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Home My WebLink AboutSP22-005PERMIT SECTION " J TYPE OF WORK JOB LOCATION. CONTRALTO T. CO 4 > DATE: 7 La EXPti L LOT000le�; ,e74 �%Rie y-ems suioxP �ro� c TCO # FEE DATE INSPECTION RECORD DATE FOOTING FOUNDATION FRAMING RGH FRAMING INSULATION PLUMBING 0 RGH PLUMBING GAS SPRINKLER ELECTRIC L� LOW -VOLT L� ALARM O AS BUILT FINAL INSP e Cc//j )937- &000 OTHER APPROVALS ARB Ll & Q< cao" BOT PB zeA OTHER ' ?4 40* awtiUmaW 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. Heiser Salvatore W. Morino CERTIFICATE OF COMPLIANCE August 16,2022 CLPB LLC 217 South Ridge Street Rye Brook,New York 10573 Re: 217 South Ridge Street, Rye Brook,New York 10573 Parcel ID#: 141.35-2-40 Sign Permit#22-005 issued on 7/26/2022 to Resurface Rooftop& Free Standing Signs This certifies that the rooftop sign box and freestanding pole sign; "Riemer Insurance Group Inc",resurfaced under the above captioned permit has been satisfactorily completed. Sincerely, Steven E. Fews / �1 Assistant Building&Fire Inspector /to D U EFEE:Z4 only: BUILD , � TMENT 1 0 AUG 2022 / � . �,- VIL E 1Df. OK --��U ';1i J� , VILLAGE OF RYE BROOK 938 Ktivc STRE ;$ p r YORK 10573 BUILDING DEPARTMENT fi . ` b O ':- PAtnJIL 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:,7 O/ .f/h /dqe- S74- Occupancy/Use: Parcel ID#: Zone: / ! _ Owner.(�pg,�n..gk 1�7,n . - Address:R} Pox� ac 6 I / aawg P.E./R.A. orContractor�� j' 14 ).:A7-C ;)6J Addness:)464 IA ' Ileff AV 1'rd[l 1��1L�-7j Person in responsible charge:_I��h as.Z A 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 NEW YORK,COUNTY OF WESTCHESTER as: being duly swom,deposes and says that he/she resides atAQ 4 6)(1 1� Wri it Name of A--p--p�llii---a�nnl) 11 (J ( (No.and St�,kQ 1° �n ` P��—a1� in the County of�6 l°`��f'_� !�-`, _ in the State of ttsat (l'iiv`I oc+n`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, fessional fees,and including the monetary value of any materials and labor which may have been donated gratis was:? C� for the construction or alteration alteratiion of:_ _ —re . f sti—, L o /1 1 — _ st �—�t •� �yri J/ l" ll Deponent further states that he/she has examined the approved plans of the structurelwork herein referred to for which a Certificate of Occupancy/Compliance is sought,and that to the best ofhis/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 orpart 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 thh de of the Village of Rye Brook, Sworn to before me this Q Sworn to before me this /d day or 20c�)7 day of-�ju� 20 as evner Signatm o Applicant — — ZNotaryPug rPrint Name of Applicant 0 �v o6s. AARIA ROSA AtARTINEZ Notary Public•State of Florida LOIS N TO -e Commission N HH 68250 NOTARY PU ATE OF NEW YORK 1 My Comm.Expires Jan 19,2025 Bonded through National Notary Assn. NO. 01 N14899825 QUALIFIED IN WESTCHESTER COUNTY COMMISSION EXPIRES DECEMBER 3, 2026 �E BRC��. O�` tim BUILDING DEPARTMENT ❑ UILDINGINSPECTOR 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: (y� DATE: PERMIT# ��-' ISSUED: �' JECT: i 7� BLOCK: �` LOT: LOCATION: '' ( �� N�' OCCUPANCY: ❑ 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 \ "� ❑ L.P. GAS ❑ FUEL TANK ❑ FIRE SPRINKLER ❑ FINAL PLUMBING ❑��C�ROSS CONNECTION -i� FINAL ❑ OTHER ■ 'f�1�t P 1mt � 1!! P P� P P P P�� Y P � �� t t t m, N M cu t � N © qx N N N a w z � � u O ■ a r 1 y y �0 z Q .. G a� n p N �- O Ln o A p U o � � �.a O � oo H gp H W 0D >CD w � Ln U'M a � w '� w y ■ !