HomeMy WebLinkAboutBP22-142PERMIT #�V/
SECTION
TYPE OF WORK
JOB LOCATjFN _
OWNER NICE
CONTRACTOR.
EST. COST
FOOTI N G
FOUNDATION
FRAMING
RGH FRAMING
INSULATION
PLUMBING CI
RGH PLUMBING
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ELECTRIC
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FEE DATE
INSPECTION RECOR.O
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OTHER APPROVALS
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VILLAGE OF RYE BROOK
MAYOR 938 I-ling 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
August 15,2022
Andrew Castellano&Helen Castellano
84 Greenway Close
Rye Brook,New York 10573
Re: 84 Greenway Close, Rye Brook,New York 10573
Parcel ID#: 129.84-2-73
Building Permit#22-142 issued on 8/5/2022 to Legalize Low Retaining Wall Replacement
This certifies that the retaining wall, constructed under the above captioned permit has been satisfactorily
completed.
Sincerely,
,r r
L�J
Steven E. Fews
Assistant Building&Fire Inspector
/to
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BUILDING TEE 'ARTMENT PERMIT# c — Z
AUG - 5 2��2 VILLAGE OF RYE BROOK ISSUED:
VILLAGE OF RYE BROOK 938 KING STREET,RYE BROOK,NEW YORK 10573 DATE: - a
BUILDING DEPARTMENT (914)939-0668 FEE: ID A //0— PA .
-_-- _._ .. wwwxy&rook.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
ttRR•RRtRttttttit►t►►■t►tltt■tt►►t►■tt►RR►RRRRRRRRR►R►Rtttttt►Rttlt►►►►►■t►►►t►►tt►►•1►►►RtRRR►RtRRtRR►R►►R►►►►tt►ttt►►t■■tt►
Address: L.v( ��s2 e, �L,� Y
Occupancy/Use: /"/ Parcel ID#: c� — �J Zone:
Owner:� if ej] + ?gndr?t°W i tt l0 n D Address: ee w& OSE'
P.E./R.A. or Contractor: {'iA Address:
Person in responsible charge: �L,4 Address:
Application is hereby made and submitted to the Building Inspector of the Village of Rye Brook for the issuance of a
Certificate of Occupancy/Certificate of Compliance for the structure/construction/alteration herein mentioned in accordance
with law:
STATE OF W YORK,COUNTY OF WESTCHESTER as:
� .n �,�. I i el ►� I�l�/)Jq h D being duly sworn,deposes and says that he/she resides at U /aR C e 0/_U 194 /o s P'
t Name of Applicant) (No.(No.and Stree
in U e. b FCQT� ,in the County of tj,C24 h e.�t0 in the State of that
ty/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:$ 7't i o /D v
for the construction or alteration of (�
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 I� �S� ,20AD_� day of , 20
Signature of Property Owner Signature of Applicant
�e)len ClAbkJ1466
Name of Property Owner Print Name of Applicant
Notary Public Notary Public
SHARI MELILLO
Notary Public,State of New York 8/12/2021
No.01ME6160063
Qualified In Westchester County
Commission Expires January 29,20.�_3
�E BRC�uk
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BUILDING DEPARTMENT
❑BUILDING INSPECTOR
�SSISTANT BUILDING INSPECTOR VILLAGE OF RYE BROOK
/ U LODE ENFORCEMENT OFFICER 938 KING STREET • RYE BROOK,NY 10573
(914) 939-0668 FAx (914) 939-5801
www ryebrook.org
- - - - - - - - - - - - - - - - - - - - INSPECTION REPORT - - - - - - - - - - - - - - - - - - - -
ADDRESS : �v l.S�)CA�
( DATE•
PERMIT# ISSUED: Z ` r SECT._BLOCK: Z LOT.
LOCATION: 20 7(.0�1 I ��W �247 \-<A�n r` U� '6CCUPANCY:
❑ 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 c2�� , '•�) t' )
❑ L.P. GAS
❑ FUEL TANK
❑ FIRE SPRINKLER
❑ FINAL PLUMBING
CROSS CONNECTION
FINAL
❑ OTHER
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BUILDING DEPARTMENT
VILLAGE OF RYA 111tOOK t AUG - 1 2922
938 KING STREET RYE BR06K,NY 10573
(914)939-0668 + VILLAGE ESP RYE BROOK
roulf mra BUILDIN , DEPARTMENT
' 19f3
ADMINISTRATIVE EXTERIOR BUILDING PERMIT APPLICATION
FOR EXTERIOR WORK WHICH DOES NOT REQUIRE VILLAGE ARCHITECTURAL_REVIEw BOARD APPROVAL
FOR OFFICE USE ONLY:
APPROVAL DATE: AUG - 3 2 22 PERMIT APPLICATION FEE.-ff
APPROVAL SIGNATURE: AV PERMIT FEES: too . —
H.O.A.APPROVAL: DATE:
DISAPPROVED: OTHER:
Application dated: is hereby made to the Building Inspector of the Village of Rye Brook,NY,for the issuance of a Permit for the
construction of bull ' gs,structures,additions,alterations or for a change in use,as per detailed statement described below.
