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HomeMy WebLinkAboutBP22-144PERMtT # / �" / / DATE: � ca� EXP: _ � % 3 SECTION � `BLOCK � LOT TYPE OF WOR e t C� �� X/ � ��/1 ��� JOB LOCATION � l S OI ®� /BPS Q/��" OWNER Q /'OSS Q� � �•7c7 /OSS ��y^�/d"��7� CONTRACTOR /� � �% - /�-�'������PZ EST. COST �� � '- �-7T���' FEE � / 7 �CO # � � � �� FEE � DATE oZ TCO # FEE DATE DATE FOOTING FOUNDATION FRAMING RGH FRAMING INSULATION PLUMBING L� RGH PLUMBING GAS SPRINKLER ELECTRIC LOW -VOLT O ALARM C� AS GUILT 0 FINAL •-. I NSP 1�/� � 7i� OTHER APPROVALS OTHER VILLAGE OF E BROOK WESTCHESgE COU , NEW YORK �, A NO: 22-188 / Certificate of Occupaurp Ehis is to certify that�,r) Jena of, 1�� , having duly filed an application on Noytowleer /67 20 .W a requesting a Certificate of Occupancy for the premises known as, 15 b J'5Y U 3k 16 i I o W r e�C��-E , Rye Brook,NY, located in a Pu C)Zoning District and shown on the most current Tax Map as Section: 190. 70 Block: / Lot: /0 and having fully complied with the requirements of the Building Code and the Zoning Ordinance under Building Permit No. 0 - , issued (1) 20 v��, 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: 9" 15 /N?e" La- 179/ /(/ Construction: 03 for the following purposes: 1 C {� e -1, C`�P G'►L 1 1'1 �� n d 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 ph 11 e;►tor sl3all\the building moved from one location to another until a permit to accomplish such change has b e e ul In DEC - 8 2022 Building Inspector,Village of Rye Brook: ? Date: "�V! (� 1 I &P- A 9TMENT For office u nl BUILDINd I PERMIT NOV 8 2�22 VILLAGE OF RYE BROOK ISSUED: 0-9-4 � 38 KING STREET,RYE BROOK,NEW YORK 10573 DATE: //—/8 a VILLAGE OF RYE BROOK (914)939-0668 FEE: 4 //01 PALM BUILDING DEPARTMENT www,rygbrook ory, 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 ttiifitiiitiiiifitiiiiiiifif tfitfiRfififiiitiftitititftRtRttiftiiiRittttii#Rfi RffiffiifiiiiittiitftiftitRitiRffffiititfiRif Ri Address: Ise A-A 11�&z 62�� Occupancy/Use: 16M11Vlk Parcel ID#: i -74x _ 0d Zone: UQ Owner: �pn Irr0f� Address: Ja'mp— P.E./R.A. or Contractor: 'iYj MjW 0( {'/g_ Address: _Ulf P Person in responsible charge: JZ /A 1 Address: —6 fl 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: / Wolp r L6rOJTMOA being duly swom,deposes and says that he/she resides at 'S v1{�1 C?I c (Print ame of Applicant) I _ _ (No.and Street) in o in the County of in the State of A ,that (City' own/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:$ Q a d cc 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 17� Sworn to before me this / day of�/V0&ry-)be/ , 20_1=Z day of /Vrn 6,Q LV I , 20 2 2-- Signabisk of Property Owner Si of Ap cant an Croylriqoi arn C aA Print a of Property er Print N e of Applican C,,-- otary lic 'A Not Put lic LOIS A GOti r4 LOIS A G Nofaw publ4c State of New YoAt Notaw public State of New YorkNo 50107?8 No 50107'8 X1??U-'1 Quahhed if)VVesrcnesiei oun ()tralif,ed ,n � 4�'estchestei . ount nunfssion Expires April 5,�(a_ qhasmfss,on Expires April 5, r �E BRC��• O� 2m 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 : 1 ��/ J DATE: PERMIT# ISSUED:_SECT: BLOCK: LOT: r LOCATION: Aa C 1 C� OCCUPANCY: -7 (0 ❑ VIOLATION NOTED THE WORK IS... W�IACCEPTED ❑ REJECTED/REINSPECTION ❑ SITE INSPECTION REQUIRED ❑ FOOTING ❑ FOOTING DRAINAGE ❑ FOUNDATION ❑ UNDERGROUND PLUMBING NOTES ON INSPECTION: ❑ ROUGH PLUMBING ❑ ROUGH FRAMING ❑ INSULATION ❑ NATURAL GAS ❑ L.P.GAS ❑ FUEL TANK ❑ FIRE SPRINKLER ❑ FINAL PLUMBING ❑ .CROSS CONNECTION ❑" FINAL ❑ OTHER M O 7 0 GCa oo 00 0 E N [ W O d S rq 00 M %m Q o •d O W cn w ON PLO 94 V o v cn 00 (� W � W a A oVig oU R+`� 4. 