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HomeMy WebLinkAboutBP22-051PERMIT DATE: EXP:� 3 �� SECTION o ....._ BLOCK LOT I3/ TYPE OF WORK _ �A jq o Cy JOB LOCATION OWNER CONTRACTOR, EST. COST tv 0 # � TCO # �r D,4 cis --0�mQf/c� �- FEE INSPECTION RECORD DATE FOOTING FOUNDATION FRAMING RGH FRAMING INSULATION O PLUMBING RGH PLUMBING GAS SPRINKLER ELECTRIC LOW -VOLT ALARM AS BUILT FINAL INSP OTHER APPROVALS ARB BOT P'B Z8A OTHER t.L4 emu+y�V 19 4m anniUmaW VILLAGE OF RYE BROOK MAYOR 938 King Street, Rye Brook,N.Y. 10573 ADMINISTRATOR Jason A.Klein (914) 939-0668 Christopher J. Bradbury www.ryebrook.org TRUSTEES BUILDING& FIRE INSPECTOR Susan R. Epstein Michael J. Izzo Stephanie J. Fischer David M.Heiser Salvatore W.Morlino CERTIFICATE OF COMPLIANCE May 16,2022 Olympia Lopatin 129 Brush Hollow Crescent Rye Brook,New York 10573 Re: 129 Brush Hollow Crescent, Rye Brook,New York 10573 Parcel ID#: 129.76-1-131 Building Permit#22-051 issued on 4/13/2022 to Replace Windows This certifies that the new windows,installed under the above captioned permit have been satisfactorily completed. Sincerely, Steven E. Fews Assistant Building&Fire Inspector /to R IBBUILD R ENT For office use only: MArc� D Y - 6 2022 VIL OF RYE OK PERMIT# 5/ ISSUED: 938 KING STRE YE BROOKS YoRK 10573 DATE: VILLAGE OF RYE BROOK 9 0 O�c FEE: ,fig( //0— PAIDK BUILDING 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 srtsrrrssss«ttrrr«ss:ss«t««r►s+sr+ssss►w+*s+wwwwwww*wwww+srsrsw+w++ww****+w«sr►«►«t►«►*+*+******+*****ssrrs«srsssrrtsrrrtsr«s Address: ice' Occupancy/� se: t 5,rs c o fi k L Parcel ID#: /r) /#, Ito r —/3l Zone: u Owner: U�y r�+�I(� � �(�(^ }-,>� Address: 6(�,3 GrC.)c%t'in"t VL7 t� Er uj)< IV 1�S P.E./R.A.or Contractor: Q;..,I I'�- A l l H6,n.c, loo c4,* Address: q�cl W I 116 C,vy. r,rfi cLA41 /v /(J yo 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 LY1 n 4i W a fir) being duly sworn,deposes and says that he/she resides at P 6rw fW cvj c✓cz e,?+ (P(PrmtN m^ ep cant) (No.and Street) J'�in ,, pr,b y)< ,in the County of i^Icj f in the State of—M Y ,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:$ for the construction or alteration of: lr i I ,- �� ✓ /1 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 ISM n 1 Sworn to before me this &� day of Q , 20 d-3L, day of FPitjNtt ,wit,' � ��� ✓�� Signature of Pr perry Owner V Signature o pplicant 0(Y1'-Dices -- Print Name ofProperty Owner Print Name oi Applicant4't-4-� �7 7 try Public otary Public ANNA KIELBASA ANNA K{ELBASA NOTARY PUBLIC-STATE OF NEW YORK NOTARY PUBLIC-STAT'E OF NEW YO No.01 K16378519 � Zi2ozl No.01 K163'7$519 Qualified in Putnam County Qualified in Putnam County My Commission Expires 07-30-2022 My Commission Expires 07-30-2022' QyE BRC��. cu � • �9az BUILDING DEPARTMENT ❑BUILDING INSPECTOR j3ASSISTANT 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:_ \,-aq G s1-1 1) I 1 �j DATE: S 1� I ZOZL L � PERMIT# 6 � ISSUED: 1 3 ECT: BLOCK: LOT: LOCATION: W �CLi� f)�C/` - /Y1 c� OCCUPANCY: ❑ VIOLATION NOTED THE WORK IS... ACCEPTED ❑ REJECTED/ REINSPECTION ❑ SITE INSPECTION REQUIRED ❑ FOOTING overt 1 C" ❑ 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 in N N o a � s N \ W v y i-i N w W i--+ v o N w ICU 0 h3 ''�t � 3 CD 0. W a o F-i 0' o a a nQ q w "U � > '° a �•� Q as V �I v� A o C d a v aG a � a W � ' w ° u ° � 'v � . W x Lin O ' x A w p Ipl CN 00 w Q � '� U 00 04 Ux w a O z s °a n..D a lu tG A v li W o 1.1 - �U pout s .ti � •N w G1 C7 A � © arnNa � o � .