HomeMy WebLinkAboutBP22-0877 �07 OTHER ARPROVALS
PERMIT #)6o c44' lD/ (p'� / DATE: EXP:
SECTION BLOCK LOT 7 ��``SOT
BOT
ARB
TYPE OF WORK
JOB LOCATION r e aT ZBA
OWNER `30 099� // 96 OHER
T__---
CONTRALTO
T. COST
CO #
TCO #
INSPECTION RECORD
DATE
FOOTING
FOUNDATION
FRAMING
RGH FRAMING
INSULATION
PLUMBING 0
RGH PLUMBING
GAS
SPRINKLER a
ELECTRIC
LOW -VOLT
ALARM
AS BUILT 0
FINAL
INSP
VILLAGE OF RYE BROOK
WESTCHEST COUNTY, NEW YORK
NO. 24-004
Certificate of ®ccupaucp
his is to certify that � be
C e9f Y
1-/
of �C having duly filed an application on
20 requesting a Certificate of Occupancy for the premises known as,
Rye Brook,NY, located in a Zoning
District and shown on the most current Tax Map as Section: O Block: --_2 Lot: 6 ,
and having fully complied with the requirements of the Building Code and the Zoning Ordinance under Building
Permit No�o -OLT7, issued 20,U, 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: l Construction: ,
for the following purposes: /w -
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 sh a ,nor sh a building be moved from one location
to another until a permit to accomplish such change en gained i�om the ding Inspector. J A N 1 61024
Building Inspector,Village of Rye Brook: Date:
For office us only:
Lo
BUILDING DEPARTMENT PERMIT# ��—Og/ VILLAGE OF RYE BROOK ISSUED: lo—
JAN 12 2024 � 93$KING STREET,RYE BROOK,NEW PORK 10573 DATE: —/a— r3S/
VILLAGE OF RYE BROOK (914)939-0668 FEE: ,d /Jp PAMN
ILL n!E F RYE BROOT www.ryebrook.orl!
APPLICATION FOR CERTIFICATE OF OCCUPANCY, CERTIFICATE OF COMPLIANCE,
AND CERTIFICATION OF FINAL COSTS
TO BE SUBMITTED ONLY UPON COMPLETION OF ALL WORK, AND PRIOR TO THE FINAL INSPECTION
Address:
�t#itiiittti#ttttiiii#iii#iii##it#iitiii##iiitiiiittitiiiiiiiiiitiii#i
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Occupancy/Use: Parcel ID#: 9, o 70 Zone:
Owner: r C Mto DE �&0 A 'P Address: 94 N S A CGO.fr~
P.E./R.A. or Contractor: Address:
Person in responsible charge: Address:
Application is hereby made and submitted to the Building Inspector of the Village of Rye Brook for the issuance of a
Certificate of Occupancy/Certificate of Compliance for the structure/construction/alteration herein mentioned in accordance
with law:
STATE OF NEW YORK, COUNTY OF WESTCHESTER as: ,.,
F�n 6 M 6-1v 0 E 17 IAA+ being duly sworn,deposes and says that he/she resides at �� �r�C N ��y c4r C
(Prin1tt Name of Applicant) (No.and Str et)
in �e � ,in the County of W E f j Ck�f elCn' in the State of that
(City/Town/Village)
he/she has supervised the work at the location indicated above,and that the actual total cost of the work,including all site improvements,
labor,materials,scaffolding,fixed equipment,professional fees,and including the monetary value of any materials and labor which may
have been donated gratis was:$ 41 aQ o n
for the construction or alteration of �Y 57ri`/
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 J�_ Sworn to before me this
day of 4 WUA1 , 20-4 day of , 20
Siva a of Property Owner Signature of Applicant
ame of Property Owner Print Name of Applicant 71
Notary Public SHARI MELILLO Notary Public
Notary Public,State of New York
No.UMEU60063 8/12/2021
Qualified In Westchester County Commission Expires January 29,201�7
�yE BR(��•
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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 : Ee tj w � C-LQSQ DATE: Z - 6 - 20211
PERMIT# u to 22, -0 e -2 ISSUED: " 7 22 SECT: (?7 BLOCK: 2 LOT: 7 U
LOCATION: R OCCUPANCY: 2/O
❑ Violation Noted THE WORK IS... B PASSED ❑ FAILED REINSPECTION
B"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
a-TINAL
❑ OTHER
