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HomeMy WebLinkAboutBP22-133 Laura Petersen From: Thomas Friedlander <friedlander.tom@gmail.com> Sent: Friday, July 29, 2022 3:27 PM To: Laura Petersen Subject: Re: Solar Permit for 66 Valley Terrace Hi Laura, That is correct.We will no longer be placing solar tiles on our roof. Thanks, Tom Sent from my iPhone On Jul 29, 2022, at 12:01 PM, Laura Petersen<LPetersen@ryebrook.org>wrote: Good afternoon Mr. Friedlander, The Building Department has been informed that you will not be moving forward with the solar PV installation and to cancel the permit. At your earliest convenience, please verify this information. 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 Ipetersenaryebrook.org 1 Laura Petersen From: Stacie Varian <svarian@tesla.com> Sent: Thursday, July 28, 2022 2:22 PM To: Laura Petersen Cc: Mike Izzo Subject: 66 Valley Terrace Good afternoon, I just wanted to inform you that the homeowner at 66 Valley Terrace has decided to cancel his project and will not be moving forward with the solar PV installation.Would you be able to cancel out this permit? Thank you! Stacie Varian Sr. Permit Coordinator 15 Tarkett Dr. New Windsor, NY 12553 E. svarian(Mtesla.com T.408.763.7754 T = =— L 1 CV \ Ln W _ � n ��'•7T .� ate. P � 1 W = w in O W � 0-4 � W> cn 1-4 C) y w W Oj 00 c W � Q F co� v � 00 W G' z � w° v c `a a V z c p r- A a r t5 Cr a^p W A W 000 s► O I1 Fil W W a w W c a w o v e p- PQ00 c1� w r� 00 O V z H F v c M : W o p N ° .VI bR cn � cc O V HgW ° � p4 U U U z w IND W ° � so A a0 w ] v� : Q'I a a a" BUIL TMENT f VI E OF RYE BROOK LF,CF �V E 938 KING EET RYE BR ,NY 10573 ,NJ 4)939-066 JUL - 8 2022 ID r VILLAGE OF RYE BROOK BUILDING DEPARTMENT FOR OFFICE USE ONLY: Approval Date: JUL .2 1 2Q1Z ermit 4,9 — Application# � � Approval Signature: ARCHITECTURAL REVIEW BOARD: Disapproved: : Date: BOT Approval Date: Case# Chairman: PB Approval Date: Case# Secretary: ZBA Approval Date: Case# Other: Application Fee: 67 Pb Permit Tees: APPLICATION TO INSTALL PHOTOVOLTAIC SOLAR ARRAY Application dated: 9 [Ca is hereby made to the Building Inspector of the Village of Rye Brook,NY,for the issuance of a Permit for the installation of a Photovoltaic Solar Array as per detailed statement described below. 1. Job Address: 66 Valley Terrace Rye Brook, NY 10573 SBL: 135.51-1-70 zone: 2 Type,kW&Location of Array, (use additional sheets if necessary): New 8.4 kw solar PV array consisting of 21 panels plus 27 kWh Energy Storage System. 3. Property Owner: Thomas Friedlander Address: 66 Valley Terrace Rye Brook, NY 10573 Phone# 1-qf 9®7" 90 /9 Cell# e-mail 4.Applicant: Stacie Varian of Tesla Energy Operations Address:1073 Rt 94 Unit 4 New Windsor, NY 12553 Phone#4(18- I C; 3 - 3_T Sy Cell# e-mail )V Ct t'_I ar\ o-kS 14.Cow 5. Design Engineer:(AV bcd) U U 16( t 6 Address:3�6,6 L{QCAC 14 Ot. PL6A ,TX �1 526q Phone# q 2 `� G - 53:1 3 Cell# e-mail?l) t6l1f�r L(2�( irLil}-CGCP•C001 6.Solar Contractor: Tesla Energy Operations Address:1073 Rt 94 Unit 4 New Windsor, NY 12553 Phone# � 6 8 --4 Ca 3 3154 Cell# e-mail j V G�I Ci()(P+(S I4 .CQM 7. Occupancy;(1-Fam.,2-Fam.,Commercial.,etc...)Pre-construction: 1-Family _Post-construction: 1-Family 8. If building is located on a corner lot,which street does it front on: 9. N.Y. State Construction Classification: N.Y.State Use Classification: 10. Construction Type&Location: O Typical Western Lumber Frame;O Timber Frame[TC];O Wood Truss[TT]; O Pre-engineered wood[PW];Located;O Floor Framing[F];O Roof Framing[R];O Floor&Roof Framing[FR];Other: 11. Number of stories: Roof Style:(hip,shed,mansard,etc...) 12. Will a New Roof Be Installed: No ErYes El (a separate roofing permit is required to re-roof an existing building) 13. Roofing Material&Number of Layers: t 8/12/2©21 14. 