� a 414;4;.4 410 4;a 4 a 4;4;9 a 4 a a a IQ 16 4 46 4;4aaa9a4;4;4;a a 419 9 a a a 4 4141441 p EC ENE BUILDaft ENT VIL OK APR - 7 M2 938 KING ETNY 10573 14 VILLAGE OF RYE BROOK BUILDING DEPARTMENT ADMINISTRATIVE EXTERIOR BUILDING PERMIT APPLICATION FOR EXTERIOR WORK WHICH DOES NOT REQUIRE VILLAGE ARCHITECTURAL REVIEW BOARD APPROVAL FOR OFFICE USE ONLY: APPROVAL DATE: APR ,7Q97 ERMIT#�: ' �� APPLICATION FEE: APPROVAL SIGNATURE: PERMIT FEES: H.O.A. APPROVAL: DATE: DISAPPROVED: OTHER: Application dated: '7—74;�� is hereby made to the Building inspector of the Village of Rye Brook,NY,for the issuance of a Permit for the construction of buildings,structures,additions,alterations or for a change in use,as per detailed statement described below. 1. JobAddress: 122 6QV►S� 4011ovd Cr`-S Rt LOOK /Vt/ D�r23 2. Parcel ID#: —/- J/ Zone: pub 3. Proposed Improvement(Describe in detail): o" e fl� -h-1 r Jq E X!S ,� t4 i o S —A oe j All �w arm Vi r' Sa bYUu� ek�t,i�or wl���e_ r*LJ1�/ Sti n 1 � eh r r vfnTc S}Z 1«5 4. Property Owner: O i c\ L o nn Address: ` e rt.,S 11ao C res (�+ g- Bra X f) Phone# 9it)-32"7 Cell# e-mail 0lymmeiC�10poi11"()C)• ^D� List All Others Properties Owned in Rye Brook: Applicant: / urn,b l e � Z r� rm rU ,�f`r 2 Address: -I'l3 9 w I ]le 4-+ �i�- N� - �� /t/ 1' /o n3 Phone# 9 qi jr) - Z{;1') -Cell# e-mail C�P(AO+CQ1-4 Q/' q, i, Architect: Address: Phone# Cell# e-mail Engineer: Address: Phone# Cell# e-mail General Contractor. c> l/ .�►"`� ►. ',/'Q Address: �39 Wilk V l u S9 3 Phone# 91 Ll `q3)-(091 Cell# e-mail (--F (4iA4TA( ''nu' (1) 8/12/2021 5. Occupancy;(1-Fam.,2-Fam.,Commercial.,etc...)Pre-construction: Y" Post-construction: 6. Area of lot: Square feet: Acres: 7. Dimensions from proposed building or structure to lot lines: front yard: rear yard: right side yard: left side yard: other: 8. If building is located on a comer lot,which street does it front on: 9. Area of proposed building in square feet: Basement: 1 S`fl: 2"d fl: 3'd fl: 10. Total Square Footage of the proposed new construction: 11, For additions,total square footage added: Basement: l s,fl: 2nd fl: 3'd fl: 12. Total Square Footage of the proposed renovation to the existing structure: 13. N.Y. State Construction Classification: N.Y.State Use Classification: 14. Construction Type&Location:()Typical Western Lumber Frame;O Timber Frame[TC];()Wood Truss[TT]; ()Pre-engineered wood[PW];Located;{}Floor Framing[F];O Roof Framing[R];O Floor&Roof Framing[FR];Other: 15. Number of stories: Overall Height: Median Height: 16. Basement to be full,or partial: finished or unfinished: 17. What material is the exterior finish: 18. Roof style;peaked,hip,mansard,shed,etc: Roofing material: 19. What system of heating: 20. If private sewage disposal is necessary,approval by the Westchester County Health Department must be submitted with this application. 21. Will the proposed project 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: (if yes,applicant must submit a separate Automatic Fire Suppression System Permit application&2 sets of detailed engineered plans) 22. Will the proposed project disturb 400 sq.ft.or more of land,or create 400 sq.ft.or more offimpervious coverage requiring a Stormwater Management Control Permit as per§217 of Village Code? Yes:_No: Area: 23. Will the proposed proje require a Site Plan Review by the Village Planning Board as per§209 of Village Code? Yes: No: V (if yes,applicant must submit