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HomeMy WebLinkAboutBP22-134PERMIT # d- 3�*LL DATE: t;16 vi p(P: al SECTION >91 BLOCK LOTQ TYPE OF WORK Q/ e ) � jr70 2t)a JOB LOCATION ISO AI14Jh O OW /PSCel)7L Q p,I OWNERQIl/?il..iO %— S Q CG/Q Ala�7L/S(7/�)07%% CONTRACTOR //4? O /1CP �c/ — c� . Se'//Q/�O �p�3 /)4jS#— 1337 EST. COST %& /f7c S� FEE ' /CO # G C FEE4 JJQ- �� DATE TCO # FEE DATE INSPECTION RECORD DATE FOOTING INSP OTHER APPROVALS ARB BOT PB ZBA ,OTHER DR 04ti�Lw�� 2 . 19 L� 4m annll tP1L6 aW 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. Keiser Salvatore W. Morlino CERTIFICATE OF COMPLIANCE August 10,2022 Olympia Lopatin&Debra Nanus 129& 130 Brush Hollow Crescent Rye Brook,New York 10573 Re: 129 & 130 Brush Hollow Crescent, Rye Brook,New York 10573 Parcel ID#: 129.76-1-131& 129.76-1-130 Building Permit#22-134 issued on 7/26/2022 to Repair Party Retaining Wall This certifies that the party retaining wall,repaired under the above captioned permit has been satisfactorily completed. Sincerely, Michael J. Izzo Building&Fire Inspector /to D only: J BUILDIN i ATMENT For office u e o AUG - 3 2022 1 VILLAGE OF RYE BROOK ISSUED: PERMIT VILLAGE OF RYE BROOK938 KING STREET,RYE BROOK,NEW YORK 10573 DATE: g-,3-a D- BUILDIUG M-7PARTMF_�IT (914)939-Q6b8 FEE:,g(//[�— PAm ._. ._.__ www.rygbropk.erg APPLICATION FOR CERTIFICATE OF OCCUPANCY,CERTIFICATE OF COMPLIANCES AND CERTIFICATION OF FINAL COSTS TO BE SUBMITTED ONLY UPON COMPLETION OF ALL WORK, AND PRIOR TO THE FINAL INSPECTION tt►ttt►tt►►ti►►iiitttff►ifiiRiiif►ififfitiRt##f#iRf##Rf�##tl#�#f#fiiiRii►RRti►►i##Rif►►t►R►tf■Rif#fi►•#tfffitii►iiRtRtR►►/tt►t►f Address: I aq awn (-bc) BI(1�5k T A icz 1-j r,t-e Occupancy/Use: Ir-WP'1 Parcel ID#: �cy�� 76 31 Q,?d 1,30 Zone: b4J Owner: Address: 10 , �4 C_2,Ut- ( - P.E./R.A. or Contractor:(,(('Q ) 60Y "() Address:3 j 11 SZ Person in responsible charge: �Wot' Gnis Address: S 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: [ ' J,Y l�l � being duly sworn,deposes and says that he/she resides atn (Print Name of Applicant) I ,, (No.and Street) in ,�j in the County of VS�2 ( I-P/ 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 improv ments, labor,materials,scaffolding,fixed equipment,professional fees,and including the monetary value of any materials and labor which may have been donated gratis was:$ D D , for the construction or alteration of: r p a— ri 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 , 20 a day of v,S , 20 a-� Signa of roperty a Signature of li t VALkS %Nkme of ropeOwner. t Name of Applicant Notary Public Notary Public SHARI MELILLO SHARI MELILLO Notary Public,State of New York Notary Public,State of New York No.01ME6160063 No.O1ME6160063 8/12/2021 Qualified In Westchester County-� Qualified In Westchester County Commission Expires January 29,2 Commission Expires January 29,202F. QyE BRC�uk o`` tim 1982 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 • " ' DATE:— PERMIT# \.C �a ' ISSUED: 4 aT: I r -ABLOCK: ( LOT: 1 0 A 0 I LOCATION: , 1C�� ` �i ���`"' oOCCUPANCY: �Z U ❑ 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 h`1\ ❑ L.P. GAS ❑ FUEL TANK ❑ FIRE SPRINKLER ❑ FINAL PLUMBING ❑ CROSS CONNECTION 13--FINAL ❑ OTHER y N 0 y L = k 66CN h a a zQ V =� w F—I V ON d o y o °1-4 wo ' H , fr o 0 a W ti. .M� °v o 2a) z o, Ir M lz u; csco M � ° M � p _ a � F4 � u O Az 00 a � z •, Imo( �i �" '-a o °a a A d � $ -� �� wO ' „ � v z w � � � o � x G1 A z O °' U' > W W 0 >4 '� z 0 oA '" G � �� a � BUILDING DEPARTMENT 2 [ECENIED VILLAGE OF RYE BROOK JUL 2 Q 2022 938 KING,ST^MT RYE BI LK,NY 10573 (914)939-0668% P vll_t�,Gl= of RYE BROOK roe yr �---�g BUILDING DEPARTMENT FOR OFFICE USE ONLY: Approval Date: J U L a o 202 it# �� Application# Approval Signature: l ARCHITECTURAL REVIEW_ BOARD: j Disapproved: Date: BOT Approval Date: Case# Chairman: PB Approval Date: Case# Secretary: ZBA Approval Date: Case# Other: Application Fee: Permit Fees: A 0 0 FENCE / WALL ! GATE PERMIT APPLICATION Application dated: is hereby made to the Building Inspector of the Village of Rye Brook,NY,for the issuance of a Permit for the installation,construction,repair or replacement of a Fence,Wall or Gate,in accordance with Section 250-6 B.