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HomeMy WebLinkAboutBP22-157PERMIT # ',�.� ! DATE: U SECTION BLOCK LOT L TYPE OF WOR JOB LOCATION/� ,,,fir OWNS o� 49 rie yr zzo�2 `�3- /9���y79� go?:07� O Oi✓� 7� C —fir/ /i lbrers camp CONTRACTOR/c%)(p/$— p�j EST. COST ` FEE �� # FEE; J�Q'P� AT TCO # FEE DATE --- 371�l01; l• DATE FOOTI N G FOUNDATION FRAMING RGH FRAMING INSULATION PLUMBING RGH PLUMBING GAS SPRINKLER O ELECTRIC LOW -VOLT O ALARM AS BUILT 0 FINAL INS OTHER APPROVALS AR BOT P8 ZBA OTHER L C BR AM anniItPJIbaW VILLAGE OF RYE BROOK - MAYOR 938 King Street, Rye Brook, N.Y. 10573 ADMINISTRATOR Jason A.Klein (914) 939-06+68 Christopher J.Bradbury www.ryebrook.otg TRUSTEES BUILDING& FIRE INSPECTOR Susan R. Epstein Michael J. Izzo Stephanie J. Fischer David M. Heiser Salvatore W.Morlino CERTIFICATE OF COMPLIANCE September 26,2022 Suzanne Elson,Marie Nora Mazzone&Abbe Fleishaker 111 &112 Brush Hollow Lane Rye Brook,New York 10573 Re: 111& 112 Brush Hollow Lane, Rye Brook,New York 10573 Parcel ID#: 129.76-1-149 & 129.76-1-148 Building Permit#22-157 issued on 8/29/2022 to Replace Existing Wood Fence This certifies that the wood property line fence,installed under the above captioned permit has been satisfactorily completed. Sincerely, Michael J. Izzo Building&Fire Inspector /to — � For office use onl : BUILDING��EVAItTMENT pERivI1T# SEP 2 0 2022 VILLAGE OF RYE BROOK ISSUED: 9-�a 938 KING STREET,.RYE BROOK,NEw YoRK 10573 DATE: 9—a0 VILLAGE OF RYE BROOK (914)939-'0668 FEE: 4 //p— PAMA BUILDING DEPARTMENT wwwxyly.r,©ok.ere 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 rrrrgrrrrrrrrrrr►rrrr►rrra rrrrr♦rrrprr►♦■p■r►rrr■r•■rp►r►►►►r►r►rr►r►rrrrrrrrrr•rrrrrrrrrrrrrrurrrrrrrr rrrrrr ra►rrrrr• Address: p yI I �aQ 76--r 1 W� Occupancy/Use: t?2s pwL�iczlI ParcelID#:-A-3�0n��am; u� psjJ rJ-� Zone:/aq- ?j!�;-t-/q�? Owner:��,7�n�,,���sav,,� aria .A&zzotta-/_Address: 11113vush 14o/I01,-) l.g14,41— P11D K1 bc- tshCcke-1- 1/.;1-0 H014r'L4- arL P.E./R.A. or contractor:��_v e�1�t?llr�wt ss: Person in responsible charge: AJ r :Qvi Pe re.Z-C ddre'M- q 114-61ST-O3Z 4 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: Su Z Ct n LAG r.,`U AN4 z w�being duly swom,deposes and says that he/she resides at II t O n>5 h OD l loc,) IAA t t (Print Name of Applicant) // (No.and Street) in ,-a VW V- ,in the County o kc Slev in the State of� that (City/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:$ I I ?U 0.O D L 1 for the construction or alteration of ���(,c c� P�(6 57 i i 1G� ly n c�� ��l�Io�t�/•J —�.�►y10 �P�t?G� h(2-+ w'o-ei'l a V d:4 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 ')o Sworn to before me this day of M�i' ,20 day of , 20 Si ature of erty Owner Signature of Applicant l I so c� ttNa—me of Property Owner Print Name of Applicant Notary Public SHARI MELILLO Notary Public Notary Public,State of New York No.01ME6160063 Qualified in Westchester County 8/12/2021 Commission Expires January 29,202—'� QyE BRC�k 1982 '��O BUILDING DEPARTMENT ❑BUILDING INSPECTOR oo 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 Tl DATE: p O -7 PERMIT# 1 ISSUED: CT: V6;911-�ICALOCK: I LOT: I � P LOCATION: —�C-� �1 \ OCCUPANCY: 1 LK ❑ VIOLATION NOTED THE 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 ❑ FI /PLUMBING ❑ o' SS CONNECTION "FINAL ❑ OTHER ■ N C In w s eq �N N N y N 0?� N W v a si ■ 141 oo 00 00 • l F v w GG u _ ,s v O � 4 -ti N ►� x, o N 1Z a G Oo r W pp o3owi°• v A ICI 0 ••Q [ 7 � � � d' �J u O a 7 N L,,r) o�D I, Q " w O WzO � ,c, w W s h+q V 1a0 c � . � W : � r O J � W a r, � h� Gti cn 9W U z O © W p � voSv21 -, ,2can n . -OD Terry'W U N l N a" y} a o v A r�Txi d 1:4 U � o 0 E '�o � w U V V 0 cW .S H o a w x O � z W O O � ° ! i z W U• [~ w d u a A W z x 09 O 141 Pol 14 W > T Vdi � c o -d BUILDI 4;- ARTMENT �l VIL OF R ROOK D E C IE 11 938 KING EET RYE B ,NY 10573 14) 939- AUG 19 2022 wwNN.ryebrook.orrg, VILLAGE OF RYE BROOK FOR OFFICE USE ONLY: Approval Date: AIJG 2 4 2022 Permit# / �' Application# Approval Signature: ARCHITECTURAL REV BOARD: Disapproved: Date: BOT Approval Date: Case# Chairman: PB Approval Date: Case# Secretary: ZBA Approval Date: Case# Other: _ Application Fee Permit Fees: -9 f Do—bot C� FENCE / WALL / GATE 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 installation,constructi n,repair o ement f a Fence,Wall or Gate,in accordance with Section 250-6 B.