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HomeMy WebLinkAboutBP22-066PERMIT # dc�— C.•l� DATE:%t6/I8ru: Q EXP4� c� SECTION 1 ) of 7 BLOCK LOT 10� TYPE OF WORK JOB LOCATION OWNER�40 CONTRACTOR:2!51:le EST. COST vo'cU # o TCO # en© v(277u. 0 FEE L�J'��f A DATE / 1 FEE DATE INSPECTION RECORD DATE INSP FOOTt N G � — FOUNDATION `- FRAMING RGH FRAMING__ INSULATION PLUMBING a� RGH PLUMBING GAS �a� SPRINKLER � � ,r _• N3w��_d-.-- ELECTRIC LOW -VOLT Cl ALARM AS BUILT FINAL - �L 7597 P��a - � l 7/ Zi C0STef /ply 61JPC.7'ViG OTHER APPROVALS ARB BOT PB VILLAGE OF RYE BROOK WESTCHESTER COUNTY, NEW YORK NO: 23-007 Certificate of ®ccupaucp This is to certify that & l� / `. I W k- of, Awc-A, N I having duly filed an application on ll offjE m Of'r g;224 20 o�o requesting a Certificate of Occupancy for the premises known as, ,D 6eJ16Fn- 1J1- Rbod , Rye Brook,NY, located in a Pu L Zoning District and shown on the most current Tax Map as Section: 134. 1 3 Block: /Lot: co and having fully complied with the requirements of the Building Code and the Zoning Ordinance under Building Permit No. 00-'7-V(,, 0 , issued 20,9' 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 th-e�-�� following New York State Classifications, Use: �-�l dYJe - Q�'17/I�( , Construction: SC J for the following purposes: 1'I 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 been obtained fro a ildi Ins ector. J AN 1 2 2023 Acting Building Inspector,Village of Rye Brook: Date: D _� �, BUILD R ENT For office use onl PERWT# as-moo VIL OF RYE kO0K ISSUED /8 aa- DDDEC 2 2 2022 38 KING STRE YE BROOK,A YORK 10573 DATE:/a—�l—Q a- 9 066&--j* FEE:.d /cQS PAID 9 VILLAGE OF RYE BROOK w 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 ssrst«rrsssrrssrsrsrsrssrrssrsssrrsssssrrrest«rrtsrrr««rtt«rssrsrsrssssrssrssrssssssesksssrsrsksssssssssrtsstssstssssrksssrss Address: 3 0 ' Ule ra-f r- koa Occupancy/Use: - Parcel ID#: / 3 - I - 61 Zone: y0ab Owner: �0 We k ' Address: 36 � fr �oa, f1� P.E./R.A. or Contractor: �r-¢�a��,� Ait,, env;Ces Address: 2q FaujceP o Person in responsible charge: 1, xv Address: 1 �( 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 _1OF/NE]W YORK,COUNTY OF WESTCHESTER as: �C C 1 1A/�'k t%) being duly sworn,deposes and says that he/she resides at 3 0 IR (Print Z,)Ot Af plicarri) (No.and Street) in �� d lC ,in the County of W - cCy (�J-zr' in the State of- j 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:$-2-6, ,�O0 , 0 D for the construction or alteration of: /n Q S 44- 60,4/y 0 N\ 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. Swom to before me this � 4-�- Swornto before me this day of VC c e i Lly- , 20 Z`L day of li C q,,L -- , 20 22 ( ,)00 ( Ko)�v �' Si re of Property Owner S Ire of)Applicant Jv� ' (� — J0 d _ r Print Name of Property Owner Print Name of Applicant r dA, �d Notary blic Notary Puthic BRYAN E. WOLKI BRVAN E. WOLKIND Notary Public, State of New or Notary Public, State of New York 12 2021 No: 02WO6004979 No: 02WO6004979 Qualified in Westchester County. Qualified in Westchester County Commission Expires March 30, 20 - Commission Expires March 30, 20`K �yE BRa? cu � 1932 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: 0 � y �" / DATE: PERMIT# `Ao ISSUED: '&I\EI7NECT: BLOCK: LOT: LOCATION: 1 '� `t � U� U� �1 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 ❑ NATURAL GAS ❑ L.P. GAS ❑ FUEL TANK ❑ FIRE SPRINKLER ❑ FINAL PLUMBING ❑ OS CONNECTION INAL OTHER • tiQ N W 00 v � v a u ■� w � Ln "s V) w a cu V) va 0-4 0 cod a O a N u � = 0 r � p C a L ■ O 4-4F GN o � o o W C ~ " O : co a � o ■ w 0o y 3 - o v V �"' v � zaz 4w a e cq y 30 /by o 00 0 O ■ Wr- cn ►►F;I� II A � �jy � �C rr' oo CN Al luiQ p AQ C O a+ +, Lj k O O v PLO .. z x V O (U a e BUILDi�._ e,� �1 . EkhTMENT LJ Vffi �Lld"E OF RYl 9ROOK 938 KING ET RYE BRUO1,NY 10573 R MAY - 5 2022 668 t e VILLAGE OF RYE BROOK BUILDING DEPARTMENT INTERIOR BUILDING PERMIT APPLICATION FOR OFFICE USE ONLY: l'� Q Approval Date: ��r _ � � Per lit # ��C7EJ'��Application Fee: $ 75— /- Approval Signature C Permit Fees:$ Z7 e) Disapproved: Other: RR#RRR*RR R!!!!RR#RRRR*RRRRRlRRRlRlRRlRRRRR*!R!R******#**#####R#RR lRRRR!!R****R*R***RRR*#*R!#!!!*R*****#**** Application dated: '7 / 6 ZZ is hereby made to the Building Inspector of the Village of Rye Brook,NY,forthe issuance of a Permit for the interior alteration of�an existing building,or for a {cha�nge in use,as per detailed statement described below. 1. Job Address: C I�I fill,1+' Kd. Kul f. D/t. ,� SBL: )2 M2 r 1-ill � 1 Zone: � 2. Proposed Improvement. (Describe in detaii): Q!'1 L C nil A A •�2f 0, {� AJOI& Can J C JEentl w gtyl f'e l v a�n o1�!n?a�a"COY'__f�1��!no ' aftd ha'-M Aa 3. Does the proposed improvement involve a Home-Occ anon as per§250-38 of the Code of the Village of Rye Brook? No: Yes:-?(- If yes,indicate. `PIER 1: TIER lI: TIER III: 4. Will the proposed project require the installation of a new,or an extension/modification to an exit automatic fire suppression system(Fire Sprinkler,ANSI. 'System, FM-200 5ystern,1'N pe I I1ood,etc...) :No: Yes: 11 hl-,,: ,kd,i i a separate Autommic bile titip,hreai„n `',Stun l"Crnnt ahhlicallon K ? k:f 'il ilctari,i:rl �f� uorrrc�l hlan�l 5. Occupancy;(I fam.,2 fam.,comm.,etc...)Prior to Construction: I f(r, After Construction: 6. N.Y State Construction Classification: N.Y. State Use Classification: 1 7. Property Owner: odtr QtrliGtn tili#,,Ad Address: 3� 1r 17J, Evil aDe Phone#:J'W 9I J-5W V-q213f Cell# F(tj !it.J email fin 4 t' ` , 1DM 8. Applicant.zro "%� Address: 3(7 Phone 4-TV qI -elf r '62q) Cell# 1 qq6 email: ONAl')-LCJA 9. Architect: Address: Phone# Cell# email: 10. Engineer: Address: Phone# Cpell# email: n 11. General Contractor �C � 1QfVjtl.S-r ,('Address: 2 tR l Or'} iV1/ Phone# Cell# Q 01111, Lbit't 12. Estimated cost of construction $ /'? o , I I Ili:_ irnr-a..,i li in �d all lah,r.m:rlcrinf. tl„Idrnv_1c.:d c lu;ln ornt.I=r (ct.I-11 ill Iccz.and malcrud and I:11"'1 hich ncn I,,AL 1n!I d °rrrfr 13. Job Timetable: Start: w- f 'La Lz_ Finish: �'I,Q�t Z L1- (1) 8/12/2021 BUILD ,. %AtTMENT DD V1L OF R2064c Oox MAY - 5 2022 938 KING ET RYE NY 10573 VILLAGE OF RYE BROOK BUILDING DEPARTMENT *hRhh*h#R**RRhR R**RRRRR##!!R!!lRRRR#!!RRlRR!!!!!RlRR!l RRRRR RRRR#RRR!