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HomeMy WebLinkAboutBP22-165PERMIT # ��_ DATE; $ �� EXP: i_.._.. ..._.... SECTION f9. 8�- i BLOCK I LOT TYPE OF WORK,e17ch /V lvl)% >sc 19e 7'0 JOB LOCATI N tzDc 9 01 Qg-I Noel f r% VeL / OWNER VaJcku Ahk'cl* O '173-3-3/9Y CONTRACTOR e// ql? DoIIINNil A-0 sejtier#NS4s epnS - 1G7aS11vaC=DQ3)&J7 5= EST. COST c FEE V/co # V FEE JqJQ I` j2j � DATE If h oZ TCO FFF _. PATE__ .. DATE FOOTING FOUNDATION FRAMING RGH FRAMING INSULATION PLUMBING C� RGH PLUMBING GAS 0 SPRINKLER ELECTRIC LOW -VOLT O INSp ,4S.,ARM 0 AS BUILTNNINNINNIN O FINAL NINNIIIIP iiiiii will IMMUNE I III iiiiiiiiii wild III OTHER APPROVALS OTHER tV�4°�av V l.G W.Vw`Li 406 QfEtt+[!ltmaW 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. Morlino CERTIFICATE OF COMPLIANCE October 11,2022 Valdet Nikci&Eneida Hoxha 229 Country Ridge Drive Rye Brook,New York 10573 Re: 229 Country Ridge Drive,Rye Brook,New York 10573 Parcel ID#: 129.82-1-14 Building Permit#22-165 issued on 9/8/2022 to Install Interior French Drain w/Discharge Drywell This certifies that the interior french drain with discharge drywell,installed under the above captioned permit has been satisfactorily completed. Sincerely, 0� -- Michael J. Izzo Building&Fire Inspector /to BUILDING DEPARTMENT For office use onl OCT ' 3 2022 VILLAGE OF RYE BROOK PERMIT# ,4��- 10� ISSUED: VILLAGE OF RYE BROOK 938 KING STREET,RYE BROOK,NEw YORK 10573 DATE: jC-.3- BUILDING DEPARTMENT (914)939-0668 FEE: 9 //0-- PA W www,ryebropk,org APPLICATION FOR CERTIFICATE OF OCCUPANCY,CERTIFICATE OF COMPLIANCE, AND CERTIFICATION OF FINAL COSTS TO BE SUBMITTED ONLY UPON COMPLETION OF ALL WORK, AND PRIOR TO THE FINAL INSPECTION ►i►tiittiti#itt#fliti►tti■►►i■t!t■it►tiltt►!it#i#►►t#flit►i#i#/##t#tltt►t■t►tittii►tt!■►tRi!l►►ti►iitti►tiiiiit►t#i►##4##►#i► Address: -2-25 Cu,,r- tr7 12.-d4t- 12" t Occupancy/Use: Parcel ID#: Zone: Owner: Address: ;X P.E./R.A.or Contractor: r*,,'� �� 1���._,�r Address: 11�" ne-�✓xlv 01 t� Person in responsible charge: V'1d_A.4- r (,,L_ 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: V , 0 d ,+ being duly swom,deposes and says that he/she resides at (Print Name of Applicant) (No.and Street) in )�y t ,in the County of 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:$ (6 'S/l , for the construction or alteration of: ��-c 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 3 Sworn to before me this day of 0 G�y. erg , 20 01- day of , 20 Signature of Property er Signature of Applicant PTIV of Property Owner Print Name of Applicant \V-\ ls�"- Not blic Notary Public SHARI MEULLO Notary Public,State of New York No.01ME6160063 untY 8/12/2021 Qualified in Westchester( 2023 Commission Expires January �yE 4Rnvt 1982 BUILDING DEPARTMENT ❑BUILDING INSPECTOR ,..', PASSISTANT 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: (�-- J�'� ''` DATE: \� �T2- PERMIT#�-(e T? ISSUED: SECT: Z)BLOCK: LOT: LOCATION: �1 ./� �« �11�'� "x , v 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 ❑ CROSS CONNECTION r� 'FINAL ❑ OTHER e : N oc00 W o a a a 9 cn �"� I-�i rj � as � '+ � ,� N � ^ ■ p tr'cc Ln en en �.{ O O ° 3 ° � a � ■ W � � � � � W O oo c ° � 'a•[ � ° p O Q OO 5 A wzQo 00 0 V C) z R� -5 0 m ~ M N a -oQ � 6� �j c/a C1' h+�1 �W t[) W v ar v z lZ Co 'C oc P4 ■ N 0 � � � `Q � u rri zo v 0-4 ~ 0 14 Ig�I I� Q z0 �C p V O o oa V CN c� g z N z Cu a :I ■ : �],�] �] �1�1 - �]fie]�]�]�]me m �■ ■ �s]�_] a �■] ■ �] BUILDING DIARTMENTI C IE N,H DD VIL114) OF R41*BROOK AUG 2 9 2022 938 KINGT RYE BROOK,NY 10573 939-0668 VILLAGE OF RYE BROOK k.o:g BUILDING DEPARTMENT FOR OFFICE USE ONLY: U 2022 Permit#: /� Approval Date: AUG ��+ "�(OS BP#: Approval Signature: Permit Fee: -Z Disapproved: Other: W Q Attached Resolutions: ( ) B.Q.T.; ( ) P.B.; ( ) Other: ' STOQRMWq ATER MANAGEMENT CONTROL PERMIT APPLICATION Application dated: '.) /r 7 is hereby made to the Building Inspector of the Village of Rye Brook,NY,for the issuance of a 5tormwater Management Control Permit for work,as per detailed statement described below. 