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HomeMy WebLinkAboutSP22-002PERMIT #`5� - � 00 DATE: 3 a.5 as EXP:_3,L 3 SECTION ®• 3s BLOCK LOT TYPE OF WORK /V W7`- un ll�SinP�S.s �r� /)(Q JOB LOCATI N �t� / � rr / 14zo OWNER h/.!� ,'1 r l 'aCiQ�Ps /y)�i/9-316/0 CONTRACTOR /'yl l/C Q 1���%/1 " a� �� C7/ d) �SU"" ��� EST. COST FEES ,%CO # FEE o/Q'gbb DATE TCO # FEE DATE INSPECTION RECORD DATE FOOTI N G FOUNDATION FRAMING RGH FRAMING INSULATION PLUMBING RGH PLUMBING GAS SPRINKLER LOW -VOLT ALARM AS BUILT 0 Z FINAL Ei 1 NSP OTHER APPROVALS ARB NiQIch /10. )oacla BOT PB IZBA 1 OTHER _ 4�y �s K4 L4a w•':WY'• 1� 40A amthwwaW VILLAGE OF RYE BROOK MAYOR 938 King Street, Rye Brook,N.Y. 10573 ADMINISTRATOR Jason A.Klein (914) 939-0668 Christopher J. Bradbury www.ryebrook.org TRUSTEES BUILDING,& FIRE INSPECTOR Susan R. Epstein Michael J. Izzo Stephanie J. Fischer David M. Heiser Salvatore W.Morlino CERTIFICATE OF COMPLIANCE June 13,2022 Washington Park Plaza Associates LLC 275 South Ridge Street Rye Brook,New York 10573 Re: 275 South Ridge Street, Rye Brook,New York 10573 Parcel ID#: 141.35-2-51 Sign Permit 22-002 issued on 3/25/2022 to Install Roof Mount Sign This certifies that the new 15'x 2'roof mount sign;American Prime,installed under the above captioned permit has been satisfactorily completed. Sincerely, Michael J. Izzo Building&Fire inspector /to EC E W E �� For office use only: n ; BUILDING DEPARTMENT PERMIT — APR 21 2022 L , VILLAGE OF RYE BROOK ISSUED: 3-�Q . 938 KING STREET,RYE BROOK,NEw YORK 10573 DATE:--/—a 7—aa VILLAGE OF RYE BROOK (914)939-0668 FEE: PAID$ BUILDING DEPARTMENT Mr%M•acbrook.org APPLICATION FOR CERTIFICATE OF OCCUPANCY,CERTIFICATE OF COMPLIANCE, AND CERTIFICATION OF FINAL COSTS TO BE SUBMITTED ONLY UPON COMPLETION OF ALL WORK, AND PRIOR TO THE FINAL INSPECTION rr►►rr►►♦rrrr►►rrr►rrrrrrr►►srr►rrrrrrr►rr►rrrrr►r►►►►►►rrrrrrr►►►►►rrrrrrrr►r►►►►►►rrr►rrr►rrrrrrpr►►►rrrrrr►srrerrr►►►►►►► Address: Occupancy/Use: , Parcel ID#: 1 1 r'Tj S -Z,— \ Zone: D.&—S Owner: 'C—O 1\%A k V1+ -!�ai -1I Address: 4S u-�'I o/y rtio 07s P.E./R.A. or Contractor: I►P xz-(O G m AWmwo Address: A4 7C 1AA44rsIt. Aio,?.y o IOJ(7y Person in responsible charge: Nt.)0 64- Address:I t 14 S4 81 LOO I l 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: l.1,5-W being duly swom,deposes and says that he/she resides at W#04,�/'}rJ (Print Name of Applicant) (No.and Street) I in ` ►d�^I J 4LE ,in the County of AF.6M� in the State of -_ /V y that (City/Town/Village) he/she has supervised the work at the location indicated above,and that the actual total cost of the work,including all site improvements, labor,materials,scaffolding,fixed equipment,professional fees,and including the monetary value of any materials and labor which may have been donated gratis was:$ 3 �;-o O� for the construction or alteration of: N 2 �rvv flA--'vkA lc�— 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 Sworn to before me this day of��LQ ,2 day of �C— , 20 2'Z Signature o Properiy Owner Signature of Applicant/ Print ame of Property Owner Print N f�4pptl�r--— otary i N b c CAROLYN MARIE CANNISTRARC JOHN M SUOaO 8 12/2021 Notary Public-Stale of New York NOTARYR IX,STATE OF NEWY011K No.01 CA6177080 Registration No.01SUW70919 Qualified in Westchester County Oualifled in WestchaW County My Commission Expires Nov.5,2023 My Commisslon Exph o March 11,2WO �yE BRCuk. O�` tim cu � 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.rygbrook.org - - - - - - - - - - - - - - - - - - - - INSPECTION