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HomeMy WebLinkAboutRP22-038PERMIT # 1V<=:pf � O&D SECTION A TYPE OF WORK JOB LOCATION _ OWNER)q FC B�EST. COST � �/C0 #� TCO # DATE : L �� _ EXP: 9 / 9 0� BLOCK LOT _ FEE DATE INSPECTION RECORD .._ DATE INSP FOOTING FOUNDATION FRAMING RGH FRAMING INSULATION PLUMBING 0 RGH PLUMBING GAS 0 SPRINKLER ELECTRIC C� LOW -VOLT C� ALARM d AS BUILT O FINAL _ A& r 3 OTHER APPROVALS ARB BOT PB ZBA OTHER V 4 t4C�m�+`ram 4 y�BCK,�,y y 19 VILLAGE OF RYE BROOK MAYOR 938 King Street, Rye Brook,N.Y. 10573 ADMINISTRATOR Jason A. Klein (914) 939-0668 Christopher J.www.;yebrook.org TRUSTEES ACTING BUILDING & FIRE INSPECTOR Susan R. Epstein Steven E. Fews Stephanie J. Fischer David M. Heiser Salvatore W.Morlino CERTIFICATE OF COMPLIANCE February 6,2023 Fred Zeller&Debra Zeller 16 Churchill Road Rye Brook,New York 10573 Re: 16 Churchill Road,Rye Brook,New York 10573 Parcel ID#: 135.26-1-24 Roof Permit#22-038 issued on 9/19/2022 to Re-Roof Existing Building This certifies that the new roof,installed under the above captioned permit has been satisfactorily completed. Sincerely, Steven E. Fews Acting Building&Fire Inspector /to D For office u�seonlBUILCYEE NT PERMIT# �L� 3� OCT 2 7 2022 VIL OK ISSUED: 9_ 38 KING STREK, YORK 10573 DATE:VILLAGE OF RYE BROOK O�c FEE: fig' //U — PAroa 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 Address: Occupancy/Use: incrS Parcel ID#: kS'5 , Owner: �'( ' Address: ku hUdC ki l g k h ), P.E./R.A. or Contractor: Address: o� C.Q,k—d V +. \ i Person in responsible charge: Address: A . A 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: �VITN Oe rY%5 ,L LL being duly sworn,deposes and says that he/she resides at IQ (s,nkt r%-ti Print Name of Applicant) (No.and Street) in Tl(1_QLGIn4VllNe intheCountyof GUIs k�ch. 4-z y- in the State of ,that (City/Town/ illage) 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: $ `► r1 0 0, u J , for the construction or alteration of: r',0 G+ r`e rv,u V t,-1 i t�p k ti U rns rIJ 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 L Sworn to before me this Lq day of I� , 20_Z?— da of ���CJ=�'� , 20 T L E STATE Si ture of erty Owner \\ �P � i, = OF NEW O �� = ignature of Applicant I � — NOTAR�yP--� l l t�� ' i STgpE {► �, SIC I i ✓ VA P' t e of Pr e O er OF Ric _ %O`� 01PA6�347�cp 1� — 1 NOTAR � rin ame of Ap Werralis4YpILIC - S 01PA63471 2C �� '��0N1E1T05����� N blic %i fss3'; y/j�jL Notai Public 1' 'U_I QyE BRC�k. Zm ,9az BUILDING DEPARTMENT UILDING INSPECTOR ASSISTANT BUILDING INSPECTOR VILLAGE OF RYE BROOK ❑CODE ENFORCEMENT OFFICER 938 KING STREET • RYE BROOK,NY 10573 (914) 939-0668 FAX (914) 939-5801 www ryebrook.org - - - - - - - - - - - - - - - - - - - - INSPECTION REPORT - - - - - - - - - - - - - - - - - - - - ADDRESS: �/ UC_ � DATE: ` Z + 2 y-� �] Z z 2 PERMIT# �ll� ISSUED: �l SECT: ' BLOCK: LOT: LOCATION: Q-- '` \ 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 " FINAL ❑ OTHER �yE[3RC�k. 1962 BUILDING DEPARTMENT ❑BUILDING INSPECTOR ASSISTANT BUILDING INSPECTOR VILLAGE OF RYE BROOK CODE ENFORCEMENT OFFICER 938 KING STREET • RYE BROOK,NY 10573 (914) 939-0668 FAx (914) 939-5801 www ryebrook.org - - - - - - - - - - - - - - - - - - - - INSPECTION REPORT - - - - - - - - - - - - - - - - - - - - ADDRESS: , V 1 1` DATE: PERMIT# ISSUED: SECT: " BLOCK: LOT: LOCATION: OCCUPANCY: Z' ❑ 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 Vim' ❑ NATURAL GAS ❑ L.P. GAS 1 S �� \ ❑ FUEL TANK ❑ FIRE SPRINKLER ❑ FINAL PLUMBING ❑ CROSS CONNECTION ❑ ,,FINAL OTHER 6 ' M : x M N N y a rZ Cl) 0 V : 0 311 40 N ■ W � � � � o � � o c � m 0 33 ■ r� � 4 a H v o 01) �j cn w .. c � q�' ae Z Gti Imo+ Oa H U W CY 5 r O w a x zzb °' " " ,./ o G Ov�i � .ti 00 w p o Con ° d cn wo as V A z O o W 4 l asw1.3 1 xw 1b ® BUIV- . ENTVOK SEA' 15 2022938 KINNY 10573 VILLAGE O17 RYE BROOK BUILDING DEPARTMENT FOR OFFICE USE ONLY SEP 1 6 2022, Approval Date: Wr t# �1 S Application# Approval Signature: ARCIIITECTU