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HomeMy WebLinkAboutBP22-14904 PERMIT #/ (D� J DATE: cl� D(P: SECTION BLOCK I LOT TYPE OF WORK t .� Q e JOB LOCATION 170 V iw WillQ.�?e OWNER /70 a% �nQ I/ CONTRACTOR f0f�)4?OV C4 99 4L EST. COST FEE. �CO # C FEEA/ /5'" TCO # DATE FOOTI N G FOUNDATION FRAMING RGH FRAMING INSULATION PLUMBING O RGH PLUMBING GAS SPRINKLER ELECTRIC M LOW -VOLT C ALARM C7 AS BUILT L7 FINAL FEE DATE INSP 633- i�k (917) 9 8/- 19tyl 1�v4 Vv`L,i 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 ACTING BUILDING& FIRE INSPECTOR Susan R. Epstein Steven E. Fews Stephanie J. Fischer David M. Heiser Salvatore W. Morlino CERTIFICATE OF COMPLIANCE March 28,2023 Diana Carolina Villa 170 Ivy Hill Lane Rye Brook,New York 10573 Re: 170 Ivy Hill Lane, Rye Brook,New York 10573 Parcel ID#: 129.76-1-43 Building Permit#22-149 issued on 8/18/2022 for 3 Replacement Windows This certifies that the three new windows,installed under the above captioned permit have been satisfactorily completed. Sincerely, Steven E. Fews Acting Building& Fire Inspector /to D IE C E- � W � I BUILD R ENT For office use onl L/ PERMIT# 07�7 9 MAR 10 2023 VIL OF RYE OK ISSUED: — — c� 38 KING STRE YE BROOK, YORK 1OS73 DATE: 3-/O-a3 �-- 9 -06 0 FEE: c /C7-- PAID,k VILLAGE OF RYE BROOK 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 ttsrrwrss»sssssrsrs+•ssssssrs++rr+r»ssswrsssss+r+rw+ssrs+sr»r+sw+wrwsssr++rs»t+»swr♦sss+w+rrswtssrr+s++»sss+s+»rw»srwss+»+ Address: L11 i2� e F->rOO'e- Occupancy/Use: �- Parcel ID#: 12�1 - 1 —` 1 Zone: u> Owner: DtaWN=l C 1VO%✓Aa V0 tq Address: Igo 1Vq VIR11 Ln 'PAC!FjN,,.,oQy P.E./R.A.or Contractor: S 14 f) C.l_V\j1QLL -t)M Address: lot I-I-�> �2IMC1%.4Q IT/e— COI��StNyll�(2 Person in responsible charge: V.,:::AMrAN 5 Address: aS 0\00\/e _ 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: ` )\QYtot Q:AyJ\V\cl\W Ct being duly sworn,deposes and says that he/she resides at ��y I` \ e�J1•�OIL (Print Name of Applicant) (No.and Street) in_ --je— ,in the County of We S\e-r in the State of ('xi that (Cityrrown/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:$ 2;'50 0 , for the construction or alteration of: S( ,IJ�Y��C7y�� Y2����LYV1�.✓�� 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 �0 Sworn to before me this day of CYi ,20),� day of , 20 Signature of Property Owner Signature of Applicant Cck Vol I V'�c\ W lC., Print Name of Property Owners n n Print Name of Applicant Notary Public Notary Public SHARI MEuLLO Notary Public,State of New York S/121 201-1 No.OIME6160063 Quallfled In Westchester County Commission Expires January 29,20L7 �E BRC'v,�. BUILDING DEPARTMENT BUILDING INSPECTOR d❑ASSISTANT BUILDING INSPECTOR VILLAGE OF RYE BROOK ❑CODE ENFORCEMENT OFFICER 938 KING STREET • RYE BROOK,NY 10573 � J (914) 939-0668 FAx (914) 939-5801 www.ryebrook.org - - - - - - - - - - - - - - - - - - - - INSPECTION REPORT - - - - - - - -- - - - --- - - - - - - ADDRESS:— i DATE: 1 .) PERMIT# ISSUED. SECT: BLOCK: LOT. t LOCATION: f7V ) + '1W OCCUPANCY: �Z t ❑ VIOLATION NOTED THE WORK IS,.