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? No: © Yes: ❑ Area: 15. Will the proposed project require a Site Plan Review by the Village Planning Board as per§209 of Village Code? No: ❑ Yes: ❑ (If yes,applicant must submit a Site Plan Application,&provide detailed drawings) 16. Will the proposed project require a Tree Removal Permit as per§235 of Village Code?No: © Yes: ❑ (If yes,applicant must submit a Tree Removal Permit Application) 17. Does the proposed project involve a Home-Occupation as per§250-38 of Village Code? No: ®Yes: ❑ Indicate:TIER 1:—TIER 11:—TIER III:_ (if yes,a Home Occupation Permit Application is required) 18. What is the total estimated cost of construction: $'�Q. Q 8 FS (Note: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.If the final cost exceeds the estimated cost,an additional fee will be required prior to issuance of the CIO). � 19. Start Date: QJ+ 2� L Completion Date: }a(J Si — �' (Y}"}Q� 7 2G 22 This application must bear 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 YOM COUNTY OF WESTCHESTER ) as: I, Stacie Varian ,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, contractor 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 _)V.4's ,20 '(� day of ____,20 -0— Public No ublic l; I Signature of Property Owner Signature of Applicant Stacie Varian Print Name of Property Owner Print Name of Applicant DREW ALEXANDER AMY M.CONN Notary Public of New York NOTARY PUBLIC,STATE OF NEW YORK I.D.OIAL641646 2 Registration No.OIC06327155 COMMISSION EXPIRES 03/01/2045 Qualified in Orange County Commission E Ires June 29,20 8/12/2021 Building Permit Check List&Zoning Analysis c . Address: V 1C7 Y Ck-V` , e—� SBL: Zone: Use: Const.Type: Other. Submittal Date: 'L2- Revisions Submittal Dates: Applicant: P `C,a C�Q i Nature of Work 2)Cl�!� e-K 0 Q So\k-,c V �� �Reviews:ZBA• PB• BOT• Other. OK ( ) ( ) FEES:Filing: BP:— 1 C/O: Flood Plane: Legalization: ( ) ( i�- 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: ( ) (k)-PLANS:Date Stamped:_�G Sealed:_i,� Copies Electronic: '_Other. ( ) (�License: t/' Workers Comp: 'Liability: 1-' 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. ( ) ( ) 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. - (t.Y RB mtg.date approval notes: ( )ZBA mtg.date: approval: notes: ( )PB mtg.date: approval• notes: APPROVED REQUIRED EXISTING PROPOSED NOTES JUL 2 1 2021 -Arm- Date• c Fin agg: Frorit Front: Sides: Main Cov Accs.Cov Ft.H S S .HS • SL Tot.!W: F Im : Hcjht/Stories: notes: BUILDING DEPARTMENT R C C E VILLAGE OF RYE BROOK 938 KING STREET RYE BROOK,NY 10573 JUL -8 2022 (9-14)9 9-06b8 VILLAGE OF RYE BROOK 'K v BUILDING Dr7PARTMENT 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: 66 Valley Terrace Rye Brook, NY 10573 Date of Submission: Parcel ID#: 135.51-1-70 Zone: )6— P7 I I a Proposed Improvement(Describe in detail): New 8.4 kw solar PV array consisting of 21 APPLICANT