REVIEW BOARD: Disapproved: A Date: BOT Approval Date: Case# Chairman: PB Approval Date: Case# Secretary: ZBA Approval Date- Case# Other: Application Fee: rJ .L"J_e' ermit Fees: I1q., p ROOF PERMIT APPLICATION Application dated: '/ 't> is hereby made to the Building Inspector of the Village of Rye Brook,NY,for the issuance of a Permit to Re-Roof an Existing Building,as per detailed statefmllent described below.in 1 �J 1. Job Address: l u (ti urr V1 k 14 4 �q Q YIP,)1L SBL: 13 '5 . ZLf Y + - 2(Zone: � Property Owner: qed W (1 P Ir Address:I tj C 6 VC kk I Phone#: 11'-I��L- �t[j(�13 Cell#: email: C 0- t4lA 2. Applicant( h Address: Phone#: 1q 1 1 `14 Cell#: -Iuu j email: ftly(V OWLAUP 3. Roofing Contractor: 4 ( Address: V �t . Phone#: �' "1 _DULACell#: (1iL1)_jQj - Jl1_Li� email: rarR 4. Job Description, list all Methods&Materials: r-C)I2 f-9 rp- ILC1C,Q 3 rfl.CAJ lr"' 13 5. Estimated Cost of Job: $ 11,Cj U 1) , Lt) (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.) 6. If corner property,indicate street frontage: 7. Construction Type: Q -ko yc'+I tN, NYS Construction Class: 8. Number of stories: Sol I UR ` Height: 9. Is garage being re-roofed: No: •Yes: { )Attached No: ( )•Yes:1k)Number of Cars: 10. Is roof peaked,hip,mansard,flat,etc: 11. Estimated date of completion:T 0"w i lc"I VU.Q �! -1- 8112 o21 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. SPTE OF NEW YORK,COUNTY OF WESTCHESTER ) as: a-N y being duly sworn,deposes and states that he/she is the applicant above named, (print name A 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 (�3h 4�6 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 fore me this I_ Sworn to before me this day o day 20 L,L i r Signature roperty Owner Sig ture of pplicant ,- 6,- Name o erty wn r ANotary e of Ap li ant i� of Public blic 10 STATE �� �� STATE � 1/OF NEW YORK _ J,OF NEW YOB` 1 NOTARY PUBLIC t / it NOTAR_� 1 parnnad M xacMes came 1 ® — S .4 1 Qwir d k w.,h. c„o,y/ o'� ,r �� DIPA634792 /O�p S L� � � 1 O1PA63475(12 / (ti % i e _2_ 8/12/2021 Perry Verrone, LLC 12 Center Street Pleasantville, NY 10570 info fterryyerroneroofing.com Office: (914)747-7663 Fax: (914)747-7665 License WC 21701 H09 REVISED 9/13/2022 REVISED 9/12/2022 6/18/2021 Prepared by Perry Fred Zeller 16 Churchill Rd. Rye Brook, NY 10573 Debra : 913-523-7446 Fred : 914-522-9800 Fredzeller01(a,gmail.com PROPOSAL PARTIAL ROOF REMOVAL AND REPLACEMENT (See Designated Sections p2) • All existing asphalt roofing removed and carted from job site • All rotted plywood replaced at$110.00 per sheet • GAF Weather Watch Ice and Snow barrier installed on all gutter edges,valleys and around skylights (6 feet up) • GAF TIGER PAW paper installed on the entire field of roof • GAF LIFETIME Timberline Architectural HDZ shingles installed on entire field of roof (WEATHERED WOOD) • GAF Cobra Ridge vent installed on all ridges of roof for attic ventilation • GAF TimberTex hip and ridge shingles installed on all ridges • Aluminum drip edge flashing installed around entire perimeter of roof • GAF Weather Blocker starters installed on all perimeter edges The price for the aforementioned work, which includes labor and material, (but excludes any additional plywood) to be added to the sum of: $11,900.00 Page 1 of 4 Initial &Date: PRICE EXPIRES 30 DAYS AFTER ESTIMATE DATE { i J Y i¢ I u p,c lL a l<A ADDITIONAL WORK OPTIONS Please check appropriate box for desired extra work - Carpentry/handyman work calculated on a time and material basis,said work performed at $110.00 per man hour plus material - Aluminum Seamless Gutters and Leaders fabricated and installed (5 inch gutters and 2x3 leaders) for an additional Copper chimney flashing fabricated and installed for an additional$900.00,if needed Building Permit for additional Cost TBD (if needed) Payment schedule is as follows: 50% 3 Days Prior to Start 45% Due the day of substantial completion S% Retention may be held for resolution of unresolved issues