R' -
1. JobAddress: 7' �11 L.I..�Q(.� �r1�� '�L f-� -at)
i
2. Parcel ID#: 9, 7 Zone:
3. Proposed Improvement(Describe in detail): e fJt
n�� f -
4. Property Ownex: ,v aPc`• •rlt�y � � �fD
Address: C/O gc- , ✓,c,c�.�'oo�Jh fv d 73
Phone#_M VV IT F7 Cell# 9/y3/p RJ t' e-mail
List All Other Properties Owned in Rye
//Brook:��t�a`L?
Applicant: e�-/7L-/C-. (� 4S/r
Address: p}
Phone#�Y 'pL� Cell Slptr e-mail
Architect:
Address:
Phone# Cell# e-mail
Engineer:
Address:
Phone# Cell# e-mail
General Contractor:
Address:
Phone# Cell# e-mail
(1)
8/12/2021
5. Occupancy;(1-Fam.,2-Fain.,Commercial.,etc...)Pre-construction: Post-construction:
6. Area of lot: Square feet: Acres:
7. Dimensions from proposed building or structure to lot lines: front yard: rear yard:
right side yard: left side yard: other:
8. If building is located on a comer lot,which street does it front on:
9. Area of proposed building in square feet: Basement: 11,fl: 21 fl: 3'fl:
10. Total Square Footage of the proposed new construction:
11. For additions,total square footage added:Basement: V fl: 2°d fl: 3'd fl:
12. Total Square Footage of the proposed renovation to the existing structure:
13. N.Y. State Construction Classification: N.Y.State Use Classification:
14. Construction Type&Location:()Typical Western Lumber Frame;()Timber Frame[TC];()Wood Truss[TT];
O Pre-engineered wood[PW];Located;O Floor Framing[F];O Roof Framing[R];O Floor&Roof Framing[FR];Other:
15. Number of stories: Overall Height: Median Height:
16. Basement to be full,or partial: finished or unfinished:
17. What material is the exterior finish:
18. Roof style;peaked,hip,mansard, shed,etc: Roofing material:
19. What system of heating:
20. If private sewage disposal is necessary,approval by the Westchester County Health Department must be submitted with this
application.
21. Will the proposed project require the installation of a new,or an extension/modification to an existing automatic
suppression system?(Fire Sprinkler,ANSL System,FM-200 System,Type I Hood,etc...)Yes: No:
(if yes,applicant must submit a separate Automatic Fire Suppression System Permit application&2 sets of d_etaile engineered plans)
22. Will the proposed project disturb 400 sq.ft.or more of land,or create 400 sq.ft�or more of' ervious coverage requiring a
Stormwater Management Control Permit as per§217 of Village Code? Yes: No: Area:
23. Will the proposed proje quire a Site Plan Review by the Village Planning Board as per§209 of Village Code?
Yes: No: (if yes,applicant must submit a Site Plan Application,&provide detailed drawings)
24. Will the proposed project require a Steep Slopes Permit as per§213 of Village Code Yes: Now/
(if yes,you must submit a Site Plan Application, &provide a detailed topographical survey)
25. Is the lot located within 100 ft.of a Wetland as per§245 of Village Code? Yes: No: 6/
(tf yes,the area of wetland and the wetland buffer zone must be properly depicted on the survey&site plan) /
26. Is the lot or any portion thereof located in a Flood Plane as per the FIRM Map dated 9/28/07? Yes: No: J
(if yes,the area and elevations of the flood plane must be properly depicted on the survey&site plan)
27. Will the proposed project require a Tree Removal Permit as per§235 of Village Code?Yes: No:
(if yes,applicant must submit a Tree Removal Permit Application) /
28. Does the proposed project involve a Home-Occupation as per§250-38 of Village Code? Yes: No:✓
Indicate:TIER I: TIER II: TIER III: (f yes,a Home Occupation Permit Application is required)
CI
29. What is the total estimated cost of construction: $ �DD Note:estimated cost shall include
all site improvements, labor,material,scaffolding,faced 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.
