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HomeMy WebLinkAboutBP22-055PERMIT #&Y SECTION., TYPE OF WORK 10B LOCATWN C�I`rl CONTRALTO EST. VcO # DATE: � EXP D BLOCK LOT �??oe7 X olq o L Y? / �irpo,? s _��'i V'P le INSPECTION RECORA I DATE I NSP 743 i �4:1 FOOTI N G FOUNDATION FRAMING 1� RGH FRAMING J )�O/C.��/�!! INSULATION PLUMBING `- RGH PLUMBING GAS SPRINKLER --- ELECTRIC LOW -VOLT ALARM AS BUILT O _ FINAL OTHER APPROVALS ARB fiOT PB zBA OTHER VILLAGE OF RYE BROOK WESTCHESTER COUNTY, NEW YORK No: 22-121 Certificate of ®ccupantp Xhis is to certify that Alam[ / A(o 4 Jena of, BJD:Dk' /V / --, having duly filed an application on u 20 cVR requesting a Certificate of Occupancy for the premises known as, &2/ G lkf Rye Brook,NY, located in a P(J�D Zoning District and shown on the most current Tax Map as Section: OI Block: / Lot: 5# and having fully complied with the requirements of the Building Code and the Zoning Ordinance under Building Permit No. , issued 20 .2a, 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 following / New York State Classifications, Use: /'��� - 11 . Construction: for the following purposes: bq-1&LZO—V- 2!a2&2,V1QDI71 1,29120 ya bc" 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 height shall be made,nor shall the building be moved from one location to another until a permit to accomplish such change has e o ain Building Inspector. AUG 2 6 ZOZZ Building Inspector,Village of Rye Brook: Date: D E C E � V R For office u e onl BUILD MENT PERMIT# —OS'5 AUG 19 2022 VIL OF RYF B4 OK ISSUED: — —a 938 KING STRE YE BROOI:, ) YORK 10573 DATE: —J — VILLAGE OF RYE BROOK 9 L0668 FEEk& PAmjg 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 *#t#*}iiti kttt#*****#**xx*#**#*##***xxtiiii#i*i***xtt*tt#t*t**#*******x*ttt*tt#*###ittiikt tftt#ki#tk#ititktkttkt#kii#*#*#iix# Address: 62 Doral Greens Drive West, Rye Brook NY 105773 Occupancy/Use:One Family ResidentialParcel ID#: /691 o;)6 Zone: Pad Owner: Paul Noto &Jennifer Noto Address: 62 Doral Greens Drive West P.E./R.A.or Contractor: Justino Contracting Inc. Address: 650 Halstead Ave, Mamaroneck, NY 10543 Person in responsible charge: Wilson Justino Address: 650 Halstead Ave, Mamaroneck, NY 10543 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: Wilson Justino being duly swom,deposes and says that he/she resides at 62 Doral Greens Drive West (Print Name of Applicant) (No.and Street) Village of Rye Brook ,in the County of Westchester in the State of NY ,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:s 28,000.00 for the construction or alteration of: Bathroom Renovation Deponent further states that he/she has examined the approved plans of the structure/work herein referred to for which a Certificate of Occupancy/Compliance is sought,and that to the best of his/her knowledge and belief,the structure/work has been erected/completed in accordance with the approved plans and any amendments thereto except in so far as variations therefore have been legally authorized,and as erected/completed complies with the laws governing building construction.Deponent further understands that it shall be unlawful for an owner to use or permit the use of any building or premises or part thereof hereafter created,erected,changed,converted or enlarged,wholly or partly,in its use or structure until a Certificate