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HomeMy WebLinkAboutBP19-004PERMIT # 13D JP700qDATE: 1114JICI SECTION , 7 �� BLOCK LOT `(D TYPE OF WORK I nwYni/ QPJ1nVr✓( OY)S JOB LOCATION - I r) i r'n++ ry nr�nl T. COST O # TCO # FOOTING FOUNDATION FRAMING RGH FRAMING _ INSULATION PLUMBING RGH PLUMBING GAS F1 SPRINKLER ELECTRIC LOW -VOLT ALARM CM AS BUILT p 0\ �FllyfLrS„v " r t rI , FEE DATE INSPECTION RECORD DATE INS P HIM Is s+ AM ` anfi�-Q la I8CD-a i g- 5445q 5�3s 3.5`U:�o �P Iq—Oo�lS/I.1.G Plvmbil-x�ax�-H��g macl()7 osr� OTH R APPROVALS I ARB BOS PB ZBR OTHER P r4ea1?!vA'jj c 4� Open Permit Letter Sent I�/13/lq VILLAGE OF RYE BROOK WESTCHESTER COUNTY, NEW YORK No: 23-17 Certificate of ®ccup ucp Xhis is to certify that Sy-) k-an 44—) OMbCt4i ! &anJ+)a W G ntYa 1 ot of, QW 9Y60Y-1 having duly filed an application on CP_mJ2-er o2 ) zo o requesting a Certificate of Occupancy for the premises known as, / IDIco4 Rood , Rye Brook,NY, located in a —l Zoning District and shown on the most current Tax Map as Section: ' Block: ) Lot: and having fully complied with the requirements of the Building Code and the Zoning Ordinance under Building Permit No.I - , issued 20 , such authority and permission is hereby granted to the property owner to lawfully occupy or use said premises or building or part thereof listed under the following New York State Classifications, Use: L - /2�m / X Construction: for the following purposes: I n 4 i�?x)G r e n o Va,+1 G r s Subject to all the privileges, requirements, limitations, and conditions prescribed by law, and subject also to the following: This certificate does not in any way relieve the owners or any person or persons in possession or control of the premises, building,or any part thereof from obtaining such other permits or licenses as may be prescribed by law for the uses or purposes for which the building or premises is designed or intended. Furthermore, it does not relieve such owners or persons from complying with any lawful order issued with the object of maintaining the premises or building in a safe and lawful condition. No changes or rearrangement in the structural parts of the building or in the exit facilities shall be made, and no enlargement, whether by extending on any side or by increasing in height shall be mad or shall the building be mo from one location to another until a permit to accomplish such change has been o d fro the Building Ins NOV - 6 2023 Building Inspector,Village of Rye Brook: Date: I D E C E��/] �7 For officMU, n, ,/v BUILD MENT PERMIT —evVIL OF RYE OK ISSUED:DEC 21 2022 09 38 KING STRE YE BROOK, YoRK 10573 DATE: / 9 -06 O-c FEE:4_ 3;5— PAtta,lQ 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 tkfk4►ftt►tittttii►Rtili►ttfllRi#lkikttkkk►tkkt#ftR►►tittt►►tii►i►f ttttiitikRk4#Rt4►kRk4ktkkkkRki#tfftRtftRtRttifR♦RtiR►►lift Address: 7 T-A L cc,-T T e R 4 F /1 k o o I.4 73 Occupancy/Use: lG�AY Parcel ID#: ���t 5s, Zone: -��- Owner: C.r,'ka,,LA: Address: 7 -F"rt- k.( &40 4y,fl4_ N�io L79 P.E./R.A. or Contractor: PACs I P „���T 4&)p Address: 5 5 L Ake/ Yt ,A,,,— Ny /soy Person in responsible charge: ►lci Ari u F u i eooy ) 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: St MCa-.,t� f}w.�,(.� being duly swom,deposes and says that he/she resides at '7 TaA cAr R-A (Print Name of Applicant) (No.and Street) in "a. Qronk ,in the County of l..Iri0f-cA041z:: in the State of A,that t( iih'lo%%n/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 0.o o D , for the construction or alteration of: T�Le„f&-1 4j 0 rk 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 Sworn to before me this day of [ i—� , 20 2 2-- day of , 20 h/ Signature of Property Owner l Jc�rv�t aiJ Signature of Applicant Pri t Na e f Property Owner Print Name of Applicant DA ryIWEW Notary Public Commission No. 01 ES6442995 NOTARY PUBLIC State of NY Commission Expires 10/24/2026 QyE BR(��. O� 2m cu � 1982 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: U` l� DATE: f �� PERMIT# �l\ I�1 ^ \ ISSUED: I I SECT: BLOCK: LOT: 14 LOCATION: CV ` ��� -l` OCCUPANCY: ❑ Violation Noted THE WORK IS... Q' PASSED ❑ FAILED REINSPECTION ❑ SITE INSPECTION �,' o` 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 P' INAL f ] OTHER 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 : A `�`"( DATE: PERMIT# ISSUED: 1 SECT: BLOCK: LOT: LOCATION: , \ 'i �J `�J 4,7 , ~OCCUPANCY: ❑ Violation Noted THE WORK IS... ❑ PASSED 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 / ❑ FINAL PLUMBING C A (, ❑ CROSS CONNECTION ` /,\ ❑ FINAL ❑ OTHER i C kC �;;C� �yE BRC�v� o`` tim '9b2 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: �A 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 I ❑ L.P. GAS I , ❑ FUEL TANK ❑ FIRE SPRINKLER ❑ FINAL PLUMBING ❑ CROSS CONNECTION ❑ FINAL ❑ OTHER 00 N M ( ] N N oC i N N W N N(14 Tr z . F x v Q � xU y kCNU S N a 0. W ~ o U z a cis x UCL ►"' a0 u CL O `r' a F• \ L w � , Q z a w � � � W N j w < - w/ > 00 Lo 00 OR Z z wLn 0-4 w , O w z a u o w � ' ' O w = z z o x w $ z v� re E� a W u I z h+y ~ Z � � M z x W W '. CN 00 IL a x iAo V w v 0 0 og CAI. d " L V P U O W z a c x z w z a ° � � � w c��E' dRnv� BUILIi&d E "TMENT NOV 2 9 2022 VILLAGE OF RYE BROOK 938 KING STREET RYE BRtozk,NY 10573 VILLAGE OF RYE BROOK (914)939-0668 BUILDING DEPARTMENT wwW.rydgook.org ELECTRICAL PERMIT APPLICATION Westchester County Master Electricians License Required Ql FOR OFFICE USE ONLY BP#: 1 % oc) / EP#: Approval Date: Permit Fee: $ ��L/ f b Approval Signature: Other: 7,; 7,;?-7#s Application dated, / hereby A&to the Building Inspector of the Village of Rye Brook NY,for the issuance of a Permit to install and/ r remo a electrical equipment,wiring, fixtures, or to perform other high or low voltage electrical work as per the detailed statement described below. By signing this document, the applicant & property owner agree that all electrical work performed will be in conformance with all ap licable Federal,State,County and Local Codes. 1.Address: SBL: �� ��— Zone: 2.Property Owner::/ 5F Address: Phone#: Cell#: email: 3.Master Electrician: Address: Lic.#:/S53 Phone#: Cell#: email: Company Name: LZ 1� j l Address: 4.Proposed Electrical Work/Fixture Count: e-(-/I z 5.31 Party Electrical Inspection Agency: STATE OF NEW YORK,COUNTY OF WESTCHESTER ) as: being duly sworn,deposes and states that he/she is the applicant above named,and does further (print name of individual signing as the applicant) state 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.) The undersigned further states 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 Sworn to before me this day of ,20 day of ,20 l Signature of Property Owner 8 u ture.of Ap h t Print Name of Property Owner Prmt Name of Applicant Notary Public Notary Public 6n3n022 STATE WIDE INSPECTION SERVICES, INC.: 0 Service With Integrity 0•0 • • SWIS • : APPLICATION tel 8145.202.7224 1 fax 914.219.1062 1 SWISNY.coml SWISTRAINING.COM Office Use Elect. Permit# _� �; Date ' ;^'- Bldg Permit# l`. C?_ Sg Ft Plumbing Permit# Final Certificate# City/Village j� ` - /� Zip .t�- - Building Dept. County P ;l Address ,`` / 'T / Cross Street Section Block Lot Owner Name/Address(If different than above) Contact Number ❑Basement ❑1st A. ❑Znd Fl. ❑3rd Fl. ❑More Than 3 Fl. ❑Garage ❑Attic ❑Outside ❑Residential ❑Commercial Receptacles Special Recept GFCI AFCI Switches Dimmers Smoke Alarms C/0 Detector Hood Trash Compact Amt Amps Range(s) Cooktop(s) Oven(s) Dishwashers Refrigerator Disposal Microwave Luminaires Generator Transfer Switch SERVICE Amperage #Panels 1P 3P I-#- Meters # Djsconnect ❑Underground ❑ New ❑ Reconnect ❑ Repair ❑Overhead JEl Upgrade ❑ Disconnect Utility ID# ❑Con Ed ❑ NYSEG ❑Central Hudson ❑ Orange/Rockland PHOTOVOLTAIC SYSTEM PV Modules Inverters AC Disconnect Junction Box Combiner Box Load Center PV Monitor Energy Storage System DC Disconnect ❑Legalization ❑ Safety Inspection ❑Consultation D !NOV 2 9 2022 I / A r -jl E /lJ rVILLAGE OF RYE BROOK BUILDING