REPORT - - - - - - - - - - - - - - - - - - - - ADDRESS: Z72� DATE: PERMIT# �p2 ISSUED: ± SECT: �s BLOCK: Z LOT: t LOCATION: ��{'`� l� �`, 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 ❑ CROSS CONNECTION FINAL OTHER 6 6 4 6- 6 v Nn QF M M rn bc�e b `� h+�ll ■. w CA F w x u ® ° P� ?4 � v C CU cc I"l M 1""° o © v E U y 00 Ln RT � as r co F"� ►�I , �, o ^ v - w .,w ' 0 v � U j Cd O ai z Ln A 0 8 4 (� W WNLn CN r 00 4 `�' o a �l � as v G, 4� a � z � � V � W a. to � v b � C O � ■ a � p wA � � bw ° . O w Ey O z z .o a CAI Z O v o " � tug _ zo °a � o� �� � W zz F O z a °,r�j 08 cn O O � � ® Z � � Y �I a w � c BUILDING DEPARTMENT FEB 18 2022 VILLAGE OF RYE BROOK R 938 KING STREET RYE BROOK,NY 1057 3VILLAGE OF RYE BROOK 1 (914)939-0668 BUILDING DEPARTMENT www,ryek0o&org FOR OFFICE USE ONLY:. Approval Date:MA R 2 1 2022 mit# Application# Approval Signature: ARCHITEC2 REVIEW BOARD: Disapproved: Date: JLZ' BOT Approval Date: Case# Chairman: ,,/� PB Approval Date: Case# Secretary: Y Co ZBA Approval Date: Case# Other: Application Fee: � � 'U Permit Fees: �] SIGN PERMIT APPLICATION Application dated: C)(- 0 ' L Z is hereby made to the Building Inspector of the Village of Rye Brook,NY,for the issuance of a Permit for the construction/installation of a sign in accordance with Village Code§250-35 as per detailed statement described below.1. Address: Z� �u 1 I SBL:,,�yZ'3S 3'15/ Zone:Dp`__� 2. Property Use or Business Name: A M C— �L\ w— ,A nJ F L i r1 E 172 �-- 3. Proposed Sign(s)(Describe in detail including number of signs,types,sizes,exact location(s),and illumination method(s)if applicable.) (A separate Electrical Pemrit will be required for any associated electrical work.) : 4. Height from grade to highest point of sign: ,to lowest point of sign: 5. Property Owner: " S �r��►�G TO►'J L rq}Q Address: 2- 7Y - '0u F1, R__� /9 6 (F Oj i Phone# ©-' Li '1 14'� 25 6 6 Cell# email: 6. Applicant: /U A 14 k Address: w'j L 1 O/N AC 0/)S (ZIP L CL r4- ej Phone# I S 3 $6 }-Z Cell# email: 7. Architect/Engineer: Address: Phone# Cell# email: 8. Sign Contractor: P M G-9 1 CAN A y-'N t N L Address: 8 41-4 C °L 12i 4R1__(l_ �j y e (LOM y A y Phone# �' r�J'0 t� Cell# email: 1 4- 8/12/2021 9. Will the proposed sign require a Site Plan Review by the Village Planning Board as per§209 of Village Code? Yes:_No: (If yes,you must submit a Site Plan Application,&provide detailed drawings) 10. Does the proposed sign involve a Home-Occupation as per§250-38 of Village Code? Yes: No: If yes,indicate: TIER I:®TIER II: TIER III:_ (If yes,a Home Occupation Permit Application is required) It. If building is located on a corner lot,which street does it front on: 12. Property frontage: 13. Property size:Sq.Ft.: Acres: 14. What is the total estimated cost of construction: $ (The estimated cost shall include all site improvements,labor,material,scaffolding,fixed equipment,professional fees,including any material and labor which may be donated gratis.) 15. Estimated date of completion: uo This application 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. STATE OF NEW YORK,COUNTY OF WESTCHESTER ) as: —4bA/!'