrr►►rrrrrrrrrrrrr Address: 4 Llleri Q L Occupancy ///Use: �ig<'1i� Parcel ID#: �`��� --�— Zone: Owner: L.i8 A � �Pc(efi Address: uC(3 lal otidaie Ue. P.E./R.A. or Contractor: k (r maiac2�mCnTntt" Dl► Address: 36 ()U i j1fArcj Aij&— /PDit IC o �' Person in responsible charge: Address: 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: ''' Li tim F Dec Let- being duly swom,deposes and says that he/she resides at 493 Ei!Ie 6dCt k, A(JFi' (Print Name of Applicant) IL (No.and Street) in R v� Up�> intheCountyof c e Sre-r in the State of ,that (City/Town/Village) he/she has supervised the work at the location indicated above,and that the actual total cost of the work,including all site improvements, labor,materials,scaffolding,fixed equipment,professional fees,and including the monetary value of any materials and labor which may have been donated gratis was:$ ocio. , for the construction or alteration of: F 1 A 2A G�' 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 �l Sworn to before me this day f � ,20 Z'Z- day of , 20 Si a re of rty Ownet Signature of Applicant Print N of Prop Owner _ Print Name of Applicant Notary Public Notary Public CHRISTOPHER J.BRADBURY 8/12/2021 Notary Public,State of New York No.01BR6159988 Oualified in Westchester County Commission Expires January 29,20ML QyE f3RC�v�. O� Zm w �7 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: I 2Ki PERMIT# -2-2 ISSUED:�4`11-22 SECT: I'v/i 2 iOCK: LOT: 1 LOCATION: OCCUPANCY: ❑ VIOLATION NOTED THE WORK IS... S.. ACCEPTED ❑ REJECTED/REINSPECTION ❑ SITE INSPECTION REQUIRED ❑ FOOTING ❑ FOOTING DRAINAGE ❑ FOUNDATION ❑ UNDERGROUND PLUMBING NOTES ON INSPECTION: ❑ ROUGH PLUMBING ❑ ROUGH FRAMING ❑ INSULATION ❑ NATURAL GAS ❑ L.P. GAS ❑ FUEL TANK ❑ FIRE SPRINKLER ❑ FINAL PLUMBING ❑ CROSS CONNECTION ] FINAL f' ❑ OTHER �yE Bk 1932 BUILDING DEPARTMENT ❑+BUILDING INSPECTOR ell�] SSISTANT BUILDING INSPECTOR VILLAGE OF RYE BROOK ,'❑C AODE ENFORCEMENT OFFICER 938 KING STREET • RYE BROOK,NY 10573 (914) 939-0668 FAx (914) 939-5801 www.ryebrook.org - - - - - - - - - - - - - - - - - - - - INSPECTION REPORT - - - - - - - - - - - - - - - - - - - - ADDRESS:— �� � DATE. PERMIT# qe (J� l�✓ 1 ISSUED: I SECT: I y ! 2 BLOCK: LOT: C>qLOCATION: `1� OCCUPANCY: i Y-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 ��} 1 o Qc ❑ L.P. GAS ❑ FUEL TANK co, ❑ FIRE SPRINKLER W\ ( `,(J ❑ FINAL PLUMBING a / ION ❑ CROSS CONNECTION ❑ FINAL \C Cs, �_l ` n n tC6 ❑ OTHER �/ - �yE BRO '9a2 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: Q `*9 \-,�(S� '24PERMIT# 1 1 ISSUED: ECT: I "4LOCK: LOT: LOCATION: 6ZZe OCCUPANCY: v �y0 x ❑ VIOLATION NOTED H�;WVORK 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 ❑ FINAL PLUMBING ❑ CROSS CONNECTION ❑ INAL OTHER • L 3 • Q '+' � 3 4J U ■ 1 fV N � W � � ■ a yy..�� '� pip '� � � � .L r�.^{ ■ ■ M^ V Q 0 y w W ■ Q q b w _ L 72 N v � y v cC r ■ l- 0000 F-1 ° C y 10 a O a M ..� $ � �r a •� � _ O z 04 >74 1-4 (n O a � � o ao � Q ■ A cc to ►� � � ..j � � A W � � � 0 � a �' aV W a aspp ■ W Zau � C 'd y � � ■ v D w 0 ^ w w z O o © v c, ►-� Z V 0 � p w w � H of -v � 0 b G� Z A aw. Z■ z a 1 W ?y U ° ' W CA W 'i o v A.all rA O �� • a ~ � W 72 w � © + W4 00 °� a IT CN a, 0 ° w41 ° � V w a u O s O � �"t ►�+ � � w v � Uz° � W y = Z w A Y 4 O v = C6 W W r Q u p O pzo Or ] o v o H a (n z V o � o ° pc�� < cn 1 Q O O - gb4 o � U V U Z C1 Z A W O 4 .y A W Z d o � cu y Q o D�j BUILDING DEP' MENT MAR 3 1 2022 VIIJ E OF RY OK 938 KING ET RYE BR NY 10573 VILLAGE OF RYE BROOK BUILDING