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BUILDING DEPARTMENT `cf"C
VILLAGE OF RYE BROOK MAY - 5 ZQ22
R[
938 KING STREET RYE BROOK,NY 10573
(914)939-066$ VILLAGE OF RYE BROOK
wvrwxygbrook.org BUILDING DEPARTMENT
ADMINISTRATIVE EXTERIOR BUILDING PERMIT APPLICATION
FOR EXTERIOR WORK WHICH DOES NOT REQUIRE VILLAGE ARCHITECTURAL REVIEW BOARD APPROVAL
FOR OFFICE USE gONLY:
APPROVAL DATE:M H 1 _ .7 2022 PERMIT#: -`-`/�� _
�7 APPLICATION FEE: b
APPROVAL SIGNATURE: PERMIT FEES:
H.O.A.APPROVAL: DATE: s 2
DISAPPROVED: OTHER:
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Application dated: C\4,-,\. 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. IobAddress: g �+ �EN'r1�A`^1�t' �y ,1�
2. Parcel ID#: f 7- ,���' c 70 Zone: Aub
3. Proposed Improvement(Describe in detail): EXTEND QUIZ F X 1 ST I O& Pi MD I
TO TIRE SIDE ( DEPTH WILL RCkAIN THE 5Amd_
4. Propertyowner: rf\E1,>EFZyCA B DIAGsA 1 I'iEt_VZA MARQUFf-�
Address: &RG7 WAY CLOSE
Phone# Cell# nm) ';Z6(- �Cl a e-mail 14L-LCL ORUV JN I Q 007 Mh 1L.Cci
List All Other Properties Owned in Rye Brook:
Applicant:
Address:
Phone# Cell# e-mail
Architect:
Address:
Phone# Cell# e-mail
Engineer:
Address:
Phone# Cell# e-mail
General Contractor:
Address:
Phone# Cell# e-mail
(1)
8/1212021
5. Occupancy;(1-Fam.,2-Fam.,Commercial.,etc...)Pre-construction: 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: I St fl: 21 fl: 31d fl:
10. Total Square Footage of the proposed new construction:
11. For additions,total square footage added:Basement: 1"fl: 2°d 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:O Typical Western Lumber Frame;()Timber Frame[TC];()Wood Truss[TT];
O Pre-engineered wood[PW];Located;O 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:
IT What material is the exterior finish:
18. Roof style;peaked,hip,mansard,shed,etc: Roofmg 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 of impervious coverage requiring a
Stormwater Management Control Permit as per§217 of Village Code? Yes:_No:_Area:
23. Will the proposed project require a Site Plan Review by the Village Planning Board as per§209 of Village Code?
Yes: No: (ifyes, 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:
(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:
(if 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:
(f 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:
Indicate:TIER I: TIER II: TIER III: //(if yes,a Home Occupation Permit Application is required)
29. What is the total estimated cost of construction: $ /- fxl,-)— Note:estimated cost shall include
all site improvements,labor,material,scaffolding,fixed quipment,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:
(2)
8/12/2021
BumDNO.— MENT
VIL OE OF RYA. t,00K
938 KING V ET RyF BRO NY 10573
1914 939r0668-
vJvy
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AFFIDAVIT OF COMPLIANCE
VELLAGE CODE §216 • STORM SEWERS AND SANITARY SEWERS
THIS AFFIDAVIT !BUST BEAR THE NOTARIZED SIGNATURE OF THE LEGAL PROPERTY OpP@ZR 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:
3. {""0E 411 ID 86 v 1A GP Gam)GS , residing at, I E►v 1.•' C L-0— 7 ,E S P, K- qaS 3
(Print name) (Address wh•re 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;
` I G u E N V F" CLO SC _ 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 crass-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,
I'
(Signatnr t o Property Owner(s))
PE v .4L- Go►v- G-s
rint Name of Property 07/ `)
Sworn to before me this
day of ��'`t- , 20- Z��zi��
1'
(Notary Public)
Jr111AR[!_
0FW*r0W
f" de:n.r.�pn lts4r. APAL ao.216
(3)
$/12/ =
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.