DEPARTMENT /r This application is valid for one(1)year from the date received by SWIS.This application is intended to cover the above listed items to be inspected,if at anytime of inspection additional items have been installed,you are authorized to make the inspection and adjust the fee for the additional items inspected.The applicant declares that there is no open applications for the above address with any other inspection company.The applicant, owner or authorized agent agrees to all the above terns and conditions as set forth for the application. Email Address J' ",' i Name ) License# C 3 Date,j__ - �? Signature r� Address ;! C �t� l�/ City/State Zip Code Phone#Company RDDState Wide Inspection Services Ck� 1080 Main Street �AN — 3 2023 Fishkill, NY 12524 a 845 202-7224 Phone 447VILLAGE OF RYE BROOK 914-219-1062 Fax STATE WIDE INSPECTION SERVICES r BUILDING DEPARTMENT Email: office@swisny.com Website: www.swisny.com Service With Integrity BY THIS CERTIFICATE OF COMPLIANCE STATE WIDE INSPECTION SERVICES CERTIFIES THAT: Upon the application of: Upon Premises Owned by: Macintosh Electric Srikanth Ambati & Pranitha Mantrala 595 Nepperham Avenue 7 Talcott Road Yonkers, ny 10703 Rye Brook, NY 10573 Located at: 7 Talcott Road, Rye Brook, NY 10573 Section: Block: Lot: Electrical Permit Number: EP 22-286 135.58 36 Certificate Number: 2022-8278 Building Permit Number: BP 19-004 A visual inspection of the electrical system was conducted at the Residential occupancy described below.The electrical system consisting of electrical devices and wiring is located in/on the premises at: 7 Talcott Road, Rye Brook, NY 10573 The First Kitchen, Bathroom, and Second Floor Bathroom were inspected in accordance with the NYS and NFPA 70-2017 and the detail of the installation,as set forth below,was found to be in compliance on the 15th day of December 2022. Name Quantity Rating Circuit Type Kitchen AFCI/GFCI 06 Dishwasher 01 Microwave 01 Hood 01 Stove 01 Switches 02 Recessed Luminaires 06 Name Quantity Rating Circuit Type Bathrooms GFCI 03 Switches 05 Luminaires 07 Officer: Frank J. Farina This certificate may not be altered in any way and is validated only by the presence of a seal at the location indicated.This certificate is valid for work performed on the date of inspection only. Page 2 t- t 4147;47;tj t-j t- lS Ln • • 'Z5 kn fn Ono io z ZW. >1 0 a � a Z 10 z 12 C4 2 W >- 3 g uj WJ --. Q fn - tn cc co 00 u 00 �= 0 � � a w o � o � F' (A C6. BUILD;bE MENT VIL E OF RYE �J K E - 4 2018 938 KIN LT RYE B ,NY 10573 (914)9 939-5801 VILLAGE OF RYE BROOK wSM or BUILDING DEPARTFAENT ELECTRICAL PERMIT APPLICATION Westchester County Master Electriciansd License Require 19 .../� FOR OFFICE USE ONLY BP#: 1 q —c-)&4_ FP#: 1 VD�s Approval Date: Z- Permit Fee: $ Approval Signature: Other: Disapproved: (fees are non-refundable) ***************************** ******************************************************************* Application dated, is hereby made to the Building Inspector of the Village of Rye Brook NY, for the issuance of a Permit to install and/or remove electrical equipment,wiring,fixtures,or to perform other high or low voltage electrical work as per the detailed statement described below. The applicant & property owner, by signing this document agree that all electrical work performed will be in conformance with all applicable Federal,State,County and Local Codes. 1.Address: 7 TA I cd-f-t- P- > - SBL: Zone: 2.Property Owner:5/i k A n1 A 4m b Af r- Address: 7 'Ti41 C e-ft ,2a Phone#: 796- 2f8- Syo Cell#: $04 -1 E email: Sri*kAN"AM64li rQ 67 W-4 Y.eow/ 3.Master Electrician:l'haLE Mt. - 66h Address: Sd y I�iMb#4I1 �. ` eo j ke eS, NY/0/b( Lie.#: /S53 Phone#:9/f'- q76- /�6?(/ Cell#:Ty-7G0-6465 email: INFo Q M,4ei1,l405Lrle---&i Cear/ Company Name: M A c i rtJ6S 6 E(t!C f, c Cog. Address: S6 y Ay;4f1bq// /f t ot, Yong kce5, NY 16 y 4.Proposed Electrical Work/Fixture Count: P-P Q l o C E E IP e i C is L-),- 1 i'c e s I N K, e-L.2 t1l . ke lQ 61 C E R e to- .