Any monies not paid as specified above will be subject to accrue interest at a rate of 1.5% monthly,and 18% per annum. All material is guaranteed to be as specified above. All work to be completed in a workmanlike manner according to the standard practices.Any alteration or deviation from the above specification involving extra costs will be executed upon a written change order and will become an extra charge over and above the proposal.All agreements are contingent upon strikes accidents or delays beyond our control. Rif Replacement Instructions for Homeowner Instructions for Homeowner INSIDE THE HOME: 1. Any precious items in the attic can be either moved to a secure place within the attic or covered and secured to protect from the vibration of the roof removal process. 2. Dust and/or sawdust may be generated in the attic due to the roof removal process,securely covering belongings is advised. Clean- up of debris in attic is outside the purview of this contract. 3. if your home has high hat lights located in the cathedral ceiling,you may want to tape the fixture to the ceiling (construction activity on the roof may cause these to come loose). Page 2 of 4 Initial&Date: 4 If you have cathedral ceilings,although it is not common, on occasion,some nails may be prone to "pop"-thus exposing the head of the nail through the sheetrock. This is unfortunate but is not the responsibility of Perry's Roofing. 5. Perry's Roofing is not responsible for any necessary electrical work required for powered products installed,a licensed electrician must be consulted. SKYLIGHTS: 1. If you have opted for a skylight replacement, please consider that the skylight manufacturer dimensions have changed over the course of the years which may alter interior placement of your new skylight. There may be interior trim work required to remedy this condition. This is not part of the roofing contract. 2. Items below the area of skylight replacement should be moved or covered during this work. 3. Please be aware that Perry's Roofing does not guarantee skylights against leaks that we have not installed new and hence they will not be covered by any warranty issued from us. OUTSIDE OF THE HOME: 1. Outside your home we make every attempt to ensure that we protect your shrubs and belongings. You can help us by removing smaller objects lawn ornaments, outside furniture, etc.,that you can handle, or that may be valuable,to a secure place. Any larger items,such as picnic tables,our men will move to a secure location and replace upon completion if time allots. Please notify us if the moved items are not replaced and we will schedule a time for them to return at your convenience. 2. Let us know if there is a power source outside that we can use. 3. Let us know if there are any special precautions regarding any item, or situation,that we should be aware of outside, prior to starting. DUMPSTER: 1. If a dumpster is necessary, it will be placed in your driveway the day before or the morning of the scheduled work. Please be sure to move any vehicles out of the garage and driveway to avoid being blocked in. The dumpster may not be removed the same day of completion. Notices to Owner Right to stop work: If any payment under this agreement is not made when due, Perry Verrone, LLC may suspend work on the job until such time as all payments due have been made. Notice of Lien: The contractor or subcontractor who performs on the contract and is not paid may have a claim against the owner which may be enforced against the property in accordance with the applicable Lien Laws. Cancellation: The owner has an unconditional right to cancel the contract without penalty until midnight of the third business day after he/she signs the contract. Cancellation must be done by giving Perry Verrone, LLC a written notice indicating the owner's intention not to be bound. Upon cancellation,any property traded in,or payments made under this contract will be