a Site Plan Application,&provide detailed drawings) 24. Will the proposed project require a Steep Slopes Permit as per§213 of Village Code Yes: No:1Z (if yes,you must submit a Site Plan Application,&provide a detailed topographical survey) / 25. Is the lot located within 100 ft.of a Wetland as per§245 of Village Code? Yes: No: V (f yes,the area of wetland and the wetland buffer zone must be properly depicted on the survey&site plan) 26. Is the lot or any portion thereof located in a Flood Plane as per the FIRM Map dated 9/28/07? Yes:-No: L� (if yes,the area and elevations of the flood plane must be properly depicted on the survey&site plan) 27. Will the proposed project require a Tree Removal Permit as per§235 of Village Code?Yes: No: (if yes,applicant must submit a Tree Removal Permit Application) 28. Does the proposed project involve a Home-Occupation as per§250-38 of Village Code? Yes: No:z Indicate:TIER I: TIER II: TIER III: (ifyes,a Home Occupation Permit Application is required) 29. What is the total estimated cost of construction: 5, 0 U Note:estimated cost shall include all site improvements,labor,material,scaffolding,fixed equipment,professional fees,including any material and labor which may be donated gratis.If the final cost exceeds the estimated cost,an additional fee will+be required`prior to issuance of the CIO. 30. Estimated date of completion: 1 1 n k S. G rovi k I W I ii 6+- be, t r) LAn J,' L4 �"�• (2) 8/12/2021 BUILg MENT V>aF RY OOK APR - 1 2022 938 KINGRYE BR ,NY 10573 VILLAGE OF RYE BROOK -0 BUILDING DEPARTMENT 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: ,3J, G1 2u1+irl , residing at, 12� ���tS�, M •' G �� l 9ye' &zJ"�/II T (Print name (Address where you live) e.7 v- 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; H I O`Jc"') crc c$(}-f" / / I o 3 ,Rye Brook,NY. (Job Address) 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 concerning either the storm sewer or sanitary sewer,and further that there are no roof drains, sump 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. (Signature of Pr perry Owner(s)) (Print Narhe of Property Own r(s)) Sworn to before me this day of pj , 20 (' ary Public; Ai NA KIELBASA _ r NQTARY PUBLIC STATE OR NEW YORK No.01 M6378519 Qualified in Putnam County (6) MY-Commission EXPifes 07-3o-2022 sn 2/202 t 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: C �rn C ,— �g a.fii n ,being duly sworn,deposes and states that he/she is the applicant above named, (print name of individ 1 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 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 stormwater or groundwater connections or sources of infiltration into the sanitary sewer system on or from the subject property. Sworn to before me this j Sworn to before me this day of , 20' - day of Fek"/ L'e 20 Signature of Tiropehy Owner f Signature ppii ant 0I a ; W� Olxr► ya&- Lti��%-fin Print Name f Property wner Print Name of�Applicant 11 No Public Notary Public ANNA KIELBASA NOTARY PUBLIC-STATE OF NEW YORK ANNA KIELBASA No.01 KI$378519 NOTARY PUBLIC-STATE OF NEW YORK Oualifieci fir,Putnam County No.01 K 163 78519 y Commission Expires 07-30-2022 Qualified in Putnam County M My Commission Exwros 07-30-2022 (g) 8/12/2021 LICENSE NUMBER "THE ORIGINAL" D O �� Family Owned And Westchester WC-8561-H97 � Operated Since 1960 Connecticut 00556256 All Home Improvements EST. 1960 439 Willett Ave. Port Chester,N.Y. 10573 Tel#(914)937-4279 