*##RR#*#RRRR RRRRRRR RR RRR RRRRRR*#R## 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: VA, residing at, 36 "rml naru i (Address is Uerc%ou I i`.l' 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; Q Rye Brook, NY. (_iub Ad ress) 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. (Si n.i ri I'ropert� Otime-r, (Print Nanieo Properl% ncrrs)) S± Sworn to before me this I day of 120 2 Z � 1 l N�)tar, i'rrhln i / MICHELLE SOSIN Notary Public,State of New York ion No.OIS06070363 MICHELLE SOSIN Registrat Qualified In WestchestaLc n (2) Notary Public,State of Now York My Commission Expires Al Registration No.01 S06070363 oualified in Westcheste o rtty My Commission Expires ri VJ xii w2021 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. STAB F NEW Y RK,COUNTY OF WESTCHESTER ) as: JO i_(A- ,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. 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 31'� Sworn to before me this day of ,20 22- day of , 20 Si l of Prope ner r Signature of Applicant , J ak& 1 Print N e of perty Owner Print Name of Applicant N fyTublic Notary Public DRYAN E. WOLKIND Notary Public, State of New York No; 02W06004�79 Qualified in Westchester County Commission Expires March 30, 20 (4) 3/21/19 Rr 64 o Ln o H o N ' F..y .r � A u � ►++ ► O � o � Q � v .� o � W O Z p4 v z W U O Cn s n z �z, � � O ^ W V Cn z r a qo O o Z o c� z z � s Z w � � ~ w a A o ° < O wON 00 ' M w p � ' 1�1 Ncra V p a o 0 3 x - r a z F �a ,. H W6 w a z �. 0 ► w V c oQ r W O a 4 ►� w w a a a o � .. �I a � m W x � yE [3RC>v p ECM U V BUILDjEPARTMENT VILLAGE OF RYE BROOK J U N 17 2022 938 KING STREET RYE B"K,NY 10573 VILLAGE OF RYE BROOK or , BUILDING DEPARTMENT ELECTRICAL PERMIT APPLICATION Westchester County Master Electricians License Required/ ' FOR OFFICE USE ONLY BP#: C�D—O�� EP#: 0 d l / V Approval Date: J UN 17,2422 Permit Fee: $ Approval Signature: Other: Disapproved: (fees are non-refundable) Application dated,ZO, ( 7—C)< 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 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: U ll Co (" IBC Q U ��iP.gf �TSBL: 3 c� 3 �C9 Zone: A 2.Property Owner: gor, n !VC, I k; l,, Address: U e ^ r Rocr(� Phone#: Cell#: // -qSI_ � / email: / 3.Master /Electrician: (9i 60 Ct M U 6I a (; G Address: 9& �G `e��C,n ���, `ilag �l��,, �,U. Lic.#: 1 Phone#: Cell#: 9/�' ��En� email: ten icoelk/ c,C Amct'J' (,1'`'� Company Name: KP oS\rc) Flec�f-1 L' Address: 90 La /` /} ��,�j j1"/s 4.Proposed Electrical Work/Fixture Count: Ij q 4�r'a pnn rPn(j�ji o S P1f [��,,ul n(r Pt9LjCt­ STATE OF NE/W�YORK,COUNTY OF WESTCHESTER ) as: G�r0 1 a M G L7 i R j j D_,being duly sworn,deposes and states that he/she is the applicant above named,and does further (print name of individual signing the applicant)state that(s)he is the legal owner of the property to which this application pertains,or that(s)he is the C/n1�D 14noch r 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 fore me this 7 day of ,20 day of C 20 �L! J Signature of Property Owner Signature of Applicant 61, Print Name of Property Owner t Name of Applic r Notary Public Notary Public;SHARI MELILLO Notary Public,State of NewYorlt No.OIME6160063 Qualified In Westchester Cou Commission Expires January 29,20_21*_'_.� 8/12/2021 STATEWIDE • Service With I'I'llegrity 1:1 Main Street,Fishkill, NY 12524 1 email.office@swisny.com SWIS JOBAPPLICATION ;. 