1. Job Address: l`�� 2. Parcel I.D.#; c� 7 i �— 1 Zone: 3. Proposed Work(Describe in detail): njV.1A,�r{hC9 T }44 �'1=i.C�ei 11Nc't 1"• lil�1C�C '��)csyw l�ric�� �G r -J a l� � ll 4. Property Owner:_ 6Ae:j tQ;j�f=, Address: 22ct Cc,:.,o±r4 &k'A a 9- Z k1Y C,57 7 � Phone# c 1 y Z f y Cell# r k9Q, email: Applicant: ArntC,t<zwN b D-y rm1--:4-_ C Address: Zf3 h-lcur .Dri ✓,r e��yl�F�'�., Ill C"C G'680`I Phone# Zt13---73 C", - 2_a'aCj Cell# Z0_-? L j'Z -_S_7 1 3 email: Architect/Engineer: Address: Phone# Cell# email: i,/�,' L,`C- r��•, General Contractor: ,►-t e,j c,, , j)T�'c7',%-t%z-_N_k_ L1 Address; Zt, e_ L J Phone# 1.0cl Cell /# 2,f email: 5. Estimated cost of site work $ / (NOTE:The estimated cost shall include all labor,material,scaffolding,fixed equipment,professional fees,backfill,grading,site restoration,carting/tipping fees and material&labor which may be donated gratis.) 1 8/12/202[ STATE OF NEW YORK,COUNTY OF WESTCHESTER ) as: ti./c I a-`t- (-/,I-- ,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 Swom to before me this day of �'� , 20 day of 4k S\-L S , 20aci Signature of Property Owner Signature of Applicant t Name of Property Owner Print Name of Applicant 0- Notar;'15ublic Notary Public SHARI MELILLO SHARI MELILLO Notary Public,State of New York Notary Public,State Of New York No.01ME6160063 No.OIME6160063 Qualified In Westchester County Commission Expires January 29,202� Qualified In Westchester County Z� Commission Expires January 29,20� 2 8/12/2021 I D ED R BUILDING DEPARTMENT VILLAGE OF RYE BROOK AUG 2 9 2022 938 KING S ET RYELOQ6XT NY 10573 VILLAGE OF RYE BROOK BUILDING DEPARTMENT AFFIDAVIT OF COMPLIANCE VILLAGE CODE 4216 • 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 . STATES OF NEW YORK, COUNTY OF WESTCHESTER ) as: V 31, A Id L-i- kl,Ics, , residing at, (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; •° , 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. (Signature of Property O r(s)) U�_ U-4 /.I., (Print Name of Property Owner(s)) Sworn to before me this 00, 20 (Notary Public) SHARI MELILLO Notary Public,State of New York No.OiME6160063 Qualified In Westchester County 3 Commission Expires January 29,20L9 sn2/2021 Building Permit Check List&Zoning Analysis Address: 7,2.9 Go."L-tn���c'� 2 SBL: Lk Zone:-I j Use: Z t => Const.Type: Other. Submittal Date: " Z Z Revisions Submittal Dates: Applicant: C \ Nature of Work: " --CZ el— C•t� T f-SG eviews:ZBA: A l l V ;j 0 %Q Z 7 PB: BOT: Other: OK ( ( ) FEES:Filing- 7s•�BP: 2A4 E3 • C/O: Flood Planer Legalization: ( ) (✓� APP: Dated ✓ Notarized: ✓ SBI_ Truss I.D. •�ross 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:Date tamped. Seale Copies: Electronic: Other. (t/f ( ) License Workers Comp: Liability Comp.Waiver. Other. ( ) ( ) 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. O O 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 ExignNG PROPOSED NOTES APPROVED AU G 3 n O2— cir • FronW Front: >rqnt: Sides: Main Cov Accs.Cov F S : Sd.H Sb: S� Tot,Img: Ft.Img: Paz He j&/Stories: notes: STOP WORK ORDER BUILWNGDETARlOoF%l,N ILI AGE OF RAF o..e .�..DO ARE HEREBY D _O m P ALL WORk AND I RWISE CFnse. & D!S STALL UNLAWFUL USE OF I HISPRovexn'/VR[.MIE [SAL; RY NY — v� w,.. ..ou .> AY pow r 9 av ..,Arm ,<;..,�T�pi""-''.