Fax(914)937-4172 http://www.DoubleRwindows.com Felix& Olympia Lopatin January-20-2022 129 Brush Hollow Crescent Rye Brook, NY 10573 (917)327-7541 olympialopatin@yahoo.com Insurance: All work involved within the following proposal is covered by Workmen's compensation,Public Liability,and Completed Operations Insurance. Ideal Majestic replacement windows contract. Supply labor& material for the following. A- Double W to replace the existing windows with the new Ideal Majestic replacement type windows. B- The windows are all vinyl with a Sahara brown exterior and white interior. C- The windows are all sliding type windows with high performance energy star glass,full screens, new PVC trim for the exterior and a small primed interior stop molding. D- The windows come with foam filled frames and all welded frames and sashes.The windows are custom made to fit each opening and will be insulated and caulked at time of installation. E- The location of the windows is as follows. Kitchen double slider, Living room 3 section slider, M.B.R.double slider, master bath a double slider. F- We will cart away all job related debris. G- A$500 discount was applied to this price. Permit fees for building dept is not included in the contract H- Permit fees with the village of Rye Brook$265 I- New windows price with increase$5,060+$265 permit fees.=$5,325 Terms: Painting,and windows cleaning to be done by others.Hidden rotten wood not included. Standard industry cash term,one half with the order,balance due upon completion. Terms may be modified to meet special conditions. Past due balances are subject to a monthly service charge of 1 1/2%(18%per annum). If the account becomes delinquent,we agree to pay any legal or collection fees expended by Double"R"arising from collection of the account.Permit&Application fees not included. Double"R"is not responsible for reconnecting existing alarm systems on windows and doors. You the owner may cancel this transaction at any time prior to midnight of the third business day. After the date of this transaction,such Cancellation must be made in person,at the offices of community improvements,or in writing postmarked prior to the fourth business day.We accept VISA or Mastercard with a 3%convenience surcharge on total amount being charged. Acceptance: The above prices,specifications and conditions are satisfactory and are accepted. Double"R"is authorized to do the work as specified. Contractor Performance Warranty: Double"R"proposes to furnish and install labor and material in accordance with above specifications in order that the above qualifies for the Manufacturer's Long-Term Warranty. In addition,all labor provided by Double"R"is unconditionally warranted for a period of Two years from the date of installation. Approximate Start Date:June/July-2022 Approximate Completion Date:_2 days Customer: $5,325.00 (Amount) Date: 0% (Sales Tax) Double "R": Carlo Labianca $5,325.00 (Total Amount) Date: January-20-2022 $2,500.00 (Deposit) $2,825.00 (Balance Due Upon Completion) Return original contract to Double"R", retain a copy for your records. Visit Our Showroom Located At 439 Willett Avenue Port Chester, N.Y. 10573 `r L l x z c x = C E F ^� � Gl Tft 13 L 3 - o $ 0 L c c_ .. g a a 'n �I N ~ - Q' CV ci E O O C p E t o U © 3 W = � vI .. ; -moos EJ C C y ° $ �w d J_ _ _ = 7 � ~ a co >w a N c i , i Lo 41 cn r i ri c c rn r •v'':. _ • 1 M CN G w ti O V (n > yCA Lu•-+ z Z O .0 ectlon a � Zui � � 7 , V > a 2 J w �G C2. a O 2 Q M _ y0 ��e aQ e LU Q o = C c O � Z pC) H U v � y � r it 4 DATE(MM/DDNYYY) A`"R" CERTIFICATE OF LIABILITY INSURANCE 1 .9/2022 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 NAME: Michelle Seeley Mazenco Insurance Agency Inc. FAX A/C No Ext: (914)235-3144 (A/C,No): (914)235-1571 2525 Palmer Avenue Suite 1 ADDRESS: michelle(wmarencoinsurance.com INSURERS)AFFORDING COVERAGE NAIL• New Rochelle NY 10801 INSURER A: UTIC'A FIRST INS CO 15326 INSURED INSURER B: ARC Home Improvements Corp INSURER C: DBA Double R All Home Improvements INSURER D: 439 Willett Ave INSURER E: Port Chester NY 10573 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. INSR POLICY hf-l- POLICY LAP LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER MWDD/YYYY MM/DD LIMITS x COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE �OCCUR PREMISES(Ea occurrence) $ 50,000 MED EXP(Any one person) $ 5,000 A Y ART512873700 05/06/2021 05/06/2022 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 X POLICY ❑PRO- ❑ JECT LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: $ AUTOMOBILE LIABILITY Ea accident) $ ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS HIRED NON-OWNED $ AUTOS ONLY AUTOS ONLY (Per accident) UMBRELLALWB HOCCUR EACH OCCURRENCE $ EXCESS LIHB CLAIMS-MADE AGGREGATE $ DED I I RETENTION$ $ - AND EMPLOYERS'LIABILITY WORKERS COMPENSATION Y/N STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE❑ N/A E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? Mandatory In NN) E.L.DISEASE-EA EMPLOYEE $ If yyes,describe under ESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached If more space Is required) Certificate Holder And in Olympia Lopatin 167 Brush Hollow Crescent,Rye Brook,NY 10573 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 Arbors HOA ACCORDANCE WITH THE POLICY PROVISIONS. 173 1/2 Ivy Hill Crescent AUTHORIZED REPRESENTATIVE RwAW4 A Mnu-w Rye Brook NY 10573 ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD NYSIF New York state Insurance Fund PO Box 66699,Albany, NY 12206 1 nysif.com CERTIFICATE OF WORKERS' COMPENSATION INSURANCE o •• a1 ^^^^^^ 133940830 MARENCO INSURANCE AGENCY INC k 2525 PALMER AVE SUITE 1 - NEW ROCHELLE NY 10801 i SCAN TO VALIDATE AND SUBSCRIBE POLICYHOLDER CERTIFICATE HOLDER ARC HOME IMPROVEMENTS CORP ARBORS HOA DBA DOUBLE R ALL HOME IMPROVEMENTS 173 1/2 IVY HILL CRESCENT 439 WILLETT AVE RYE BROOK NY 10573 PORT CHESTER NY 10573 POLICY NUMBER CERTIFICATE NUMBER POLICY PERIOD DATE W2358 628-2 1 65338 04/16/2021 TO 04/16/2022 1/28/2122 THIS IS TO CERTIFY THAT THE POLICYHOLDER NAMED ABOVE IS INSURED WITH THE NEW YORK STATE INSURANCE FUND UNDER POLICY NO. 2358 628-2, COVERING THE ENTIRE OBLIGATION OF THIS POLICYHOLDER FOR WORKERS' COMPENSATION UNDER THE NEW YORK WORKERS' COMPENSATION LAW WITH RESPECT TO ALL OPERATIONS IN THE STATE OF NEW YORK, EXCEPT AS INDICATED BELOW, AND, WITH RESPECT TO OPERATIONS OUTSIDE OF NEW YORK, TO THE POLICYHOLDER'S REGULAR NEW YORK STATE EMPLOYEES ONLY. IF YOU WISH TO RECEIVE NOTIFICATIONS REGARDING SAID POLICY, INCLUDING ANY NOTIFICATION OF CANCELLATIONS, OR TO VALIDATE THIS CERTIFICATE,VISIT OUR WEBSITE AT HTTPS://WWW.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 FRANK J VERRASTRO TREASURER RALPH CACCOMO ARC HOME IMPROVEMENTS CORP TWO PERSON CORPORATION 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 T �V DIRECTOR,INSURANCE FUND UNDERWRITING VALIDATION NUMBER: 345457177 U-26.3