� O en o 3 .^ to ~ � ( � [r V C, 440 441 D m oo � c7 In ro v c°� z o rlj W � z ° rr A C7 WC m z Zo H W � A � QME o U m. en CIN y h W OO 1� WN a n Z Z (V H OC O M a O FBI V °�+ v H •C cn W a+ U z o c, z z E t a � �� u m W x V V V d U0 dr o t? Q qJ e2 � W H w w z o 00 Sao :u oz © � o 14 o0-4 0 v F+y v V a I m 0 z cn a4 a a" w x ol BUII, 4NG "RTMENT VILLA0GE OF.RYE$ROOK JUN 3 0 2022 938 KING S'rREEr. 1v*BR�oX,NY 10573 ( I9) -0668 VILLAGE OF RYE BROOK wW, r - ook:or BUILDING DEPARTMENT d###*f#i4ii#iii##fiifiiirtirt###itff#t#rt##tt#t#ft4rtt#4i#ttt#d#dfidiidiffffi44i##f4#4i4f#fi##4444#d4diii##i#*t FOR OFFICE USE ONLY: alp �` ^� \ c Approval Date: JUL 2 6 Lu mit#>.� C7�1— v Application# Approval Signature: ARCHITECTURAL REVIEW BOARD: Disapproved: Date: BOT Approval Date: Case# ; Chairman: PB Approval Date: Case# ; Secretary: ZBA Approval Date: Case# , Other: Application F . b Permit Fees:_ > tf#f##4#4##i##itrtiidf#dififif#f#f44rt#irt##i#f###rtrtff#fffd*id*i*i�Sti#iii#t#fffii4##*#f##4##4attrt#tot####44dff SIGN PERT APPLICATION Application dsted:1�JCJ is MI hereby made to the Building Inspector of the Village of Rye Brook,NY,for the issuance of a Permit for the construction/installation of a sign in accordance with V;7Qk'Ae-- Code§250-35 as per detailed statement described below, ss: d 1. Addre I 54- SBL:L-j/,3J-,�-l/Q Zone: 2. Property Use or Business Name: Y ✓0 3. Proposed Sip(s)(Describe in detail including number of signs,types,sizes,exact location(s),and illumination method(s)if applicable.) A separate Electrical Permit will be req iced for any dated Cl al wo l Clab In 2 r� U40 Efad P,er1 i tr 4. Height from grade to highest point o sign: to lowest �0$� P Bn- point of sign: 5. Property Own erCVtO,GG�.jr d Address: 60�o�A�SU L Q��_A r�' o Phone# 11# �-rf�3- j0 ` fem u rie �� i aye.CAAA 6. Applicant: t Address: d f tf►1 6" ke• e t��t..13 �'r'& 16?83 Phone# _ 1 43 1-L U6 Cell# email:_"CUe-0 rA 'T 1!Q n. 4 ty-v 7. Architect/Engineer: Address: � Phone# Cell# email: 8. Sign Con s d-S i res Adds: 1k'Fr bj j C6 �. A llhg6k4 W 107S3 Phone# ,37' G Cell# tj email; �SLg: �t4 COKE -t- 8/12/2021 9. Will the proposed require a Site Plan Review by the Village Planning Board as per§209 of Village Code? Yes:-No: X (if yes,you must submit a Site Plan Application.&provide detailed drawings? 10. Does the proposed sign involve a Home-Occupation as per§250-38 of Village Code? Yea: No:'If yes,indicate: TIER 1:—TIER Il:_TIER III:_ (1f yes,a Rotnc Occupation Permit Application is required) 11. If building is located on a corner lot,which street does it front on: 12. Property frontage; _1 149; 13. Property size:Sq.Ft.: Acres: 14. What is the total estimated cost of construction: $ (The esttniatcd cost shall include all site itaprovemenu;,labo ,material,scaffolding,fixed equipment,professional fees,including anymaterial and labor which may be donated gratis.) 