20 o a � v M `J W V w by x U $ e °v cr h+y V V z g o x OA C7 A z ;,g � a � W [� O . l't A W z Q Q A o z �I ;p a 04 W �P. 2 � 'mX -0 BUICET AUTME1vTREVISED 4 2022APPLICAT'�rP�l � V><tI B`ltoolK938 KINGR00t:,NY 10573 JUL 18 2022 DATED' 6�,8 VILLAGE OF RYE BROOK oI BUILDING DEPARTMENT �r***********x** FOR OFFICE I SL O\IA : Approval Date: AUG — 4 �� 2 rmit# �� Application # Approval Signature: V ARCHITECTURAL RE EW BOARD: Disappro%ed: : Date: BOT Approval Date: Case# Chairman: PB Approval Date: Case# : Secretary: ZBA Approval Date: Case# Other: Application Fee Permit Fees: 1 0O- rt,�*****+****rt*rt*****rt***********ss**a****+***rt***rt*************y'*** rt*rt********s*+srt**+r****++****+*****art* EXTERIOR BUILDING 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 construction of buildings,stru hures.additions,alterations or for a change M use,as per detailed statement described below. 1. JobAddress: f ( J I Parcel [D#: �r�l , 1(eC 29 ` ���� /L� zo]nee: /� If� 1 3. Proposed Improvement(Describe in detail): k h�4 PCAL-n0 _ rl{Y� ) yi f a /,- o 4. Property Owner: Address: hkve Phone# Cell# e-mail _ UZA t?,I1� 'JI�',�OLCOM List All Other Properties Owned in Rye Brook: �k Applicant: Address Phone# Cell # figoX igt akat e-mail _kdM r,1 Architect: A Address: Phone# Cell # e-mail Engineer: Address: Phone# Cell# e-mail General Contractor: >'1 �C�Z Q Address: Phone#NQ 91ro-M Cell# -017q e-mail Al Acme (I} 8/12/2021 5. Occupancy;(I-Faro.,2-Fam.,Commercial.,etc.. )Pre-construction: Post-construction: 6. Area of lot: Square feet: Acres: 7. Dimensions from proposed building or structure to lot lines: Iront yard: rear yard: !f R right side yard: cr left side yard: other: 8. If building is located on a corner lot,which street does it front on: n h 9. Area of proposed building in square feet: Basement: A ICI I"fl: 2"d fl: 3rd f1: 10, Total Square Footage of the proposed new construction: IL For additions,total square footage added: Basement: I si fl: 2^d fl: — 3"f1: 12. Total Square Footage of the proposed renovation to the existing structure: 11 13. N.Y.State Construction Classification: n 11x Y.State Use Classification: TI AA 14. Number of stories: AJQ Overall Height: n Median eight: 15. Basement to be full,or partial: 1 finished or unfinished: /�Q 16. What material is the exterior finish: 17. Roof style;peaked,hip,mansard,shed,etc 4 Roofing material: 18. What system of heating:. in [) 19. If private sewage disposal is necessary,approval by the Westchester County Health Department must be submitted with this application./I a 20. Will the proposed project require the installation of new,or an extension/modification to an existing automatic e suppression system?(Fire Sprinkler,ANSI.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 detailed engineered plans) 21. Will the proposed project disturb 400 sq. ft.or more of land,or create 400 sq.ft.or more of imperytous coverage requiring a m Storwater Management Control Permit as per§217 of Village Code? Yes: No: t/' Area: 22. Will the proposed project require 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) 23. Will the proposed project require a Steep Slopes Permit as per§213 of Village Code Yes: No: (if yes,you must submit a Site Plan Application,&provide a detailed topographical survey) 24. Is the lot located within 100 ft.of a Wetland as per§245 of Village Code? Yes: No: (fyes, the area of wetland and the wetland buffer gone must be properly depicted on the survey&site plan) 25. 