(1)(g),of the Code of the Village of Rye Brook,as per detailed statement described below. Swimming pool fences must conform to the State Code. 1. Job Address: I 5 1 C C7 2. Occupancy/Use: S.B.L.#: 149, 71r,-1-1.31 8 la9. 3. Proposed Fence Wal FGateescribe in detail): R 3 620 S ELLJ1 C'S l� to r 4. Prope fi0IQ rvi o in LZPcL-h Address: &pf� a] 11 mac Phone# Cell# 914 3 I i email: Applicant: ©�M I?i a 1,0 ID a,:b Ill LL Address: �(�lC� Q�)S LA-1 6c de RCC_KL - Phone# Cell#911 3 a'] �7W( email: ©I L4M a lGl rxY,Lf'1 e -6 Coi COO Architect/Engineer: Address: Phone# Cell# email: Contractor: C;p�(yj-j Vjj) VjC�� _4 e D Gy d0.V1 D /_ Address&Phone: ?,1..4�Fro in L< _ �-17Oy - 60 U 1 1- (OG,I � �/'?I 5. If building is located on a comer lot,which street does it front on: , C��� 6. What is the estimated cost of constructioY (NOTE:The estimated cost shall include all site improvements,labor,material,scaffolding,fixed equipment,professional fees,and material and labor which may be donated gratis.) 7, Estimated date of completion: 1 8/1212021 Please note that this application must include the notarized signature(s) of the legal owner(s) of the above-mentioned property, in the space provided below. Any application not bearing the legal property owner's notarized signature(s) shall be deemed null and void, and will be returned to the applicant. STATE OF NEW YOM COUNTY OF WESTCHESTER ) as: ,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 O- Swom to before me this �() day of 'Ju`y , 20 day of -j �A``-1 , 20 _ a Sqwtw o np er C of pplica t L 1'14�4111 Print Name of Property Owner a Applicant Notary Public Notary Public SHARI MELILLO Notary Public,State of New York No.O1ME6i6OO63 SHARI MELILLO Qualified In Westchester County ��1--, Notary Public,State of New York Commission Expires January 29,2012 No.O1ME6i6W63 Qualified in Westchester County Commission Expires January 29.20 2 8/12/2021 NYCINYS-Minority Business Certified BBB Accredited Business ti 11DER SERVICE AWARD Licensed and Insured T4:'k6088559 F,5166089j5 Nassau Lac.H130e160000 Weslcf•ester Lac.wC J<63e-N21 E-1 WWW.urran.fanCCu�.CM, Su11dM Lic'HN2150 NYC Lic'.21 WC45-DCA FENCE CONTRA, NAME:Debra Nemus and Ol m is Lo atin DATE: 06-21-2022 ADDRESS: 129-130 Brush Hollow Cres,Rye Brook, NY TELEPHONE:914-843-1197 EMAIL: olympialopatin@yahoo.com JOB SITE: 129-130 Brush Hollow Cres,Rye Brook,NY DESCRIPTION: JOBS CANNOT BE CHANGED OR CANCELLED THE DAY PRIOR TO THE INSTALLATION PRICE #1:(Between 129&130) -Repair the existing wood fence and replace it with 1 new wood post k iZ Z-D PRICE $450 yj Q ,r #2:(Between 129&130) - Repair the existing retaining wall, 4 rails of 6x6x8 and 3 small corners and nail it, and haul away debris PRICE $1,375 1 �r ( 1 7-ZO h e-ed e,,4 -Serrano Fence&San,Inc.does not provide o uarontee or an old retaining wall.Any other extra work will be at an additional charge.Serrano Fence&Son,Inc.is not responsible for any damage to flowers or plants. -Owners are responsible for moving any chairs,tables,plants and any other items that might interfere with the repair. TOTAL PRICE,MATERIALS AND LABOR $1,825 DEPOSIT DUE AT SIGNING $821.25 REMAINING BALANCE $1,003.75 THIS JOB