15. Estimated date of completion:. This application 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. STAGE OF NEW YORK,COUNTY OF WESTCHESTER ) as: SP�� '17�� _ ,being duly sworn,deposes and states that he/she is the applicant above named, (print name o individual signing as the applicant) and rther states that (s)he is the legal owner of the property to which this application pertains, or that (s a is the 4-0►- for the legal owner and is duly authorized to make and file this app tc (indicate architect,c2m c 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. Swom to before me this �f Sworn to before me this 2 1 day of Q _ , 20070?" day of ( ,20 of Property Owner Signature of li t 54 Print f aperty Pant" cant Notary Pub c No Public ..........i& MARIA ROSA MARTINEZ �• ^t Notary Public•State of Florida LOTS NI ETO A' Commission t HH t89 NOTARY PUBLIC, STATE OF NEW YORK ovr� My Comm,Expires Jan t9,2025 Bonded through National Notary Assn. NO. OI N14899825 QUALIFIED IN WESTCHESTER COUNTY COMMISSION EXPIRFS DECEMBER 3, 2026 -z- 8/12/2021 Building Permit Check List&Zoning Analysis Address: SBL I�1, � - `Z- -'4C) 1 Zone: C \ Use: Const.Type: Other. Submittal Date: �o v22 Revisi ns Submittal Dates: Applicant S N S (11 Nature of Work. -2 U OL LQ- fit- (t Reviews:22A:J Ul' PB: BOT: Other. NEED OK 1 ( ) ( ) FEES:Filing. L�BP: !'" ' 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. Short Fees: N/A: ( ) ( ) SITE PLAN:Topo: Site Protection: S/W Mgmt.: Tree Plan: Other. ( ) ( ) SURVEY:Dated Current Archival• Sealed. Unacceptable: ( ) (s�-PLANS:Date Stamped:_j,-- Sealed ✓ Copies: -'— Flectronir. ✓Other. ( ) (� License: ✓Workers Comp: •✓liability:�mp.Waiver. Other. ( ) ( ) CODE 753#: Dated N/A: ( 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• 2L notes: ( )ZBA mtg.date: approval: notes: ( )PB mtg.date: approval• notes: APPR VED REOUMED EXISTING PROPOSED NOTFS JUL 2 6 2022 Am: Date: Circle: Front Front Sides• &W. Main Coo Accs.Cov F S : S .HS • : Ft,I=: p HHci&/Stories: notes: CQ V.CN l�S L BUILDN'r IL? JUN 3 J VI O ;R� OOK Z�.-2 938 KING ,BR NY 10573 VILLAGE C?�- � CE r<--ROOK i - �3t_Rf DilG DE['� i�'i =^,iT t*s*r*s*t*s**r**r*ss**rtrrtsssrtrsrrrtsssssssstsst**r**sssssssssrsstrsr*rr*rss*rssssstt*tsr*s*rrr*rstts**rr ARCHITECTURAL REVIEW BOARD CHECK LIST FOR APPLICANTS This form must be completed and signed by the applicant of record and a copy shall be submitted to the Building Department prior to attending the ARB meeting. Applicants failing to submit a copy of this check list will be removed from the ARB agenda. Job Address c)11- Ste- I,,� t,,��M Date of Submission: Parcel ID#:_I41I, 3Jr--2 —` Zone: Proposed Improvement(Describe in detail): e c xIs-.k - APPLICANT CHECKLIST: n MUST BE COMPLETED BY THE APPLICANT The following items must be submitted to the Building f.7 14e& hi ,S- -73" Department by the applicant-no exceptions. Property Owner: C2 1. Completed Application 7d a 2. ( )Two(2) sets of sealed plans. (one full size(maximum Address: ,XJ . I�,plan size=36"x 42"}and one 11"x17") Phone# OS—lJ 3. ( )Two(2)copies of the property survey. — -- 4. ( )Two(2)copies of the proposed site plan. Applicant appearing before the Board: 5. 