of Occupancy or Certificate of Compliance shall have been duly issued by the Building Inspector as per§250-IO.A.of the Code of the Village of Rye Brook. Sworn to before me this /o�— Sworn to before me this ' day of C> (J , 200Z day of 20_2� — ( -\ '�v"A �< - Signatur of Pr erty Owner Si ature icant A/" A/0Z Print Name of Property Owner Print cant 'Z-2g�� 2'� Notary,Public otary Pu is RUTH F L POST Notary Public,State of New York Registration No.:02PO6394512 PAUL NOTO 3/12/2021 Qualified in Westchester County NOTARY PUBLIC.STATE OF NEW YORK COrniniaslon Expires July 08,2QZ-_3 QUALIFIED INNWEST4,1754 R COUN COMMISSION EXPIRES SEPT.30,20 QyE BRcu- o`` �m '9a2 BUILDING DEPARTMENT ❑BUILDING INSPECTOR ,'-O/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 _ �r/ ISSUED: ' C/1 \� ,;�L�CK: l L � � I SSU SECT. l LET: LOCATION: ' 1 ` \� �C `�=S < � OCCUPANCY: ❑ VIOLATION NOTED THE WORK IS... ACCEPTED ❑ REJECTED/REINSPECTION ❑ SITE INSPECTION �1 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 ❑ OTHER QyE BRa?�, 1982 BUILDING DEPARTMENT ❑BUILDING INSPECTOR ASSISTANT BUILDING INSPECTOR VILLAGE OF RYE BROOK / �J CODE ENFORCEMENT OFFICER 938 KING STREET • RYE BROOK,NY 10573 (914) 939-0668 FAx (914) 939-5801 www.ryebrook.org - - - - - - - - - - - - - - - - - - - INSPECTION REPORT - - - - - - - - - - - -- - - - - - - - ADDRESS : (n-a (:6 4 G � � c' �l DATE: PERMIT# / �2^ 0�5 ISSUED: 126 S CT: BLOCK: LOT: LOCATION: OCCUPANCY: ❑ VIOLATION NOTED THE WORK IS... _Q<'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 ❑ OTHER _ Lin C,C cV O _ CV eq \ W v NNq y N eq N a .. m W O c� 04 O �, w I-•1 tri ] � � o � N N o � c w eq ep _ r i � ^ °v O � o V O v O Ada c C ao en �-I W V di° v O 0 W O U o � ° � V M [� cr � w \ 0 z w z en z Q, 0 aj WGINw .: y c � F•I M v\ Nr \ ya by _ �0 �Vy d u O d �1 bCh rT� 14 w V Vd z N z w w w BUILD q'MENT V VIL E OF RYE', OOK 938 KING ET RYE BR6 NY 10573 APR 2 0 2022 4 939V066�$'� VILLAGE OF RYE BROOK BUILDING DEPARTMENT INTERIOR BUILDING PERMIT APPLICATION FOR OFFICE USE ONLY: Approval Date: Mn, ermiiApplication Fee:S_ / Approval Signature: Permit Fees:$ ' Disapproved: Other: Application dated: 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 existin building,or for a change in use,as per detailed statement described below. 1. Job Address: &7 bQg*t 6gfepyS b,!Le Lt/I • SBL: L-2-q.2 n — I - .5,Z Zone: 2. Proposed Improvement.(Describe in detail): 24rqnW yr, 9&, oyykT)'0._) -WV jKl'"t - "r or"t -14a1.Cr�+_ i13, SV40-0t Sinj1CF AZ-6--> Fool Ak k/lu— -1]'t.=J --M%1?M4G` G to 1J, AU.. >`str" 4 v✓K 4a: r,o 7b­, — A4o l-if y✓ - 3. Does the proposed improvement involve a Home-Occupation as per§250-38 of the Code of the Village of Rye Brook? No: V-11 Yes: If yes,indicate: TIER L• TIER I1: TIER ID: 4. 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 1 Hood,etc...) :No: Po* 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: I IF o­ After Construction: ►f44^- 6. N.Y State Construction Classification: N.Y. State Use Classification: 7. Property Owner: TlkU(, 4 SEhNt?:;Fk ^A:$TO Address: ZZ bOICAL 6�+Z6EAlS Dtei(Ac W. Phone# Cell#43!Y- 703- OS ?2 email: A,,oto zy FM A GC.Go"^ 8. Applicant: WIAO" xS p Address:63D 1h trJ1LC1Q) R0, A"4m'9&*•o15-0 3 Phone# Cell# email: 14- 6w�a>'� 9. Architect: Address: Phone# Cell# email: 10. Engineer: Address: Phone# Cell"# email: 11. General Contractor: �s4*Lo CtyW, ZXZ Address: 6aD 1-r L67e*0 4t-E,^gM4rWA.A APf/0Sy3 Phone#')wz'M M%O Cell# I*W y_PA3 email:QRQcE Q t(yS ^<yc,&+ -60V_1 12. Estimated cost of construction $ 2AOOO W_ (NOTE:The estimated cost shall include all labor,ma erial,scaffolding,fixed equipment,professional fees,and material and labor which may be donated gratis.) 