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HomeMy WebLinkAboutBP22-139PERMIT #,[)L SECTION TYPE OF WORK JOB LOCATION.. C%J EST. COST r �co # 9 LOT_ o V ik o/ fo TCO # FEE DATE tofiqmZolk DATE FOOTING FOUNDATION FRAMING RGH FRAMING INSULATION PLUMBING 0 RGH PLUMBING GAS SPRINKLER ELECTRIC LOW -VOLT a ALARM AS BUILT 0 FINAL 1 NSP riM jr000�Amoo- / YI 14Uillec- OTHER APPRoVALS 1 ARB BC�T ipR ZF3A I OTHER VILLAGE OF RYE BROOK WESTCHESTER COUINTTY, NEW YORK N<>• 23-042 Certificate of ®ccupaucp Ehis is to certify that ��a y�- A i k U/l i V )G� &-kn /�l of Rye, I7Yon y , having duly filed an application on 20 _requesting a Certificate of Occupancy for the premises known as, W Fcad , Rye Brook,NY, located in a g- 7 Zon 1 n0 District and shown on the most current Tax Map as Section: 1 f5,15� Block: -:3 Lot: and having fully complied with the requirements of the Building Code and the Zoning Ordinance under Building Permit No. - k3q issued 20_�R� 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:R-6/oAe--rOJ7 1J' V , Construction: for the following purposes: tfaa I (ze , Q YPrnyp- ( 0* y7 Subject to all the privileges, requirements, limitations, and conditions prescribed by law, and subject also to the following: This certificate does not in any way relieve the owners or any person or persons in possession or control of the premises, building,or any part thereof from obtaining such other permits or licenses as may be prescribed by law for the uses or purposes for which the building or premises is designed or intended. Furthermore, it does not relieve such owners or persons from complying with any lawful order issued with the object of maintaining the premises or building in a safe and lawful condition. No changes or rearrangement in the structural parts of the building or in the exit facilities shall be made,and no enlargement, whether by extending on any side or by increasing in height shall be made,nor shall the building be moved from one location to another until a permit to accomplish such change has been ob d from t ttg inspector. MAR 1 7 1013 Acting Building Inspector,Village of Rye Brook: Date: D BUILDINd-'&'-�ZTMENT For office t e onl : PERMIT# � 39 VILLAGE OF RYE BROOK ISSUFID: QCT 2 2�22 938 KING STREE'rl RYE BROOK, YORK 10573 DATE: JQ is-aa (914),9 -00 FEE: PAID• VILLAGE OF RYE BROOK I lro k BUILDING_DEPARTMENT APPLICATION FOR CERTIFICATE OF OCCUPANCY, CERTIFICATE OF COMPLIANCE, AND CERTIFICATION OF FINAL COSTS TO BE SUBMITTED ONLY UPON COMPLETION OF ALL WORK, AND PRIOR TO THE FINAL INSPECTION ` Address: Tb ��� !'t �� I �L �� j��t Occupancy/Use: R�SIbc—M AL Parcel ID#: 5� — 3` y Zone: 7 Owner: k Address: P.E./R.A. or Contractor: ( MGAddress:4W ft 333 DLfi I l 0( �k Y N r l Person in responsible charge:CktM k\) Address: �04(-TF— tAIfV-' i pJ Y, i'J603 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: A/N �c ((b J ung duly swom,deposes and says that he/she resides at333 OC..D T PQRPOWN U-t)03 (Print Name of App icant) (No.and Street) in W RM,- 2LA I NS ,in the County of `w �C � � in the State of My ,that Wity/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:$ 5 bw,an for the construction or alteration of- (-)N G f`1 \DR Qzl�ZUWTI� - 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 I -a Sworn to before me this day of ,—:A" 20 day of , 202 Signature of Property caner Signature of Applicant �(J l bZQ« — I VA04Z N: I Name of Property Owner Print Name of Applicant Notary Public 7 Notary Public ANA111 MELILLO Notary Public,State of New YorK No.O1ME6160063 Qu.