wfwwwwwwwrsrww##**,e«*rt+tir#*irw�+*wwwwww*trw�r*+�w,r*www***w*wwwwwwwwwwwwwwwwww*w*ww*wwkww*wtr**www+t,rwwtwwwfwwwww*
STATE OF NEW YORK,COUNTY OF WESTCHESTER ) as:
III 6 rUW ;r ,being duly sworn,deposes and states that he/she is the applicant above named,
(print name of individual signing as the agplic M)
and further states that (s)he is the legal owner of the property to which this application pertains, or that (s)he is the
—J— 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.
rt�
Sworn to before me this 7 Sworn to before me this
day of S� �' 20 'V lY day of_ 20
Sigpaikm ofp y Signature of Applicant
r
Print Name of Property Owner Print Name of Applicant
4�'
Notary Public Notary Public
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(4)
8/12=1
Building Permit Check List&Zoning Analysis
Address: ?ZFFt-n w4,�-,q Cc—D L F SBL: t 7,7_, 1) 2 — Q
Zoned Use: Z- Const.Type: Other.
Submittal Date: S Revisions Submittal Dates:
Applicant: ✓�l✓�CL o,0 F,S
Nature of Work: k�L-Ata—L:F
Reviews:ZBA: MAY - g 2022 pg: BOT: Other.
OK
( ( ) ES:Filing: S• BP: Flood Plane: ✓Legalization:
( ) ( P: 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.�Z 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: I-W.I.C.:_Battery:_Other.
( ) ( ) PLUMBING Plans: Permit Nat.Gas: LP Gas: N/A/: Other.
( ) ( ) FIRE SUPPRESSION:Plants: Permit: N/A: Other.
( ) ( ) H.V.A.C.: Plants: 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 Plants: 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:
REOMED EXISTING PROPOSED NOTES APPROVED
Ate: Data; MAY - n �n��
c;n�M
Front:
Sides:
&ar.
Main Co
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Sd,H/Sb:
SFA:
:
Hag /stories:
notes:
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F 5 2022 173'/z Ivy Hill Crescent
VILLAGE OF RYE BROOK Rye Brook, NY 10573
BUILDING DEPARTMENT 914-939-2440
f
May 3, 2022
Frederico Bediaga and Heloiza Marques
81 Greenway Close
Rye Brook, NY 10573
Re: Addition to Deck- Permit Required
Dear Frederico Bediaga and Heloiza Marques,
The Architecture and Grounds Committee (A&G) has reviewed your
application for the above named work. This project requires a permit from
The Village of Rye Brook. You are directed to submit this letter to the
Village along with your permit application. Once the permit is obtained, a
copy must be provided to A&G for final review and consideration.
Work on the project may not begin until you receive written notice of
acceptance from A&G.
If any changes are made to the original plans submitted to A&G, due to
input from the Village or arising during construction, the Committee must be
notified in writing. Work cannot proceed until you receive written approval
for those changes.
Failure to comply with these procedures will result in fines and/or work
stoppage.
If you have any questions, please contact me at: Property Manager.
Ashlee Pasquale
Property Manager
� I
MAY 1
VILLAGE 2022
RYE ...
S
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_ :�• .n �r_ ��>>�,' ��� ��A ytJ.` was`►\n ,71
. , y. •l .,A � +. e A .. ter' _•_X-ti+`%.. .�,
her•-• Pj,,�R L`�. � it i��, ,1.� t��� ``1 ��,,,.•1 ��`'� S`�M�.