30. Estimated date of completion:
(2)
8/12/2021
BUILDING DEPARTMENT _
VILLAGE OF RYE BROOK AUG - 1 2022
938 KING STREET RYE BROOK,NY 10573
(914)939-0668. VILLAGE OF RYE BROOK
g BUILDING DEPARTMENT
AFFIDAVIT OF COMPLIANCE
VILLAGE CODE §216• STORM SEWERS AND SANITARY SEWERS
THIS AFFIDAVIT MUST BEAR THE NOTARIZED SIGNATURE OF THE LEGAL PROPERTY OWNER AND BE SUBMITTEO
ALONG WITH ANY BUILDING OR PLUMBING PERMIT APPLICATION. ANY BUILDING OR PLUMBING PZRNXT
APPLICATION SUBMITTED WITHOUT THIS COMPLETED AND NOTARIZED FORM WILL BE RETURNED TO THE APPLICANT.
STATE OF NEW YORK, COUNTY OF WESTCHESTER ) as:
1
residing at,
(Print name) (Ad(ress whe you live)
being duly sworn, deposes and states that(s)he is the applicant above named, and further states that(s)he is the
legal owner of the property to which this Affidavit of Compliance pertains at;
-.0 y n� (!?/e-r,,5- ,Rye Brook,NY.
(Job Address)
Further that all statements contained herein are true, and that to the best of his/her knowledge and belief,that
there are no known illegal 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.
f
9r ��LJ
ignature of Property Owner(s))
?Fmrf Name of Property Owner(s))
Sworn to before me this
of , 20 � )
(Notary Public)
SHARI MELILLO
Notary Public,State of New York
No.01ME6160063
Qualified In Westchester County, (3)
Commission Expires January 29,2C�
8/12/2021
This application must be properly completed in its entirety by a N.Y. State Registered
Architect or N.Y. State Licensed Professional Engineer & signed by those professionals where
indicated. It must also include the notarized signature(s) of the legal owner(s) of the subject
property, and the applicant of record in the spaces provided. Any application not properly
completed in its entirety and/or not properly signed shall be deemed null and void, and will be
retumed to the applicant. Please note that application fees are non-refundable.
STATE OF NEW YORK,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. 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 Lk c ��A , 20j day of , 20
ignature of Property Owner Signature of Applicant
Print Name of Property Owner Print Name of Applicant
i
Notary Public Notary Public
SHARI MELILLO
Notary Public,State of New York
No.OIME61SO063
Qualified in Westchester County
Commission Expires January 29.202_3�
(4)
8112/2021
Building Permit Check List&Zoning Analysis
Address: C L-P E,- SBL: ( z�l ,,4j If — 7—
Zone Use: Z l O Cont.Type:_"tT3 Other: L F C,/l L t /L-t�9,�
Submittal Date: I Z Z Revision Submittal Dates:
Applicant: �i A Si F L IL,A ti 3
Nature of Work: L E-4 A L t-L F nz:R:�(1/5-C R L o w —17p Tn-t n e j 4 L L
Reviews:ZBAA U G - 3 2 02 2 PB: BOT: Other.
1�1
OK
( ( ) FEES:Filing. ? BP: t 00 C/O: Flood Plane: Legalization:
( ) (.)"'APP: Dated: ✓ Notarized: SBL: -✓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:Date Stamped Sealed Copies Electronic Other.
( ) ( ) License Workers Comp: Liability Comp.Waiver. Other.
( ) ( ) CODE 753#: Dated: N/A:
( ) ( ) HIGH-VOLTAGE ELECTRICAL:Plans: Permit N/A: Other.
( ) ( ) LOW-VOLTAGE ELECTRICAL:Plan: 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:Plan: 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 Plan; 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:
REOLOED EXISTING PROPOSED NOTFS APPROVED
Art
Cir • -
Front:
Front
Sides:
Main Cor.
Accs.Cov:
Ft.H/Sb
S .H Sb:
a&
Tom
P kui
Height/Stories
notes:
D
L 2 2 2022 LiJ�--; 173'/z Iv Hill Crescent
VILLAGE OF RYc BROOK y
I BUILDING DEPARTMENT Rye Brook, NY 10573
914-939-2440
July 20, 2022
Helen Castellano
84 Greenway Circle
Rye Brook, NY 10573
Re: Retaining Wall
Dear Helen Castellano,
The Architecture and Grounds Committee (A&G) has reviewed your
application for the above named work. This project requires a permit from
The Village of Rye Brook. You are directed to submit this letter to the
Village along with your permit application. Once the permit is obtained, a
copy must be provided to A&G for final review and consideration.