-Oled In Westchester county Comm.bston Expires January 29,202`3 jE aR�k• O� Zm cu � �7 Fo 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 : vt�l DATE: 0�1�- 0 PERMIT# ISSUED: ' ?SECT: BLOCK: LOT: W LOCATION: �O !/ � V`I 9 GQ� (Q) 1 OCCUPANCY' ❑ VIOLATION NOTED THE WORK IS. ACCEPTED ❑ REJECTED/REINSPECTION ❑ SITE INSPECTION f 1 {• REQUIRED ❑ FOOTING C ❑ 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 l27 FINAL ❑ OTHER r s CN en N ;� W fl O ^� s N N N ~ 72 oc i W . a y w s _ p v� �, w a w O a a o ti ' C) cn o. v sei UD V oO ti b p bA �I �7 bA L +► � � H fn O c " 2 72 00 e W O oo 00 fn y w ty� Fil - en 00 _ zo ON A11 w ,: q 1.0 . VoO U 0 0 U� A zo Cl) % cn 1�1 CM O V 00 a C z z ` u 'b ay w U cy O A G4 cV F y a z g a Oil v k. U Q 'n l U o P E W III�I'II LL, phi I� k. C) A ° u z v Q' u A z o � a � � o � o o z H C - C A z x `� �I Ga P�•i �l W � xv��i � �� - _ CL 1W/ BU i I,[3 r MENT VIL '* iE OF RY OOK AUG - 2022 938 KING Sl*_Ei,RYF RR NY 10573 — — ­( 1:4 41�i6$-1; VILLAGE OF RYE BROOK BUILDING DEPARTMENT INTERIOR BUILDING PERMIT APPLICATION FOR OFFICE U§E ONLY: Approval Date: AUG Permit#: _ Application Fee: Approval Signature' AT Permit Fees: Disapproved: Other: Application dated: t -f--� is hereby made to the Building Inspector of the Village of Rue Brook,NY,for the issuance of a Permit for the interior alteration of an cxisnng building,or for a change in use,as per detailed statement described below, �jt f 1. Job Address: {,. iM Q�°✓ �/ SBL: .� ,,��'3 _"I !Zone: 2. Proposed Improvement.(Describe in detail): v"Ov1 � 3. Does the proposed improvement involve a Home-Occupation as per§250-38 of the Code of the Village of Rye Brook? No: Yes: if yes,indicate: TIER L TIER 11: TIER III: 4. Will the proposed project require the installation of a new,or an extensionimodification to an existing automatic fire suppression system(Fire Sprinkler,ANSL System,FM-200 System,Type I Hood,etc...) : No: Yes: (if yes,please submit a separate Automatic Fire Suppression System Permit application&2 sets of detailed engineered plans) 5. Occupancy;(I fam.,2 fam.,comm-,etc...)Prior to Construction: _Z—L <Z� After Construction: >4V^kq—' 6. N.Y State Construction Classification: V 1 N.Y.State Use Classification: 7. Property Owner: Q_Ap L wpsa Address: ,,_9 t/ (9'J �, Phone# Ccll# Q� �(3-5— 832.o email: y0G, tOk k, ,ra� 8. Applicant: Address: f?VIC, Phone# Cell# email: 9. Architect: Address: Phone# Cell# email: 10. Engineer: Address: Phone# Cell# email: 11. General Contractor V -t14NT '[�}1►� lddress: 5 3 ! Phone# Cell# mail: �a 12, Estimated cost of construction $ � 57(9CrJa (Pi01 E- ITc cwitnaicd c"stilt include all labor,material,. •afN)i furg,tlxed equipinem,professional fees,And material and labor which may be donated gratis) 13. Job Timetable: Start: Finish: (ll 8/l2/2021 v : BUILD MENT V1L J K AUG - [022 938 KING �` � NY 10573 VILLAGE OF RYE BROOK BUILDING DEP.4RTNICNT AFFIDAVIT OF COMPLIANCE VILLAGE CODF; �216 - STORM SFWERS AND SANITARY SEWERS THIS AFFIDAVIT MUST BEAR THE NOTARIZED SIGNATURE OF THE LEGAL PROPERTY OWNER AND BE SUBMITTED ALONG WITH ANY BUILDING OR PLUMBING PERMIT APPLICATION. ANY BUILDING OR PLUMBING PERMIT APPLICATION SUBMITTED WITHOUT THIS COMPLETED AND NOTARIZED FORM WILL BE RETURNED TO THE APPLICANT. STATE OF NEW YORK, COUNTY OF WESTCHESTER ) as: residing at, �� �,�gE,Go�y Uol �_ ibo� X-YY ics��3 +.