13. Job Timetable: Start: Finish: (1) 8/12/2021 BUILD MENT © E EMED VIL E OF RY 1OK 938 K NG ET RYE BR ,NY 1057 APR 2 2022 `s 4 -0 �j`r VILLAGE OF RYE BROOK 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 . STAT�1 NEW YORK, COUN OF WESTCHESTER ) as: C , residing at, r Print n,imc) (Address where you liver) being duly sworn, deposes and states that(s)he is the applicant above named, and fiurther states that(s)he is th ���LLL""" legal owner of the property to which this Affidavit of Compliance perta' at; V , Rye Brook,NY. (.Iob�ddrcss► 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 Co (5i1_111Aturc ofProperty Or%ncrl,)I 216w AA774/0 (Print Name ol'Propert, (?wncr(s)) Sworn to before me this day of 120 ZZ (Notan hficl �� RU7W F L POST Notary Public,State of New York Registration No.:02PO6394512 Qualified In Westchester County, 'CWnmiselol►Expires July 08,20.3 (2) 9/12/2021 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. STA OF NEW YO K,COUNTY OF WESTCHESTER ) as: w I or -J�.s 'P60 ,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 :: IC trL1c1 G-MK. 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 I g Swom to before me this day of 20 Z,Z day of i , 20 .2 7— SignatukreProperty Owner Signature f pplicam J_ Print Name ol'Property Owner Print Name of Applicant Notary P blic Notary Public RUTH F L POST Notary Public,state of Now York PAUL NOTO Registration No.:02PO6394512 NOTARY PUBLIC STATE OF NEW YORK . + Qualified In Westchester County NO. 4-v 74 �`OnYrY8810ft Expires July 09,20 � CUALIFIF-DCOMMISSION EXPIRES SEPT.3G,IN VVESTCHl­STFR 24N� (4) 8/12/2021 a 0 FP N O W a � a( L O a W �en F Vi a W OWC fV r x C U r a �, k N M o O w w ry c w N en as D ►� fell zoo Q a ' O en 61W r -D w ,o f, O 00 = O �+ � z It 0.4 _ 10-� x ai ►n a< F V z v' a c " x o zz z o U N o W W z N , z w c F, = W H Q a wg s U it w p rr m z O ,n O, g or x � o a w � o � , < F _ �I ca a a z ca w = < _ BUItj"'NC, DEPARTMENT MAY 2 4 2022VILOF RYE OK 938KIN RY B,,NY 10573 VILLAGE OF RYE BROOK ) 939 BUILDING DEPARTMENT e .Or ELECT AL PERMIT APPLICATION Westchest Co ty Master Electricians License Required FOR OFFICE USE ONLY Al 2 _ O EP#: -a g MAY 2 4 2 z Approval Date: Permit Fee: $ Approval Signature: V Other: Disapproved: (fees are nun-refundable) Application datei 72 Q 712- is hereby made to the Building Inspector of the Village of Rye Brook NY,for the issuance of a Permit to install and/of 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. 1.Address: r C xsJ SBL: /l—S—Z Zone: 2.Property Owner: - I /�r�A ress: Z v i'G► r Phone#: y�L� 6�'`Cell#: email: Peb G // L CcYit�l. 3.Master Electrician: Address: �L� C,& 0� (/1 �� /l/rlr AK&4 Lic.#: Phone#: L , ell#: email: YI t (Z P/.