- �A ,�' p, A,� „rZi�" y,,tc. A. .,ye-Y�`"��;�, ;A,� 1`��'�". •'' . fiVNI � - :4.�fi � 1•f�l � I�i•1 IOOii J/t1��!{}4•`1•'1'•'�r 'y /��i If/•1 ,#��`��iy� �ff• ��_��•�r ,y � :,. '�1" '� �` ��M -'�y�1/1 •1./1 11 3l1 it€,.Illfllil--��V�#d!€: 11►1/1 `i" - i -�1111/111� 11�1'11(IIf- s��� �'.'. '� �;' `.--.:111�1111: k?E,, 1 111'. YI (11 Cy..s>. g s 11�11 ,'fat-'€$ga:.1111�111 �e .F+�c$ti,`INI111�?fa* <; •9�,11 111� � y� af'.?,. M .0 = > _ a _ O w00 CD r"1 cn co — \,ectionLIJ WC J U 'ON 9 LU Q co C. t ' M LO z 3 rl .r �✓ 4G El low Y —. co - = _ NGo CO tj _ r Ir .. - __��, 5 4r r•: I ate'-S.Fs�ti. r. 1 11 �. O mil` 4,-1111111 Lay f+ 111 111 ;- ° �,I+I11'T"�.•4��i 111 1 •�a��•111 (y ��" 1 1 1 (1•;. IPD' .r•- zgi - 11!1 /lly 3�yjfg p I11 111" y 4@� yl1 11111 p 1 1 •'109! 1111AP •R I AgtD rfr'1�1 U� V J •V �i.Yl� rrJ" �I• 'I �,J.yNV hn/tll� r �'. -'Aw DATE(MM/DD/YYYY) AFRO® CERTIFICATE OF LIABILITY INSURANCE 8/30/2022 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 John M. Glover Agency PHONE Penn S inola FAX P.O. Box 700 ac N •203-956-2495 Arc No:203-274-9405 Norwalk CT 06852 AODRIEss: pspinola@jmg.com INSURERS AFFORDING COVERAGE NAIL 0 _ INSURER A:Main Street America Assurance Company 29939 INSURED AMERDRY-01 INSURER B:Ohio Security Insurance Company 24082 American Dry Basement Systems LLC 28 Del Mar Drive INSURERC: Brookfield CT 06804 INSURERD: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:961747845 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. IPOLICY EXP LTR TYPE OF INSURANCE POLICY NUMBER MM/LDIDY EFF MM DD/YYYY LIMITS A X I COMMERCIAL GENERAL LIABILITY MPP5818M 3/13/2022 3/13/2023 EACH OCCURRENCE $2,000,000 DAMAGE TO RENTE15-- CLAIMS-MADE I-XI OCCUR PREMISES Ea occurrence f 500,E MED EXP(Any one person $10,DDO PERSONAL 8 ADV INJURY $2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE 9 4,000,000 POLICY�JEST LK LOC PRODUCTS-COMP/OP AGG $4,0D0,000 OTHER: _ A AUTOMOBILE LIABILITY MPP5818M 3/13/2022 3/13/2023 COMBINED SINGLE LIMIT $2 000,000 Ea accident1 -ANY AUTO BODILY INJURY(Per person) _ OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY(Per acciderd) f X HIRED X NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY Per accident $ UMBRELLA LIAR L]OCCUR EACH OCCURRENCE _ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION $ B WORKERS COMPENSATION N XWS64899427 3/27/2022 3/27/2023 X S ATl1TE R CT and NY AND EMPLOYERS'LIABILITY Y/N ANYPROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $500,000 OFFICER/MEMBEREXCLUDED7 ❑ N/A (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $500,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT f 500,000 DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached If more apace Is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Town of Rye Brook 938 King Street Rye Brook NY 10573 AUTHORIZED REPRESENTATIVE ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD INEwK Workers' CERTIFICATE OF STATE Compensation NYS WORKERS' COMPENSATION INSURANCE COVERAGE Board 1a.Legal Name 8 Address of Insured(use street address only) 1 b.Business Telephone Number of Insured 203-775-7900 American Dry Basement Systems LLC 28 Del Mar Drive 1c.NYS Unemployment Insurance Employer Registration Number of Insured Brookfield CT 06804 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 061493555 2.Name and Address of Entity Requesting Proof of Coverage 3a.Name of Insurance Carrier (Entity Being Listed as the Certificate Holder) Ohio Security Insurance Town of Rye Brook 3b.Policy Number of Entity Listed in Box"l a" 938 King Street XWS64899427 Rye Brook NY 10573 3c.Policy effective period 03/27/2022 to 03/27/2023 3d.The Proprietor,Partners or Executive Officers are included.