('rrrtt.narsoc) kAddres �khcrc gou 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; fir. 0�0v 16 y . �� 5 Rye Brook,NY. Further that all statements contained herein are true, and that to the best of his/her knowledge and belief, that there are no known illegal cross-connections concerning either the storm sewer or sanitary sewer,and further that there are no roof drains, sump pumps, or other prohibited stormwater or groundwater connections or sources of inflow or infiltration of any kind into the sanitary sewer from the subject property in accordance with all State, County and Village Codes. 1�el Sworn to before me this 20 I-Z-- (Notary Public, SHARI MELILLO Notary Public,State of New York No.OIME6160063 Qualified In Westchester county Commission Expires January 29,20_j (2) 8/12/2021 This application must be properly completed in its entirety and must include the notarized signature(s) of the legal owner(s) of the subject property, and the applicant of record in the spaces provided. Any application not properly completed In Its entirety and/or not properly signed shall be deemed null and void and will be returned to the applicant. Please note that application fees are non-refundable, STATE OF NEW YORK,COUNTY OF W'ESTCHESTER ) as: 'ice+ &.of ii ,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 tl c legal owner of the property to which this application pertains, or that (s)hc is the for the legal owner and is duly authorized to make and file this application. (indicate architecL contracts ,agent,:attorney,etc.) That all statements contained herein are true to the best of his/her knowledge and belief,and that any work performed,or use conducted at the above captioned property will be in conformance with the details as set forth and contained in this application and in any accompanying approved plans and specifications,as well as in accordance with the New York State Uniform Fire Prevention&Building Code,the Code of the Village of Rye Brook and all other applicable laws,ordinances and regulations. By signing this application,the property owner further declares that he/she has inspected the subject property,and that to the best of his/her knowledge there are no roof drains.sump pumps or other prohibited stormwater or groundwater connections or sources of infiltration into the sanitary sewer system on or from the subject property. Sworn to before me this Sworn to before me this day of 0 2-9 _ day of 09/ , 20 ZZ r I . 4ad—4-1 of ignai rope Signature 4 Applicant Otto t ame of Properly Owner 'Jame of Applicant \-Al 13�6 Notary Public Notary Public Sli{1R1 MELILLO SHARI MELILLO Notary Public,State of New York rvwtary Public.Ststs of New YarK No.01ME6160O63 No,OIME6160063 Quallfied in Westchester County qualified in Westchester County -� r�nrnni;sslon Expires January 29,2&2 3 Cr;rrttnission Expires January 29,20� (4) 8/12l2021 F i N O n i+l oo 00 m u 1 ii am W V U 11 W ►a xx Q Q F1 to i p,y (/, w O � � J �,aS W • x W Q z z N w 00 r O O w M N oo O � Fii � ►� w � � w 7 � � 00 a - O A � ONu can. z � a 00 0-4 POO M � z A � N oZ W It0*0 H U � 0-4 A v C6 V) �..� A o � z w r z r U � i Q w z �' t r . r E DRC� D E C EN E BUILDING bEPAR'TMENT VILLAGE OF RYE BROOK AUG 7 2022 938 KING STREET RYE BRC}@r�k,NY 10573 VILLAGE OF RYE BROOK (914)939-0668 BUILDING DEPARTMENT www.Uobrook.org ELECTRICAL PERMIT APPLICATION Westchester County Master Electricians License Required J q/ l FOR OFFICE USE ONLY BP#: 3 / EP#: �( /V Approval Date: AUG 18 1 11 Permit Fee: $ I Approval Signature: Other: Application dated, fr' — � is hereby made to the Building Inspector of the Village of Rye Brook NY,for the issuance of a Permit to install and/or remove electrical equipment,wiring, fixtures, or to perform other high or low voltage electrical work as per the detailed statement described below. By signing this document, the applicant & property owner agree that all electrical work performed will be in conformance with all applicable Federal,State,County and Local Codes. 