12.7224 I fax9l4.219.10621 • • • 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 ❑ 1 st FI. Q 2nd FI. ❑3rd Fl. ❑More Than 3 FI. ❑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 D CCMWIE LJUN 117 DDI -- Z VILLAGE OF RYE BROOK BUILDING DEPARTMENT This application is valid for one(1)year from the date received by SWIS.This application is Intended to cover the above listed Items to be inspected,If at any time of Inspection additional items have been installed,you are authorized to make the inspection and adjust the fee for the additional items inspected.The applicant declares that there is no open applications for the above address with any other inspection company.The applicant,owner or authorized agent agrees to all the above terms and conditions as set forth for the application. Inspector Date Finalized Inspector# Company Name Date Signature Address City/State Zip Code License# Phone# State Wide Inspection Services cjk--:) 1080 Main Street Fishkill, NY 12524 X H S 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: Kensico Electric Bryan Wolkind 90 Jefferson Avenue 30 Bellefair Road Valhalla, NY 10595 Rye Brook, NY 10573 Located at: 30 Bellefair Road, Rye Brook, NY 10573 Section: Block: Lot: Electrical Permit Number: EP22-118 124.73 61 Certificate Number: 2022-3324 Building Permit Number: BP22-066 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: 30 Bellefair Road, Rye Brook, NY 10573 The Second Floor Master Bathroom was inspected in accordance with the NYS and NFPA 70-2017 and the detail of the installation,as set forth below,was found to be in compliance on the 27th Day of June 2022. Name Quantity Rating Circuit Type Luminaires 13 GFCI 02 Switches 04 Dimmers 02 Qom` 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. N N L o 14 k y ON u (� w � W ►-1 y x . O cl p '"", z o z $ Q s O A � �l I O C a, P. „ L o @ z 00 Ln y V w z O QU Uz a \ \ ty I MAN CLn z , z CA zz r� r ►-a � z � c°� N p � H h�l O � H ~ _ z z w pq S" cps a W W AO rr, CC O F 1.4 o < V a G+ `�j ►Ti ' ✓" a v� o z M a BUILDING DEPARTMENT VILLAGE OF RYE IRROOK SEP 13 2022 jD 938 KING STR) ET RYE B ,NY 10573 VILLAGE OF RYE BROOK � � - BUILDING DEPARTMENT PLUMBING PERMIT APPLICATION FOR OFFICF (:SE O�I.I BP #: 4ZZ)Q_0&( PP#: 0Q)-11 7 Approval Date: SEt 1 3 2 Permit Fee: $ Approval Signature: VW y Other: Disapproved: (fees are non-refundable) Application dated, 9 01 1 �-�- 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 plumbing work will be in conformance with all applicable Federal,State,County and Local Codes. 1.Address: 30 9��IC' il1 r Q SBL: ! 2�, 1 3 — ) —"6 -Zone:)0146 2.Proposed Work: Seu jhdo u,, 3.Property Owner: �(� I W 0 j t1 Address: 3 0 Z I r // e l770 (v/ Phone#: - 9 �4 1 Cell#: email: r Can D 4.Master Plumber. 0 Address: 3Z Qi!r,fA !pp/'e I' Lic.#: Phone#: �(^q tf- Cell#: 4-WZ- q 3Nmail: . ec©S Ck`C. iLCQ�I� cve-i Company Nam Ce n e UAI_ht K Address:3Z INDICATE FIXTURES& LINES TO B 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 2nd Floor 3rd Floor 4°'Floor 5'Floor Exterior 5.