+ t T)r- (it'ir t5 ry R, 7%eoo,,Le #�. ********************************************************************************************************* STATE AO'F NEW YORK,COUNTY OF WESTCHESTER ) as: J�haLc h I_l ft&f(L 5 k ,being duly sworn,deposes and states that he/she is the applicant above named,and does further (print name of individual kjning as the applicant) / state that(s)he is the legal owner of the property to which this application pertains,or that(s)he is the C/e e "e Al Oa64MCIOA for the legal owner and is duly authorized to make and file this application. (indicate architect.contractor.agent,attomcy.etc.) The undersigned further states 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 Sworn to before me his day of trJ Z 20�_ day of I n0 Signature of Property Owner Signature of Applicant Sir kA�l+h Amfbek-/* - Print Name of Property Owner Print Nam o Applic _ 9w, ARLENE A HENh Notary Public WTAR1'PUBLIC STATE�N , u Ilc wPA c.I M LIC.#01 HE61873M NI>ta&y OI _ 003M 1Y• COMM. w+ `« Z Z P 05/19/26�Y� Z(1 l'On"Wom t- Ise. �MMISSION IN IbE:,,TC fiM '� Westchester Rockland Electrical Inspection Services, Inc. y Phone: 914-347-3 95 DO NOT WRITE HERE-FOR OFFICE USE ONLY 43 North Lawn Avenue Fax: 914-347-3596 Elmsford, NY 10523 `I` BUILDING PERMIT NO. jb TEMP# DATE CITY OR VILLAGE ZIP CODE TOWNSHIP COUNTY STREET AND NO.OR ROAD /Q / O�. ^ POLE NUMBER BETWEEN WHAT TWO CROSS STREETS IS PREMISES`LOCATED? ,/`/ SECTION BLOCK LOT OCCUPANT'S NAME BUILDING OCCUPANCY OWNER'S NAME AND ADDRESS HOME TELEPHONE NUMBER CURRENT SUPPLIED BY FROM THEIR OFFICE WORK TELEPHONE NUMBER LIST BELOW ALL EQUIPMENT WHICH YOU INSTALLED NUMBER OF OUTLETS NO.OF FIXTURES& MOTORS -"" USE LOCATION LAMP RECEPTACLES r ,. N Y LL�I� � SIDEWALL SWITCH INCADE FLUORE NO. H.P. .l tlAC\ L-- I TION OUTSIDE BASEMENT I'FL. AGE DF RYE BROOD 2'FL. BUILDING DEPARTMENT 3-FL. REMARKS:LIST OTHER ELECTRICAL DEVICES NOT SET FORTH ABOVE: J16Q�e THIS APPLICATION IS INTENDED TO COVER THE ABOVE LISTED ITEMS TO BE INSPECTED.IF AT ANY TIME OF INSPECTION ADDITIONAL ITEMS HAVE BEEN INSTALLED,YOU ARE AUTHORIZED TO MAKE THE INSPECTION AND ADJUST THE FEE FOR THE ADDITIONAL ITEMS INSPECTED AS PROVIDED BY THE APPLICANT.THE APPLICANT DECLARES THAT THERE IS NO OPEN APPLICATIONS FOR THE ABOVE WITH ANY OTHER INSPECTION COMPANY.WREIS,INC. IS NOT LISTING,LABELING,UNDERWRITING OR CERTIFYING ANY EQUIPMENT, MATERIALS OR DEVICES WHICH ARE PERFORMED BY OTHER CERTIFIED TESTING AGENCIES OR INSPECTION COMPANIES.THE APPLICANT,OWNER,OR AUTHORIZED AGENT AGREES TO ALL THE ABOVE TERMS AND CONDITIONS AS SET FORTH FOR THE APPLICATION. SIZE OF SERVICE FEEDERS CHARACTER OF WORK NEW❑ ADDITIONAL❑ EXPOSED❑ CONCEALED❑ MUST ENTER APPLICANTS IDENTIFICATION NUMBER SERVICE ENTERS BUILDING OVERHEAD❑ UNDERGROUND L L—L] I I I I AVOID DELAYS BY GIVING FULL AND ACCURATE INFORMATION.ALL SPACE MUST BE FILLED IN OR APPLICATION MAY BE RETURNED. PP�ldc r NAME OF C SIGNAT_URE:OF A COMPANY DATE OF APPLICATION - STREET ADDRESS TELEPHONE NO. Cr"OR POST OFFM LICENSE NO.WHEN APPLICABLE e N = 0 F- C w "' U ►� a 40 co 00 ►�1 � M ��� � u W Z O ^^ M Ca 0 = M••I � � � .. a � U � w j � Q Lr A � a BUILDING DEPA.R/TMENT VILLAGE OF RYE ''� OOK D - C E 938 KING S*EET RYE BROQK,NY 10573ID (914)93046 AX-($W, 939-5801 FED 2 1 2019 wwlvh��o. .org PLUMBING PERMIT APPLICATION VILLAGE OF RYE BROOK PARTMENT FOR OFFICE USE ONLY BP#: J J—Cc+ PI'#: Approval Date: F EB 2 12019 Permit Fee: $ I (� Approval Signature: Other: Disapproved: (fees are non-refundable) Application dated, is hereby made to the Building Inspector of the Village of Rye Brook NY, for the issuance of a Permit to install and/or remove Plumbing as per detailed statement described below.The applicant&property owner,by signing this document agree that said plumbing work will be in conformance with all applicable Federal,State,County and Local Codes. 1.Address: "7 __rALCU7f 2 A SBL: l3S�,��1. 3�one: 2.Proposed Work: 1?-E/1t4GE �� t .U�s �%/XrBl2 FS �f� /, .