1.Address: 76 w I've A f O v R cA P SBL: 13 S-,5 2 - j~`I y Zone: 2.Property Owner: E D LA",/4 p A i ir o l 1; Address: Phone#: 9/�`f 33 0 3 a� Cell#: email: 3.Master Electrician: Ah aI&--f-�1• //p,`S 4 0 e f y Address: ( I ,( Wei V,'(A n-/ l r ..t Iry►�vV 7 Lic.#: 161 L Phone#: 1'-/— 0-13VCell#: email: Company Name: Address: �v 4.Proposed Electrical Work/Fixture Count: i — L i S A 1.'1 e n'e 5.31 Party Electrical Inspection Agency: STATE OF NEW YORK,COUNTY OF WESTCHESTER ) as: A#7)r e— 54rf-« ,being duly sworn,deposes and states that he/she is the applicant above named,and does further (print name of individual signing as the applicant) // / state that(s)he is the legal owner of the property to which this application pertains,or that(s)he is the L CG 1r V-' for the legal owner and is duly authorized to make and file this application. (indicate architect,contractor,agent,attorney,etc.) The undersigned further states that all statements contained herein are true to the best of his/her knowledge and belief,and that any work performed,or use conducted at the above captioned property will be in conformance with the details as set forth and contained in this application and in any accompanying approved plans and specifications,as well as in accordance with the New York State Uniform Fire Prevention&Building Code,the Code of the Village of Rye Brook and all other applicable laws,ordinances,and regulations. Sworn to before me this Sworn to before me thi 0 day of ,20 day of 20 r Z Signature of Property Owner Signature of Applicant l4— Print Name of Property Owner Name of Applicant Notary Public Notary Public SHARI MELILLO Notary Public,State of New York No.01ME6160063 Qualified In Westchester County 6/23/2022 Commission Expires January 29,2023 STATEWIDE • Service Willi hileqri1.v 1:1 Main Street, Fishkill, NY 12524 1 emod:office@swisny.com SWIS JOB APPLICATION / 914.219.1062 • • • Office U e Elect.Permit# j`/� 1 i �] Date Bldg Permit# Utility ID# r3jq/` 22 Final Certificate# City/Village A Zip Township County a' / Address 76 vv a d,S a r fi& 0 ,'L( Cross Street Section Block Lot Owner Name/Address(If different than above) �`� of A ' ,- ;, Contact Number ❑Basement ❑1 st FI. ❑2nd Fl. ❑3rd FI. ❑More Than 3 FI. ❑Garage ❑Attic ❑Outside ❑Residential ❑Commercial Receptacles Special Recept GFCI AFCI Switches Dimmers Smoke Alarms Carbon Monox Hood Trash Compact Amt Amps Range(s) Cooktop(s) Oven(s) Dishwashers Refrigerator Disposal Microwave Warm Draw Incandescent Fluorescent SG SERVICE Amperage Voltage 1 P 3P #Meters #Disconnect ❑Underground ❑New ❑Reconnect ❑Overhead ❑Change ❑Visual Re-Inspection ❑ Safety Re-Inspection ❑ Re-Inspection Additional Information + KG 17 2022 VILLAGE OF RYE BROOK BUILUNG-DEPARTMENT This application is valid for one(1)year from the date received by SWIS.This application is Intended to cover the above listed items to be inspeqWd,if at any dme of Inspection additional items have been installed,you are authorized to make the Inspection and adjust the fee for the additional items inspected.The applicant declares that there is no open applications Ibr the above address with any other Inspection company.The applicant,owner or authorized agent agrees to all the above terms and conditions as set forth for the application. Inspector Date Finalized Inspector# Company Name i r- , 1. Date Signature Address 1 City/State �;' Zip Code License# i Phone# ;rI i / ?