returned within 10 business days following the receipt of the cancellation notice by Perry Verrone, LLC. Acceptance of Proposal: I have read the introductory packet along with this document and accept the specified conditions as stated,and the prices associated with such. I understand that upon signing this proposal,all documents presented becomes a binding contract. You are authorized to do the work as outlined. Payment will be made as indicated above. Signature Date Page 3 of 4 Initial& Date: ir New York State Department of Taxation and Finance S T 1 2 4 New York State and Local Sales and Use Tax Certificate of Capital Improvement (212) After this certificate is completed and signed by both the customer and the contractor performing the capital improvement, it must be kept by the contractor. Read this form completely before making any entri s. This certificate may not be used to purchase building materials exempt from tax. Name of customer(print or type) Name of contractor(print or type) Perry Verrone, LLC Address(number and street) Address(..umber and street) 12 Center Street City State ZIP code City State ZIP code Pleasantville New York 10570 Sales tax Certificate of Authority number(if any) Sales tax Certificate of Authority number(if any) 26-2754386 To be completed by the customer Describe capital improvement to be performed: Roof removal and replacement Project name Street address(where the work is to be performed) city State ZIP code I certify that: • I am the(mark one) 0 owner ❑ tenant of the real prop"identified on this form:and • the work described above will result in a capital improvement to the real property within the guidelines of this form;and • this contract(mark one) ❑ includes ❑x does not include the sale of any tangible personal property that,when installed,does not become a permanent part of the real property(for example,a free-standing microwave or washing machine). I understand that: • I will be responsible for any sales tax, interest, and penalty due on the contractor's total charge for tangible personal property and for labor if it is determined that this work does not qualify as a capital improvement,and • I will be required to pay the contractor the appropriate sales tax on tangible personal property(and any associated services) transferred to me pursuant to this contract when the prop installed by the contractor does not become a permanent part of the real property;and • I will be subject to civil or criminal penalties(or both)undo the Tax Law if I issue a false or fraudulent certificate. Signature of customer Title Date To be completed by the contractor I,the contractor,certify that I have entered into a contract to perform the work described by the customer named above,and that I accept this form in good faith.(A copy of the written contract,if any, is attached.) I understand that my failure to collect tax as a result of accepting an improperly completed certificate will make me personally liable for the tax otherwise due,plus penalties and interest. Signature of contractor or officer Title Date President This certificate is not valid unless all entries are completed. 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The same shingleyou • • • • now • • Technology which powers • widest • • area. 2 O xx Timberline® HDZ'm Shingles 4 41 Benefits: Product details: ■ LoyerLock"Technology—Proprietary durability, strength, and exceptional Product/System Specifics technology mechanically fuses the wind uplift performance. ■ Fiberglass asphalt construction common bond between overlapping ■ Dimensions(approx.):131/ x 39 W is StainGuard®Algae Protection— (337 x 1,000 mm) shingle layers. Helps protect the beauty of your • Exposure:5%'(143 mm) ■ Bundles/Square:3 ■ Up to 99.9%nailing accuracy— roof against unsightly blue-green ■ Pieces/Square:64 The StrikeZone" nailing area is so algae discoloration' ■ StainGuard^Algae Protection' ■ Hip/Ridge:TimberTex�:TimberCrest-, easy