CHECK LIST: MUST BE COMPLETED BY THE APPLICANT panels plus 27 kWh Energy Storage System. The following items must be submitted to the Building Department by the applicant-no exceptions. Property Owner:Thomas Friedlander 1• (t.,)Completed Application 2. (Lf Two(2)sets of sealed plans. (one full size 'maximurn Address: 66 Valley Terrace Rye Brook, NY 10573 allowable plan size=36"x 42"1 and one I 1"x 17") 3. ( )Two(2)copies of the property survey: Phone# 914-907-9079 4. (/,4-Two(2) copies of the proposed site plan. Applicant appearing before the Board: 5. (fie electronic/disc copy of the complete Stacie Varian of Tesla Energy Operations application materials. v-A 6. (0 Fi�Fee. Address: 1073 Rt 94 Unit 4 New Windsor, NY 12553 7. ( Any supporting documentation. 8. ( ) HOA approval letter. (if applicable) 1J Phone# 9. (( 'Photographs. Architec ine 10.( ) Samples of finishes/color chart. (a sample board or Phone# -g — q -,5 model maybe presented the night of the meeting) �ot- 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 Sworn to before me this day of ! A41;,- , 20 27/ day of , 20_�� Signature of Property Owner Signature of Applicant �Q1(yl1 F�Lp Stacie Varian Print Name of Prope wrier Print Name of Applicant (0 ublic Notary Public ORLON ALDL414M N01wy KAft of Nsw York AMY M.CONN I D OIAL641646 NOTARY PUBLIC,STATE OF NEW YORK Registration No.OIC06327165 COMMMM O(PIM03/01/2025 Oualffied in Orange County Commission Expires June 29,20 8/12/2021 c VILLAGE OF RYE BROOK BUILDING DEPARTMENT 938 KING STREET, RYE BROOK,NY 10573 (T) 939-0668 (F) 939-5801 ARCHITECTURAL REVIEW BOARD Wednesday, July 20, 2022 NAME&LOCATION TYPE OF APPLICATION - MOTION SECOND APPROVED REJECTED APPL.# 7 Talcott Rd Roof Top Solar Array Consent 57254 (Ambati) System Agenda 18 Belle Fair Rd 4'High White Vinyl Consent 5726 (Desai) Privacy Fence - Rear Agenda 412 N. Ridge Street Roof Top Solar Array Consent 5 7?7 (Yu) System Agenda 65 Winding Wood New 6' High Fence In Consent 5728 Rd(Rubin) Rear, 4'High Side Front Agenda 66 Valley Terrace Roof Top Solar Array Consent 5729 (Friedlander) System Agenda 283 Neuton Ave Roof Top Solar Array Consent 5730 System Agenda 30 Argyle Road 2 Story Addition, & 1 5731 (Nunziato) Story Addition 14 Elm Hill Drive Re-Do Rear Patio, Add 5732 (Levinson) Fire Pit& Outdoor Kitchen 217 S. Ridge Street New Business Signs 5733 (Riemer Insurance group) 37 Winding Wood New Rear Wood Deck & 5734 Road (Chi) Masonry Patio 116 S. Ridge Street New Sign & Store Awning 5735 (Win Ridge) For"Chopt" ML y/ NM MR f SE JM V/ 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 PAGE 2 July 20, 2022 NAME&LOCATION TYPE OF APPLICATION MOTION SECOND APPROVED REJECTED APPL# 6 Edgewood Drive 2nd Story Side Addition 5737 (Shalem) 32 Country Ridge Amendment to Prior 5738 Dr. (Hochfelder) Approval 6 Eagles Bluff Basement Addition 5739 (Bruantuch) w/Patio Above & Mesa Block Wall ML NM MR SE JM SF AC MI KC T - 5 ■L r' 1 Testa Road.Austin,TX 78725 P 650 681 5100 F 650 681 5101 Version#95.0-1 PIL June 8,2022 Certification Letter JUL — 8 2022 ! Project/Job#1055629 VILLAGE OF RYE BROOK Project Address: Friedlander Residence BUILDING DEPARTMENT 66 Valley Terrace Rye Brook,NY 10573 AHJ Rye Brook Village SC Office New Windsor Design Criteria: Applicable Codes=2020 RCNYSBCNYS/EBCNYS with 2020 NYSUCS,ASCE 7-16,and 2018 NDS Risk Category=II