[*'* LF,04 ,being duly sworn,deposes and states that he/she is the applicant above named, ndi(print name of ividual sig ning as the pph� 'cant) and further states that (s)he is the legal owner of the property to which this application pertains, or that (s)he is the 1ATa Aak9sx, 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 th�ee Code of the Village of Rye Brook and all other applicable laws,ordinances and regulations. Sworn to before me this *r' Sworn to before me this --J day of , 2 day of J n�` f ,20 Or Signature of Property Owner Signature of Appli t Zme of Prop Owner t Name of Applicant No c 6"ARIE ANNISTRARO Notary Public-State of New York CAROLYN MARIE CANNISTRARO No.01 CA6177080 Notary Public-State of New York Qualified in Westchester County No.OICA6177080 My Commission Expires Nov. 5,2023 Qualified in Westchester County My C mmission Expires Nov.5,2023 -2- 8/12/2021 Mike Izzo From: Mike Izzo Sent: Wednesday, April 13, 2022 4:23 PM To: 'Brothers Hima' Cc: 'martha7087@aol.com'; Steven Fews; 'Tara Orlando'; Laura Petersen Subject: RE: 275 s ridge st Attachments: CO - CC Application 8.2021.pdf Dear Mr. Ahmetaj, Thank you for the email. After reviewing your permit file for the subject address, I find a number of outstanding items which must be addressed before we can schedule any final inspections. You have three open construction/demo permits and one open sign permit. The oldest one is Demo Permit #DP21-007 issued 10/7/21 to demolish interior finishes. You must file for a C/O to close this permit and remit the appropriate C/O fee. The fee is based on the final cost of the demo work which must be provided by you on the C/O Application. A copy of the C/O Application is attached hereto for your convenience. Next is BP22-007 issued 1/19/22 for the interior renovation of the restaurant. The file indicates that not one of your trades called for any inspections for anything during the renovation work including plumbing, HVAC, fire sprinkler, fire alarm, line voltage or low voltage electrical. Neither do we have a copy of the approval from the NY State Liquor Authority for the new bar. Once these items are resolved you must file a C/O application and fee as previously described, then you can request a final inspection. Next is BP22-012 issued 1/24/22 for the storefront renovation. Again, the file indicates no inspections requested or performed, and no C/O application or C/O fee. Finally, SP22-002 issued 3/25/22 for the new roof sign: no inspections, no C/O application, and no C/O fee. Please arrange to resolve these open issues to the satisfaction of the code. To schedule an inspection, please contact one of our Office Assistants by telephone, Monday through Friday between the hours of 8:30am and 4:00pm at (914) 939-0668. Thank you. A/��ae/(7, /zzo Building & Fire Inspector Village of Rye Brook, NY (914) 939-0668 From: Brothers Hima <himabrothers@gmail.com> Sent: Monday,April 11, 2022 2:37 PM To: Mike Izzo<Mlzzo@ryebrook.org> Subject: 275 s ridge st Mike good afternoon I hope this email finds you well I be ready for final inspection in this 2 days is any way you can stop by please I have done Fire alarm report Striker system Report Fire suppression system Report Fire extinguisher report Hood cleaning report Emergency lights test and report Greas trap report Please let me know if I need anything else And when is a good day for you to come in. Thankyou Edin Ahmetaj z Building Permit Check List&Zoning Analysis Address: 7iZ�� S•` 1��S'� S`t SBL: < <3 - z - S Zone: — Use: Cont.Type: Other. Submittal Date: 2- ( Z Z Revision Submittal Dates: Applicant: W "_1-0 r—_ fa ��-.bZ A pp Nature of Work _TLOQV—^ ",0 r : �_2 \,r I c� lL 1y Reviews:ZBA: F E B 2 5 2 0 2 2 pB: BOT: Other. (� () FEES:Filing.