�/ CA-C) State Wide Inspection Services 1080 Main Street Fishkill, NY 12524 "wKi 0 5 845 Phone 914-2194-219-1062 Fax STATE WIDE INSPECTION SERVICES Email: officegswisny.com Service With Integrity Website: www.swisny.com BY THIS CERTIFICATE OF COMPLIANCE STATE WIDE INSPECTION SERVICES CERTIFIES THAT: Upon the application of: Upon Premises Owned by: White Plains Electric Eduart&Ivanke Nikolli 139 Haviland Lane 76 Windsor Road White Plains, NY 10601 Rye Brook, NY 10573 Located at: 76 Windsor Road, Rye Brook, NY 10573 Section: Block: Lot: Electrical Permit Number: EP 22-190 135.52 44 Certificate Number: 2022-6042 Building Permit Number: BP 22-139 A visual inspection of the electrical system was conducted at the Residential occupancy described below.The electrical system consisting of electrical devices and wiring is located in/on the premises at: 76 Windsor Road, Rye Brook, NY 10573 The First Floor Bedroom, Bathroom,and Family Room were inspected in accordance with the NYS and NFPA 70-2017 and the detail of the installation, as set forth below,was found to be in compliance on the 6th day of October 2022. Name Quantity Rating Circuit Type Receptacles 30 Switches 20 Luminaires 30 A Visual Inspection of existing conditions was performed on October 6`h,2022 of the First Floor Bedroom, Bathroom, and Family Room and Conforms to NFPA 70-2017 NEC. No Defects Were Noted. officer: Frank 1. Farina This certificate may not be altered in any way and is validated only by the presence of a seal at the location indicated.This certificate is valid for work performed on the date of inspection only. / Building Permit Check List&Zoning Analysis Address: So 2 SBL: I -;� <-r 2 --3 —'(4f •Zone:-T2 '-7 Use: 2 l Cont.Type: Other._ L F Q L( Z -1 7 o N Submittal Date: Zt3 It 1 Z'?— Revisions Submittal Dates: Applicant: l )(O L L. l Nature of Work: G-�,G a L l Z.F 1 N�-21 o R— Reviews.ZBA: AUG - 3 2022 PB• BOT• Other. NEW OK ( ( ) FEES.Filing: S% BP: 3 7 9, '� C/O: Flood Plane: DD . APP: Dated otarized ✓ SBL: ✓ D( ) (� Truss I.D. Cross Connection: H.O.A.: ( ) ( ) Scenic Roads: Steep Slopes: Wetlands: Storm Water Review: Street Opening. ( ) ( ) ENVIRO:Long. Shore Fees: N/A: ( ) ( ) SITE PLAN:Topo: Site Protection: S/W Mgmt.: Tree Plan Other. ( ) ( ) SURVEY:Dated Current Archival• Sealed: Unacceptable: ( ( ) PLANS:D tamped Sealed Copies: Electronic Other. ( (,�License ate Workers Comp: ✓ Liabilit)r ✓Comp.Waiver. Other. ( ) ( ) CODE 753#: Dated; N/A; (� ( ) HIGH-VOLTAGE ELECTRICAL:Plan: Permit N/A Other. ( ) ( ) LOW-VOLTAGE ELECTRICAL:Plan: Permit: N/A Other: ( ) ( ) FIRE ALARM/SMOKE DETECTORS:Plan: Permit H W.I.C.:_Battery _Other ( ) ( ) PLUMBING:Plan: Permit Nat.Gas: LP Gas: N/A/: Other. ( ) ( ) FIRE SUPPRESSION:Plan: Permit: N/A: Other: ( ) ( ) H.V.A.C.: Plan: 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. ( )ARB mtg.date: approval notes: ( )ZBA mtg•date: approval notes: ( )PB mtg_date: approval• notes: REQUIRED EXISTING PROPOSED NOT>±s APPROVED AnAUG 3 2072 circle: Frog Front. Front: Sides: Min cow Accs.Co F S Sd,H/Sb GQFA: Tom: Park . HHight/Stories: notes: 4 = 1y/ w ' k w 10 061 ONO ci F� 40 5 z ^ CD Q cc F � �e V Z f p jt _ 9 .i 0-4 w r� ell m cooi - 0 A W � a a --.� �-_ -„'_`.� .•"_"_...� �..._ � tea/ ���+-..-��� \...i �� y L N 0 0 •=' p Ev U '- v i O y 7 � L O � a CD O W VW tn o 4 �c, el tt Z t G f bt Ul 40 41 � r L � _'. C G C •� f . r r... .