DEPARTMErJT FOR OFFICE USE ONLY: Approval Date: APR — 1 2022 er mil# Application# Approval Signature: ARCHITECTURAL REVIEW BOARD: Disapproved: : Date: BOT Approval Date: Case# Chairman: PB Approval Date: Case# Secretary: ZBA Approval Date: Case# Other: Application Feet Permit Fees: ' ROOF PERMIT APPLICATION Application dated: 2 /2zis hereby made to the Building Inspector of the Village of Rye Brook,NY,for the issuance of a Permit to Re-Roof an Existing Building,as per detailed statement described below. II II11 1. Job Address: 3 1511Q,na0AQ QV SBL: f"4 �,z�, Zone:��-� Property Owner: Wa i o, VC,\ tj iC_ Address: "9 S Fi It"C110- AV- Qu a. R Mo< to-,9 3 Phone#: -Cell#: �(�t(-830_ I6Z-4 email: NINkVQ�rn 20h0-k olaLcvr'ww 2. Applicant: 5%c�1 LldQ 1C, 0,ccL Address: -aOl 1Q A IN 0,nA (314S4 Qr NYI 051 3 Phone#: 91q Litt Cell.#: email: lrl&t7 .DPWOA OU)tWOK. (,anti 3. Roofing Contractor:�a. u tN d 0 G'u Ay«ASCLLo_ Address: 30 k U k UA INV. 00r� C405k Q-r t y (C 53 3 Phone#: 91 Ll - 4 181 -4 5 -)4 Cell#: email: 4. Job Description,list all Methods&Materials: 5. Estimated Cost of Job:S 1 6,©D O (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.) b. If comer property,indicate street frontage: 7. Construction Type: NYS Construction Class: 8. Number of stories: Height: 9. is garage being re-roofed:No:( )•Yes:( )Attached No:( )•Yes:O Number of Cars: 10. Is roof peaked,hip,mansard,flat,etc: 11. Estimated date of completion: -t- 811212021 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. *t*k t**N:Y********************************�c**kit***********+:*t.****xkk*:F*1k**7:�:��;*�9::F*:k***9:*•k•k*i;�Fk*t.:F:tkki:-x::is STATE OF NEW YORK,COUNTY OF WESTCHESTER ) as: Q c� a C., Co• , being duly sworn, deposes and states that he/she is the applicant above named,. (print name of individual signing as the applicant) and further states that (s)he is the legal owner of the property to which this application pertains, or that (s)he is the for the legal owner and is duly authorized to make and file this application. (indicate architect,contractor,agent,attorney,etc.) That all statements contained herein are true to the best of his/her knowledge and belief,and that any work performed,or use conducted at the above captioned property will be in conformance with the details as set forth and contained in this application' and in any accompanying approved plans and specifications,as well as in accordance with the New York State Uniform tire Prevention&Building Code,the Code of the Village of Rye Brook and all other applicable laws,ordinances and regulations. Sworn to before me this t Tit -y —� Sworn to before me this Z�`(7h _ (LIN o' �1�l�`� , 20 d*are 202.2 1 J Siicature of Pro Owner Applicant _Lib1A, ec<& 6lQau>ndo 6Ncy11asn,(a_ Print Name of Property Qwner _ Print Name of Applicant i Nota Public Notary Pu lic KEVIN E3.ZAPATA /KEVIN B.ZAPATA Notary Public,state of New York Notary Public,State of New York No.01ZA6377362 . No.Di2A6377362 Qualified in Westchester county Qualified In Westchester County- commission Explrez July 2,2022 Commission Explre6 July 2,2022 80242021 BUILD MENT D VIL I OF RY OOK 938 KING ET RYE I3R ,NY 10573 JUL 19 2022 4)9 9-OC"" . VILLAGE OF RYE BROOK w BUILDING DEPARTMENT FOR OFFICE.. USE.ONLY: Approval Date: JUL 1 9 1O emit# Application # Approval Signature: ARCHITECTURAL RE BOARD: Disapproved: Date: BOT Approval Date: Case# Chairman: PB Approval Date: Case# Secretary: ZBA Approval Date: Case# Other: Amendment Fee:g z)S—Pb Permit Fee: ApPPLI\CATION TO AMEND APPROVED PLANS Application dated: is hereby made to the Building Inspector of the Village of Rye Brook,NY,to amend the approved plans associated with an existing open permit,and/or from any prior approvals granted by the approval authority as per detailed statement described below. 