(1)(g),of the Code of the Village of Rye Brook,as per detailed statement described below. Swimming pool fences must conform to theState Code. 1. Job Address: I 1 , 1._. V 2. Occupancy/Use: S.B.L.#: 07 9,- — — Zone. LProposed Fence/Wall/Gate(des 'be in detail): IS C'�-\!'Aa (NCA Q 6-kk 17) (10, . 4. Property Owner. k rr !! Address: Eck ( l l Phone# SQ —5" Ce # L mail: 7t j Applicant: .rL,� CA !> C: + Address: Phone# f Cell# email: Architect/Engineer: Address: Phone# Cell# email: Contractor: ._ cw-(-\tp Address& Phone: Y 6- 5. If building is located on a corner lot,which street does it front on: 0 e- 6. What is the estimated cost of construction L 13 &L� (NOTE:The estimated cost shall include all site improvements,labor,material,scaffolding,fixed equipment,professional fees,and material and labor which may be donated gratis.) 7. Estimated date of completion: �a 8/12/2021 Please note that this application must include the notarized signature(s) of the legal owner(s) of the above-mentioned property, in the space provided below. Any application not bearing the legal property owner's notarized signature(s) shall be deemed null and void, and will be returned to the applicant. STATE OF NEW YORK,COUNTY OF WESTCHESTER ) as: Mafie eta Mazz�t+L ,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. Sworn to before me this 1� Sworn to before me this day of A.l�,r>al , 20 "LZ day of vrJ ,20 Signature of Pr perty Owner i ture of pplicant Print Name of Property Owner Print Name of Applicant Notary Public Notary Public CHRISTOPHER J.13RADBURY CHRISTCpHER J.eRADBURY Notary Public,State of New York Notary Public,State of New York No.01 B Rb 159985 No.01 BR6 t 59985 Qualified in Westchester County Qualified in Westchester County Commission Expires January 29,20 23 Commission Expires January 29,20 23 2 &1212021 r Building Permit Check List&Zoning Angx_sis Address: L �� Z.�.i !4- •(-lq�,�_o w L A4-401— SBL: 2�t I Zone._� Use. Z 1 Const.Type: Other. Submittal Date: 9� "L T Z Z Revisions Submittal Dates: Applicant: "tH Z 2 0"E- Nature of Work �i� "D c..o,G i�. �C t �' L�O - ter_L t N F, t views:ZBA: AUG 2 4 2022 PB• BOT• Other hMEP OK ( ( ) FEES:Filing. 7 BP:A M0�I�r C/O: Flood Plane: Legalization: ( ) (.,APP: Dated: ✓ Notarized:y/ 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: ( ) ( ) ITE PLAN:Topo: Site Protection S/W Mgmt.: Tee Plan. Other. ( ) ( SURVEY:Dated: Current Archival•.L, Sealed Unacceptable: ( ( )'PLANS:Date tamped Sealed. Copies: Electronic: Other. License Workers Comp:v"Liability: �.�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: REQUIRED EXISTING PROPOSED NOTES APPROVED Dale* AUG 2 4 2022 Circle: F=W Front. Fronr Main Cov Accs,Cov Ft.H S S .H Sb: SEA. Tom: Ft.Irr' Pr Hight/Stories notes: 173'/2 Ivy Hill Crescent Rye Brook, NY 10573 914-939-2440 � f,V, L'7-- L' l AUG 1 9 2022 L--J August 11 , 2022 ' — VILLAGE OF RYE BROOK BUILDING DEPARTMENT Marie Nora Mazzone 111 Brush Hollow Lane Rye Brook, NY 10573 Re: Privacy Fence Replacement Dear Marie Nora Mazzone, 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. As per the A&G committee, you have permission to extend the fence 6ft in height to the end of the patio without an angle. 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 Manage Ashlee Pasquale Property Manager 173'/z Ivy Hill Crescent Rye Brook, NY 10573 914-939-2440 August 11 , 2022 =AUG VILLAGE OF RYE BROOK Abbe Fleishaker BUILDING DEPARTMENT 112 Brush Hollow Lane Rye Brook, NY 10573 Re: Privacy Fence Replacement Dear Abbe Fleishaker, 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. As per the A&G committee, you have permission to extend the fence 6ft in height to the end of the patio without an angle. 