--07ACCEPTED ❑ 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 Q FINAL ❑ OTHER m ■ 9 ■ � N ■ � � v m m CV 0 W v ■ N � Q a� ay ono 00 1-4 w O a ti ■ q� r q 1� rj � p jai Q ■ V t� ° .b "b d0� � � � � ■ M w LC U pZ w �y/2 o 2 A ■ o ■ � � � �.r Z O w O p q x W C W w Ln 0644 'S p ■ oq w G w o v o w 0 V � z � y � � W W ZCL a V J-4 W W N c~a � � � � ■ rn w z z V w a Zu. cn ~ � � � W Ln O Q cq — H 1.0 Q z g S y v w A ►-� c� A 4 c°) oy t W 0, " Ra 0 3 z as v z w w O b cn BUILDING DEPARTMENT VI LOAD i;r of Ry I.. lilkOOK AElG 9 2022 938 KING S'fREET RYE BROOK,NY 10573 VILLAGE OF RYE BROOK (914)939-06 S BUILDING DEPARTMENT 996- ADMINISTRATIVE EXTERIOR BUILDING PERMIT APPLICATION FOR EXTERIOR WORK Wim, It DOEs NOT REC 1fIRE VII.I.A(;F;ARC HITE("r iRAL REVIEW BOARD APPROVAL. FOR OFFICE USE OWS: 1 7 Z!1-) �,/ APPROVAL DATE: PERMIT#: 1 _ APPLICATION FEE? APPROVAL.SIGNATURE: � PERMIT FEES: � ©0 H.O.A. APPROVAL: DATE: DISAPPROVED: OTHER: Application dated: C-4.=) 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,structures,additions,alterations or for a change in use,as per detailed statement described below. 1. JobAddress: t'1O Lv 4jtr Ln �-( � �f�� 0-1 10� '5 2. Parcel ID#: 1 4 9+ 7 6` 1' '7 3 Zone:,P U 6 3. Proposed Improvement(Describe in detail): W%Y1'd9 VJ 4. Property Owner: I Y\Q C01Y0k*s'f\a W q Address: k-10 jvj t*1l LV\ L Y:woo�_- Phone# 'A%Lk 3tiO 6�'SZ Cell# e-mail \/tlrct�C gIV`p1�� fJ� List All Other Properties Owned in Rye Brook: Applicant: Address: Phone# Cell# e-mail Architect: Address: Phone# Cell# e-mail Engineer: Address: Phone# Cell# e-mail General Contractor: VACtVVMl S S T (joy Tlz_��: Address: , 011 — cA i Cat � 1-611 i N Phone# Cell# e-mail 8/12/2021 5. Occupancy;(1-Fan.,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: front yard: rear yard: right side yard: left side yard: other: 8. If building is located on a corner lot,which street does it front on: 9. Area of proposed building in square feet: Basement: 15`fl: 2"d fl: 3rd fl: 10. Total Square Footage of the proposed new construction: 11. For additions,total square footage added:Basement: 1"fl: 2`fl: 3rd 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]; ()Pre-engineered wood[PW];Located;O Floor Framing[F];O Roof Framing[R];()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 fire suppression system?(Fire Sprinkler,ANSL System,FM-200 System,Type I Hood,etc...)Yes:_No: 'A (if yes,applicant must submit a separate Automatic Fire Suppression System Permit application&2 sets of detailed engineered plans) 22. Will the proposed project disturb 400 sq. ft.or more of land,or create 400 sq.ft.or more of impervious coverage requiring a Stormwater Management Control Permit as per§217 of Village Code? Yes: No: K Area: 23. 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) 24. 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) 25. Is the lot located within 100 ft.of a Wetland as per§245 of Village Code? Yes: No: (if 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: (if yes, the area and elevations of the,/lood 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 1: TIER II: TIER III: (ifyes,a Home Occupation Permit Application is required) 29. What is the total estimated cost of construction: $ q o Note:estimated cost shall include all site improvements, labor, material,scaffolding,fixed 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 C/O. 30. Estimated date of completion (2) 8/12/2021 U [ C [J`, LL � e BUILD iI '.> MENT VIL E OF RY OOK AUG - 9 2022 938 KING ET RYE BR '!,NY 10573 �J 4 -064$�` VILLAGE OF RYE BROOK µ 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 FORM WILL BE RETURNED TO THE APPLICANT . STATE OF NEW YORK, COUNTY OF WESTCHESTER ) as: � �irol-►� V,11V► �'D�cavla , residing at, 190 �V 1-�1� l.Yl L (Print nunleI (Address%cherc you liVC) 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. p JV1 Vk1 1J l.