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HomeMy WebLinkAboutBP22-184PERMIT # - Z DATE: U IXP: �® 3. SECTION /,S, #1 BLOCK / LOT TYPE OF WORK JOB LOCA ONV�PJI.--eT�-----T -- OWNER,Mn GZSP .a %rtiZ2A/ !" nlz s!VA iiiiii IF rd SA 0 m DATE FOOTING FOUNDATION FRAMING RGH FRAMING INSULATION PLUMBING CI RGH PLUMBING GAS O SPRINKLER ELECTRIC 0 LOW -VOLT ALARM AS BUILT FINAL EE FS FEE DATE INSP Z.5 /,Io 98/a C9/z/)77 o//7 3 OTHER APPROVALS • AS-BUILT/FINAL SURVEY REQUIRED PRIOR TO FINAL INSPECTION PCP/ ve �yE BR(�v� 193 tC VILLAGE OF RYE BROOK MAYOR 938 King Street, Rye Brook,N.Y. 10573 ADMINISTRATOR Jason A. Klein (914) 939-0668 Christopher J. Bradbury www.tyebrook.org TRUSTEES BUILDING& FIRE INSPECTOR Susan R. Epstein Steven E. Fews Stephanie J. Fischer David M. Heiser Salvatore W. Morlino CERTIFICATE OF COMPLIANCE December 28,2023 Afton Rosenfeld 56 Lincoln Avenue Rye Brook,New York 10573 Re: 56 Lincoln Avenue, Rye Brook,New York 10573 Parcel ID#: 135.41-1-7 Building Permit#22-184 issued on 10/4/2022 for a New Fence This certifies that the new four foot high aluminum safety fence along bridge,installed under the above captioned permit has been satisfactorily completed. Sincerely, Steven E. Fews Building& Fire Inspector /to E C EN E BUILD :BROOK, ENT For office a onl : J/ DDD PERMIT#Z �? VIL OK ISSUED:f(}-L/-a a DEC 2 8 2022 38 KING STRE YORK 10573 DATE:, O� FEE: 110.oO PAID�[i 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 #iiiiiii#tiiii►ik#ki#kfti4#it##tt#i#i##i#i#ti##it4ktttiitii#t#i#i#iiit■if#tittii#tii###i#iitifftitft R##itifiift#tttiifiii#ktt Address: t:�(Q L,I NCO(,t"� Ave Occupancy/Use: Parcel ID#: 126 .4t - 1 - 7 Zone: Owner: kkkCAAN, 12b5��-o Address: S(o LiKuLg Ave P.E./R.A. or Contractor: �Qrt'lm� �?�JlC.��t�(o C.a Address: CF Person in responsible charge: Ckaf2 SLtL2 Address: " N 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 Y��ORK, COUNTY OF WESTCHESTER as: N latp�(. R-VNG4N PC—(,17being duly sworn,deposes and says that he/she resides at 5tp 0 Ka(� M I✓ (Print Name of Applicant) (No.and Street) in (`�Pj �== ,in the County of yJt5(,,'T a�sTER— 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:$ 5660 n 'W , for the construction or alteration of: yo(JJ U� �etJG 1�9 FOL S A�6 PvW�� 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 '2Ji St Sworn to before me this day of R ,-XSk , 20 22 day of , 20 / 1 1 1 AI- Sitp&a of Property Owner Signature of Applicant Print Name of Property Owner Print Name of Applicant SONU PATES Y011K Notary Public NOTARY PUBLIC-STATE OF NEW Notary Public No.l)1PA5435573 Qualified in Queens County 8,12 2021 MY Commission Expires()ra 202f9 a2 1BUILDINGDEPARTMENT 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 : �" ° ( I l DATE' P L _ PERMIT# - ISSUED:�� CT: BLOCK: LOT: LOCATION: (.J i �j yw ENV `71 fe OCCUPANCY: ❑ Violation Noted THE WORK IS... ASSED ❑ FAILED 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>TAL PLUMBING ❑/CROSS CONNECTION �(] INAL �� OTHER QyE BRC�uk. Q�i� ��O•c 1982 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 : DATE: PERMIT# ISSUED: SECT: BLOCK: LOT: LOCATION: 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 a e z N w ■ I 00 N �.' v w ■ Nl \ \ w y �c F+y n a