�L
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eAA
�' �F� � +� 4, � . •F _ �` .,ram•
I appreciate your help,
Heloiza D
MAY 16 2022 DD
VILLAGE OF RYE BROOK
BUILDING DEPARTMENT
3
Laura Petersen
From: Helo Lorenzi <helolorenzi@hotmail.com> E �
Sent: Friday, May 13, 2022 9:35 AM
To: Laura Petersen MAY 1 6 2022
Subject: 81 Greenway Close
VILLAGE OF RYE BROOK
BUILDING DEPARTMENT
Good morning, Laura
Regarding our application for our patio extension we still missing contractors documentation, which is being a problem,
we are not finding anyone who wants to make this small work.
For this reason we would like to do it ourselves. How does it work?
Follow attached pictures of the area (the extension will be inside the white line).
1
Laura Petersen
From: Helo Lorenzi <helolorenzi@hotmail.com>
Sent: Sunday, June 5, 2022 10:35 AM
To: Laura Petersen
Subject: RE: 81 Greenway Close
Good morning, Laura
I got the estimate for our patio extention, which is $1000. Let me know if we need to send you any other
information or document.
Thank you
Heloiza
De: Laura Petersen<LPetersen@ryebrook.org>
Enviado:terp-feira, 17 de maio de 2022 14:40
Para: Helo Lorenzi <helolorenzi@hotmail.com>
Assunto: RE: 81 Greenway Close
Great! Thank you! One last thing, do you have the estimated cost of construction yet?
Laura (Petersen
Office Assistant
Village of Rye Brook
938 King Street
Rye Brook, New York 10573
Phone(914)939-0668 1 Fax (914)939-5801 1 Ipetersen(a)ryebrook.org
From: Helo Lorenzi <helolorenzi@hotmail.com>
Sent:Tuesday, May 17, 2022 1:38 PM
To: Laura Petersen<LPetersen@ryebrook.org>
Subject: RE:81 Greenway Close
I'm sorry I had attached the same documents two times.
Follow the insurance.
Thank you
De: Laura Petersen<LPetersen@ryebrook.orp,>
Enviado:terra-feira, 17 de maio de 2022 14:34
Para: Helo Lorenzi <helolorenzi@hotmail.com>
Assunto: RE: 81 Greenway Close
Thank you. Please send your homeowners insurance declaration page also.
i
Laura
Laura Petersen
Office Assistant
Village of Rye Brook
938 King Street
Rye Brook, New York 10573
Phone(914)939-0668 1 Fax(914)939-5801 1 petersen(c'bryebrook.or_q
From: Helo Lorenzi<helolorenzi@hotmail.com>
Sent:Tuesday, May 17, 2022 1:32 PM
To: Laura Petersen<LPetersen@ryebrook.org>
Subject: RE:81 Greenway Close
Good afternoon, Laura
Follow attached the doctuments requested.
Let me know if we need to send you anything else.
Thank you,
Heloiza
De: Laura Petersen<LPetersen@ryebrook.org>
Enviado: segunda-feira, 16 cle maio de 2022 10:20
Para: Helo Lorenzi<helolorenzi@hotmail.com>
Assunto: RE: 81 Greenway Close
Good morning,
I have attached a BP-1 form for your notarized signature. We will also require a copy of your
homeowners insurance declaration pages.
This information can be emailed to me or you can bring it to the Building Department.
Thank you
Laura
Laura Petersen
Office Assistant
Village of Rye Brook
938 King Street
Rye Brook, New York 10573
Phone(914)939-0668 1 Fax (914)939-5801 1 loetersen aa.)rvebrook.org
From: Helo Lorenzi<helolorenzi@hotmail.com>
Sent: Friday, May 13, 2022 9:35 AM
To: Laura Petersen<LPetersen@ryebrook.ore>
Subject:81 Greenway Close
Good morning, Laura
2
GEICO Insurance Agency, LLC
Issued by Homesite Insurance Company of New York
P.O. Box 5300 Evidence of Insurance For Policy
Binghamton, NY 13902-9953 Number 36419988
Tel. (866) 372-8903 Fax (877)273-2984 This policy covers the listed location(s)from:
12:01 AM October 7,2021 through
Insured Name and Mailing Address: 12:01 AM October 7,2022(local time)
FREDERICO DE BEDIAGA GOMES
81 Greenway Close Send payment to:
Rye Brook, NY 10573-1505 PO Box 414356
Boston, MA 02241-4356
Insured Location
81 Greenway Close Rye Brook NY 10573-1505
Residence: Primary home
Deductible: $1000
Hurricane Deductible: 5% ($25050.00)
Coverage Limit
Section I - Property
A. Dwelling $501,000
B. Other Structures $50,100
C. Personal Property $250,500
D. Loss of Use $150,300
Section II - Liability
E. Personal Liability $300,000
F. Medical Payments to Others $1,000
Total Policy Premium $2016.00
Total Amount Due $336.00
Total Amount Paid -$1680.00
'Please note that installment fees are not included in these totals and vary by payment plan option.