to hit that a roofer placed 999 ■ High Performance—Designed Seal-A-Ridge":ZIRidge;Ridglass" out of 1,000 nails correctly in our test. ■ Starter:Pro-Startz;QuickStart": with Advanced Protections Shingle WeatherBlocker"' ■ WindProven" Limited Wind Technology. Applicable Standards&Protocols: Warranty—When installed with ■ Seamless compatibility—The new • UL Listed to ANSI/UL 790 Class A the required combination of GAF ■ State of Florida approved y Accessories,Timberline` HDZ"' Timberline" HDZ"Shingles are com- ■ Classified b UL in accordance with Shingles are eligible for an industry patible with traditional Timberline HD°' ICC-ES AC438 g g y Shingles for the some look and feel • Meets ASTM D7158,Class H first:a wind warranty with no ■ Meets ASTM D3161,Class F maximum wind speed limitation.2 homeowners and contractors rely ■ Meets ASTM D3018,Type 1 on for beauty and endurance. ■ Meets ASTM D3462S ■ Our legendary Dura Grip'sealant ■ ICC-ES Evaluation Reports ■ Perfect Finishing Touch—For the ESR-1475 and ESR-3267 pairs with the smooth microgranule best look, use TimberTex" Premium ■ Meets Texas Department of Insurance surface of the StrikeZone" nailing Requirements area for fast tack.Then,an asphalt-to- Ridge Cap Shingles or TimberCrest" ■ ENERGY STAR"Certified(White Only) Premium SBS-Modified Ridge (U.S.Only);Rated by the CRRC;Can asphalt monolithic bond cures for Cap Shingles. be used to comply with Title 24 cool Availability: roof requirements Colors & Availability: Results based on study conducted by Home Innovation Research Labs. an independent research lab,comparing installation of Timberline HD" Shingles to Timberline"HDZ"Shingles on a 16-square root deck using standard 4-nail nailing pattern under controlled laboratory conditions. _ Actual results may vary 15-year WindProven"limited wind warranty on Timberline"HDZ` Shingles requires the use of GAF starter strips,roof deck protection, ridge cap shingles,and leak barrier or attic ventilation See GAF Roofing Barkwood Birchwood Biscayne _ Copper Canyon System bmded Warranty for complete coverage and restrictions.Visit gat com/LRS for qualifying GAF products. 'SloinGuard"algae protection is available only on shingles sold in packages beonrg the StainGuard"logo Products wit StainGuord" algae protection are covered by a 10-year limited warranty against blue-green algae discoloration See Gilt`Shingle&Access"limited LYomanty,for complete coverage and restrictions. to be mixed on one roof.Timberline"HDZ`Shingles and Timberline HD` Fox Hollow Gray Golden Amber Hunter Green Shingles must have matching 6-digit codes found on the end of the bundle When mixed,always use Timberline HDs installation instructions. 'Periodically tested by independent and internal labs to ensure compliance with ASTM D3462 at time of manufacture 'Lifetime refers to the length of warranty coverage provided and means i as long as the original individual owner(s)of a single-family detached _ residence[a eligible second owner(s)]owns to property where the qualifying GAF products are installed.For other owners/structures.LifetimeMission Brown Patriot Red o, - coverage is not applicable.Lifetime coverage on shingles requires use of GAF Lifetime shingles only.See GAF Shingle&Accessory Limited Warranty o for complete coverage and restrictions.Lifetme coverage on shingles and _ accessories requires use of any i;AF Lifetime Shingle and any 3 qualifying GAF accessories See GAF Roofing System limited klbrion for complete coverage and restrictions.Visit got con i for qualifying GAF products Note It is difficult to reproduce the color clanty and actual color blends Sunset Brick Weathered Wood _ - • of these products.Before selecting your color,please ask to see several 'ull-size shingles Ft © _a ' AMERFGN g A c3 yv `ur"��" We protect what matters most ..,A%VAW II�YYIM.P....- 'r's__"�_ -�=._nor. r._-_�—' ---- � �__ ___�Zi_�•-�- --_' xs= --- _._— ,_--�_=ems=_•:eti==s-c=_ �'�'�`/e"%-i�._.o�. .