�OA-1 Company Name: �� �LJECTR(C, C Ll L? � Address: � J e7 (/'� S� G(yPtA, 4.Proposed Electrical Work/Fixture Count: _ (Ud'G .0 IN CO ATE OF N W YO OUNTY OF WESTCHESTER ) as: nf being duly swom,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 to Sworn to before me day of ,20� t is day of 0 Sign f Property O^ner Sig licant / �• o 4 av �S Print ame of Property Owner rintN e f pplic Notary Public �T— RUTH F L POST Pub Notary Public,State of New Yak PAUL NOTO luaifeediRegistration No.: nester oust NOTARY PUBLIC.STATE OF NEW YORK / Qualified in Westchester Countli NO. 4740754 Commission Expires July 08,21mj QUALIFIED IN WESTCHESTER COU COMMISSION EXPIRES SEPT.30,20 8/12/2021 Westchester Rockland Electrical Inspection Services, Inc. << Phone: 914-347-3595 L DO NOT WRITE HERE-FOR OFFICE USE ONLY 43 North Lawn Avenue �� Fax: 4-34i-3596 • Elmsford NY 10523 \ r. 1 A `� B P MIT NO. TEMP# DATE CITY OR VILLAGE ZIP CODE TOWNSHIP U 77 STREET AND NO.OR ROAD PO UMBER BETWEEN WHAT TWO CROSS STREETS IS PREMISES LOCATED? SECTION BLOCK LOT OCCUPANT'S NAME BUILDING OCCUPANCY OWNER'S NAME AND ADDRESS HOME TELEPHONE NUMBER CURRENT SUPPLIED BY FROM THEIR OFFICE WORK TELEPHONE NUMBER LIST BELOW ALL EQUIPMENT WHICH YOU INSTALLED NUMBER OF OUTLETS NO.OF FIXTURES& MOTORS HEATERS OFFICE USE LOCATION LAMP RECEPTACLES ONLY SIDEWALL SWITCH INCADE FLUORE NO. H.P EACH NO. WATTS EACH INSPECTION OUTSIDE �^.-_ -� BASEMENT 1"FL. 2-FL. 3' FL. VILLA LE OF RYE BROOK REMARKS:LIST OTHER ELECTRICAL DEVICES NOT SET FORTH ABOVE: 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 AS PROVIDED BY THE APPLICANT.THE APPLICANT DECLARES THAT THERE IS NO OPEN APPLICATIONS FOR THE ABOVE WITH ANY OTHER INSPECTION COMPANY.WHIMS, INC.IS NOT LISTING,LABELING,UNDERWRITING OR CERTIFYING ANY EQUIPMENT, MATERIALS OR DEVICES WHICH ARE PERFORMED BY OTHER CERTIFIED TESTING AGENCIES 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 i 7 EXPOSED❑ CONCEALED MUST ENTER APPLICANTS IDENTIFICATION NUMBER SERVICE ENTERS BUILDING OVERHEAD i 7 UNDERGROUND'-] AVOID DELAYS BY GIVING FULL AND.ACCURATE INFORMATION.ALL SPACE MUST BE FILLED IN OR APPLICATION MAY BE RETURNED. NAME OF COMPANY DATE OF APPLICATION SIGNATURE OF APPLICANT X STREET ADDRESS TELEPHONE NO. CITY OR POST OFFICE ZIP CODE LICENSE NO.WHEN APPLICABLE 00 F � 0 4+ • ~ N W u • N N N � C. N to 00 p `r' bi ►� ^ \ C o A r v N W � w , o Z z � a N $ z o p o N 1 p C L w N a tn t < ` F1 n W 00 �+ U W � f! z 00 U O 'a 00 z z U >Lr) v ►• z � o � < o z It > ° V W cNv 0 �' it � � U � U itV W c x u o QU p W o w � � N z a Q z + A � W a A W aQ a z as w = � �6t444twt4 4;4aa4 tdUtoC;4;4i6tt4�6 t;tittwttaUtt4 4444 ; 644gA D [E C IMF� ID B U I L IT) kd'�_ Q4&�"TMENT VILLAGE OF RYE BROOK J U L 2 9 2022 938 KING STREET RYE BROOK,NY 10573 VILLAGE OF RYE BROOK (914)939-0668 BUILDING DEPARTMENT www.ryebrook.org ELECTRICAL PERMIT APPLICATION Westchester County Master Electricians License Required FOR OFFICE USE ONLY BP#: o EP#: Approval Date: Permit Fee: $ Approval Signature: Other: Application dated,77—D is hereby mad to the Building Inspector of the Village of Rye Brook NY,for the issuance of a Permit to install and/or remove electrical equipment,wiring, fixtures, or to perform other high or low voltage electrical work as per the detailed statement described below. By signing this document, the applicant & property owner agree that all electrical work performed will be in conformance with all applicable Federal,State,County and Local Codes. 1.Address: ( 6 V CLA �� (()E- wCSSBL: ( Z . 