First Mortgagee
Loan Number: 8000238875
Homepoint Financial
ISAOA/ATIMA
PO Box 5017
Troy, MI 48007
Notes:
H03—Homeowners
HO 04 20-Specified Additional Amount Insurance for Cov A limit 25%
HH D1 06 CW 11 14 Page 1 of 2
The Coverage A Dwelling amount is based on replacement cost as described in the policy. Certain
exceptions apply. Please review your policy for further details.
All information and representations herein are subject to the policy terms and conditions. Coverage is
contingent upon receipt of the initial payment of premium
prior
•to the effective date of the policy.
01
Authorized Representative Date May 16, 2022
This evidence of property insurance is issued as a matter of information only and confers no
rights upon the certificate holder. This evidence of property insurance does not amend,
extend or alter the coverage afforded by the policy above.
HH D1 06 CW 11 14 Page 2 of 2
Affidavit of Exemption to Show Specific Proof of Workers' Compensation Insurance
Coverage for a 1, 2, 3 or 4 Family, Owner-occupied Residence
**Thit form cannot be used to waive the workers'eompensadlon right or obligations of any party.**
Under penalty of perjury, I certify that 1 am the owner of the 1,2, 3 or 4 family, owner-occupied residence
(including condominiums) listed on the building permit that I am applying for, and I am not required to show
specific proof of workers' compensation insurance coverage for such residence because (please check the
appropriate box):
I am performing all the work for which the building permit was issued.
❑ I am not hiring,paying or compensating in any way,the individual(s)that is(are)performing all the work
for which the building permit was issued or helping me perform such work.
I have a homeowners insurance policy that is currently in effect and covers the property listed on the
attached building permit AND am hiring or paying individuals a total of less than 40 hours per week
(aggregate hours for all paid individuals on the jobsite)for which the building permit was issued.
I also agree to either:
♦ acquire appropriate workers' compensation coverage and provide appropriate proof of that coverage on
forms approved by the Chair of the NYS Workers' Compensation Board to the government entity issuing
the building permit if I need to hire or pay individuals a total of 40 hours or more per week(aggregate hours
for all paid individuals on the jobsite)for work indicated on the building permit,or if appropriate,file a CE-
200 exemption form; OR
♦ have the general contractor, performing the work on the 1, 2, 3 or 4 family, owner-occupied residence
(including condominiums)listed on the building permit that I am applying for,provide appropriate proof of
workers'compensation coverage or proof of exemption from that coverage on forms approved by the Chair
of the NYS Workers' Compensation Board to the government entity issuing the building permit if the
project takes a to 1 of 40 hours or more per week(aggregate hours for all paid individuals on the jobsite)for
work' n the building permit.
(Signature of Homeowner) (Date Signed)
R E r1�P.l C,o VE P-)e_o!P G�-A GovA 1 Home Telephone Number 3 o S 69q 94 9.'
(H eowner's Name Printed)
Sworn to before me this i (V day of
Property Address that requires the building permit: - /h
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(County Clarkor Notary a c
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NMARY PL9M 99a)K s.N9w YORK
R.gi w.a Na.OTaasa e
(J S 2 NOTARY PUBIC STATE OF NEW YORK
7 --- CasnYWesI'l APAL7D.3M
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Once notarized,this BP-1 form serves as an exemption for both workers'compensation and disability benefits insurance coverage.
BP-1 (12/08) NY-WCB
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VILL RYE BROOK
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DATE APPRO D MAY -
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