(Only check box if all partners/officers included) ❑X 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"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 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". 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 by: John Forlmo (Print name of authorized representative or licensed agent of insurance carrier) Approved by: g/ V. 8/31/2022 (Signature) (Date) Title: Chief Executive Officer Telephone Number of authorized representative or licensed agent of insurance carrier: 203-838-5554 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 CT HIC#0654483 \/C�&e� - "f Y C-'-., 0(3(viai Ameri*canDry B �� nSystems, LLC. ase e t Corporate Office Mailing Address 5 Oak Lane Office: 1-888-748--2002 • 203-775-7900 28 Del Mar Drive Danbury, CT 06811 Brookfield, CT 06804 BASEMENT FIELD REPORT Name Vel Date q' Arrival Time 2Z og2nL Address 2201 CCXAn-�CVHomet ---,,j- City State Zits Work Phone Inspector �6,Ai�_ l �pPREVENTATIVE NEEDS SERVICE ❑ EMERGENCY SERVICE ALL PROBLEMS LOOR PROBLEMS STRUCTURAL Floods Seepage/Moisture Hydrostatic Pressure Footing Undermined Damp Window Wells Standing Water Floor Undermined Efflorescence — Warped Paneling Floor Cracks Wall Cracks Mold - Musty Blistered Paint Beveled Floor (Vert./Horiz) Cracks -Walls - Floor DEGREE OF WALL PROBLEM ❑ No ProblemV)Voderate ❑ Fungus/Dry Rot Severe Insect Infiltration DEGREE OF FLOOR PROBLEM ❑ No roblem Moderate ❑ Severe TYPE OF FOUNDATION CP BST ooter onolithic Total • _ uperDry FloorNVall System' #1 most comprehensive in Basement Waterproofing. -�-- -- '- Sypcturalintegrity into ty �© /Engineering tab technology ' II uperSlurry/walls --- - - ! --}-- i fsuperCrete/floor � p T- - False water table; Yateral pressure/outside walls; __._ -�-• -.._.___.._._.�i _ _ f------ CSV anaged at or below the hydrostatic point --- ------ -- ydrostatic pressure/underneath floor; : t i i i - hydrostatic pressure eliminated under floor - .-- - -- Efflorescence; ;__.._...___......_�.._ _.. .._ _.._..___._. ___ __ -� •..-•-�_i ❑ ock/tap hollow cores and acid neutralize/SuperSlury poured/S u p e rS I u rry +1 91st cover all contents of basement with plastic 1 enviroboot point of contact, HEPA air filtration ' -- negative air machines/full room air filtration �.. _.. j.. .. _ --;- { I Ii - - - B01ding code; fully code compliant for; ` OVtraditional three peice foundation _...�........-.------ -.-.....' ' (slab min 3.5'concrete/SuperCrete . ............. .. ; - -- ;- - T ❑ monolithic two peice foundation .._._...,..._.._ ._:___.. _ _ :._...... _ . _ ❑ stone foundation/false footing .............. - ----- ran ee a rra n V• V Floor crack/wall crack guarantee; any floor and or wall cracks after installation will be repaired by "Su erDry Wall System": Install AmericanDry at no cost to customer. ft. Wall flow channel Yaintenance free guarantee; our System i Leave En 9 y s perpetually Engineering Tabs elf-cleaning and requires zero maintenance. "SuperSlurry"walls Clog free guarantee; if our 4n ADS pipe clogs from soil Tie Into"Super Dry Floor System" or iron ocher bacteria a full refund to customer, repair "SuperQry Floor System": Install of the system and continue to 100% honor the original 119 ft.4-inch corrugated/perforated ADS pipe warranty Pitched 1" per 10" Packed in stone Re-cement with "SuperCrete" Other: ft. "Stone Foundation Step Out System" 2 64c�n e- Fy o� Ma 1A �e4pt-k VIM e bl � Pumps kWq Hr'3P4 160.ss Other 1 5CkC-k<,. 4- -4- Warranties mac' L, _.___ Gontractor/R.E.Agent- Commericicx\/ N Yd E,::; Ll:� e idDintial Rate: G�cake o ns: AUG 2 9 M22 Senio Citizen: VILLAGE OF RYE BRO K .- BUILDING DEPART, OMal investment; $ _ _