2 �' I S Zone:AuL 2.Property Owner: ( �(�� �()i(� �f�t � J�U Address: 6 kffk� D/'I,e- 4 Phone#:ql to 2 ) C)S ZZ Cell#: /f/ email: C00i ry a_ D . C / 3.Master Electrician: t rdkt(�((O tM KA A S Address: 2L C-,, ✓7- /4r/Uk Lic.#:1 L6� Phone#: V16/Gl3 c-U2 Jf Cell#: ���f / n��v� email: lh&1P,_Yi�t1tCC1A1CC&/e /. (-Cv" Company Name: Address: 2 S r 4.Proposed Electrical Work/Fixture Count: 5.31 Party Electrical Inspection Agency: S .S STATE OF NEVW� YORK,COUNTY OF WESTCHESTER ) as: �!l2a_I�(-(' 61 I[- A being duly swom,deposes and states that he/she is the applicant above named,and does further (print name of individual signing as e�appil cant) 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 Sworn to before lie s 2 1/ day of ,20 day of \ 20 Signature of Property Owner tgnature o T can G' e S Print Name of Property Owner Print Name of Applicant Notary Public Notary Public 6/23/2022 • STATEWIDE INSPECTION Service With bitegrity I81 Main Street,Fishkill, NY 12524 1 emoil:office@swisny.com SWIS JOB APPLICATION84 1 914.219.1062 • • • Office Use Elect.Permit# Date Bldg Permit# Utility ID# Final Certificate# City/Village Zip Township County Address Cross Street Section Block Lot Owner Name/Address(if different than above) Contact Number ❑Basement M 1st 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 Range(s) Cooktop(s) Oven(s) Dishwashers Refrigerator Disposal Microwave Warm Draw Incandescent Fluorescent SERVICE Amperage Voltage 1 P 3P #Meters #Disconnect ❑Underground ❑New ❑Reconnect ❑Overhead ❑Change ❑Visual Re-Inspection ❑ Safety Re-Inspection ❑ Re-Inspection Additional Information RLC� i� �MC� � JUL 2 9 2022 VILLAGE OF RYE BROOK BUILDING DEPARTMENT This application is ve valid for one(1)year from the date received by WAS.This application is intended to cover the above listed items to be inspected,if at any time of inspection additional items ha 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 t Date Signature Address City/State Zip Code License# Phone# 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 Service With Integrity Website: www.swisny.com BY THIS CERTIFICATE OF COMPLIANCE STATE WIDE INSPECTION SERVICES CERTIFIES THAT: Upon the application of: Upon Premises Owned by: JBG Electric Corp Paul &Jennifer Noto Francisco Barajas 62 Doral Greens Drive West 24 Walnut Street Rye Brook, NY 10573 New Rochelle, NY 10801 Located at: 62 Doral Greens Drive West, Rye Brook, NY 10573 Section: Block: Lot: Electrical Permit Number: EP 22-158 129.26 5.2 Certificate Number: 2022-4380 Building Permit Number: BP 22-055 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: 62 Doral Greens Drive West, Rye Brook, NY 10573 The First Floor Master Bathroom were 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 3rd day of August 2022. Name Quantity Rating Circuit Type GFCI 02 Switches 04 State Wide Inspection Services did not perform a Rough inspection(Rough Performed by WREIS). A Visual inspection and Final inspection were conducted only. �J oxc.ij'/'k'�' f Officer: Frank J. 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. c� r . aNt Lin4 w a v O-" r X W WC14rg LA �..., x •� � N z o � ;� x } z Z w z 0 oo ° � O in z oo A w V U Z ' z Q/i N V ; �f `/ C ~ ►C w ~ ., � w A x H tn a< Ln c z 1 ovw) • M...� � w � � N � v o �y a m a 4 w z8 � w .. o Ln ' � L'a N F= S ►.