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 I R IECFcHW D A & G APPLICATION FORM AUG 19 2022 Page 1 of 2 VILLAGE OF RYE BROOK BUILDING DEPARTMENT VOIReview A&G Guidelines, AHOA Declarations and By-Laws pertaining to your project. Consult with the Property Manager for any clarification of pertinent A&G Guidelines. Lpr"'Include in Request Section: a) Exact measurements of affected area &materials to be used b) Detailed description of project c) For fences and patios: exact location to be marked with stones, stakes, and/or paint, preferably done by installer VZr_SS'ubmit with Application: a) A"Before" picture b) Contractor's license& insurance (if applicable) c) Permit from VRB (if applicable) d) Plot plan (if applicable) e) Architectural drawings(if applicable) f) Oil Tanks, Fencing and Painting: requires an additional form to be filled out and submitted with this application (consult with Property Manager) vt�If any information is missing, the Property Manager can NOT accept the application. 40'AHOA and A&G are not liable for the cost of any plans, regardless of approval or denial. pzronce A&G receives the complete application, the area will be inspected and A&G will respond to the request in a timely manner. approved, Homeowner is then responsible to notify the Property Manager when work Begins and Finishes. Once the project is complete, an "After" picture must be submitted to the Property Manager to be kept on file.A&G and/or the Property Manager will then inspect the work done for adherence to the approved application. If work is not in compliance with the approved application, Homeowner is subject to fines and/or assessments and/or restoration of the property according to A&G Guidelines and the original approved application. �ote:Any work done without proper Prior authorization is also subject to fines &/or assessments, as well as possible removal and/or restoration. Please check each box as read, and then sign and date this page. Homeowner Signature Unit# Date RIEC FHWIE AUG 19 2022 A & G APPLICATION FORM VILLAGE OF RYE BROOK Page 2 of 2 1 BUILDING DEPARTMENT Homeowner Name (print/type): Address: liU� `� o e: �1 C Email: � )��S �r!�j Date: e Print or type a detailed explanation of your proposed project: D c re Nnce w�C o . �2Cr Cc� rnm ►�- �� u,( C C� ��—� C X- 4-a v\L 9K Y-n Homeowner Signature Dat A & G APPLICATION FORM Page 1 of 2 �Revi w A&G Guidelines,AHOA Declarations and By-Laws pertaining to your project. /�� Consult with the Property Manager for any clarification of pertinent A&G Guidelines. ' " , 14 Xinclude in Request Section: a) Exact measurements of affected area &materials to be used b) Detailed description of project c) For fences and patios: exact location to be marked with stones, kes and/or paint, preferably done by installer D _."ubmit with Application: a) A"Before" picture AUG 19 2022 ID b) Contractor's license&insurance (if applicable) c) Permit from VRB (if applicable) VILLAGE OF RYE BROOK d) Plot plan (if applicable) BUILDING DEPARTMENT e) Architectural drawings(if applicable) f) Oil Tanks, Fencing and Painting: requires an additional form to be filled out and submitted with this application (consult with Property Manager) If any information is missing, the Property Manager can NOT accept the application. �HOA and A&G are not liable for the cost of any plans, regardless of approval or denial. �nce A&G receives the complete application, the area will be inspected and A&G will respond to the request in a timely manner. If approved, Homeowner is then responsible to notify the Property Manager when work Begins /and Finishes. ,�I Once the project is complete, an "After" picture must be submitted to the Property Manager to veV be kept on file. A&G and/or the Property Manager will then inspect the work done for adherence to the approved application. if work is not in compliance with the approved application, Homeowner is subject to fines and/or assessments and/or restoration of the property according to A&G Guidelines and the original a roved