*List Other�E�quip/men't//Pr/ovi/de Details: /�a r�0 V'G �n� 1 n_O[Lf/ _S 6"r�� �ct Y Knt Moue Q/82 (A34 � b�� 4a &P)Oye &ry ril-f-kif 2 SiXk( f AC, e- , Retnoye. and (Notarized Signatures Re4uired Next 2 Pages) 8/12/2021 e STATE OF NEW� /YORK,COUNTY OF WESTCHESTER ) as: 001F,O 1 W 61 t,1 d ,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 3,r Sworn to before me this day of LK -�— ,20 ')-2 day of ,20 Si e of Property ner ature of Applicant r Cho k Ole, Co `�CCo 2 Print N of Pro r Print Name of Applicant No ubli Notary Public SHARI MEULLO BRYAN E. WOLKIND Notary Public,State of New York Notary Public, State of New York No.01ME6160063 No: 02WO6004979 Qualified in Westchester County Qualified in Vestchester County Commission Expires March 30, 20 Commission Expires January 29,20 _ 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 BUILDING.DEPARTMENT VILL'A4 OF RYE 14ROOK SEP 3 ZQ22 938 KING S.TR�EET RYE BROOK,NY 10573 ( 14) 0668 VILLAGE OF RYE BROOK w�sa;r ooi vr� 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: � r J O residing at, 3 D04 P'. (Print n,uuc l (Add uu li,c 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; d &1 k -1'r 12J „ ,Rye Brook, NY. 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. `41-'iA�, hi AQ6 (Signa ue of ropeitN 0xxncr(,)) '-J—o d-l' -can/K f r6j (Print Namc ol'Propem O\vncr(s)i Sworn to before me this day of 20 2'L (N a 1' lic BRYAN E.WOLKIND Notary Public, State of New York No: 02WO6004979 Qualified in Westchester County? Commission Expires March 301320 _ 8/12/2021 Building Permit Check List&Zoning Analysis Address: -EL ':�7A,r,?.- ,� SBL: t 2 Li • 2, — l - (o Zone:�v t Use: t ConstA Type: �� Other Submittal Date: S Z Z Revisions Submittal Dates: Applicant: W O I-�l Nature of Work: A-rI4- I�.s--) y V,77 O N Reviews:ZBA " PB: BOT: Other. ( ( ) FEES:Filing. S? BP: 2 `� C/O: Flood Plane: 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: Electronic Other. ( ) (� License -" Workers Comp: Liability. -*� Comp.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. (V� ( ) PLUMBING Plans: Permit Nat.Gas: LP Gas: N/A/: Other. ( ) ( ) FIRE SUPPRESSION:Plans: Permit: N/A: Other. ( ) ( ) H.V.A.C.: Plans: Permit: N/A: Other. ( ) ( ) FUEL TANK Plans: Permit: Fuel Type: Other: ( ) ( ) 2020 NY State ECCC: N/A Other. ( ) ( ) Final Survey Final Topo: RA/PE Sign-off Letter As-Built Plans: Other. ( ) ( ) BP DENIAL LETTER: C/O DENIAL LETTER: Other. ( ) ( ) Other. ( )ARB mtg.date: approval• notes: ( )ZBA mtg.date: approval: notes: ( )PB mtg.date: approval:- notes: REQUIRED EXISTING PROPOSED NOTES APPROVED e Date: MAY - 9 2022 cat : Fr m Front. Front: Ste: Main Cov Accs.Cov Ft.H/Sb: S .HS : a& Tom: Fc img P ku' HHight/Stories notes: w ww fit _ '-3�=SL;• �.'Fli�° y,ta. ''�� �P 4 � r hlr� N � C _ - A U) W •Nw J LL! j o = oLection C 4i cn Q X _ _ oin I ��� �,,, Q W �' , O eq co Q nr = F, . ►." �+ J W wee �Q Z aQ ram:LU -k J i " :C co rtos► � J i- O ra y 3 z A At CN it x ' 1 .3 -- ,:, o ,rNNW— is �". . . . , `'F VIVA IN ''.•i••'' /w�4l� `ta.�+.. ���iwr!ly�,'t�1�(i ACO' CERTIFICATE OF LIABILITY INSURANCE "tLUY,urrYYY) 0' ?4r2022 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(Ees)must have ADDITIONAL INSURED provision;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 endorsements) PROOLICER r6NTAfTL!alnc Hukjdn NAME BNC kisurarice Agency PHONE.