-Y\ 9--je P)roolc- N )C59 3 , Rye Brook,NY. (J„h: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. (Signature ot'Vroherty lhw wri,)) LQ Y\q 1�1VQ11v�a y`�l"I (Print Name of Property(hN nerl�)I Sworn to before me this day of u N ' , 920 y iNut� Public) i DEAN AL.EXANDER RMICE SA NOTARY PUBLIC (3) CONNECTICUT MY COMMISSION EXPIRES NOVEMBER 30,2022 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 returned to the applicant. Please note that application fees are non-refundable. TATE OF NEW YORK,COUNTY OF WESTCHESTER ) as: �Cky,tca ('�yr,�1Ytca y�(�q ,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 C� Sworn to before me this day of 20 day of , 20 Signature of Property Owner Signature of Applicant � �,a,�Q C,�►��l�Q vas Print Name of Property Owner Print Name of Applicant A,nL'iL Notary Public Notary Public SHARI MELILLO Notary Public,State of New York No.OIME6160063 Qualified In Westchester County,, Commission Expires January 29.20� (4) 8/12/2021 173'/2 Ivy Hill Crescent Rye Brook, NY 10573 914-939-2440 141 AUG 1 1 2022 August 11 , 2022 VILLAGE OF RYE BROOK Diana Carolina Villa BUILDING DEPARTMENT 170 Ivy Hill Lane Rye Brook, NY 10573 Re: Replacement of 3 Windows Dear Diana Carolina Villa, 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 All Seasons Windo NFRC: Door S stems Platinum Doubleylider (00) Nalionnl Fmoslintlon I A P — M — 24 - 00161 — 00001 _ Rating Council D bl Glazed — — Stainless Spacer Energy Smart Package ENERGY PERFORMANCE RATINGS U-Factor (U .S./I-P) Solar Heat Gain Coefficient 0029 0028 HBO.. ADDITIONAL PERFO �,IA NCE RATINGS Visible Transmittance [..eakkge (U.S./I-P) 0051 Om3 Manufacturer stipulates that thwe ratings conform to applicable NFRC procedures for determining whole product performance. NFRC ratings are determined for a fixed set of environmental conditlons and a specffk product size. NFRC does not reeomend any product and does not warrant the sultabllfty of any product for any specfilc use. Consult manufacturer's literature for other product performance Informatlor www,nfrc,org s Q c� ^ ^� v f 3 c C. rmfw $ c ~ - 00 n 41 Cud 1fi Q� ✓% W IVT r C C Q � L r.r �— z= V C OL L �Ak L � w L � L '✓� N 'C yr Cd �— y Uw NrCN L � to �..� (n L Q F" CIO = ,..� C C O O 40 1-f . 2— . t�Wy- 4.r.�rs _=•.�'�1 a .. ',rs�w 'V� •��..� J��*st...�.. .t/�..icr_- s „ , f ,� 1- �1�1, ` ' �pt r r ' ' ' f t..rKe (erirnrr K '\� Jana"Sla.uno Ne+lrAr+trr(uuut�I+c.uli+a A.Ce)IT1 pirrcter,t'nnwnut 1'ra.+uon Y ��,L. Department of Consumer Protection - � !Ionic Improvement License S&D CONTRACTING INC. 191-13 JAMAICA AVENUE C HOLLIS,NY-11423 I hi..liccnsc i.tsxucd in acvord we wuh AtIlde XVI ul ttw 51'"Oic,trr County C otwumtt PrNectioo fade and is�71u1 tmly ii" rrc ttrc t�f the ttitictal dcyttrtni yfl s�tl I'nk ft,f:itvcmhir or immig[raltoin slAus is rkv rNutfal for t.ctmrwc of this liccaw �e 1! 1 ttl I'M fURR)%'S ac�N4911 a : conSU?1 .--' I.icmkc Number >N� A Date of Expi atiun 1 =s 1112412022 WC-23822-H10 t ° �r"h0srcr c�c` s» r ! ,Ist .�a. �'"�ec'tr`-.rP 5� .1;�;� .s*••y>�--mr �a' ���j��rpz��.-;^� ,�.,Tr�'...,j?�.' -''=.�">' �.�r '�1N.t�-�1;;*'�_'G`:J ,�.�f-i1 � '•+''. rll.%�.j 3 ���� �l � ';+rl l�.V.