Work on this project has already been completed without approval from
A&G and from the Village.
If you have any questions, please contact me at: Property Manager.
Ashlee Pasquale
Property Manager
It
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Homeowners Declarations Page
Narragansett Riiy Policy Number: NYH0054623
Imnr,m i l uq ui�
Andrew Castellano 45000 GEICO Insurance Agency, LLC
84 GREENWAY CLOSE One GEICO Blvd
RYE BROOK, NY 10573 Fredericksburg, VA 22412
855 721-9250
Policy Period: 01/15/2022 12:01 am to 01/15/2023 12:01 am Standard Time at insured location F515&
Transaction Type: Renewal
Effective Date of Transaction: 01/15/2022 12:01 am
Transaction Premium: $1 149.00
• NVI
84 GREENWAY CLOSE
RYE BROOK, NY 10573-1505 Westchester
Coverage is provided where a premium or limit is shown for the coverage
Coverage-A- Dwelling $288,000
Coverage- B-Other Structures $28,800
Coverage-C- Personal Property $201,600
Coverage- D- Loss of Use $86,400
Coverage-E-Personal Liability $500,000
Coverage- F-Medical Payments To Others $5,000
In case of a loss under Section 1, we cover only
• _ that part of the loss over the deductible stated: •
All Perils Other Than Hurricane: $750
Hurricane Deductible Percentage: 5%
Hurricane Deductible: $14,400
Homeowner Premium: $1,602.00
Premium Debits: $0.00
Premium Credits: ($453.00)
j TOTAL PREMIUM: $1,149.00
. - �• -
Ordinance or Law Coverage 10% Included
HO 23 95 05 02 Off Premises Theft Exclusion Included
HO 04 90 10 00 Personal Property Replacement Cost $179.00
HO 04 46 10 00 Inflation Guard 4% Included
HO 04 20 10 00 Additional Amount of Insurance for Coverage A 50% $72.00
Loss Assessment Coverage $1,000 Included
Water Back-up and Sump Discharge or $5,000 Included
Overflow Coverage- New York
Personal Injury Included
NBICHODEC1219 PO BOX 9950 • Providence, RI 02940-4150 Page 1 of 3
Prepared on December 13 , 2021
NBICRENMSO418
Narragansett Bay
Policy Number: NYH0054623 Agency ID: N8899
Andrew Castellano 45000 GEICO Insurance Agency, LLC
84 GREENWAY CLOSE One GEICO Blvd
RYE BROOK, NY 10573 Fredericksburg, VA 22412
The finest compliment you can give an insurance company is your renewal business. We
appreciate the opportunity to continue to provide your coverage and handle your insurance
needs.
One of our goals is to provide our customers with loss prevention suggestions. With today's
rising home heating fuel costs, many people have chosen to use a professionally installed
woodstove or fireplace as a supplemental heating source. We recommend fireplaces,
stovepipes, and chimneys be cleaned and inspected annually (by a certified technician or local
fire inspector) to help prevent losses caused by fire. Preventative maintenance is key to the
safe operation of these heating sources.
Enclosed are your renewal policy declarations pages. Your business is important to us and I
thank you for renewing your coverage with Narragansett Bay Insurance Company - The #1
Choice for Responsible Homeowners
Sincerely ,
Timothy M. Moura
President
Narragansett Bay Insurance Company
25 Maple Street. Pawtucket. RI 02 860-2 1 04 • Mail PO Box 820,Pawtucket,RI 02862-0820
T 401-725-5600 • F 401-721-9899 • www.NBIC co
m
Homeowners Declarations Page
Narragansett Bay Policy Number: NYH0054623
Identity Fraud Expense Coverage $15,000 Included
NBICNYMAR 08 14 Mariner Plus $125.00
NBIC HO EB 10 19 Equipment Breakdown Coverage (Deductible - $100,000 $32.00
$500)
HO 04 96 10 00 No sec. II Liab. Cov., Ltd. Sec. I Prop Cov. for
Home Day Care
NBIC HO Hurricane NY 04 Hurricane Percentage Deductible
14
NBIC NY SP 08 20 NY Special Provisions
NBICCBIS 06 16 Notice on Credit Based Insurance Scores
NBICGIARWLMPD 08 19 GEICO Renewal Letter
NBICNJNYPOLEXC 04 13 Total Pollution Exclusion
NBICNYTPD 02 10 NY Third Party Designee
NBICPP 11 09 Privacy Policy
NBICWLCI 11 09 Claim Information
NBICWLFN 12 11 Notice on Flood Insurance
NBICWLHP 11 09 Hurricane Preparedness
NBICWOD 02 15 Waiver of Deductible
HO 04 16 10 00 Premises Alarm or Fire Protection System