-Eja. (914)937-123D LAC (914)937 1124 1049 90 S Ridge St Ste UL-2 ADORcss croldan0brlcagency tom NSURERIS)AFFOPOM COVERAGE NAIC p Rye Brook NY 1 05 73-2 938 pA R A lot mhams Mutual Insurance Corrwwy 23329 a6UlED INSURE R B Lou F"Tr,+,y Jr b Robed Owen INSURE c Dba Gerwrl%l Fume Slrwes INSURER D 5635 Neftfiand Averkre INSURER F Bronx NY 10471.2341 INSURE R i COVERAGES CERTIFICATE NUMBER: CL2191302745 REVISION NUMBER: HIS IS TO CERTIFY THAT THE POIK:IES OF INSURANCE LISTED BELOW HAVE BEEN ISSUE D TO THE INSURED NAMED ABOVE FOR THE Poticy PERIOD NDICATED kOTWTTHSTANDMG ANY REQUIREMENT TERM OR CONDTION OF ANY CONTRACTOR OTHER DOCUMENT WIl H RESPECT TO WHICH INS .:£RPFICATE MAY BE ISSUED OR WAY PERTAIN 1-HE INSURANCE AFFORDED BY7HE POLICIES DLSCRIBEDHEREINIS SUBJECT TOAL.I THE TERMS E tr:LUSIONS AND CONDITIONS OF SUCH PO(ICIES LIMITS SHOWN MAY HAVE BE IN REDUCED BY PAID CLAIMS LIR T"K OF adKXLW IE Im POLICY kA MICR LPAETS GENERAL liAN&M EACH OCCURRENCE S 2000.000 CLsIv-* ® AM OCe;:A PRE MI% pvw+v*,.e, 1500.000 WO EXP JArV a paten! 1 15.000 A Y 801"1105281 10,11112021 10,11r2022 PERSONAL r AUv N.JURV 1 2,000.00 GEM A,GM GATE LW APPLTES PE.R GENERAL AGGREGATE $ 4'000.000 P.1-1 ED JECT tJ LOP' PRJNXKM COMPA)PA G S 4,000.000 OT1�P 4 A[SOMON.[ OKA I t S PAY AUM BOrYIY INJURY(Ps.OVUM,' S ovown LQ+[DULJEL BODY V IN JURY IPW wrldwr) S ALTDti�7t� ALIUS MiE"9 W %AIIN[EA S ALfT06[itr ALTOS ONLY Iw S tltiNgILLA LW OCLLvI EACH OCCURRENCE S EXCESS LAM CLAeE5.444DE AGGREGATE S X'D I I RETEKTYJN I i EUNICE=C70 09DISAIM ) M AND EI/EOvEW LUMOLnv T M AT T R Oai]PR7LlA1RT�R�1�gfT`vE Q ILIA E L.EACH ACCIDENT S ryriCE 43EIATcR EJKSL'OFD'• (l rYwl!N El. f res D9FASF FAEkPLOYEF S % ASE POLJCr LAtT SJf Ymr1no,10 art 4T[diS Ylpa l %i DESCRE'noft OF OffRATI NG I L.00AMONG I VDGCL"IACUM 141,AdabaW Rk"O is Ed.s01Aa f""M P""ChaA■.ners*PWQ Is npu464 V%AW d Ry.r Brvr*a rcbx5ed as an siddemo v s+red+M1en mquxad Lhnd wr.ten Conran or Agrsrmcrn CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POI tCIES BE CANCELLED EEFORE THE FXPIRA71ON DATE THEREOF NOTICE WILL RE DELIVERED IN Wage d Rye BrDDk ACCORDANCE LIM THE POLICY PROVISIONS 938 Krig STTea AIZTELORJI[U RE[N2LSEN7AINE Rye Brook NY !W,73 l c 1988.2015 ACORD CORPORATk)N Ail rTghls reaervtd ACORD 25(201W3) Tt-w ACORD rwrrle and logo are registered marks of ACORD A Ew YM Workers' Certificate of Attestation of Exemption sTATE Compensation from New York State Workers' Compensation and/or Board Disability and Paid Family Leave Benefits Insurance Coverage "I his lurnn cannot be used to ►raii'e the►i•orkers'compensabon rights or obligations of any party.** The applicant may use this Certificate of Attestation of Exemption ONLY to show a government entity that NMv York State specific workers'compensation and/or disability and paid family leave benefits insurance is not required. The applicant may NOT use this form to show another business or that business's insurance carrier that such insurance is not required. Please provide this form to the government entity from which,you are requesting a permit,license or contract. This Certificate will not be accepted by government officials one year after the date printed on the form. In the Application