�CIrUfE"i i Z'Ce XL 11:4LfSI- : M ACP 12CV &#- V 644-b FS , SE T GoG+7'jW C,. 1' 3.Property Owner: sr1 Icgn}k Am"' Address: *7 Tic / Phone#: /�/`�' SJ 3-Sj?�- Cell#: email: PI'e m ie 1 i rdu5`MYLo�t` `gC'f�r`S�� � 4.Master Plumber: Address: _41 Z Lic.#: JZ� Phone#. Cell#: ?) -60#Z email: I �4► u o LO��,/ Company Name: L 1* PLu µf 8 /Y79- Address: F Z G,T/ Staww' INDICATE FIXTURES& LINES TO BE INSTALLED AS PER THE FOLLOWING SCHEDULE: Location Water Urinals Drinking Sinks Showers Bath Laundry Domestic Fire Sanitary Natural/ Other* Total Closets Fountains Tubs Tubs Service Service Sewer LP Gas Basement 1 st Floor I 2nd Floor 3rd Floor 4 Floor 5 Floor Exterior 5.* List Other Equipment/Provide Details: Notarized Signatures Required Next Page -I- 6/1/18 STATE OF NEW YOORK,COUNTY OF WESTCHESTER ) as: � �E.u« C97.oSSo'►')iWt� ,being duly sworn,deposes and states that he/she is the applicant above named, (print name of individual signing as the applicant) and fiurther states that(s)he is the legal owner of the property to which this application pertains,or that(s)he is the S�P(�l�lvV1 for the legal owner and is duly authorized to make and file this application. (indicate architect,contractor,agent,attorney,etc.) That all statements contained herein are true to the best of his/her knowledge and belief,and that any work performed,or use conducted at the above captioned property will be in conformance with the details as set forth and contained in this application and in any accompanying approved plans and specifications,as well as in accordance with the New York State Uniform Fire Prevention&Building Code,the Code of the Village of Rye Brook and all other applicable laws,ordinances and regulations. By signing this application,the property owner further declares that he/she has inspected the subject property,and that to the best of his/her knowledge there are no roof drains, sump pumps or other prohibited stormwater or groundwater connections or sources of infiltration into the sanitary sewer system on or from the subject property. S 1" Sworn to before me this Sworn to before me this day of /0 0 E C ,20 6 day of `t ,20 L 44� --`—Z� Signature of Property Owner ignature of Applicant Print Name of Property Owner Print Name of Applicant Notary Public otary u lic Rkd C.Uas ALEXANDRA H.FRANK KY. Notary Public,State of New Yaks Quamed in ZL No.01FR6363731 r.r,7vr'-"—FIOMS Qualified In Westchester County Commission Expires A49ust 2$1 20 This application must be properly completed in its entirety and must include the notarize slgna ure(s)of the legal owner(s)of the subject property, and the applicant of record in the spaces provided. Applications not properly completed in its entirety and/or not properly signed shall be deemed null and void and will be returned to the applicant. -2- 6/1/18 BUILDING DEPARTMENT D lam- (C IE � V IE VILLAGE OF RYE BROOK - DD 938 KING STREET RYE BROOK,NY 10573 FEB 21 2019 (914)939_ b$ 9 39-5801 �. VILLAGE OF RYE BROOK PING-DEPARTMENT x*;x�xxxxx*��;x����*�*��;�xx�,�x*;xxx�xxx*xx,�xx�*�+►«**�**�*x*,��***;**x�**************�******�******�**** AFFIDAVIT OF COMPLIANCE VILLAGE CODE §216 ESTORM SEWERS AND SANITARY SEWERS THIS AFFIDAVIT MUST BEAR THE NOTARIZED SIGNATURE OF THE LEGAL PROPERTY OWNER AND BE SUBMITTED ALONG WITH ANY BUILDING OR PLUMBING PERMIT APPLICATION. ANY BUILDING OR PLUMBING PERMIT APPLICATION SUBMITTED WITHOUT THIS COMPLETED AND NOTARIZED FORM WILL BE RETURNED TO THE APPLICANT. STATE OF NEW YORK, COUNTY OF WESTCHESTER ) as: �j M Ia'k , being duly sworn, deposes and states that (s)he is the applicant (Print name) above named, and further states that (s)he is the legal owner of the property to which this affidavit pertains at, T0. l C 5-r+ 2 d , Rye Brook,NY, (Address) or that (s)he is the, A&f W&'L for the legal property owner, (Indicate architect.agent.attorney.etc.) and is duly authorized to make and file this affidavit. 