application. Note-Any work done without proper Prior authorization is also subject to fines&/or assessments, as well as possible removal and/or restoration. Please check each box as read, and then sign and date this page. r" Homeowner Si nature Unit# Date RECG [EOM[ AUG 19 2022 A & O APPLICATION FORM VILLAGE OF RYE BROOK Page 2 of 2 BUILDING DEPARTMENT Homeowner Name (print/type): _a(J�� Address: l 1V`('1��1'l 40 lo(.C_J LON Phone: Email: E Date: i Print or type a detailed explanation of your proposed project: t 0,AJh� ► r) lac e_ a 4-a v\L ( S l Homeowner Signature Date i r all fiil�,i ill I Ohl Uri �°7. • 1.. z�, C4� '�t. ��'. Imo.+ Ci �G�,z} t"•y , r •�� r I `!! ,'mom •'►` � � � y ,� '.l:Y �ir4 -� Q Y y� C 4 yc= ' .4 3p �,• µ� s^ l S x , , f 4s" caul _ U VIICI �t t k r A e�. a. k u, �---- . } t 4P ry, 00, �p S v 9 '4j^ tlMx ¢r a i .. 3. .ti Ian„` I... w- v:•8H/- i r` c ' a. x / � .. IL , ,.r F S a� w. 'i i - s f b wm .. + ,� a ,df � • .�R� a y D 04. : Al. 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F op i c a N , p N � > Q CN LO tj e v � 7 I �, O O •O � :'� F L ,� i G " � a• j ,? UJ fnLIJ LU CD pp $!r CD W ctionw. :F J x L 'oLLJ r N LLJ n 4, l(j oz LU y w c woo- A b r�t � %v pY W MENDS (h Oil — o'+Irhu, :y;,•Q�' - . +MIRY` AC R® CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDIYYY`) 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 WANED, 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�007 FAAixc No: --- _- — - 5 Concourse Parkway E�ORe Suite 2150 contaCt@hISCOx.COm Atlanta GA,30328 INSURERS AFFORDMOCOVERAGE NAILS _ INSURER A: Hiscox Insurance Company Inc 10200 INSURED --- PEREZ M&W HOME IMPROVEMENT LLC INSURER B: --- - 1215 PARK ST INSURERC: PEEKSKILL,NY 10566 INSURER0: 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. IIISR 1 TYPE OF INSURANCE L SUB -- POLICY EFF POLICY EXP -- .. - LTRPOLICY NUMBER LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE s 1,000,ODO CLAIMS MADE FTIOCCUR ED PREMISES Ea occurrence f 100,000 _ MED EXP(Any one ) f 5,000 A N UDC-4611114-CGL-21 M312021 09/23/2022 PERSONAL BADVINJURY f 1,000,000 GENL AGGREGATE LIMIT APPUES PER GENERAL AGGREGATE s 2,000,000 X POLICY❑JECT LOC PRODUCTS-COMPIOP AGG s 2.000,000 OTHER S AUTOMOBILE LIABILITY CO,EAMBINED SINGLE LIMIT S rill ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY(PM accident) $ HIRED NON-OWNED PROPERTY DAMAGE AUTOS ONLY AUTOSONLY r S --- S UMBRELLA LIAR R EACH OCCURRENCE f EXCESS LLAB OCCU M OCCU AIDE AGGREGATE f DED RETENTIONS f WORKERSCOMPENSATION PER OTH- AND EMPLOYERS'LIABILRY Y I N STATUTE FR ANYPROPRIETORIPARTNERIEXECUTIVE E.L EACH ACGDENT f OFFICERAIEMBER EXCLUDED' ❑ NIA (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE S If yes describe under DESCRIPTION OF OPERATIONS below IF DISEASE-POLICY LIMIT S DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Addlbonal Remarks Schedule,may be attached if more space Is requfreq CERTIFICATE HOLDER CANCELLATION VILLAGE OF RYE BROOK 9W 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 ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD PORK Workers' CERTIFICATE OF STATE Compensation NYS WORKERS' COMPENSATION INSURANCE COVERAGE Board 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 1c NY 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 Camer (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 parinerVatficers included) Q all excluded or certain pa rtners/o Moe rs excluded This certifies that the insurance carrier indicated above in box'3"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 Rem 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 7' 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 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 Rakesh Gupta (Pnni name of authorized representative or licensed agent of insurance carrier) Approved by _ � � 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 HOT authorized to issue it. C-105.2(9-17) www wcb ny gov ! 0 Z00 \ \ Ile h a g N ti ! i v 7Col Ory ry AUG 19 2022 VILLAGE OF RYE BROOK BUILDING DEPARTMENT i i i i t 1