1. Job Address: 493 Ellendale Av.Rye Brook 10573 Existing Permit#: RP 22-009 2. Parcel ID#: 141.28-1-9 Zone: R-7 Original Approval Date: 4/4/2022 3. Proposed Amendment(Describe in detail): N4wiwbwme-Replacement of existing EPDM roof to TPO flat roof system. 4. Property Owner: Libia Declet&Gerardo paico Eusebio Address: 493 Ellendale Av.Rye Brook 10573. Phone# Cell# (914)830-1627 e-mail Q# CAM— 7 c3 Applicant: KG Management&Development Corp. MQ/ •C�� Address: 36 Quintard Dr.Port Chester,NY 10573. Phone# Cell#(914)481-4974 —e-mail kgm.dev@outlook.com Arch itect/Engineer: Address: Phone# Cell# e-mail 5. Occupancy;(1-Fam.,2-Fam.,Comm.,etc...)Prior to construction: 1 Family After construction: 1 Family 6. Will the proposed amendment require the installation of a new,or an extension/modification to an existing automatic fire suppression system?(Fire Sprinkler,ANSL System,FM-200 System,Type I Hood,etc...)Yes: No: X (if yes,you must submit a separate Automatic Fire Suppression System Permit application&2 sets of detailed engineered plans) 7. Will the proposed amendment disturb 400 sq.ft.or more of land,or create 400 sq.ft.or more of impervious coverage requiring a Storm water Management Control Permit as per§217 of Village Code?Yes:_No: X Area: 1 8n 2no21 8. Will the proposed amendment require a Site Plan Review by the Village Planning Board as per§209 of Village Code? Yes: No: X (if yes,you must submit a Site Plan Application,&provide detailed drawings) 9. Will the proposed amendment require a Steep Slopes Permit as per§213 of Village Code Yes: No: X (if yes,you must submit a Site Plan Application,&provide a detailed topographical survey) 10. Is the lot located within 100 ft of a Wetland as per§245 of Village Code? Yes: No: X (if yes,the area of wetland and the wetland buffer zone must be properly depicted on the survey&site plan) 11. Is the lot or any portion thereof located in a Flood Plane as per the FIRM Map dated 9/28/07? Yes: No: X (if yes,the area and elevations of the flood plane must be properly depicted on the survey&site plan) 12. Will the proposed amendment require a Tree Removal Permit as per§235 of Village Code?Yes: No: X (ifyes,you must submit a Tree Removal Permit Application) 13. Does the proposed amendment involve a Home-Occupation as per§250-38 of Village Code? Yes: No:X Ifyes,indicate: TIER I: TIER II: TIER III: (if yes,a Home Occupation Permit Application is required) 14. Will the proposed amendment result in additional square footage to the building or subject structure, and if so, provide such additional footage here. N/A (Please submit additional Bulk Regulation Application Pages for review) 15. What is the total added cost of the work associated with the amendment: $ 5,000 (The estimated cost shall include all site improvements,labor,material,scaffolding,fixed equipment,professional fees,including any material and labor which may be donated gratis.) 