��i lb�� .k� ' A��® DATE IMM/DD/YYYY) V CERTIFICATE OF LIABILITY INSURANCE 08/08/2022 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 endorsement(s). PRODUCER CONTACT SAMANTHA POLITI NAME: $tdteFartn PHONE AX 914-241-2990 FAIC No: 914-241-2945 SAMANTHA POLITI STATE FARM AGENCY EL • - ADDR-MAIESS: 532 BEDFORD ROAD INSURE S AFFORDING COVERAGE NAIL i BEDFORD HILLS,NY 10507 INSURER A: State Farm Fire and Casualty Company 25143 INSURED INSURERS: _ S&D CONTRACTING INC INSURERC: 19113 JAMAICA AVE INSURER D: HOLLIS, NY 11423-2527 INSURERE: 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. I R' TYPE OF INSURANCE .S.SUBR POLICY NUMBER MM DDIYYYY MM/D1 EXP LIMITS POLICY i:FF—F1POUCY LTRwVD LT COMMERCIAL GENERAL LLABIL17Y EACH OCCURRENCE $ 2,000,000 DAMAGE T R 100,000 J CLAIMS-MADE ®OCCUR PREMISES Ea occurrence $ MED EXP(Any one person) $ 5,000 A 98-CU-ZO98-6 07/24/2022 07/24/2023 PERSONAL&ADV INJURY $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: I GENERAL AGGREGATE $ 4,000,000 JECT POLICY PROF71 LOC PRODUCTS-COMP/OP AGG $ 4,000,000 $ OTHER. COMAUTOMOBILE LIABILITY Ea accident) SINGLE LIMIT $ ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY Par acciderd $ UMBRELLA LAB OCCUR EACH OCCURRENCE S 5,000,000 A EXCESSUA13 CLAIMS-MADE 98-CJ-H235-1 02/08/2022 02118/2023 AGGREGATE $ 5,000,000 DIED I I RETENTION$ PER WORKERS COMPENSATION STATUTE ERH AND EMPLOYERS'LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE YNIA E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? (Mandatory in NH) E.L.DISEASE-EA EMPLOYE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Project Address 170 Ivy hill lane Rye brook NY 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. DEPT OF BUILDING AUTHORIZED REPRESENTATIVE 938 KING ST RYE BROOK, NY 10573 ©1 8-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD 1001486 132849.12 03-16-2016 roRK Workers' CERTIFICATE OF STATE Compensation NYS WORKERS' COMPENSATION INSURANCE COVERAGE Board la.Legal Name&Address of Insured(use street address only) 1 b.Business Telephone Number of Insured 917-981-1991 S&D CONTRACTING INC 19113 JAMAICA AVE. 1c.NYS Unemployment Insurance Employer Registration Number of JAMAICA NY 11423 Insured Work Location of Insured(Only required if coverage is specifically limited to 1 d.Federal Employer Identification Number of Insured or Social Secudty certain locations in New York State,i.e,,a Wrap-Up Policy) Number 113292126 2.Name and Address of Entity Requesting Proof of Coverage 3a.Name of Insurance Carrier (Entity Being Listed as the Certificate Holder) STATE FARM VILLAGE OF RYE BROOK 3b.Policy Number of Entity Listed in Box'1a" DEPT OF BUILDING 92-CX-YO11-9 938 KING ST RYE BROOK NY 10573 3c.Policy effoctive period nsmpnm? to nsinpon73 3d.The Proprietor,Partners or Executive Officers are included.(Only check box if all partners/officers included) ❑X all excluded or certain partnerstofficers excluded. This certifies that the insurance carrier indicated above in box 1"insures the business referenced above in box"'Ia"for workers' compensation under the New York State Workers'Compensation Law. (To use this form,New York(NY)must be listed under Item3A 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 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 hy: IORGF SAFN7 _ (Print n authorized representative or licensed agent of insurance tamer) Approved by: 1202 Z, (Signiitui, ) te) L. Browne 32-2287 Title:COM ERCIAL INSURANCE REPRESENTATIVE 56 - t.leens FBA7 Telephone Number of authorized representative or licensed agent of insurance carrier: 7188200108 Please Note:Only insurance carriers and their licensed agents are authorized to issue Form C-105.2.Insurance brokers are NO authorized to Issue It. C-105.2(9-17) www.wcb.ny.gov