of Business Applying For: (Legal Entity Name and Address): Contracdirs License Central homt senim/repaJre From:The Villa Re of Rye Brook 126 highland fir From: y (orilandi Manor NY 10%7-74.15 PHOM.:91d-V9-'54' FFt\:XXX\Ii4.N1 Workers'Compensation Exemption Statement: The above named bustness is ceniNing that it isNOT REQUIRED TO OBTAIN NEW YORK STATE SPECIFIC WORKERS'COMPENSATION INSURANCE COVERAGE for the following rea_wn: The business is a LLC.LLP,PLLP or a RLLP;OR is a partnership under the laws of New York State and is not a corporation Other than the partners or members.there are no employees,day labor,leased employees,borrowed employees.part-time employees.unpaid volunteers(including family members)or subcontractors. Partners;Membtrs: rebat owcn,louis fcmew Disability and Paid Famih Leave Benefits Exemption Statement: The above named business is ccrufymg that it is NOT REQUIRED TO OBTAIN NEW YORK STATE STATUTORY DISABILITY AND PAID FAMILY LEAVE BENEFITS INSURANCE COVERAGE for the following reason. The business MUST be either I) owned by one individual, OR 2) is a partnership(including LLC,LLP,PLLP,RLLP,or LP)under the laws of New York Stale and is not a corporation, OR 31 is a one or two person owned corporation,with those individuals owning all of the stock and holding all offices of the corporation(in a two person owned corporation each individual must be an officer and own at least one share of stock); OR 4) is a business with no NYS location. In addition,the business does not require disability and paid family(rave benefits coverage at this time since it has not employed one or more individuals on at least 30 days in any calendar year in New York State (Independent can&actors are not considered to be employees under the Disability and Paid Family Leave Benefits Law.) I,robes oven,am the Partner with the above-rained►ega!entity 1 affirm that due to my position with the atwvc-named business 1 have the knowledge, mfixmauxm and authority to make this Catifieste of Attestation of Exemption 1 hereby affirm that the statements made herein arc true,that I have not made any materially false sumvients and i make this Certificate of Attestation of Exemption under the penalties of perlury I further affirm that 1 undcrsuad that any false suacnient represenutiar,or concahnent will subject me to felony criminal prosecution.including lain and civil habtbty m accordance with the Workers'Compensation Law and all other New York State laws. By submitting this Certificate of Attestation of Exempboo to the government eiinty listed abovv I alai hereby affirm that if cacurnsuvices change so that workers'compensation insurance and'or disability rind paid famliv Icave benefits coverase is roquired,the above-named legal entity will immediately acquire appropnate New York State specific workers' compensation insurance arAor disability and paid family leave benefits covmrge and also immediately furnish pmof of that coverage on forma approved by the Chun of the Workers'Comprn+Ttinn n!v,the povemmem entity listed above SIGN71HERE Signature: /� Date: 2 R""�t"d k,Yemptiun Certificate vwnher 2022-027083 April 25, 2022 NYS Workers'C'on►pe nation Board CF 200n1 20ii i