�i-t�lsJl3m SS3.__.____-__-_.- .i®�ii :ffi.f3?��___•—•_ •-•�•-•^•�—•_..— - .sass r•'-.c:..s.__.� IM __ �.+'.�_ S3 _.-•-sue..- � - NO LF _ a—•-� ter— _ -Ye�.t -^_--Ja3�IIS�SL�S � Jar:CS9^:E-_•R'iG6r� ice- C o `t \ a T C C O C o .d �2 O �+ cc > w : CNO i• H p M fV C 0. v X � 4w„ O y O �j '. O ` 3 N r- U R w o y �•l J O w C y Zz ui z Qto ectionLL �y ` O cn � F G7 � C pw .. 0 p a J Ono CLj � p v y G� ca E ar cpi 'C U C U rA � y N I, pip y v as U V � /+� rn J AC"R" CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DDlVYYV) `� 8/1/2022 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 Levitt Fuirst Associates. Ltd. NAME: Catherine Dolce 520 White Plains Road PHONE •914-457-4200 j=.Nor914-457-4.2.20 EIL Tarrytown NY 10591 ADDDDREESS: info@leviftirst.com INSURERS AFFORDING COVERAGE NAIL N INSURER A:Admiral Insurance Company24856 INSURED PERRVER-01 INSURER is:Accident Fund Insurance Compan ! 10166 Perry Verrone LLC 12 Center Street INSURERC: Pleasantville NY 10570 INSURER0. INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:1229745749 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. em LTRTYPE OF INSURANCE �ADDL SUBR POLICY NUMBER MP POLICY EFF POL DmYY LIIfrB A x COMMERCIAL GENERAL LIABILITY 937258902375890 7!112022 7/1/2023 EACH OCCURRENCE $1,000,000 AMAGE To CUNTED UMS MADE OCCUR PREM MIS EaEoccumance f 300,000 MED EXP Any one S 5,000 PERSONAL&ADV INJURY $1,000,000 GENL AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $2,000,000 X POLICY JECOT LOC PRODUCTS-COMP/OP AGG $2 000 000 OTHER: I $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT s Ea accident ANY AUTO BODILY INJURY(Per person) S OWNED SCHEDULED BODILY INJURY(Per accident) _ AUTOS ONLYPAUTOSONLY AUTOS I PROPERTY DAMAGE HIRED NON-OWNED HAUTOSONLY Per accident) I s _ S B UMBRELLA LAB X OCCUR 9073490723490 7/1/2022 7/1/2023 EACH OCCURRENCE $5,000,000 X EXCESS LIAB CLAIMS-MADE AGGREGATE $5,000,000 _ DED X RETENTION$in nnn $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY Y/N STATUTE ER _ ANYPROPRI ETO W'PARTNE Ib'EXECUTI VE OFFICER/MEMBER EXCLUDE D? ❑ N/A I E.L.EACH ACCIDENT $ (Mandatory in NH) E.L.DISEASE-EA EMPLOYE S If yes describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Certificate Holder and/or the entities listed below would be covered as an additional insured per attached endorsement.to the extent provided therein if required by written contract.on a primary non contributory basis on the general liability.Waiver of Subrogation applies. Primary and non contributory on the Umbrella Certificate Holder is included as additional insured when required by written contract 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. Village of Rye Brook 938 King Street Rye Brook. NY 10573 AD7HORIZED RE PfRE/SENTATIVE ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD YORK Workers' CERTIFICATE OF STATE Compensation NYS WORKERS' COMPENSATION INSURANCE COVERAGE Board 1a, Legal Name&Address of Insured(use street address only) 1b.Business Telephone Number of Insured 914-867-1747 Perry Verrone LLC DBA Perry's Roofing 12 Center Street 1 c.NYS Unemployment Insurance Employer Registration Number of Pleasantville,NY 10570 Insured 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 26-2754386 2. Name and Address of Entity Requesting Proof of Coverage 3a.Name of Insurance Carrier (Entity Being Listed as the Certificate Holder) Continental Indemnity Village of Rye Brook 3b.Policy Number of Entity Listed in Box"la" 938 King Street 46-884191-16 Rye Brook, NY 10573 3c.Policy effective period 03l01/2022 to 03/01/2023 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: Steven Diamond(President) (Print name of authorized representative or licensed agent of insurance carrier) Approved by: 02/28/2022 (Signature) (Date) Title: Licensed Insurance Broker Telephone Number of authorized representative or licensed agent of insurance carrier: 516-488-3040 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