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. (Signaunv of PropcilN Owner) Signature of Applicant) (Print Name of Property Owner) (Print Name of Applicant) Sworn to before me this Sworn to before me this d'��SF day of /0 OC c , 20/$ day of &LLA i , 20�_ (Notary Public) otary Public) RdwINoRJ�IUCANO�Y. QUWAALEXANDRA K FRANcoq)hCll!) Con.nkakr„ MR L" Notary Puft,Stab of Now York No.OIFR6363711 QuOIW#od In Weddwabr copy Commission EWM AWW 28,ZQ24 11/16/18 Article II: Sanitary Sewers [Adopted 2-13-2018 by L.L. No. 3-2018] § 216-15 Removal of illegal connections or discharges to sanitary sewer. A. No person shall discharge or cause to be discharged any nonsanitary substance, including but not limited to, stormwater, surface water,groundwater roof runoff, subsurface drainage, cooling water, air-conditioning and refrigerating wastewaters or unpolluted industrial process water or other similar discharge or entry into the sanitary sewer system. Any existing connection or discharge resulting in a nonsanitary discharge to the sanitary sewer system shall be terminated. B. Prior to any final decision from the Building Department on any plumbing permit or building permit application for a one-or two-family residential dwelling unit,the property owner shall submit a sworn affidavit to the Building Department stating that to the best of the property owner's knowledge, after the property owner's inspection of its property,there are no roof drains, sump pumps or other prohibited stormwater or groundwater connections or sources of inflow or infiltration on the subject property. This section shall not apply to applications for a building permit for work that is not being performed to the dwelling unit. C. Prior to the issuance of the certificate of occupancy,the Superintendent of Public Works/Village Engineer or Building Inspector shall be permitted to enter and inspect the premises and all structures to determine compliance with this section. If an applicant has security measures in force which require proper identification and clearance before entry into its premises,the applicant shall make the necessary arrangements to allow access to the Superintendent of Public Works/Village Engineer, Building Inspector or authorized designee. It shall be a violation of this chapter to refuse to grant the Superintendent of Public Works/Village Engineer, Building Inspector or authorized designee access to the premises.No certificate of occupancy shall be issued until such inspection has occurred. D. Except as provided in Subsection F below, any illegal connection or discharge into the sanitary sewer system shall be remedied by the property owner and reinspected by the Superintendent of Public Works/Village Engineer or Building Inspector within 30 days of the issuance of any inspection report which states that the structures or property contains an illegal connection or discharge into the sanitary sewer system. Any remedial work must be performed by a licensed plumber pursuant to a permit issued by the Village. A certificate of occupancy shall not be issued until any illegal connection or discharge has been remedied to the satisfaction of the Superintendent of Public Works/Village Engineer or Building Inspector. E. Any building permit application for construction of a new house or teardown(as defined in§ 250-2) shall require relining of any existing sewer lateral or replacement of the existing sewer lateral with a new sewer lateral to its connection with the sewer main. F. It shall be a violation of this chapter for any person to reconnect roof drains. sump pumps or any other source of prohibited stormwater and/or groundwater discharges to the sanitary sewer system and/or to construct or alter a lateral or other sewer line in such manner as to cause infiltration or inflow to the sanitary sewer system. BUILD ENT VI E O:FR OK 938 KING �`�ET R NY 10573 (914)91 � BRINY ry AFFIDAVIT OF COMPLIANCE VILLAGE CODE &216 ESTORM 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 FOFN WILL BE RETURNED TO THE APPLICANT. STATE OF