x a rA W a. �61 �� x �--� o o N w to Im ;4 Cu , U x a y O © o N ` as Ln l y �° Ca > ° ° A ■ 00 O F+� 1-4 V 4 ^ ; C%*4 z O '3 y m 3 °' w 00 x j w /'� C v�i p„ v O y A � w O � 114, �Q. co v z o a w of ■ �i ° �+ z O U� O o a V z 1.14 aum j 4 Cq F� cn T, W w � a � U a Q v o Cl) pq z O rn = zx z04 O c vdbo x "' aE v w y � z g O o ov v� 4v r" Z U y Zoe ,� q U dLLI Harz BUILD RTMENT p [, nU� VIL OF R ROOK 938 KIN � EET RYE B ,NY 10573 SEP — 7 2022 ], 14 39 r VILLAGE OF RYE BROOK BUILDING DEPARTMENT FOR OFFICE USE ONLY: Approval Date: SEP 2 2 2022 Poe It � ; Application#.- :Zoq Approval Signature: ARCHITECTURAL REVIEW BOARD vT Disapproved: : Date: BOT Approval Date: Case# Chairman: PB Approval Date: Case# Secretary: ZBA Approval Date: Case# Other: Application Fee Permit Fees: t FENCE / WALL / GATE PERMIT APPLICATION Application dated: 9'7-a-'*) is hereby made to the Building Inspector of the Village of Rye Brook,NY,for the issuance of a Permit for the installation,construction,repair or replacement of 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 the State Code. 1. Job Address: sr. A U E 2. Occupancy/Use: S.B.L.#: L -- Zone: — �- 3. Proposed Fence/Wall/Gate(describe in detail):f� 1061AWk nct-� © C' 4 Rf CO R X V U 0n e tJu M E ESN c r (a At'atJCo 2�900V__ 4. Property Owner: I&A ICH Ik e t— 120SC—M T C—L'D Address: S t L' &\j C p, Phone# Cell f - /8 Z email: MPG �OG1Uir�QkJGE4a�7 L�.Ltx� Applicant: 454Wt. A5 QUJMe1?n. Address: Phone# Cell # email: Architect/Engineer: KCAL ACC UAp4,0 SUQ_Qej(NCO Address: Phone# .3% 9S'7- 2-4oO Cell# ',, email:04ISU4NID5U12-U C.catM Contractor: IMl�1{It1 Ul Cat BCD �,,-c�)En Address& Phone: �19� 'D t N3 (�D. T'�' N� D C.T 0 G 9 U 3 5. If building is located on a corner lot,which street does it front on: 6. What is the estimated cost of construction 1500b. UU (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:M ON 20 Z?, 8112/2021 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 NIFW PORK,CO]JN�Y OF WESTCHESTER ) as: Wr Vu e Q5 C , 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_le�owner of the property to which this application pertains, or that (s)he is the for the le ea d 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 NAA's k , 20 22 day of , 20 Sign of Property Owner Signature of Applicant Print Name of Property Owner Print Name of Applicant A,-�F-- Notary Pu Notary Public SONU PATEL NOTARY PUBLIC-STATE OF NEW YORK No.01 PA6435573 Qualified in Queens County My Commission Expires 06-27.2026 811212021 Building Permit Check List&Zoning Analysis Address: eo C t, Aj T- SBL: I Zone: 2— t Z Use: V A G A h-►\Const.Type: N A Other. Submittal Date: cl L Z Z Revisions Submittal Dates: Applicant: ��S E�F��l� (7 40 �7 Nature of Work �-{ �� Q N L0 n.►G� Reviews:ZBA: S E P 7 2022 PB: BOT• Other. OK ( ( ) FEES:Filing. 7 5�,, BP: 00 C/O: Flood Plane: Legalization: APP: Dated: ✓ Notarized SBL: -- Truss I.D. Cross Connection: H.O.A.: ( ) ( ) Scenic Roads: Steep Slopes: Wetlands: Storm Water Review: Street Opening. ( ) ( ) ENVIRO:Long. Short Fees: N/A: ( ) ( ) SITE PLAN:Topo: SiteProtection: S/W Mgmt.: Tree Plan: Other. ( ) ( •SURVEY:Dated Z Current: ✓ Archival: Sealed: Unacceptable: ( ) ( ).,,PLANS:Date tamped Sealed Copies: Electronic: Other. (�► ( License Workers Comp:�ty Comp.Waiver. Other. ( ) ( ) CODE 7S3#: 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. 