0 One electronic/disc copy of the complete application materials. 6. Filing Fee. Address:��4 uil' e. ),-f(� `l3 7. Any supporting documentation. Phone# �� 7 �(� r 8• ( )HOA approval letter. (rf applicable) 9. }Photographs. Architect/Engineer: 10.(7)Samples of finishes/color chart. (a sample board or Phone# model may be presented the night of the meeting) By signature below, the owner/applicant acknowledges that he/she has read the complete Building Permit Instructions&Procedures, and that their application is complete in all respects. The Board of Review reserves the right to refuse to hear any application not meeting the requirements contained herein. Sworn to before me this Swom to before me this day of� , 20�a day o vr.G� ,20 S e of Property Owner S lure of Ap lie n A. Print Property Print Name o Applicant No Notary blic "RIAROSAMARTINEi LOTS NIETO �� .. Notary Public State o`Florida NOTARY PUBLIC, STATE OF NEW YORK Commission#HH 68250 of tip`' My Comm.Expires Jan 19,2025 NO. O1 N14899825 corded through National Notary Assn. QUALIFIED IN WESTCHESTER COUNTY COMMISSION EXPIRES DECEMBER 3,ggjyA6l VILLAGE OF RYE BROOK BUILDING DEPARTMENT 938 KING STREET, RYE BROOK, NY 10573 (T) 939-0668 (F) 939-5801 ARCHITECTURAL REVIEW BOARD Wednesday, July 20, 2022 ANNOUNCEMENT: PER THE GOVERNOR'S EXECUTIVE ORDER THIS MEETING WILL BE HELD VIRTUALLY THROUGH THE ZOOM PLATFORM. THE PUBLIC CAN ACCESS THE MEETING THROUGH THE FOLLOWING LINK: https://us02web.zoom.us/i/81417970741 OR BY OPENING ZOOM AND ENTERING THE MEETING ID: 81417970741 NAME & LOCATION TYPE OF APPLICATION MOTION SECOND APPROVED REJECTED APPL.# 7 Talcott Rd Roof Top Solar Array Consent 57254 (Ambati) System Agenda 18 Belle Fair Rd 4' High White Vinyl Consent 5726 (Desai) Privacy Fence - Rear Agenda 412 N. Ridge Street Roof Top Solar Array Consent 5727 (Yu) System Agenda 65 Winding Wood New 6' High Fence In Consent 5728 Rd (Rubin) Rear, 4'High Side Front Agenda 66 Valley Terrace Roof Top Solar Array Consent 5729 (Friedlander) System Agenda 283 Neuton Ave Roof Top Solar Array Consent 5730 (Limarzi) System Agenda 30 Argyle Road 2 Story Addition, & 1 5731 (Nunziato) Story Addition 14 Elm Hill Drive Re-Do Rear Patio, Add 5732 (Levinson) Fire Pit & Outdoor Kitchen 217 S. Ridge Street New Business Signs �•� (� 5733 (Riemer Insurance group) J v 37 Winding Wood New Rear Wood Deck & 5734 Road (Chi) Masonry Patio ML NM MR / SE / JM f SF AC MI KC 116 S. Ridge Street New Sign& Store Awning 5735 (Win Ridge) For"Chopt" 27 Lawridge Road Legalize Rear Patio Work. 5736 (Goldstein) Add Spa to Inground Swimming Pool 6 Edgewood Drive 2nd Story Side Addition 5737 (Shalem) 32 Country Ridge Amendment to Prior 5738 i Dr. (Hochfelder) Approval 6 Eagles Bluff Basement Addition w/Patio 5739 (Bruantuch) Above & Mesa Block Wall ML NM MR SE JM SF AC MI KC V 7r. #Ilk r � Y s r � r J \ � 'r• k �'Y y v�sr� �'• -17 x `1v 1 E-.• s t oft . 