HO 00 03 10 00 HO3 Special Form
GIAWLSP 11 09 GEICO Shelter Pride
IL N 001 09 03 Fraud Statement
HURRNOTNY 04 14 Hurricane Important Notice NY
HO 16 10 01 09 Water Exclusion Endorsement
HO 24 93 05 02 Worker Compensation- NY
UT•
Deductible ($149.00)
Age of Home ($12.00)
Safe Home Discount ($60.00)
At Home Credit ($30.00)
Renewal Credit ($119.00)
Protective Devices ($24.00)
Companion Policy ($59.00)
• ' A •
LOANCARE, LLC - ISAOA/ATIMA 0043522648
PO Box 202049
FLORENCE, SC 29502
"INTIMERMniff
NBICHODEC1219 PO BOX 9950 • Providence, RI 02940-4150 Page 2 of 3
Prepared on December 13 , 2021
Homeowners Declarations Page
Narragansett Bay Policy Number: NYH0054623
MIXImur.nxr l',nu� u��
Protection Number of
Class Territory Tier Occupancy Families Year Built Construction
4 1706 4 Owner 1 1978 Frame
THIS DECLARATION, TOGETHER WITH THE POLICY JACKET, HOMEOWNERS POLICY AND ENDORSEMENTS
ISSUED TO FORM A PART THEREOF (IF ANY), COMPLETES THE ABOVE NUMBERED HOMEOWNERS POLICY.
• - - . FOR ALL OTHER INQUIRIES, •NTACT YOUR AGENT.
800.343.3375 (option 2, then 1) or 45000 GEICO Insurance Agency, LLC
httl?://www.nbic.com/company/report-a-claim.Asp?( (855)721-9250
NBICHODEC1219 PO BOX 9950 - Providence, RI 02940-4150 Page 3 of 3
Prepared on December 13 , 2021
Affidavit of Exemption to Show Specific Proof of Workers' Compensation Insurance
Coverage for a 1, 2, 3 or 4 Family, Owner-occupied Residence
"This form cannot be used to waive the workers'compensation rights or obligations of any party."
Under penalty of perjury, I certify that I am the owner of the 1, 2, 3 or 4 family, owner-occupied residence
(including condominiums) listed on the building permit that I am applying for, and I am not required to show
specific proof of workers' compensation insurance coverage for such residence because (please check the
appropriate box):
❑ I am performing all the work for which the building permit was issued.
❑ I am not hiring,paying or compensating in any way,the individual(s)that is(are)performing all the work
for which the building permit was issued or helping me perform such work.
I have a homeowners insurance policy that is currently in effect and covers the property listed on the
attached building permit AND am hiring or paying individuals a total of less than 40 hours per week
(aggregate hours for all paid individuals on the jobsite) for which the building permit was issued.
I also agree to either:
♦ acquire appropriate workers' compensation coverage and provide appropriate proof of that coverage on
forms approved by the Chair of the NYS Workers' Compensation Board to the government entity issuing
the building permit if I need to hire or pay individuals a total of 40 hours or more per week(aggregate hours
for all paid individuals on the jobsite)for work indicated on the building permit,or if appropriate,file a CE-
200 exemption form; OR
♦ have the general contractor, performing the work on the 1, 2, 3 or 4 family, owner-occupied residence
(including condominiums)listed on the building permit that I am applying for,provide appropriate proof of
workers'compensation coverage or proof of exemption from that coverage on forms approved by the Chair
of the NYS Workers' Compensation Board to the government entity issuing the building permit if the
project takes a total of 40 hours or more per week(aggregate hours for all paid individuals on the jobsite)for
work indicated on the building permit.
�x, Ci .5 ao as
I (Signature of Homeowner) (D to Signed) L/ (} _l/ �7
ice`el l I'A Sted I (t Y\D Home Telephone Number �/�` —l� 7'�9 /
(Homeowner's Name Printed)
Sworn to before one this �' _ day of
Property Address that requires the building permit: sty
IeeenLW
(County Clerk o3}{AfI:IqpftL(13rblic)
Notary Public,State of New York
No.01ME6160063
Qualifled in Westchester County
Commission Expires January 29,202il-4
Once notarized,this BP-1 form serves as an exemption for both workers'compensation and disability benefits insurance coverage.
BP-1 (12/08) NY-WCB