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. (4RB mtg.date: Z 2`_approval otes: ( )ZBA mtg.date: approval• notes: ( )PB mtg.date: approval• notes REQUIRED EXLSTING PROPOSED NOTES APPKU Afa ti te• SEP 2 2 2022 Circle: F%� Front Front Sides: R&ar. Main Cow. Accs.Cov F S S .HS • S�Fa Tot, I : Ft Imp: P HHight/Stories: notes: BUILD MENT D v v VIL OF RY OOK 938 KING ET RYE BR ,NY 10573 SEP - 7 2022 � 4)9 9-0 VILLAGE OF RYE BROOK BUILDING DEPARTMENT ARCHITECTURAL REVIEW BOARD CHECK LIST FOR APPLICANTS This form must be completed and signed by the applicant of record and a copy shall be submitted to the Building Department prior to attending the ARB meeting. Applicants failing to submit a copy of this check list will be removed from the ARB agenda. Job Address:��p ()NU kvl�� Date of Submission: Parcel ID#: Zone: 9/7/W:2,-)-,' Proposed Improvement(Describe in detail): 1Q5-MU , 1A UMWum (7CtJCi�j APPLICANT CHECK LIST: t� l �rr ii COP- --SR,�` , Mt!S7 C.- BE 011PLETED Bi' THE APPLICANT �" Y The following items must be submitted to the Building Department by the applicant -no exceptions. Property Owner: 1• (✓f Completed Application 2. ( )Two(2) sets of sealed plans. (one full size (maximum Address: 6 L( N C,cu( Me allowable plan size=36"x 42") and one 11"x 17") Phone# LSCo 1� 9 G1 -93 1 2 3. (v)'�Two(2)copies of the property survey. T- 4. ( (`Two(2)copies of the proposed site plan. Applicant appearing before the Board: 5. (l'One electronic/disc copy of the complete n I],�Is � �� application materials. 1Gl1Gt 6. (. Filing Fee. Address: 42g Dfr0 K-D • 7. (-4"Any supporting documentation. Phone# ✓4 77 77 4—00 8. ( ) HOA approval letter. ff applicable) 9. ( ) Photographs. Architect/Engineer: 6C,IEUCj--�Q q-y l Wo 10.( ) Samples of finishes/color chart. (a sample board or Phone#(�p�J�� ��j ^ Z4 model may be presented the night of the meeting) By signature below, the owner/applicant acknowledges that he/she has read the complete Building Permit Instructions& Procedures, and that their application is complete in all respects. The Board of Review reserves the right to refuse to hear any application not meeting the requirements contained herein. Sworn to before me this Sworn to before me this day of flU60s-h , 20 12 day of , 20 Si a of Property Owner Signature of Applicant )tihI ),I R o5e tx- e-\O Print Name of Property Owner Print Name of Applicant RiL -P- SONU PATEL Notary Pub NOTARY PUBLIC-STATE OF NEW YORK Notary Public No.01PA6435573 Qualified in Queens County My Commission Expires 06-27-2026 8/12/2021 BRnv� Village of Rye Brook Agcnd u�y� �� Architectural Review Board Meeting C.0.. ;+ Wednesday,September 21,2022 at 7:30 PM �j Village Hall,938 King Street 1. ITEMS: 1.1. #5741 (Consent Agenda)Re-Appearance Marilyn Ullman&Lena Vladsky 51 Greenway Lane&52 Greenway Lane New Arbors standard design fencing. 1.2. #5753 (Consent Agenda) Srikanth Ambad&Pranitha Mantrala 7 Talcott Road Rooftop solar array. 1.3. #5754(Consent Agenda) Marc Abramson&Erika Abramson 47 Hillandale Road 6'-0"high white vinyl fence in rear yard. 1.4. #5755 (Consent Agenda) Matthew Byrnes&Helene Byrnes 7 Deer Run New windows to facilitate interior bathroom renovation. 