� - - 1 Policy Number: See Below Date Entered: 8/1/2022 A ® DATE IYVVV) CERTIFICATE OF LIABILITY INSURANCE a/1/2022zo22 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 su h endorsement(s). CONTACT PRODUCER NAME, Steven Stockfcder FAX TRI-NORTHERN ASSOCIATES,INC. PHONE 111 GREAT NECK RD-STE#303 E-MAIL Ea (516)466-9854 (516)466-6333 /c,Ne; ADDRESS: chrisnewelltng2 ,,aoLcom GREAT NECK,NY 11021 INSURER(S)AFFORDING COVERAGE NAIC N INSURER A: Utica First Insurance Company 15326 INSURED Valiant Design Build,Inc. INSURER B: INSURER C 333 Old Tarrytown Road-Suite 1B INSURER D: White Plains, NY 10603 INSURER E: 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 ,OLICIIES.YMITS SHOWN MAY HAVE BEEN REDUCED BY FAJD CLAIMS. INSR ADDLISUBRI POLICY EFF POLICY EXP LIMIT LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER M/DD/YYVY M/DD/VYYVIS A C MERCIALGENEILffY EACH OCCURRENCE $ 1,000,000 CLAIII&MADE IKOCCUR X X ART3000139520 01121/2022 01/21/2023 PREMISES Ea occurrence $ 50,000 MED EXP(Any one person) $ 5,000 PERSONAL BADVINJURY $ 1 000,000 _aEl L AGGRFjG LIIVIIT APPLIEf PER GENERAL AGGREGATE $ 2>000,000 POLICY PIRG- LOC PRODUCTS-OOMP/OPAGG $ 2,000,000 LJECT OTHER $ COMt3iNtUSINULL:LIMIT-- AU OMOBILELIABILITY (Ea accident) $ ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS AUTOS ONLY AUTOS Per accident $ A U:=LALIAB OCCUR X X EACH OCCURRENCE $ 5,000,000 ExcEss LIAB CLAIMS-MADE ULC 1453384-00 Ul/21/2022 01/21/2023 AGGREGATE $ 5,000,000 DED RETENTION$ $ WORKERS COMPENSATION STATUTE ER AND EMPLOYERS'LIABILITY ANVPROPRIETOR/PARTNER/EXECUTIVE Y❑ N/A E.L.EACH ACCI 'ENT $ OFFICER/MEMBER EXCLUDED? (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ e under DCsObN OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLI S(A ORD 1,Additional Remarks Schedule,ma)be aIla had if more space Is required) Additional Insured:VILLAGE OF RYE BROOK,938 KING STREET, RYE BROOK,NY 10573 CERTIFICATE HOLDER CANCELLATION VILLAGE OF RYE BROOK 938 KING STREET SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN RYE BROOK,NY 10573 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE Steven Stockfeder ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD NYSIF New York State Insurance Fund PO Box 66699,Albany,NY 12206 1 nysif.com CERTIFICATE OF WORKERS' COMPENSATION INSURANCE i*A'rr AA A A A A 811700450 +� 4 INTREPID INSURANCE BROKERAGE 4 GROUP INC -Pjd 566 E 187TH ST BRONX NY 10458 SCAN TO VALIDATE AND SUBSCRIBE POLICYHOLDER CERTIFICATE HOLDER VALIANT DESIGN BUILD INC VILLAGE OF RYE BROOK 333 OLD TARRYTOWN ROAD SUITE 1 B 938 KING STREET WHITE PLAINS NY 10603 RYE BROOK NY 10573 POLICY NUMBER CERTIFICATE NUMBER POLICY PERIOD DATE W2386 676-7 1 120638 04/08/2022 TO 04/08/2023 8/1/2022 THIS IS TO CERTIFY THAT THE POLICYHOLDER NAMED ABOVE IS INSURED WITH THE NEW YORK STATE INSURANCE FUND UNDER POLICY NO. 2386 676-7, COVERING THE ENTIRE OBLIGATION OF THIS POLICYHOLDER FOR WORKERS' COMPENSATION UNDER THE NEW YORK WORKERS' COMPENSATION LAW WITH RESPECT TO ALL OPERATIONS IN THE STATE OF NEW YORK. EXCEPT AS INDICATED BELOW, AND, WITH RESPECT TO OPERATIONS OUTSIDE OF NEW YORK, TO THE POLICYHOLDER'S REGULAR NEW YORK STATE EMPLOYEES ONLY. IF YOU WISH TO RECEIVE NOTIFICATIONS REGARDING SAID POLICY, INCLUDING ANY NOTIFICATION OF CANCELLATIONS, OR TO VALIDATE THIS CERTIFICATE,VISIT OUR WEBSITE AT HTTPS://WWW.NYSIF.COM/CERT/CERTVAL.ASP.THE NEW YORK STATE INSURANCE FUND IS NOT LIABLE IN THE EVENT OF FAILURE TO GIVE SUCH NOTIFICATIONS. THIS POLICY DOES NOT COVER CLAIMS OR SUITS THAT ARISE FROM BODILY INJURY SUFFERED BY THE OFFICERS OF THE INSURED CORPORATION. PRESIDENT QERIM KURPALI VALIANT DESIGN BUILD INC 1 OF 1 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS NOR INSURANCE COVERAGE UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICY. NEW YORK STAT SUR NCE FUND T �/ DIRECTOR,INSURANCE FUND UNDERWRITING VALIDATION NUMBER: 824251404 U-26.3