4 r >r L Ac R os/zo/2022 ® CERTIFICATE OF LIABILITY INSURANCE DATE(MM/ - Y) ozz . r 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 INSURERS),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT Stacie Washington NAME: Borrelli Partners Insurance Agency PHONE (g14)939-7900 FAX (914)407-5088 A/C No EM: AIC No 287 Bowman Avenue E-MAIL swashington@borrellipartners.com ADDRESS: Suite 406 INSURER(S)AFFORDING COVERAGE NAIC p Purchase NY 10577 INSURER A: Travelers Casualty Ins Cc of America 19046 INSURED INSURER B: Travelers Indemnity Co 25658 Lanza Corporation INSURER C: Phoenix Ins Cc 25623 dba Sign Design&J C Awning INSURER D: 404 Willett Ave INSURER E: Port Chester NY 10573 INSURER F COVERAGES CERTIFICATE NUMBER: CL2252603715 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 CONTRACTOR 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 ADDLISUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER MM/DD/YYYY MM/DD/YYYY LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE 1 f OCCUR PREMISES Ea occurrence $ 300,000 MED EXP(Any one person) $ 5,000 A 6805J175092 06/05/2022 06/05/2023 PERSONAL&ADV INJURY $ 1,000,000 GENTAGGREGATE LIMITAPPLIES PER GENERAL AGGREGATE $ 2,000,000 PRO- X POLICY ECTT 7 LOC PRODUCTS-COMP/OPAGG $ 2,000,000 OTHER $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident, ANYAUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per accident $ AUTOS ONLY AUTOS ) HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY Per accident UMBRELLA LIAR I X OCCUR EACH OCCURRENCE $ 5,000,000 B X EXCESSLIAe CLAIMS-MADE EX5J175240 06/05/2022 06/05/2023 AGGREGATE $ 5,000,000 DED I X RETENTION$ 10,000 $ WORKERS COMPENSATION I PER OTH- AND EMPLOYERS'LIABILITY Y/N STAT X UTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACHACCIDENT $ 500,000 C OFFICER/MEMBEREXCLUDED? FYI N/A UB5J175160 06/05/2022 06/05/2023 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 500,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) BLANKET Al-OWNERS,LESSESS OR CONTRACTORS,AI-MANAGERS OR LESSORS OF PREMISES,AI-STATE OR POLITICAL SUBDIVISIONS PERMITS RELATING TO PREMISES,Al LESSOR OF LEASED EQUIPMENT,PRIMARY&NON-CONTRIBUTORY WORDING,WAIVER OF SUBROGATION-WC POLICY INCLUDES BLANKET WOS CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN Village of Rye Brook ACCORDANCE WITH THE POLICY PROVISIONS. 938 King Street AUTHORIZED REPRESENTATIVE Rye Brook NY 10573 ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD NEW YO K Workers' CERTIFICATE OF STATE Compensation Board NYS WORKERS' COMPENSATION INSURANCE COVERAGE 1a.Legal Name&Address of Insured(use street address only) 1b. Business Telephone Number of Insured Lanza Corporation 914-937-6360 DBA Sign Design and J C Awning 1c NYS Unemployment Insurance Employer Registration Number of 404 Willett Avenue Insured Port Chester, NY 10573 Work Location of Insured(Only required if coverage is specifically limited to 1d. Federal Employer Identification Number of Insured or Social Security certain locations in New York State,i.e,a Wrap-Up Policy) Number 13-3525268 2.Name and Address of Entity Requesting Proof of Coverage 3a Name of Insurance Carrier (Entity Being Listed as the Certificate Holder) Phoenix Ins Co Village of Rye Brook 3b, Policy Number of Entity Listed in Box"la" 938 King Street U65J175160 Rye Brook, NY 10573 3c Policy effective period 06/05/2022 to 06/05/2023 3d, The Proprietor,Partners or Executive Officers are ® included.