REQUIRES 4S%DEPOSIT AT SIGNING —Shop drawing not included on the price— PAGE 1 ►1� ® NYCINYS-Minority Business Certified t ~' BBB Accredited Business _ SUPER S.",CF f AWARD Licensed and Insured `l r•o�JN A.sn,w.FMCOn,nY'�i5:0 TN:Sk AOe B3`A hr.SN ACE wJ3 HaSsau Uc.H13 160 W-rcnrsrtr r:c.wC-J U.H11 Emdl:r„onu�zmgmnl coin WWW.NrrOEW{BIICOYO-COA1 SufldM Lrc-HI-61I50 NYC Lac IIOUWSD(:,l FENCE CONTRACT conditions:All permits to be obtained and paid for by the customer.It is the customer's responsibility to dentify and mark property lines.Serrano Fence and Son, Inc.will not be held responsible for damage to wiring )tumbing,sewer line,gas line,etc.,or any other area that has not been prior marked.Except as otherwise xovided herein,this Agreement is non-cancellable.Serrano Fence 8 Son,Inc.is not responsible for damage to sprinkler,electric lines,gas lines or any underground items.We are not responsible for permits. -arty termination of the contract will result in a penalty.Serrano Fence is not responsible forany fence damaged Jue to the weather(e.i.hurricane,strong winds,etc.)All installations will be done on a scheduled date,weather )ermitting. Materials(warranty 3VC Fence(*)-1 year,PVC Gates- 1 year,Chain link-10 years,Wood is a natural product with no guarantees against cracking,warping,checking,splitting,staining,nail bleeding,etc.Serrano Fence and Son, Inc.strongly ecommends staining or seating these conditions. Railing(*):PVC-1 year;aluminum pipe-Lifetime(no rust);Iron with zinc metalizing;5 years(no rust);Iron vithout zinc metalizing-no guarantee against rust. Evidence ifslamming(including wing)voids gate warranty.The warrantydoes not cover consumer iegligence.Gaps may exist under fences.We are not responsible for unlevel ground.Installations not paid n full are not covered under warranty.Fences are installed according to customer specifications. liny and all payments required pursuant to this Agreement are to be made directly to Serrano by cash,check or :redit card(subject to a 4%fee). Failure to receive payment on time wilt incur on 6%added interest until full Payment is received.Payments must be made in full once fence installation is completed.Customer shall be equired to pay an additional$40 to Serrano for any returned checks. Customer shall be responsible to pay all :osts and expenses incurred by Serrano(including reasonable attorneys'fees,court costs and expenses)in :onnection with any efforts on behalf of Serrano to collect outstanding payments from Customer. ALL MATERIALS ARE GUARANTEED TO BE AS SPECIFIED,AND THE ABOVE WORK TO BE PERFORMED IN ACCORDANCE WITH THE DRAWINGS AND SPECIFICATIONS SUBMITTED FOR ABOVE WORK AND COMPLETED IN SUBSTANTIAL WORKMANLIKE MANNER. Note:This contract maybe withdrawn by us if not accepted within 3 days The above prices,spectflcatlons,guarantees,and conditions are satisfactory•and are hereby accepted.You are authorized to do the work as specified. Payments will be made as outlined a ore. Custorner'sSignature: Date: � 4va, , Serrano Fence Signatu Date: 06/23/22 . If you have any questions regarding this contract please email us at serranofences@gmail.com Thank You For Doing Business With Us! PAGE t A l ' 41 C (,t-E �t ct v�uu Building Permit Check List&Zoning Analysis Address:-- L Iq 4- 1 t4 L.) GSZ SBL• Zone: Use: Const.Type: Other. Submittal Date: Z Z Z Revisions Submittal Dates: Applicant: U A ti S rt— L O B &-rt of Nature of Work. 1,--)q ►aC� W A L Reviews ZBA: J U L 1 9 2022 PB• BOT Ocher. QK ( ( ) ES:Filing. 