1.5. #5756 (Consent Agenda) Philippe Ledesma&Tonella Ledesma 7 Bell Place 6'-0" high white vinyl privacy fence along rear yard. 1.6. #5757 (Consent Agenda) Benjamin Tapper&Erica Tapper 4 Deer Run Rooftop solar array. 1.7. #5767 (Consent Agenda) Pawling Holdings LLC 261 North Ridge Street New stone and clapboard siding. 1.8. #5768 (Consent Agenda) Ann Parkin&Jody Rasch 25 Hillandale Road Rooftop solar array. Page 1 of 4 1.9. #5769 (Consent Agenda) Michael Rosenfeld&Afton Rosenfeld Lincoln Avenue 4'-0"high aluminum fence along bridge. /1.10. #5771 (Consent Agenda) Blake Silverman&Alexa Silverman 18 Milestone Road 4'-0"high fence in rear yard along BelleFair Boulevard and 4'-0"high fence in side yards. Consent Agenda n Approvals: Motion A L Second \"CK—N Abstention Aye; — \ Nay; C Adjournment; Notes 1.11. #5758 Blake Jacoby&Paula Jacoby 16 Elm Hill Drive Rear deck and hot tub. Approvals: Motion Second Abstention Aye; Nay; Adjournment; Notes 1.12. #5759 Michael Seidenfeld&Daniella Schneider 5 Jacqueline Lane Rear patio&retaining wall. Approvals: Motion Second Abstention Aye; Nay; Adjournment; Notes 1.13. #5760 Daniel Debari&Catherine Debari 11 Elm Hill Drive One-story addition. Approvals: Motion Second Abstention Aye; Nay; Adjournment; Notes Page 2 of 4 gn/22,12:52 AM Products-Fencing Products L Contact: 888-365-1920 0 Online Support: sales@fencingdirect.com Account - V?My Cart-0 items F7j FENCING DIRECT Home / Products / 4' H x 6' W Bradford Aluminum Fence Panel Black 4' H x 6' W Bradford Aluminum Fence Panel Black BA73002245 2 $118.66 (You Save 30%) https://wwwfenci ngdi rect.com/products/detail/4-h-x-6-w-clarian-al u minu m-fence-panel-black 1/14 N C c� U 1 � ° � T tt g U o �► e N S N c y QOF O f oLO , Eu u C C �s ug C Q or / 1 T u - l U) I AE. O W IL a w in Li ^ O H R E y W CE g O m a W a� V O co = 3 � CL 2 a o q 0 it 0 0-4 CL ` E V $ "a O <= it • t� V W �_ , o E o \ Ln q U \ r _ — - -- --- -- • Aco d CERTIFICATE OF LIABILITY INSURANCE DATE(MM DD YYY II 03/02/22 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(ias)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 endorsements. PRODUCER CONTACT EACT TONY CIRINO Anthony Cirino PHONE (860)329-0103 FAX No. 860 120-0504 _LA426 North Main Street .1L • Inaguy9laol.corni Southington,CT 06489 ___ INSURE AFFORDING COVERAGE NAIC 0 INSURER A: FARM FAMILY CASUALTY INSURANCE OIOE•1�Ep a1SURED INSURERS: OPTIMUM BUILDING CORP INSURER C: 70 PROSPECT STREET INSURERD: INSURER E PORT CHESTER,NY 1 573 NY 10573 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. e/iR TYPE OF SISURANCE ��� POLICY EFF POLICY EX►LTR - - LNR>t - X COMMERCIAL GENERAL LMSIUry EACH OCCURRENCE { 1,000,000 CLAIMS-MADE a OCCUR PREMISES Ea okEccrrren f 100 000 _ MED EXP Wy one person f S 000 A Y Y 3101 L6417 02/01/22 02/01/23 PERSONAL a ADv INJURY s 1,000,000 GENN'L AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE f 2,000,000 X POLICY�:]PE T LOC PRODUCTS-COMP/OP AGO i 2,000,000 OTHER : AUTOMOBILE LIABILrrY COMBINEDt)SIRUMTW Me acciden —ANY AUTO BODILY INJURY(Per person) f OWNED F 1 SCHEDULED AUTOS ONLY AUTOS BODILY INJURY(Peraccldartt) S