(Only check box if all partnersrofiicers included) all excluded or certain partners/officers excluded. This certifies that the insurance carrier indicated above in box"3"insures the business referenced above in box'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". Will the carrier notify the certificate holder within 10 days of a policy being cancelled for non-payment of premium or within 30 days if cancelled for any other reason or if the insured is otherwise eliminated from the coverage indicated on this certificate prior to the end of the policy effective period? DYES ®NO This certificate is issued as a matter of information only and confers no rights upon the certificate holder. This certificate does not amend, extend or alter the coverage afforded by the policy listed, nor does it confer any rights or responsibilities beyond those contained in the referenced policy This certificate may be used as evidence of a Workers'Compensation contract of insurance only while the underlying policy is in effect Please Note: Upon cancellation of the workers'compensation policy indicated on this form,if the business continues to be named on a permit,license or contract issued by a certificate holder,the business must provide that certificate holder with a new Certificate of Workers'Compensation Coverage or other authorized proof that the business is complying with the mandatory coverage requirements of the New York State Workers'Compensation Law. Under penalty of perjury,I certify that I am an authorized representative or licensed agent of the insurance carrier referenced above and that the named insured has the coverage as depicted on this form. Approved by: Stacie shington J(P nt name of authorized represe�nnplive or li nse gent of insurance carrier) Approved b / / 0� f 0 : 6/20/2022 / (Date) Title CL anager . lam' Telephone Number of authorized representative or licensed agent of insurance carrier: 914-939-7900 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(9-15) www.wcb.ny.gov Riemer Insurance Group, Inc. SIGN DESIGN 217 South Rid a Road ` FFt J° r4T 9 R e NY yF1 COPY, 404 1,11:?e*t Ndenue LE i Chcsfi_`r NY i0157- Phone 9'4-937-C-760 y dll.SIGr•cCC15r..y,�I dFaIQ'�.C( j 4 F �;'0je*.C�` Steve Dr3•tir B% Josh Ronlsh SR Rieniern - �_ ,till. CT 1--_ -- — — Insurance Group,Inc. Jaic 6-15-22 Job r;en'• Riemer Insurance Group emert - - Insurance (J'rout), Inc. Do L- -- ---- ooaraa Roof Top Light Box Existing Aluminum Roof Top Cabinet Light Box. - Actual Dimensions 96.25 if x 24.5" - Viewable Face Inside of Light Box Frame 92.25" x 20.5" CLIENT ACCEPTANCE Sign Face is 3/16" Cast Translucent Acrylic With 3M European Blue Translucent High Performance Vinyl. All Text and Logo Art Will Be Knock Out Cut. Print Name All Interior Lighting to be Converted to LED From ExistingFluorescent