� � c x cV z H A z A oa H Q o z Q a � < tg10 BUILDING DEPARTMENT MAY 2 3 2022 -DD VILLAGE OF RYE BROOK 938 KING STREET RYE BROOK,NY 10573 VILLAGE OF RYE BROOK (914)939-0668;' BUILDING DEPARTMENT www.ryebrook.org PLUMBING PERMIT APPLICATIONFOR OFFICE USE ONLY BP#: e--:�c;)�OS� PP#: Approval Date: MAY 2 kR22 Permit Fee: $ Approval Signature: Other: Disapproved: (fees are non-refundable) Application dated,����►�r C-)C4- is hereby made to the Building Inspector of the Village of Rye Brook NY,for the issuance of a Permit to install and/or remove Plumbing as per detailed statement described below.The applicant&property owner,by signing this document agree that said plum g work will be in �conformance with all applicable Federal,State,County and Local Codes. 1.Address: �� O� ' �� �+v��l SBL: / , r)%o /-S, a Zone:Aw _ 2.Proposed Work: uQ Q 3.Property Owner: &U/ A10iQ Address: Phone#: 91,q—70 3_ 0 Cell#: 99 i� emai 4.Master Plumber: Addr ss: Lic.#: /v-)41 Phone#: Cell#: I� ; III email: $ Company Name: e;TM " y* Address:-I Address:—Ily k Wk INDICATE FIXTURES&LINES TO BE INSTALLED AS PER THE FOLLOWING SCHEDULE: Location Water Urinals Drinking Sinks Showers Bath Laundry Domestic Fire Sanitary Natural/ Other* Total Closets Fountains Tubs Tubs Service Service Sewer LP Gas Basement 1st Floor Z I I 2nd Floor 3"Floor 4'b Floor 5m Floor Exterior 5.*List Other Equipment/Provide Details: 6 S / l'V ON fol W &Jtr (Notarized Signatures Required Next 2 Pages) -1- 8/12no21 TATE OF NEW Y C,COUNTY OF WESTCHESTER ) as: ,being duly swom,deposes and states that he/she is the applicant above named, ' t name of individual signing as the applicant) and fVffier states/that(s) a is the lWal wner of the property to which this application pertains,or that(s)he is the u�l NU 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. Sworn to before me this Sworn to before me this day of ,20 day of ,20�y Signature of Property Owner Signature of Applicant Print Name of Property Owner a of Applicant Notary Public No blic PAUL NOTO NOTARY PUBLIC.STATE OF NEW YORK NO. 4740754 QUALIFIED IN WESTCHESTER COUN�_` COMMISSION EXPIRES SEPT.30,20 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.Applications not properly completed in its entirety and/or not properly signed shall be deemed null and void and will be returned to the applicant. -2- 8/12/2021 STATE NEW YORK,COUN OF WESTCI>ESTER ) as: // ��• JO ,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 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 "W Sworn to before me this day of 20 2 Z day of ,20 Sig at of Property Owner Signature of Applicant Print Name of Property Owner Print Name of Applicant Rl1TH F L POST Not Public Registration' , to of NewYo* Notary Public Qualified in Westchester County Commission Expires July 08,26t3 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. Applications not properly completed in its entirety and/or not properly signed shall be deemed null and void and will be returned to the applicant. -2- 8/12/2021 BUELDITaDEPA MENTDD VILLAGE OF RY'=. OOK MAY 2 3 2022 938 KING i%6ET R),F BR, ,NY 10573 „ 1�4)92 VILLAGE OF RYE BROOK .e " . 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, COUN OF WESTCHESTER ) as: ,,, / aU ( A residing at, �— C 4. 