HIRED NON-OWNED PROPERTY DAMAGE : AUTOS ONLY AUTOS ONLY UMBRELLA LIAR OCCUR EACH OCCURRENCE f _ EXCESS LAB CLAIMS#IADE AGGREGATE : DIED RETENTION = WORKERS COMPENSATION77 AND EMPLOYERS'LIABILITY YIN ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT = OFFICERIMEMBER EXCLUDED? NIA (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE : It yes deswbe under DESCRIPTION OF OPERATIONS ONOw E.L.DISEASE-POLICY LSAT DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES(AGGRO 101,AddlUorral Remarks Schedule,may be attached N mom space Is rpulred) VILLAGE OF RYE BROOK IS INCLUDED AS ADDITIONAL INSURED ON GENERAL LIABILITY CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE VILLAGE OF RYE BROOK THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 938 KING STREET ACCORDANCE WITH THE POLICY PROVISIONS. 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 NYSIF New York State Insurance Fund PO Box 66699,Albany,NY 12206 1 nysif.com CERTIFICATE OF WORKERS' COMPENSATION INSURANCE (RENEWED) a a A A A A A A 133887956 OPTIMUM BUILDING CORP 429 DEN RD a 429 DEN ROAD STAMFORD CT 069033811 SCAN TO VALIDATE AND SUBSCRIBE POLICYHOLDER CERTIFICATE HOLDER OPTIMUM BUILDING CORP VILLAGE OF RYE BROOK 5 BEECHWOOD BLVD 938 KING ST RYE BROOK NY 10573 RYE BROOK NY 10573 POLICY NUMBER CERTIFICATE NUMBER POLICY PERIOD DATE W1478 260-1 814417 04/09/2022 TO 04/09/2023 4/12/2022 THIS IS TO CERTIFY THAT THE POLICYHOLDER NAMED ABOVE IS INSURED WITH THE NEW YORK STATE INSURANCE FUND UNDER POLICY NO. 1478 260-1, COVERING THE ENTIRE OBLIGATION OF THIS POLICYHOLDER FOR WORKERS' COMPENSATION UNDER THE NEW YORK WORKERS' COMPENSATION LAW WITH RESPECT TO ALL OPERATIONS IN THE STATE OF NEW YORK, EXCEPT AS INDICATED BELOW, AND, WITH RESPECT TO OPERATIONS OUTSIDE OF NEW YORK, TO THE POLICYHOLDER'S REGULAR NEW YORK STATE EMPLOYEES ONLY, IF YOU WISH TO RECEIVE NOTIFICATIONS REGARDING SAID POLICY,INCLUDING ANY NOTIFICATION OF CANCELLATIONS, OR TO VALIDATE THIS CERTIFICATE,VISIT OUR WEBSITE AT HTTPS:IIWWW.NYSIF.COM/CERT/CERTVAL.ASP.THE NEW YORK STATE INSURANCE FUND IS NOT LIABLE IN THE EVENT OF FAILURE TO GIVE SUCH NOTIFICATIONS. THIS POLICY DOES NOT COVER CLAIMS OR SUITS THAT ARISE FROM BODILY INJURY SUFFERED BY THE OFFICERS OF THE INSURED CORPORATION. CHRISTOPHER SCELFO-PRESIDENT OPTIMUM BUILDING CORP ONE PERSON CORPORATION THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS NOR INSURANCE COVERAGE UPON THE CERTIFICATE HOLDER THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICY, NEW YORK STAT SU NCE FUND T �V DIRECTOR,INSURANCE FUND UNDERWRITING VALIDATION NUMBER:918570676 U-26.3 SYMBOL—END ZIT n Il ;q A` A_45000 <- 05_--z y DW gOAE E '°-�°"� MEAD y 45000 5- .!, B o bl 1 h LL 1,B I N U _ U9 Ng5•00 q� ``�•� R f99>'1' "" j/_ zrzi-�---------- - ��� — — — --— —-x� — — F a SB4'S1'00"W 263.91" ' -- �I ; FILE COPY E FOUND MON iH i'n'SHO'36 40'N R a,��/ 61�O PERCH} yr �b DAIEAPPRO�EFZ�"7Qf p yO'o ryl NIItPN6 0. •MNwaWN/ - k\o��_ 'bSo hA v�eBe of Me�roox to " _____� "✓q. 9oaq - y�00 S84°0>'00"W F4.33' 4 � ApprovalU Y CAalrman ate �O � C3 14.I D- WESTERLEIGH ROAD SILDING CIIF w >oz a s_a Bi OF RYE BROOK O DEPARTMENT a >3u k q3 RUILTIFiNAL. 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