—340• 4k, BP: C/O: Legalization: ( ) (­�APP: Dated: ✓ Notarized SBL: Truss I.D. Cross Connection: H.O.A.: ( ) ( ) Scenic Roads: Steep Slopes: Wetlands: Stone 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:Plan: 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 Plan: 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. GARB mtg.date: 3 t(o Z- aPProvaL• ` notes: ( )ZBA mtg.date: approval• notes: ( )PB mtg.date: approvaL• notes: REQUIRED EXLSI'ING PROPOSED NOTES APPROVED n,te. MAR 2 1 2012 Fri Frsn� Main coy Accs•Coo Ft.H/Sb: Sd.H/Sb: -GF . Tot.Imp Ft.Imp Raddw- Hag /Stories notes: D EC ENE BUILDING, RTMENT FEB 18 2022 ] 3D VILLAG OF RY OOK VILLAGE OF RYE BROOK 938 KING S'F&ET RYE BR60K,NY 10573 BUILDING DEPARTMENT 4 4 9,06461 ` 6i ARCHITECTURAL REVIEW BOARD CHECK LIST FOR APPLICANTS This form must be completed and signed by the applicant of record and a copy shall be submitted to the Building Department prior to attending the ARB meeting. Applicants failing to submit a copy of this check list will be removed from the ARB agenda. Job Address: 235 S 1 11)(0 E- -S-) Date of Submission: Parcel ID#: /-W,,35- Q-S/ Zone:0, 'J ot- I R - -L Z Proposed Improvement(Describe in detail): N �WJV APPLICANT CHECK LIST: MUST BE COMPLETED BY THE APPLICANT The following items must be submitted to the Building 1 v/ Department by the applicant-no exceptions. Property Owner: W{�+� I !1�S0 f L►�}74- 1. (�Completed Application n/ 2. Two(2)sets of sealed plans. (one full size (maximum Address:Z 4,5 S 41 1/6 allowable plan size=36"x 42")and one 11"x17") 3. ( )Two(2)copies of the property survey. Phone# 4. ( )Two(2)copies of the proposed site plan. Applicant appearing before the Board: 5. One electronic/disc copy of the complete application materials. �� .N ' r�l 6. (, )Filing Fee. Address: VU 1 L`I d>y UA13Q y 3 lb 7. Any supporting documentation. VU 1�-rop) C�T O r 8. ( )HOA approval letter. (ifapplicable) Phone# o �-4- 9. Photographs. Architect/Engineer�- 10."Samples of finishes/color chart. (a sample board or Phone# model may be presented the night of the meeting) By signature below, the owner/applicant acknowledges that he/she has read the complete Building Permit Instructions&Procedures, and that their application is complete in all respects. The Board of Review reserves the right to refuse to hear any application not meeting the requirements contained herein. Sworn to before me this Swom to before me this g day of , 20 day of , 20 22" Signature of Property Owner Signature of Applicant t-a4r, Aft,a4') Print Name of Property Owner Print N�i t Notary Public Notary Public OZ'6Z kmnuer sondx3 uolsslwwOO �Z/(tunoo J91se401s9M ul petglleno 5866919ti910'ON )poA MGN 10 9;>?3S`ollgnd tiMONs/12ao21 AbngQyyg'f d3HdOISI81-10 ` VILLAGE OF RYE BROOK BUILDING DEPARTMENT 938 KING STREET, RYE BROOK, NY 10573 (T) 939-0668 (F) 939-5801 ARCHITECTURAL REVIEW BOARD Wednesday, March 16, 2022 ANNOUNCEMENT: PER THE GOVERNOR'S EXECUTIVE ORDER THIS MEETING WILL BE HELD VIRTUALLY THROUGH THE ZOOM PLATFORM. THE PUBLIC CAN ACCESS THE MEETING THROUGH THE FOLLOWING LINK: https://us02web.zoom.us/i/81417970741 OR BY OPENING ZOOM AND ENTERING THE MEETING ID: 81417970741 NAME & LOCATION TYPE OF APPLICATION MOTION SECOND APPROVED REJECTED APPL.# 32 Lincoln Ave Amendment - Change Consent 5563 (Samad) Driveway Configuration Agenda 64 Windsor Road Replace Existing Window Consent 5674 (Metz) & Door Openings with Agenda New Doors in Rear. I 1 Lawridge Drive New Skylight, (Interior Consent 5675 (Goldstein) Renovations) Agenda 15 Red Roof Drive 4 Ft Black Aluminum 5676 (Gotlieb) Fence In Rear Yard (Legalization) 65 Rock Ridge Amendment To Prior Consent 5677 Drive (Ayala) Approval Agenda 1 I Elm Hill Drive New Patio Door in Place Consent 5682 (Debari) Of Window Agenda 275 S. Ridge Street New Roof Mounted Sign 5678 (Washington Park "American Prime" lC I�C Plaza v 14 Lawridge Drive Exterior Renovations and 5679 (Mendelsohn) Alterations @ Front Facade. 