Wind Speed=120 mph(3-s Gust-Vutt),Exposure Category C,Partially/Fully Enclosed Method Ground Snow Load=30 psf -MP1:Roof DL=11 psf,Roof LUSL=17.3 psf(Non-PV),Roof LUSL=9.4 psf(PV) -MP2:Roof DL=9.5 psf,Roof LUSL=17.3 psf(Non-PV),Roof LUSL=9.4 psf(PV) -MP3:Roof DL=9.5 psf,Roof LUSL=17.3 psf(Non-PV),Roof LUSL=9.4 psf(PV) Note: Per IBC 1613.1; Seismic check is not required because Ss=0.281 <0.4g and Seismic Design Category(SDC)=B<D To Whom It May Concern, A jobsite survey of the existing framing system of the address indicated above was performed by a site survey team from Testa.Structural evaluation was based on site observations and the design criteria listed above. Based on this evaluation,I certify that the alteration to the existing structure by installation of the PV system meets the prescriptive compliance requirements of the applicable existing building and/or new building provisions adopted/referenced above. Additionally,I certify that the PV module assembly including all standoffs supporting it have been reviewed to be in accordance with the manufacturer's specifications and to meet and/or exceed all requirements set forth by the referenced codes for loading. The PV assembly hardware specifications are contained in the plans/docs submitted for approval. �P4eof:NEWyo NY 5 �~;O YORi R� Q�P q,L * �J �0 i - Digitally signed by Yurianto Yurianto 6 n to c= cn= affito Yur anto US o=UnUnaffiliated ou=A01410D00000176B07 sFQA �101990 i a n t o CB son:I m the Reason:I am the author of ROFESSIONP� this document Location. Date By 1810-05 Yuri at 6:10:07 PM, 61812022 : x oa :50000 1 Tesla Road,Austin,TX 78725 T 5 I...� r--+ P650681 -Ir"' FrP^r815,n, Version#95.0-1 PIL HARDWARE DESIGN AND STRUCTURAL ANALYSIS RESULTS SUMMARY TABLES X-X Spacing X-X Cantilever Y-Y Spacing Y-Y Cantilever Configuration Uplift DCR MP1 64" 24" 41 NA Staggered 57.7% MP2 72" 24" 41" NA Staggered 64.9% MP3 72" 24" 41" NA Staggered 64.9% Portrait Hardware-Portrait Modules'Standoff Specifications Hardware X-X S acin X-X Cantilever Y-Y Spacing Y-Y Cantilever Configuration U lift DCR MP1 48" 20" 14' NA Staggered 78.2% MP2 48" 20" 74" NA Staggered 78.2% MP3 48" 20" 74" NA Staggered 78.2% Mounting Plane Roof Pitch Qualification Results De reeg Member Evaluation Results MP1 43° Member Irripact Check OK MP2 43° Member Impact Check OK MP3 43° Member Impact Check OK i 1 Tesla Road.Austin.TX 78725 P 650 681 5100 F 650 681 5101 Version#95.0-1 PIL HARDWARE DESIGN AND STRUCTURAL ANALYSIS RESULTS SUMMARY TABLES agwam • - X-X Spacing X-X Cantilever Y-Y S acin Y-Y Cantilever Configuration Uplift DCR MP1 64" 24" 41" NA Staggered 57.7% 7 MP2 72" 24" 41" NA StagWred 64.9% MP3 72" 24" 41" NA Staggered 64.9% • X-X Spacing X-X Cantilever Y-Y SpacingY-Y Cantilever Configuration Uplift DCR MIDI! 48" 20" 74" NA Staggered 78.2% MP2 48" 20" 74" NA Staggered 78.2% MP3 48" 20" 74" NA Staggered 78.2% 7— 1 1 — ��* � -a 7MP3 •'• �es Member Evaluation Results 43' Member I ct Check OK 43' Member Impact Check OK 43* Member Impact Check OK 1 Testa Road,Austin,TX 78725 _ T 5 L r1 P 650 681 5100 F 650 681 5101 Version#95.0-1 PIL L/ June 8,2022 JUL - 8 2022 Certification Letter VILLAGE OF RYE BROOK Project/Job#1055629 BUILDING DEPARTMENT Project Address: Friedlander Residence 66 Valley Terrace Rye Brook,NY 10573 AHJ Rye Brook Village SC Office New Windsor Design Criteria: -Applicable Codes=2020 RCNYSBCNYS/EBCNYS with 2020 NYSLICS,ASCE 7-16,and 2018 NDS -Risk Category=II -Wind Speed=120 mph(3-s Gust-Vult),Exposure Category C,Partialy/Fully Enclosed Method -Ground Snow Load=30 psf -MP1:Roof DL=11 psf,Roof LUSL=17.3 psf(Non-PV),Roof LUSL=9.4 psf(PV) -MP2:Roof DL=9.5 psf,Roof LUSL=17.3 psf(Non-PV),Roof LL/SL=9.4 psf(PV) -MP3:Roof DL=9.5 psf,Roof LUSL=17.3 psf(Non-PV),Roof LUSL=9.4 psf(PV) Note: Per IBC 1613.1; Seismic check is not required because Ss=0.281 <0.4g and Seismic Design Category(SDC)=B<D To Whom It May Concern, A jobsite survey of the existing framing system of the address indicated above was performed by a site survey team from Testa.Structural evaluation was based on site observations and the design criteria listed above. Based on this evaluation,I certify that the alteration to the existing structure by installation of the PV system meets the prescriptive compliance requirements of the applicable existing building and/or new building provisions adopted/referenced above. Additionally,I certify that the PV module assembly including all standoffs supporting it have been reviewed to be in accordance with the manufacturer's specifications and to meet and/or exceed all requirements set forth by the referenced codes for loading. The PV assembly hardware specifications are contained in the plans/docs submitted for approval. OF NEW yo NY O V(�R7�� Digitally signed by Yunanto Yunanto r DN:cn=Yunanto Yunanto C1� nto —uso=unaffiliated .` ? ou=A01410D00000176807 S CBF250000A7A2 FpA 101980 i a n o Reason:I am the author of ROFESSIONP this document Location: Date: 0608 By Yuri 0 at 6:10:07 PM, 6/8/2022 20 18:10-05: 0 ,�',`. !� .a�A�. ��• �.,,•e�.y�^y .. .• '`y,��yi�. `.,�." ,',�'•.�A�„i0�'1��n ��y. ea��"?a �.f�n 97. . A R. .f �I � 'A �A -`lW r 0 Ro VAk •� U�i, ►�/ 1111�1I��L ARI V•' 'I"'1)1'/1/1"' fm 1 li.I►Pf m v�'Al ��: � `�11/1�►��.'����� d'' 11 11� r L t;'s,.��1�11_!�itF`f+ tisi e. hl.11 ��3#fs._.t_is�l`r.'1�1,111/. ♦ .a► �k; 1'1 11 +! •i !(0)>� / N 10 b N ;ra i cs Z 04 l > c p o G cV Go a0 u U J A 5 .^ - : LO �. <eotlon w A i•. O U) v W C :as tti ISM y w f- LLJ U) co RMI `��--- U - ;:� cn t ► + "�a�a�,1� ►h i�i�'?r .;:,i 1 r r�rl 4 �{h�•�'"� '1 .1,k . . +''�/�1� 77Y t =► /I 1 1 1 ► � 4 I 1 1 1 �1�4V' '�I/�t'�' ' '• '' ''� �j •41 �j 41 ^ �G'i � ^ •�! �A1 M^inRE'N^��� �•IAt"'I� �(ial��N`' ISO Y R A. OR0® DATE /YYYY) v CERTIFICATE OF LIABILITY INSURANCE 11ro112021 /2o21 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 CONTANAME:CT Kayla Ferrell MARSH RISK& INSURANCE SERVICES FOUR EMBARCADERO CENTER,SUITE 1100 PHONE NwFItU 415 743 8025 rlgrCX mot: CALIFORNIA LICENSE NO.0437153 E-MAIL SAN FRANCISCO,CA 94111 ADDRESS: Attn:SanFrancisco.Certs@marsh.com/FAX 212-948-0398 INSURE S AFFORDING COVERAGE NAIC/ CN104275261-STND-GAWUE-21- INSURER A:Zurich American Insurance Company 16535 INSURED Tesla Energy Operations,Inc. INSURER B:Steadfast Insurance Company 26387 901 Page Avenue INSURER C:American Zurich Insurance Company 40142 Fremont,CA 94538 INSURER D:N/A N/A INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: SFA-003420547-22 REVISION NUMBER: 4 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 VVITH 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. NPOLICY EFF POLICY EXP TR TYPE OF INSURANCE INSD WVD ADDLSUBR POLICY NUMBER IMMIDDIYYYYI 1MMfDD1YYYY1LIMITS