NEW YORK, COUNTY OF WESTCHESTER ) as: n residing at, 7 'TA L co'7 T Q-O (Print name) (Address%+here 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; 7 TA L c©TT , 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. L� '_1 (Signature of Pro(xrtN Owner(s) Wrint\amC 01 I'rol,C11\ O%\ner(s)) Sworn to before me this 10 FRE[DEC ( �7 Lday of O L 20 °2018 (Notary PnhhL) VILLAGE OF RYE BOOK BUILDING DEPARTMENT i Ai°urs©oax�� 11/27/18 BUILD ITU TMENT For office use only: PERMIT# VIL4A� 1 OF RYEIfdOK ISSUED: 938 KING STREE'�,#i�YE BROOK,PI YORK 10573 DATE: (914)930468 _( A'939-5801 FEE: PAID 17 ",iv Yo .o AP%ATIONOR CERTIFICATE OF OCCUPANCY,CERTIFICATE OF CO LANCE, AND CERTIFICATION OF FINAL COSTS TO BE SUY UPON COMPLETION OF ALL WORK, AND PRIOR TO TIDE FINAL INSPECTION ititittt►►ti►t►it►tfitii ttttftt!►t#ftftfittttitttit♦♦t♦tti♦i►i♦►ff4ift►lfttf►►►t►it►►fi►ttt►►i►t ttftt►►tiittttttttti►►►t►t Address: Occupancy/Use: Parcel ID#: Zone: Owner: Address: P.E./R.A.or Contractor: Address: Person in responsible charge: Address: Application is hereby made and submitted to the Buil 'ng Inspector of th illage of Rye Brook for the issuance of a Certificate of Occupancy/Certificate of Compliance for the structur construction/ teration herein mentioned in accordance with law: STATE OF NEW YORK,COUNTY OF WESTCHEST as: being duly sworn,deposes an ays that he/she resides at (Print Name of Applicant) (No.and Street) in ,in the County of in the State of ,that (Cityrrown/Village) he/she has supervised the work at the location indicated above d that the actua'1 total cost of the work,including all site improvements,labor, materials,scaffolding,fixed equipment,professional fees, d including the mone ry value of any materials and labor which may have been donated gratis was:$ \\ , for the construction or alteration of: Deponent further states that he/sh/fRyeBrook. i d the approved plans of the structure/work her ' referred to for which a Certificate of Occupancy/Compliance is sought the best of his/her knowledge and belied the strut /work has been erected/completed in accordance with the approved planendments thereto except in so far as variations therefore ave been legally authorized,and as erected/completed complies with therning building construction.Deponent fiu ther understands t it shall be unlawful for an owner to use or permit the use of any buildises or part thereof hereafter created,erected,changed,convert or enlarged,wholly or partly, in its use or structure until a Certificpancy or Certificate of Compliance shall have been duly issued b e Building Inspector as per §250-10.A.of the Code of the VillBrook. Sworn to before me this Sworn to before me this day of , 20 day of , 20 Signature of Property Owner Signature of Applicant Print Name of Property O r Print Name of Applicant Notary Public Notary Public sisn s E � m a° n� Q • o � O • y`. v mw w ,n,n M p � a 2 g mE � 15 75 � a • Q Q � fN fn N i( m� ¢ $ a Icn f❑❑❑ci❑❑ o o m m 2 a ,n ui U) .� U nTFa na+,a annn nTkn 9Tn) t 4r V�1yJ W�UJJ t(t• � C� J tt V4 VvY1 J VILLAGE OF RYE BROOK MAYOR 938 King Street, Rye Brook, N.Y. 10573 ADMINISTRATOR Paul S. Rosenberg (914)939-0668 Fax (914) 939-5801 Christopher J. Bradbury www.ryebrook.org TRUSTEES BUILDING✓>i FIRE Susan R. Epstein INSPECTOR Stephanie J. Fischer Michael J. Izzo David M. Heiser Jason A. Klein December 13, 2019 Via I"Class Certified Mail Srikanth Ambati& Pranitha Mantrala 7 Talcott Road Rye Brook,New York 10573 Re: 7 Talcott Road, Rye Brook, New York 10573 Notice of$500.00 Fee for Expired Permits Open Building Permit#19-004 Issued: 1/4/2019- Expiration Date: 1/4/2020 Dear Property Owner, Please allow this letter to serve as a reminder that your open permit(s) noted above, as is the case with all Building Permits issued by the Building Department must be closed out with a Certificate of Occupancy or Certificate of Compliance in accordance with §250-10.A. of the Code of the Village of Rye Brook. Building Permits have a life of