818 King Street Driveway Expansion, 5680 (Carabal-Mendes) Concrete Walk, & Stone Retaining Wall ML NM MR ✓ SE JM SF AC ✓ MI KC VILLAGE OF RYE BROOK BUILDING DEPARTMENT 938 KING STREET, RYE BROOK, NY 10573 (T) 939-0668 (F) 939-5801 ARCHITECTURAL REVIEW BOARD Wednesday, March 16, 2022 ANNOUNCEMENT: PER THE GOVERNOR'S EXECUTIVE ORDER THIS MEETING WILL BE HELD VIRTUALLY THROUGH THE ZOOM PLATFORM. THE PUBLIC CAN ACCESS THE MEETING THROUGH THE FOLLOWING LINK: https://us02web.zoom.us/i/81417970741 NAME & LOCATION TYPE OF APPLICATION MOTION SECOND APPROVED REJECTED APPL.# 23 Sleepy Hollow Demolish Sunroom: Install 5681 Rd (Kaplan) Gravel Patio, Steps, Railing & Door 67 Winding Wood 2nd Story Addition, & 5682 Road (Schneider) Front Portico Roof 6 Whippoorwill Amendments To Prior 5683 Road (Adelson) Approval ML ✓ NM MR i/ SE JM V SF AC MI KC �j DATE(MM/DD/YYYY) A`"R" CERTIFICATE OF LIABILITY INSURANCE 1/25/2022 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 Jake Rodriguez Insure24hrs Brokerage,Inc PHONEMo. 718 207 1444 FAX No, 718-233-3174 PO Box 1122 E-MAIL ADDRESS: sales@insure24hrs.com INSURERS AFFORDING COVERAGE NAIC If Wilkes Barre PA 18703 INSURER A: Acceptance Indemnity Insurance Company 20010 INSURED INSURER B: American Awning&Sign Depot Inc INSURER C: 847 C Whittier Street INSURER D: INSURER E: Bronx NY 10474 INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR TYPE OF INSURANCE ADDL UBR POLICY NUMBER MM/DD/YYYY MM/DD/YYYY LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTE117- CLAIMS-MADE �✓ OCCUR PREMISES Ea occurrence $ 100,000 MED EXP(Any one person) $ 5,000 A Y Y BND0003420 00 10/22/2021 10/22/2022 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 ✓ POLICY PRO JECT LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea..dent ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY Per accident UMBRELLA LIAR OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED I I RETENTION$ $ WORKERS COMPENSATION PER I OTH- AND EMPLOYERS'LIABILITY Y/N STATUTE I I ER ANYPROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? ❑ N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached If more space Is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE BUILDING DEPARTMENT THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN VILLAGE OF RYE BROOK ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE 938 KING STREET RYE BROOK NY 10573 01988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD Z4Workers' INEW RK CERTIFICATE OF ATE Compensation NYS WORKERS' COMPENSATION INSURANCE COVERAGE Board 1a. Legal Name&Address of Insured(use street address only) 1b. Business Telephone Number of Insured American Awning& Sign Depot 718-450-8100 Inc 1c.NYS Unemployment Insurance Employer Registration Number of 847C Whittier St Insured Bronx, NY 10474-4907 Work Location of Insured(Only required if coverage is specifically limited to 1 d.Federal Employer Identification Number of Insured or Social Security certain locations in New York State,i.e., a Wrap-Up Policy) Number 45-3817516 2.Name and Address of Entity Requesting Proof of Coverage 3a.Name of Insurance Carrier (Entity Being Listed as the Certificate Holder) SIRIUS AMERICA INS CO BUILDING DEPARTMENT 3b. Policy Number of Entity Listed in Box"1 a" VILLAGE OF RYE BROOK 938 KING STREET, WC50887 RYE BROOK,NY 1573 3c.Policy effective period 09/02/2021 to 09/02/2022 3d.The Proprietor,Partners or Executive Officers are ❑ included.