A X COMMERCIALGENERALLIABILITY GLO1074588-04 10/31/2021 10/31/2022 EACH OCCURRENCE $ 2.500,000 CLAIMS-MADE Fx_1 OCCUR Includes Host Liquor Liability DAMAGE TO RENTED 2,500,000 PREMISES Ea occurrence E X SIR:$750,000 MED EXP(Any one person) $ 5,000 B X Tort Contrac Liab,No XCU Exd SXS-7426362-02(Excess GL- 10/31/2021 10/31/2022 PERSONAL&ADV INJURY $ 2,500,000 GEN'L AGGREGATE LIMIT APPLIES PER: limit:$6,750,000 excess of primary GENERAL AGGREGATE $ 20,000,000 X POLICY PRO LOC GL limits on right;applies to PRODUCTS-COMP/OP AGG $ 6,000,000 JECT OTHER: Solar Products Only) $ A AUTOMOBILE LIABILITY BAP 1074586-04 10/31/2021 10/31/2022 COMBINED SINGLE LIMIT $ 10,000,000 Ea acddent) X ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per accident) E AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE E AUTOS ONLY AUTOS ONLY Per:. dent E AjBRELLA LIAB UR EACH OCCURRENCE $ CESSIAB CLAIMS-MADE AGGREGATE $ D RETENTION$ $ C WORKERS COMPENSATION WC 1074583-04(AOS) 10/31/2022 X PER X OTH- AND EMPLOYERS'LIABILITY STATUTE ER A Y/N WC 1074584-04(MA,WI) 10/31/2021 10131/2022 1,000,000 ANYPROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT E A OFFICER/MEMBEREXCLUDED9 NIA CA XSWC EWS 1074585-04 $50M is XS 10/31/2021 10131/2022 (Mandatory In NH) ( E.L.DISEASE-EA EMPLOYEE $ 1,000,000 If yes,describe under $10M SIR;$1M EEIEA is XS$10M SIR) 1,000,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,maybe attached if more space Is required) Evidence of insurance. CERTIFICATE HOLDER CANCELLATION Village of Rye Brook SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 938 King Street THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Rye Brook,NY 10573 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE 'lyl Td ,Riau & /KimaKCC .5m,,W @ 1988-2016 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD PORK Workers' CERTIFICATE OF STATE Compensation NYS WORKERS' COMPENSATION INSURANCE COVERAGE Board 1 a.Legal Name&Address of Insured(use street address only) 1 b.Business Telephone Number of Insured 650-963-5100 Tesla Energy Operations,Inc. 901 Page Avenue 1c.NYS Unemployment Insurance Employer Registration Numberof Fremont,CA 94538 Insured 49-892777 Work Location of Insured(Only required if coverage is specifically limitedto 1d.Federal Employer Identification Number of Insured or Social Security certain locations in New York State,i.e.,a Wrap-Up Policy) Number 02-0781046 2.Name and Address of Entity Requesting Proof ofCoverage 3a.Name of Insurance Carrier (Entity Being Listed as the Certificate Holder) American Zurich Insurance Company Village of Rye Brook 3b.Policy Number of Entity Listed in Box"1a" 38 King Street WC 1074583-04 Rye Brook, NY 10573 3c.Policy effective period 10/31/2021 to 10/31/2022 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"3"insures the business referenced above in box"1 a"forworkers' 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 isearlier. 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: Susan B. Kendziora (Print name of authorized representative or licensed agent of insurance carrier) Approved by: � � 10/31/2021 (Signature) (Date) Title:Vice President-Enterprise Support Operations Telephone Number of authorized representative or licensed agent of insurance carrier: 800-382-2150 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 INTERNAL USE ONLY