6j (Print name) (Address w ere you live) 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; Dolloll - , 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 Property Own 0� a" z A6 7 (Print Name of Property Owner(s)) Sworn to before me this C� day of )'7 , 20/ 7 RUTH F L POST 7 ] 'z Notary Public,State of NewYo* Registration No.:02PO6394512 J Qualified in Westchester County (N blic) Commission Expires July 08,20.- 3/12/2021 Building Permit Check List&Zoning Analysis Address: Co Z_ 'tea A t. CLEF=:2� � . W • SBL: L 2`i • 2 (o Zone:0-1> Use: Z 1 C> Const.Type: _ Other. Submittal Date Z O 7,2_ Revisions Submittal Dates: Applicant �_l 0 i O Nature of Work �r rj Wz N Reviews:ZBA: APR 2 5 2022 PB: BOT: Other. QK ( ( ) FEES:Filing: 7�•�BP: 1-1 Z�D- 'C/O: Flood Plane: Legalization: APP: Dated: ✓ Notarized: ✓ SBL: `-Tr.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: Electronic Other. ( ) ( License: ✓ Workers Comp: 'Liability: Co_rnp.Waiver. Other. ( ) ( ) 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. O O 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 EXISTING PROPOSED NOTFS APPROVED Ate: Fla Front Front silo: lW Main COv Accs,Coy F S : Sd.H/Sb: _GE& Tom: EL-IMP: PP Hci&/Stories: notes: '. `�A��' �S A!- �h •yti' AF yr�"" ♦An '�t9,.p;. �1Ah.. �1 A! '� -.'�A •j� ♦• �y • : .. � i i• •• k[r; � ly r' � rc• r � Jb atG r, d.+•.<s1 kG : '�:. !�._=.af ,�,;,111;1 't3,1 � ,11,•i/1'PI `�:.i,�r 11111�'1/1'�' t��� �i 111•Ih/111 �#i����i Ti�,r�I,•14511 ��j� i� 11•i4•1111�, l�/11 �1.1./(,,, R!�"'�`� , "� v�r..: N111 :._ ,a�►-.: 1_h111P.,�t��g•:=-a-'ttr.4il�ll yi �:_�.411111 �_ \INlld..t.��c �.�,,,ill,�!,r`��y��it y�Nlll yjr� „,c�:i h E O c _ L N y' ^ 4:• 75 to O :',� V � O O f N =- �.•. �n Z w = c C- section : c• , 4 H •• U w p 3 L o .mac,. _ •u �. ae,iY�• LO CC 4 0tj s 0 NO i ram.;.;..��,.T,�."�v G /�� J J �•�� � �� •ee M �, ca •... ;� O 4 �.5 ( * )pp<(0)> • . . . . . . . . . .. . . :_ 1j '^c". i!r llll,ll 's ems.aaar,1111`Lt , @yea �' :,SIN�I" 1 i h �{�— ,1►11,h d11T"1, 11/111 11111, r 1•1,1', 1 1 "��� � � ✓�Vai� �V� r<�v�j - ^9,'V� VJ} V ...s�F�V�W s� i� V�t 1�V 3�!�• ��® DATE(MM/DD/YYYY) A C" CERTIFICATE OF LIABILITY INSURANCE 04i21/2022 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: ALEXIS ANN SALUBRO Albert Palancia Agency, Inc. PHONE (914)698-1373 FAX N,: (914)898-0125 PO Box 26 ADDDRESS: aloxls@palanclainsurance.com Mamaroneck, NY 10543 INSURERS AFFORDING COVERAGE NAICS INSURERA: UTICA FIRST INSURANCE CO. 15326 INSURED INSURER B JUSTINO CONTRACTING INC INSURERC: 650 HALSTEAD AVE STE 108 INSURER D: MAMARONECK, NY 10543-2743 INSURERE: INSURER F: COVERAGES CERTIFICATE NUMBER: 00001680-1588029 REVISION NUMBER: 135 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 TYPE OF INSURANCE ADOL SUER POLICPOLICY NUMBER MM/DDY EFF POLICY MM/DD EXP LIMITS LTR A X COMMERCIAL GENERAL LIABILITY Y ART3000212620 05/20/2021 05/20/2022 EACH OCCURRENCE $ 1 000 000 CLAIMS-MADE I DAMAGE TO RENTE15- OCCUR PREMISES a occurrence $ IVIED EXP Any one person) $ 5,000 PERSONAL R ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 X POLICY JEC PRO- LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: $ AUTOMOBILE LIABILITYCOMBINED SINGLE LIMIT = Ea acGdent ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per accident) f AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY Par acc dent $ UMBRELLA LULB OCCUR EACH OCCURRENCE $ EXCESS LIAR HCLAIMS-MADE AGGREGATE $ DIED I I RETENTION $ WORKERS COMPENSATION STA ER AND EMPLOYERS'LIABILITY Y/N ANY PROPRIETOR/PARTNERIEXECUTIVE I E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? N/A (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ His describe under DESCRIPTION OF OPERATIONS below I I I E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached If more space Is required) VILLAGE OF RYE BROOK IS INCLUDED 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. 