(Only check box if all partners/officers included) ❑ all excluded or certain partners/officers excluded. This certifies that the insurance carrier indicated above in box"T'insures the business referenced above in box"l a"for workers' compensation under the New York State Workers' Compensation Law (To use this form, New York(NY)must be listed under Item 3A on the INFORMATION PAGE of the workers'compensation insurance policy). The Insurance Carrier or its licensed agent will send this Certificate of Insurance to the entity listed above as the certificate holder in box"2". The insurance carrier must notify the above certificate holder and the Workers'Compensation Board within 10 days IF a policy is canceled due to nonpayment of premiums or within 30 days IF there are reasons other than nonpayment of premiums that cancel the policy or eliminate the insured from the coverage indicated on this Certificate. (These notices may be sent by regular mail.)Otherwise,this Certificate is valid for one year after this form is approved by the insurance carrier or its licensed agent, or until the policy expiration date listed in box"3c",whichever is earlier. This certificate is issued as a matter of information only and confers no rights upon the certificate holder. This certificate does not amend, extend or alter the coverage afforded by the policy listed, nor does it confer any rights or responsibilities beyond those contained in the referenced policy. This certificate may be used as evidence of a Workers'Compensation contract of insurance only while the underlying policy is in effect. Please Note: Upon cancellation of the workers'compensation policy indicated on this form, if the business continues to be named on a permit, license or contract issued by a certificate holder,the business must provide that certificate holder with a new Certificate of Workers'Compensation Coverage or other authorized proof that the business is complying with the mandatory coverage requirements of the New York State Workers' Compensation Law. Under penalty of perjury, I certify that I am an authorized representative or licensed agent of the insurance carrier referenced above and that the named insured has the coverage as depicted on this form. Approved by: Steven Diamond (Print name of authorized presentative or licensed agent of insurance carrier) 00, Approved by: 01/24/2022 i�`i'i r'" �� (Signature) (Date) Title: President Telephone Number of authorized representative or licensed agent of insurance carrier: Please Note: Only insurance carriers and their licensed agents are authorized to issue Form C-105.2. Insurance brokers are NOT authorized to issue it. C-105.2 (9-17) www.wcb.ny.gov O FILE COPY O` mO m �n M v r M m V LY N 0 (n L a fp X X W U0 p m LV = m s U (,) Y Z r N Y � L`i U ULij J ` N = QUZm 90 Z Us a in a`o mdSz m O a a, X J O J C7 p w MID LLJ z W W O _ � mz z zm0 w � . D z Q , O Q 0 Doo Q � 00Z 0 w� QM� U HMO T co LO E g� o N g X O arnnE E� CD u o N Q ` cow u'+t N �a r S tn wN � Eo • O ate ° .0r cm TN X,EN OO o av � t � 'ff+ Z Cr Z .� GJ Q ~ Nr O ZUQFa'w� o� c U T- oQ' 1 cv m r, O^ mo oo 00 0 CO 0 U _ P� s E � Lei Q W W M Q W M 2i w � U J S W li LL ` E$ Z � J mYcn CY J � UZ .N. 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