7 S• BP: t�p• C/O: Flood Plane: Legalization: ( ) (�P: Dated ✓ Notarized: ✓SBL ✓Thus 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 f 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. ( ) ( ) 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 A Date: JUL,*-)O 2022 Circle: FroaW Front: Front: Sides: Main Co Accs.Cow Ft.H Sb: Sd.H Sb: SL Tot,Imp P ku' H6ght/Stories: notes: 173'/2 Ivy Hill Crescent Im- Olympia ED Rye Brook, NY 10573 914-939-2440 July 13, 2022 ympia Lopatin 129 Brush Hollow Crescent Rye Brook, NY 10573 Re: Retaining Wall Repair Dear Olympia Lopatin, This letter serves as confirmation that the Architecture& Grounds (A&G) Committee has reviewed and accepted your application for the above named work.This approval is valid for six(6) months from today's date. If any changes need to be made to the original plans submitted to A&G either before or during construction, the Committee must be notified in writing and your application must be amended.Work must stop and cannot proceed until you receive written approval for those changes. You are required to inform the Property Manager when work begins. When the project is complete, the Property Manager must again be notified so that an inspection may take place. Please include a photograph of the work as well. Failure to comply with these procedures will result in fines and/or work stoppage. If for any reason you have to replace 50% or more of the retaining wall, you will need to go to the Village to get a permit. If you have any questions, contact me at: Property Manager. Ashlee Pasquale Property Manager 173'h Ivy Hill Crescent D � (� I � W IE Rye Brook, NY 10573 V� L� U �/ 914-939-2440 JUL 2 0 2022 July 13, 2022 VILLAGE OF RYE BROOK BUILDING DEPARTMENT Deb Nanus 130 Brush Hollow Crescent Rye Brook, NY 10573 Re: Retaining Wall Repair Dear Deb Nanus, This letter serves as confirmation that the Architecture& Grounds(A&G) Committee has reviewed and accepted your application for the above named work. This approval is valid for six(6) months from today's date. If any changes need to be made to the original plans submitted to A&G either before or during construction,the Committee must be notified in writing and your application must be amended.Work must stop and cannot proceed until you receive written approval for those changes. You are required to inform the Property Manager when work begins. When the project is complete,the Property Manager must again be notified so that an inspection may take place. Please include a photograph of the work as well. Failure to comply with these procedures will result in fines and/or work stoppage. If for any reason you have to replace 50%or more of the retaining wall, you will need to go to the Village to get a permit. If you have any questions, contact me at: Property Manager. Ashlee Pasquale Property Manager m .�, ram►- %O-A ., r f : a4 r 'A 441 itts., A �+Jd � , IfJ �1�s�" �� �, 1 • � � ,}c11. "�..k�-_"%\."—��L/�l(�,. ,A 1. 1) - v41 C s 00 AL 1!00 V, A C C afa� r' O itaR)► W N LLI LO :I Z W Q' LilOp U- w a lJ --�\M. .v i► Q 3 •� Lf. Q G Arc: C� o O LL Jet, 30 lo . ..) r"�'. � � .` .c ups)►} '� f �/ I J � Y7 1l.•�i % •)► "' `uca++zitcia iic XXXXXXfXX17IXYXY•Y7:]CYY XYXXKL�YxxxxxY.Xy6Lr — k �.� r � ��ti� "r' ray♦ , 1; Y?�XXXX_lU[XX%%HYxxxxxxxxy `'.' ')fit. r'}��\ \rah t�l. ��11 'Ir• •. 1� ii/i�: � ',1 � � til jl�` � t��i, � .. -- - 1..i,1 '�_ '�tfi�� C . 1 .,� .., rrr„�, .1.;: �,, . 