16. N.Y. State Construction Classification: N.Y.State Use Classification: 17. Estimated date of completion: This application must be properly completed in its entirety by a N.Y. State Registered Architect or N.Y.State Licensed Professional Engineer&signed by those professionals where indicated. It must also 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: KG Management&Development , 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 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,rand that to the best of his/her knowledge there are no roof drains,sump pumps or other prohibited stormwater or groundwater connections or sources of infiltration into the sanitary sewer system on or from the subject property. Sworn to before me this If rh Sworn to before me this day of �'v ,20_?:::Z of 20 f X Signatu o 'roperty Owner Si re o 4pplicant — 'i��7 — Print N e Property Owner Print Name of Applicant Nota6 Public Notary P c 2 KENIN B.ZAPATA KENIN 15.ZAPATA `:otary Public,State of New York Notary Public,State of New York No.01ZA6377362 No.OVA6377362 Qualified In Westchester County Qualified In Westchester County Commission Explree Ju!­ 2,2021� Commission Explrer Ju!, 2,202;rC, 8/12/2021 p jD BUILD :W '�� TMENT �� MAR 31 2022 VIL�`�rGE OF RYE`�0OK 938 KING STET RYE BRo0k,NY 10573 VILLAGE OF RYE BROOK P44 J .� BUILDING DEPARTMENT w�9v�t ��'J I c11�fv FOR OFFICE USE ONLY: Approval Date: APR — 1 2022 mit# c�cT'co 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: b Permit Fees: ©o ROOF PERMIT APPLICATION Application dated: -I is hereby made to the Building Inspector of the Village of Rye Brook,NY,for the issuance of a Pennit to Re-Roof an Existing Building,as per detailed statement described below. 1. Job Address: L Il Q.nd CAI¢ QV• RY¢ roc K I o S 3 SBL: I"1 I.z �J_ I — Zone:VF Property Owner: L1V�0. VO.t riCAC Address: �93 EItanAc l� Av- Ru a. �rooK loc,9 3 Phone#: Cell#: email: 2. Applicant:_cSiNAId L ICA G(C— Address: ?,Ol (;k¢'I\ NJ. Oc(4 C(A2S4Q(- N/105 13 Phone#:-aLq-- Ll t I - 1-iI i Cell ©ukWoK. WV'-A 3. Roofing Contractor: S�Qt1d0 yugY�1C,SC co— Address: 301 ik V, eor GILQ5A o NY 10633 Phone#:9 I Lj ' t1 $1 - ` C1 •)`i Cell#: _email: )C&M. Oa tl t,"J©U 4�cxo K .co M 4. Job Description,list all Methods&Materials: L 5. Estimated Cost of Job:S 16,000 (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.) 6. If corner property,indicate street frontage: 7. Construction Type: NYS Construction Class: 8. Number of stories: Height: 9. 1s garage being re-roofed: No: ( ) •Yes: ( )Attached No:O•Yes: O Number of Cars: 10. Is roof peaked,hip,mansard,flat,etc: 11. Estimated date of completion: -I- 8/12/2021 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. .. :******isr.*':i:*A•*****i;*ic**r.****r.*******:k**ir***************is**********************r.****ic ie*k*****r,*r.i;is ie**:k**:': STATE OF NEW YORK,COUNTY OF WESTCHESTER ) as: �`]¢ pndt) &L)o.vlk_sAcc, ,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 an 4 rc..c o t• for the legal owner and is duly authorized to make and file this applicatioA. (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. Sworn to before me this r cl Th Swom to before me this `,(,l711 day o 1�l�`� , 20 �L2.. da of C r , 2022- Sigl ature of Pro caner a re f Applicant Lel,lA- ? 