Ballast and Bulb System Using `'�P:�d ,� Existing AC Electric Source. I �al Date- FontPrj?ERIMT# � � �:�� ;�'�� f �� r°°k np�raCOLOR S P EC'S:Font s. Garamond Premr A►rchitectrur I Fie iew Board 3EU Approval Date: � ' DAN APP -D Chairman.:___-_ — r -- -- - G mSP CTOR ilk"ofF"000k N PMS Z80C white THIS PRINTED COLOR RENDERING IS INTENDED TO BETTER TF_R APPROXIMATE COLOR. I-►UES AND DISTRIBUTION-r--_/\I BEST EFFORTS HA��E BEEf�! ��IADE TG SI��UL%�,TE TE-IE A' TUAL COLOR(S). /�ll! Ii-h� — �I �� c _ l�� f Graphics\Riemer Insurance Group\Light boxes e 4 .��r° IE HOWEVER, E,..AC E COLOR(S) G, N ONLY BE SE`N r R01M THE SPECIFIED COLOR SYS T EMS S �,F�I P 0R 'SAMPLE U U jun a U 4u Z a - I VILLAGE OF RYE BROOK BUILDING DEPARTMENT Rmiemer nsurance Group, Inc. SIGN DESIGN 217 South Ridge Road k 11/rr i. Rye, NY \ w. 4404'Ah:{ett Anent-e _rT Chcstul NY 1057" n i aho,ic:9i4-937-E=50 '-AV ii4-9-1 i-'O!".565.5 "UiE G: Steve D-tar S Josh Ronish 1 A Cr c 6-15-22 .t. Cl Riemer Insurance Group Ri insurance emer GrouD. Des,,!iE,-k I 0 Hanging Cabinet Light Box Existing Aluminum Hanging Cabinet Light Box. _ .. ,. . _ __z .° . . Face Lit On 2 Sides Perpendicular to the Street. - Actual Dimensions 73" x 36.5" - F R CLIENT ACCEPTANCE Viewable Face Inside of Light Box Frame 70" x 33.5 y'1 Sign Face is 3/16" Cast Translucent Acrylic With 3M European Blue Translucent High Performance Vinyl. -int Name All Text and Logo Art Will Be Knock Out Cut. All Interior Lightingto be Converted to LED From �3qr:Name Existing Fluorescent Ballast and Bulb System Using Approval Dae- Existing AC Electric Source. COLOR SPEC'S: Font is: Garamond Premr Pro Revision Date- PMS 280c White THIS PRINTED COLOR RENIDERING IS INTENDED TO BETTER APPROXII`;IA T E COLOR HUES AND DISTRIBUTION. This cistor"desitnis!he eackjsike BEST EFFORTS HAVE BEEN MADE TO SIMULATE THE ACTUAL COLORS j, All ri h's of Signi,s use ,-d pC.Av,n.�:� >�II��.gtia:c its use aid�e rod�.::,ti�:,r I--I��`J��EVER, EXACT COLOR(S) CAI ! ONLY BE SEEN FROM THE SRECIFIF-D COLOR SYS T E_M(� CHIP OR SA�(PLE ZMGraphics\Riemer Insurance Group\Light boxes areieser�ed. Rmiemer Insurance Group, Inc. SIGN DESIGN 217 South Ridge Road _ Rye, NY To the left (business) 4014 �1ettA.venue To the ri ht residential ;o:�Cn�St�t ��Y 10573 g Phono:9i4-9 %-6 60 FAX:91.4-93 -0105 S!CcCCCL r` ESIan.CC"-I \ < - -------------------- ----- - _- �� :1-oicc:C-'act:Steve J�_�.r.Sy Josh Ronish CT 6-15-22 soh C,I gin' Riemer Insurance Group y� INN, JffL. .ate 'a �4 Desc.-ri;%:iCn Across the street (CVS Plaza borderingRye Ridge Plaza CAM 1 �r • • CLIENT ACCEPTANCE `a • Print Name S gn Name. ` f Appro,,al Da*-,- id 1 r c t ' .cY-•�"'— ".. m_..a- - -- - '`.'Z Revis;on Date' THIS PRINTED COLOR RENDERING IS INTENDED 1-0 BETTER APPROXIMATE COLC)F-1Z HUES AND DIST RIBUT10'l This oesinnistn exc:I save BEST EFFORTS HAVE BEEN MADE TO C-31MULATE THE ACTUAL CGLGR(S). �:�oper��o siyn�esgn&J.C.�`v�ni�,u Z:\1 Graphics\Riemer Insurance Group\Light boxes AII'�:ul'`S;°its use a"d ep'-oau:t,�- HO\f1JEVER, EXACT COL OR(S) CAN ONL, BE SEEN FROM THE SPECIFIED COLOR S�1fSTEM� S CHIP OR S��MPLE are►eserved.