11 „/„ +rt�a• r �,rl�l,,, MMIDD ACORO® CERTIFICATE OF LIABILITY INSURANCE FDATE o7/zo/7/120/z0 YYYY) 2z 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 endorsements. CCT PRODUCER Grapeville Agency Associates NgME LISA BENWAY PO Box 460 (ANON . (518)966-4466 — �F :(518)966 9797 4821 State Route 81 E-MAIL LBENWAY@GRAPEVILLEAGENCY.COM ADDRESS: Greenville NY 12083- INSURER(S)AFFORDIING COVERAGE NAIC INSURERA,Erie Insurance Company 26263 INSURED INSURER Travelers Insurance Co of America 12432 Serrano Fence&Son Inc INSURER C: _ 36 Frankel Ave INSURER D: -_ Freeport NY 11520- INSURER E;, I 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 TYPE DURANCE ADDL SUBR POLICY EFF POLICY EXP LYTS A X COMMERCIAL GENERAL LIAB&M Q36-5120070 12/01/2021 12/01/2022 EACH OCCURRENCE 1,000,000 CLAIMS-MADE aOCCUR DAMAGE TO RENTED 1,000,000 MEDEXP one 5,000 PERSONAL&ADV INJURY 1,000,000 GENT AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE 2,000,000 POLICY❑X PRO- ❑LOC PRODUCTS-COMP/OP AGG _2,000,000 CT AUTOMOBlB L1ABBUTY COMBINED SINGLE LIMIT $ ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per aodderd) $ AUTOS ONLY AUTOS - -—- HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY__[ AUTOS ONLY -- S A UMBRELLA UAB X OCCUR Q36-5170194 12/01/2021 12/01/2022 EACH OCCURRENCE 5,000,000 X EXCESS LIAR CLAIMS—MADE AGGREGATE 5,000,000 X RETENTION$ 10, B WORKERS COMPENSATION UB-3N231891-22-42-G 2/22/2022 0=2023 X I PERTUTE oTH- AND EMPLOYERS'LIABILITY 1YYy'-'//I-'MMy'1 ANY PROPRIETOR/PARTNER/EXECUTIVE u EJ—EACH ACCIDENT 1,wo,ow OFFICERWEMBER EXCLUDED' u NIA (Mandatory in NH) E.L.DISEASE-EAEMPLOYEE 1,000,000 M .describe under POLICY 1.000,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORO 101,Addkk"Remarks SdudNM,mey be aftsdod H nwm tptm is rpuked) CERTIFICATE HOLDER CANCELLATION AI 043763 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE VILLAGE OF RYE BROOK THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN BUILDING DEPARTMENT ACCORDANCE WITH THE POLICY PROVISIONS. 938 KING STREET RYE BROOK NY 10573- AUTHORIZED REPRESENTATIVE ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD STATE OF NEW YORK WORKERS'COMPENSATION BOARD %CERTIFICATE OF NYS WORKERS'COMPENSATION INSURANCE COVERAGE la.Legal Name&Address of Insured(Use street address only) lb.Business Telephone Number of Insured SERRANO FENCE&SON INC. 631-484-1337 36 FRANKEL AVE. 1c.NYS Unemployment Insurance Employer FREEPORT,NY 11520 Registration Number of Insured Work Location of Insured(Only required ifeoverage is specifically Id.Federal Employer identification Number of Insured limited to certain locations in New York State,i.e.,a Wrap-Up or Social Security Number Policy) 47-4792661 2.Name and Address of the Entity Requesting Proof of 3a. Name of Insurance Carrier Coverage(Entity Being Listed as the Certificate Folder) TRAVELERS CASUALTY INSURANCE VILLAGE OF RYE BROOK 3b.Policy Number of entity listed in box"Is" BUILDING DEPARTMENT UB-3N231891-22-42-G 938 KING STREET RYE BROOK NY 10573 3c. Policy effective period 2-22-22 to 2-22-23 3d. The Proprietor,Partners or Executive Officers are Included. (Only cheek box If all partnen/nitieen included) Q✓ 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"la'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 will also notify the above certificate holder within 10 days IFa policy is canceled due to nonpayment ofpremiums 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. (7lrese notices may he sent by regular mail.)Otherwise,this Certificate is va/hl for one year after this for m is approved by the insurance carrier or its licensed agent,or until the policy expiration date listed in box"3c,whichever is earlier. Please Note:Upon the 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: USA BENWAY — . of authorized representative or licensed agent of innin nee carrier) Approved by: d &111w"f 7-20-2022 (Signature) (Date) Title: Licensed Agent Telephone Number of authorized representative or licensed agent of insurance carrier.518-966-4466 ext 28 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. 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