'Doae-t Sgyy)do 6?vgJr Print Name of Property..qwner Print Name of Applicant Nota Public C Notary Pu Ilc KEVI N B.ZAPATA 'KEV I N B.ZAPATA t Notary Public,State of New York Notary Public,state of New York No.oM6377362 No.017A6377362 Qualified in Westchester County Qualified in Westchester County- commission Explres July 2,2022 commission Explres July 2,2022 8/12L2021 - i .;j �, 1 k��•Y 1 CD U ction Ut; �".. J Z :� Q�p A�; W J cn 0 0 Q W � •� N �� �� f� t I uj 'Wn M a. 74 F o Qcc e� 1 s tb ` 04 � 1 y.. Q \I i Al �. \ ` 4 ^ Jai" � •t �j K� PO Box 66699,Albany,NY 12206 nysif.com CERTIFICATE OF WORKERS' COMPENSATION INSURANCE 0 -Tw A A A A A A 842953545 ' A-1 AGENCY 35 E GRASSY SPRAIN RD STE 504 ipy YONKERS NY 10710 SCAN TO VALIDATE AND SUBSCRIBE POLICYHOLDER CERTIFICATE HOLDER K G MANAGEMENT&DEVELOPMENT,CORP VILLAGE OF RYE BROOK 36 QUINTARD DRIVE 938 KING STREET PORT CHESTER NY 10573 RYE BROOK NY 10573 POLICY NUMBER CERTIFICATE NUMBER POLICY PERIOD DATE W2487 322-6 670646 10/15/2021 TO 10/15/2022 3/21/2022 THIS IS TO CERTIFY THAT THE POLICYHOLDER NAMED ABOVE IS INSURED WITH THE NEW YORK STATE INSURANCE FUND UNDER POLICY NO. 2487 322-6, COVERING THE ENTIRE OBLIGATION OF THIS POLICYHOLDER FOR WORKERS' COMPENSATION UNDER THE NEW YORK WORKERS' COMPENSATION LAW WITH RESPECT TO ALA. 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:/ANWW.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 KLEVER GUAYLLASACCA VICE PRESIDENT MILDRED MARTINEZ K G MANAGEMENT&DEVELOPMENT,CORP 2OF2 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 STAT SUR NCE FUND DIRECTOR,INSURANCE FUND UNDERWRITING VALIDATION NUMBER:661656057 U-2.6.3 A�� DATE(MM,DDIYY AC" YY) CERTIFICATE OF LIABILITY INSURANCElb.� r 3121/2022 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 1 _NAME: AA AGENCY PHONE _WE 914 237-6776 A-1 AGENCY (t�Ic,.Llo�Ext)c 91( 4)237-6655 -- --- 1 tac'►�J__(.__1-_-...— 35 EAST GRASSY SPRAIN ROAD STE 504 ADDRESS__ alrosetmCtmail.com YONKERS, NY 10710 __..- INsuRER(s1 AFFORP!!K1 COVERAGE _ NAICA 914 237-6655 _ _-- --__.. wsuaER A PELEUS_INS CO. ..........._.-- - INSURED INSURER B: ...—._ _.._.... _ ._._...._ _ _._. K G MANAGEMENT&DEVELOPMENT CORP INSURERC ___..._._ 36 QUINTARD DRIVE INSURERD: PORT CHESTER,NY 10573 INSURERS 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 TH15 i 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' ADDL SUBR POLICY EFF —POLICY EXP LTR TYPE OF INSURANCE POLICY NUMBER MOD IMMMONYM LISTS _+ I X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE CLAIMS-MADE �X;OCCUR --PREMISES_LEa oc�rtence $ 100 000 _r �MED EXP(Andon one.person)_i._$_ 5,000—L A _ X 600GLO205268-00 10/1112021 10/11/2022 �ftRsoNALaADyil,IJURY 5_ 1,000,000 !GEN'L AGGREGATE LIMB APPLIES PER: _GENERAL AGGREGATE 2,0001000 PRODUCTS-COMPIOPAGG $� 2,000,000 POLICY L a LOC ._---.-- -`--__..— $ _ OTHER: __ AUTOMOBILE LIABILITY MB NED SINGLE LINT ($ - Ea_sccideMl—.._ j ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per accident)I$ AUTOS ONLY AUTOS ------ —1---- HIRED NON-OWNED PROPERTY DAMAGE AUTOS ONLY i AUTOS ONLY UMBRELLA LIAB OCCUR ! EACH OCCURRENCE $ EXCESS LIAR CLAIMS-MADE DED RETENTION$ pER OTH- I WORKERS COMPENSATION AND EMPLOYERS'LIABILITY Y ..... .STATUTE ANY PROPHIE rORIPARTNER/EXECUTIVE ❑ El EACH ACCIDENT $ OFFICE RIMFMBFR EXCLUDED? NIA (Mandatory in NH) I ,E L DISEASE EA EMPLOYE $ If yes,describe under ' DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT i S ^_ ; i DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101.Additional Remarks Schedule,may be attached If more space Is required) SUBJECT TO POLICY TERMS CONDITIONS AND EXCLUSIONS OF THE ACTUAL INSURANCE POLICY AT TIME OF ISSUANCE. • VILLAGE OF RYE BROOK LISTED AS ADDITIONAL INSURED. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE i VILLAGE OF RYE BROOK THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 938 KING STREET RYE BROOK, NY 10573 AUTHORIZED REPRESENTATIVE ©1988-2015 ACORD CORPORATION. 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