938 KING STREET RYE BROOK, NY 10573 AUTHORIZED REPRESENTATIVE AAS 1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD Printed by AAS on 04/21/2022 at 12:49PM DATE(MMIDDlYYYY) ACORO� CERTIFICATE OF LIABILITY INSURANCEF04/18/2022 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: ALEXIS ANN SALUBRO Albert Palancia Agency, Inc. ,CNN M. (914�9&1373 (FAX, No):(914�98-0125 PO BOX 26 E-MAIL Mamaroneck, NY 10543 ADDRESS: alexis@palanclainsurance.com INSU S AFFORDING COVERAGE NAIL/ INSURERA: UTICA FIRST INSURANCE CO. 15326 INSURED INSURER B: ShelterPoint Life Insurance Company 81434 JUSTINO CONTRACTING INC INSURERC: 650 HALSTEAD AVE STE 108 INSURERD: MAMARONECK, NY 10543-2743 INSURER E INSURER F' COVERAGES CERTIFICATE NUMBER: 00001680-1588029 REVISION NUMBER: 133 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 CONTRACTOR 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 TYPE OF INSURANCE A DL SUBR POLICY EFF POLICY EXP LTR POLICY NUMBER MMIDD MMIDD/Y LIMITS A X COMMERCIAL GENERAL LIABILITY Y ART3000212620 05/20/2022 05/20/2023 EACH OCCURRENCE $ _ 1,000,000 CLAIMS-MADE OCCUR DAMAGE T R EN XI PREMISES Ea occurrence $ MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 APOLICY� JERT LOC PRODUCTS-COMP/OP AGG $ 2 000 000 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY(Per accdent) $ HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY P� ident $ - UMBRELLA LIAR OCCUR EACH OCCURRENCE $ EXCEBB LIAR CLAIMS-MADE AGGREGATE $ DED I I RETENTION$ $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY Y/N TATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICERIMEMBER EXCLUDED? N/A E.L.EACH ACCIDENT $ (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ B DISABILITY D450690 08/01/2021 08/01/2022 STATUTORY DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) VILLAGE OF RYE BROOK IS INCLUDED 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. 938 KING STREET RYE BROOK, NY 10573 AUTHORIZED REPRESENTATIVE (AAS) 1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD Printed by AAS on 04/18/2022 at 11:47AM NYSIF New York State Insurance Fund PO Box 66699.Albany, NY 12206 1 nysif.com CERTIFICATE OF WORKERS' COMPENSATION INSURANCE o AF — f . ^^^^^^ 205236238 ALBERT PALANCIA AGENCY INC 116 MAMARONECK AVE PO BOX 26 MAMARONECK NY 10543 SCAN TO VALIDATE AND SUBSCRIBE POLICYHOLDER CERTIFICATE HOLDER JUSTINO CONTRACTING INC VILLAGE OF RYE BROOK 650 HALSTEAD AVE STE 108 938 KING STREET MAMARONECK NY 10543 RYE BROOK NY 10573 POLICY NUMBER CERTIFICATE NUMBER POLICY PERIOD DATE W2419 015-9 830391 06/10/2021 TO 06/10/2022 4/18/2022 THIS IS TO CERTIFY THAT THE POLICYHOLDER NAMED ABOVE IS INSURED WITH THE NEW YORK STATE INSURANCE FUND UNDER POLICY NO. 2419 015-9, 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 wilson justino JUSTINO CONTRACTING INC ONE 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 STATE S7NCE FUND V DIRECTOR.INSURANCE FUND UNDERWRITING VALIDATION NUMBER: 717434809 U-26.3