1s the lot or any portion thereof located in a Flood Plane as per the FIRM Map dated 9/28/07? Yes : No: (rfyes,the area and elevations of the flood plane must be properly depicted on the survey&site plan) 2& Will the proposed project require a Tree Removal Permit as per§235 of Village Code? Yes: No: (rf yes,applicant must submit a Tree Removal Permit Application) 27. Does the proposed project involve a Home-Occupation as per§250-38 of Village Code? Yes: No: Indicate: TIER E TIER 11: TIER III: (ifyes,a Home Occupation Permit Application is required) 28. List all zoning variances granted or denied for the subject property: 29. What is the total estimated cost of construction: $ ? Cf'l Note: The estimated cost shall include all site improvements,labor,material,scaffolding,fired equipment,professional fees, including any material and labor which may be donated gratis. ff the final cost exceeds the estimated cost,an additional fee will be required prior to issuance of the C/O. 30. Estimated date of completion: ' j�1 ��-�� J (2) 8/12/2021 BUILDING DuARTMENT D �� � � V E VM LAGE OF RYE BROOK 938 KING STREET RYE BRom,NY 10573 J U L 18 2022 (914)939-0668 vvv,reLe�k.�rg VILLAGE OF RYE BROOK 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 SUBMITTED ALONG WITH ANY BUILDING OR PLUMBING PERMIT APPLICATION. ANY BUILDING OR PLUMBING PERMIT APPLICATION SUBMITTED WITHOUT THIS COMPLETED AND NOTARIZED PORN WILL BE RETURNED TO THE APPLICANT, STATE OF NEWL YORK, COUNTY OF WESTCHESTER ) as: 31, 1 Grn 2 , residing at, )f� VA ,f'f� /C40 Cj,e /ff� (Print name) (Address where 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; 1_0 9m, Lok, ( 5�4 ,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. �A A04W (signature operty er(s)) S4.r\ (�S bSSMan (Print Name of Property Owner(s)) Sworn to before me this 1�ah day of 4\- , 20 2 Z (Notary Public CHRISTOP J.BRADBURY Notary Public,State of New York No.01 BR6159985 Oualified in Westchester County (3) Commission Expires January 29,20�ZL 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 owners? 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 XW6Z0R,KCOUNTY 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 a4l- Sworn to before me this /µPLI day of , 201 1 day of iJL 20_2, -2— a l Sign. a of Property Owner Sign re of Applicant C.� fm 74A Cryj Print a of Property Owner 7MApphcant N Pub No Puhl LOIS A (;0R&UN Notaw Public State of New yorft LOIS A Gol No 5010718 Notary Public State ur New y Qualified In Westchester C un No 501071 g ork 9SWne"ion Expires April 5, Ouallfted in "'estchester C�umssion,Expires A Ofdrlty pn15, (gl 8/122021 Building Permit Check List&Zoning Analysis k Address: SBL: { r (o — Z Zone: Use: Z t'J Const.Type: Oth . Submittal Date: { Z Z- Revisions Submittal Dates: ,Z- Applicant: 4:217L s kVk,A t..J Nature of Work. L-rl IQ �C�•, dui 2 Reviews:ZBA: A UG - PB: BOT: Other. OK ( FEES:Filing. 7 S•r �.BP. 1 oP- C/O: Flood Plane: Legalization: ( P: Dated ✓ Notarized SBL ✓1 cuss 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-Dat Stamped Sealed,Copies: Electronic Other. ( (.-I' License: Workers Comp: ✓ Liability: -7 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: REOUIRED EXISITNG PROPOSED NOTES APPROVED Circle: eye: AUG - 4 2022 Fie Front~ Front: sue: R Main cor Accs.Co� Ft.HS : S .H Sb: Tot,In : EL IMP: Hight/Stories: note. ( W .O ? Z 173'/z Ivy Hill Crescent Rye Brook, NY 10573 914-939-2440 August 3, 2022 R AUG - 4 2022 RYE BROOK Jena Grossman BIUILDINGGDEPARTMENT 158 Brush Hollow Crescent Rye Brook, NY 10573 Re: Deck Replacement with Trex Dear Jena Grossman, 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 the project may not begin until you receive written notice of acceptance from A&G. If any changes are made to the original plans submitted to A&G, due to input from the Village or arising during construction, the Committee must be notified in writing. Work cannot proceed until you receive written approval for those changes. Failure to comply with these procedures will result in fines and/or work stoppage. If you have any questions, please contact me at: Property Manager. Ashlee Pasquale Property Manager U EVE EIJ�L'/ JUL 18 2022 0 VILLAGE OF RYE BROOK BUILDING DEPARTMENT oC t- tt, I� a� YS. ' � '� �G r; •'ids � �,�,, .:•t. �.',►It .' k ; Mir. , + . :r i a ILM, (� ElM. A,_ MEL Laura Petersen From: Laura Petersen Sent: Monday,August 8, 2022 1:51 PM To: janjen0831 @aol.com Cc: Adrian Perez Subject: Building Permit Application - 158 Brush Hollow Crescent Good afternoon, The building permit application has been approved by the Building Inspector. Before I can issue the building permit the following items must be submitted to our office; General contractor's contact name `. Copy of general contractor's valid Westchester County Home Improvement License. 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 IpetersenCa)rvebrook.or4 i wh- I 9• n•-"."- A t NT'5..''�•'JS•`: -A A'h ..yeb -y;ht t. r . a .=r �`x} =.111►11►1:. . . :.�as�''�►,,,',ttl . . . . . . . . �►►►►(111It►►t.'F. . . . . .':f►►►fl1. �..'.,/...- '' ,► 1�1 <cs+uill' Ls. s t\f 1 �- 1 1 Y s 3 r 111,►11 t bYi'�11�111. S f ? h3�11►�111 3as�� L't;,l�►�►�.+'I h 11►� I ' ®r, rL LO m G L + red' O °'.cm rA L 1 C LU CD u Own) w ~ IOC) c o U a `Qtotiection CL lrA E uj UJ uj ! V fir• w MIN •. O a ¢ :, : :.. .. = o 4) � .. CN co - . to Y!tSA� F//:�•Y,l i1t�►����1"{f.,E�;�A��(�?»���N�.''�lt►i►►l1 l�',.!�l �'A�i,4*-s,,,�,���,/'Iy1ti 1►►Nts i5��.�_A�'`',.��u,•)''���t.,1t►Nti'l��Lb E's#�A er�S��#jf.f.,f,>IIflil►�l�ityll l p:$-.♦i jjj Id•►►►i',�;>i:..a a ..i`4I1 a �, Y/figgIO I'►t►�►1• s N, l � :ti�25'�`L A "A �i1�' }} � �'���` . tt ddt!y1�y�m +� � ��( u¢y1,+7 qqA� 1ei/} /A '•'� . y2 'J_` "�Y�,W., �-'�" �' � `"`�St^7� �a ice. �•'RR'.''-- - '--%�•'l�,Q'� � - l/ ,4co CERTIFICATE OF LIABILITY INSURANCE DATE(MWDD/YYYY) 07/12/2022 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsements. PRODUCER CONTACT NAME: _ Hiscox Inc. PHONE (888)202-3007 FA/C No 5 Concourse Parkway E-MAILDD contact@hiscox.com Suite 2150 Atlanta GA,30328 INSURERS AFFORDING COVERAGE NAIC# _ INSURER A: Hiscox Insurance Company Inc 10200 INSURED INSURER B: PEREZ M&W HOME IMPROVEMENT LLC 1215 PARK ST INSURER C: PEEKSKILL, NY 10566 INSURERD: 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 POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP R POLICY NUMBER MM/D YYYI (MWDDIYYYYI LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 AMAG TO RENTED CLAIMS-MADEX I OCCUR PREMISES Ea occurrence $ 100,000 MED EXP(Any one person) $ 5,000 A N UDC-4611114-CGL-21 09/23/2021 09/23/2022 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER. GENERAL AGGREGATE $ 2,000,000 X POLICY❑PECT RO- ❑ J LOC PRODUCTS-COMP/OPAGG $ 2,000,000 OTHER $ AUTOMOBILELIABILITY COMBINED SINGLE LIMIT $ Ea ac den ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY Per accident $ AUTOS ONLY AUTOS ( ) HIRED r $ NON-OWNED PROPERTY DAMAGE AUTOS ONLY AUTOS ONLY Per accident $ UMBRELLA LIAB L]OCCUR EACH OCCURRENCE $ EXCESSLIAB CLAIMS-MADE AGGREGATE $ DED I I RETENTION$ $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY YIN STATUTE R ANYPROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? ❑ NIA (Mandatory in NH) E.L.DISEASE-EA EMPLOYE $ It yes.descnbe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) CERTIFICATE HOLDER CANCELLATION VILLAGE OF RYE BROOK 938 KING STREET SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE RYE BROOK NY 10573 THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE J ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD YORK Workers' CERTIFICATE OF STATE Compensation Board NYS WORKERS' COMPENSATION INSURANCE COVERAGE 1 a. Legal Name&Address of Insured(use street address only) 1 b. Business Telephone Number of Insured Perez M &W Home Improvement LLC 914-618-0373 1215 Park St 1 c. NYS Unemployment Insurance Employer Registration Number of Insured Peekskill, NY 10566 N/A Work Location of Insured (Only required if coverage is specifically limited to 1 d. Federal Employer Identification Number of Insured or Social Security certain locations in New York State,i.e., a Wrap-Up Policy) Number 85-3120492 2. Name and Address of Entity Requesting Proof of Coverage 3a. Name of Insurance Carrier (Entity Being Listed as the Certificate Holder) National Liability & Fire Insurance Company VILLAGE OF RYE BROOK 3b. Policy Number of Entity Listed in Box 1 a" 938 KING STREET N9WC403498 Rye Brook, NY 10573 3c. Policy effective period 03/17/2022 to 03/17/2023 3d. The Proprietor,Partners or Executive Officers are ❑ included.(Only check box it all partners/officers included) X] all excluded or certain partners/officers excluded. This certifies that the insurance carrier indicated above in box"T' insures the business referenced above in box 1 a"for workers' compensation under the New York State Workers'Compensation Law. (To use this form, New York(NY)must be listed under Item 3 on the INFORMATION PAGE of the workers'compensation insurance policy). The Insurance Carrier or its licensed agent will send this Certificate of Insurance to the entity listed above as the certificate holder in box"2". The insurance carrier must notify the above certificate holder and the Workers'Compensation Board within 10 days IF a policy is canceled due to nonpayment of premiums or within 30 days IF there are reasons other than nonpayment of premiums that cancel the policy or eliminate the insured from the coverage indicated on this Certificate. (These notices may be sent by regular mail.)Otherwise,this Certificate is valid for one year after this form is approved by the insurance carrier or its licensed agent,or until the policy expiration date listed in box"3c",whichever is earlier. This certificate is issued as a matter of information only and confers no rights upon the certificate holder. This certificate does not amend, extend or after 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 1 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: Rakesh Gupta (Print name of authorized representative or licensed agent of insurance carrier) Approved by: _ j•�,� t} --` 07/12/2022 �^ (Date) Title: Chief Operations Officer Telephone Number of authorized representative or licensed agent of insurance carrier: 844-472-0967 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 � >0000 O Alt O / ♦: lbCV Bea X j 4000 14* C rMtcMY 15.0 o ,�,�'r. � � a` X - i t � QJ' � norm.160 9 to %0 Ar 4&,�y ,� 0� � / �0 a us � t . , ,arc.IL TRY � AA or AIC, or ooil q NX 03Os Ovw tW �oC. .0I Moe llljjj� A. 000 COO4 '0I IPERMff c 4LI 124 .Z (� — t — lo 'Z 2 AUG - 4 APPR ECIIII�!!IIIIII' -�-1111111111-�-�� JUL 18 OUNDING 1"Mavj,ViHwdfte ►w gVI pGNGOF RyE BROO Ic �EPARTAgEIVT