twelve (12) months and the expiration date is noted on the front of the permit. Please be advised that should you fail to properly close out your permit(s) in accordance with the law, effective November I, 2009 the Village will be imposing a $500.00 Administrative Fee in connection with all open expired Building Permits issued after January I. 2003. Please note that this Administrative Fee applies to each individual permit and must be remitted in addition to any other required fees associated with closing the permit(s),as well as an) court imposed fines should a summons(es)be issued. Thank you for your attention in this matter, and please feel free to contact this office should you require any further information. Michael J. Izzo Building& Fire Inspector mizzo(&rvebrook.org /ec cc: Steven E. Fews, Assistant Building Inspector CD C) Jill j" 4�� �^ 0 0 (t UI) 0 fLlJ 0 r(r) U) CL 0 Noc-, :t%4i� 3.6 C3 r-I m CO C3 .tc nj 0 ru B -0 w ru C3 5 Z C3 :4 � C3 X 0 0 0 • rq C3 -0 r-q C3 >: CC z GO CID 04 co 0L.L ad wi g " co Building Permit Check List&Zoning Analysis Address: `Z _�KA L LOTS- SBL: 13-s�.�'� — L " 3 Zone 2 Use Z 112 Const Type: Other. Submittal Date: k Z 13.l I t '2- Revisions Submittal Dates: Applicant: Nature of Work: 4 .art— n N, Reviews:ZBA: Z I I J2 PB. BOT: Other. ( ) FEES:Filing. BP: �u�C/O: Legalization: APP: Date Stamped ✓ Properly Signed. ✓ SBL Verified. H.O.A.Approval• ( ) ( ) 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 Stamped ✓ Sealed '' Copies: '2-- Electronic: Other. ( ) ( License: ✓ Workers Comp: Liability: -Comp.Waiver. Other. ( ) ( ) CODE 753#: Dated N/A: ( ) (iy 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. ( ) ( ) 20I6 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 E.N=NG PROPOSED NOTES APPM19CU DATE Area: Circle: Fron�ta¢e Front: Front: Sides: Rear. Main Cov Accs.Cor. Ft.H Sb: Sd.H Sb: GFA: Tot.hnp: Ft Imv: PA;kW. Height/Stories: notes: Tara Gerardi From: Tara Gerardi Sent: Thursday,January 03, 2019 9:10 AM To: 'srikanthambati@gmail.com' Subject: Building Permit Application - 7 Talcott Road The building permit application has been approved by the Building Inspector, before I can issue the building permit the following items must be submitted to our office, 1. Estimated cost of construction to determine the building permit fee ($15.00 per $1,000.00) TARA A. GERARDI SECRETARY — PLANNING BOARD, ZONING BOARD OF APPEALS & ARCHITECTURAL REVIEW BOARD VILLAGE OF RYE BROOK 938 KING STREET RYE BROOK, NEW YORK 10573 OFFICE (914) 939-0668 FAx (914) 939-5801 ^`fto �g��'^" ���r 'f' •."- ,diF k �':- -.s�tlt�A �i_6_ J z � +{�1� <t0)> ��. -.:�i6`.:..�'s_- ;.:..► ��w�.:._a___.:av�G__..ia•_.�.... -u.vs-r _'i_:�. Svt/l :- �c..y_nt1`.li�{I -•` 1 1 1 03 C14 O cl O • t section ti }. o cc ram. H o (ems n> � i•r'' G� U) Q ". O POQ W w >1 V y - 4-4 O .. ':. O r y Z 04 O 1 go 1 Sc.tsu: 3 .". '�'�"-�c.: •r-t-�r�-�----c.�{li y�'" '•"-..t,��k-•^'�'_�{ 11{. _ �_. ACORO DAT EtMNNR YYYI 4/2018 � ID/Y CERTIFICATE OF LIABILITY INSURANCE 11i1WDDrY 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 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 NAME. Special Trade Services Company I PHONE Fn. 212-729-8595 lAfc.No�2f9-1-144 - A O No,_ 138 W 25th Street D-DRE dan .Gatti AD-DRESS: 1 Oth Floor --INSURER(S)AFFORDING COVERAGE NAIL N` New York NY 10001 A: Northfield Insurance Company,A++ --- 27987 INSURED NNSUREIt B: Premier Industry Group LLC IISURERC 552 Kimball Ave. INSURER D- INSURER E: Yonkers NY 10704 MISURER 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, EXCLUSJONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR"--- ANSD SUBR WVD POLICY NUMBER POLICY EFF POLICY EXP LMMR LTR TYPE OF INSURANCE (�,yyy) ryY,n X COMMERCIAL GENERAL LIABILITY 1 EACH OCCURRENCE S 1,000,000 CLAIMS-MADE X OCCUR 'CETORENTEU I - - _PREMISES(Ea occurrence) ---s.--I00.ODO_---- i MED EXP(Any one person) S 5,000 A ! Y Y WS338297 1/1712018 1117,2019 PERSONAL&ADV W.f w 3 1.000,000 GEW AGGREGATE LIMIT APPLIES PEP,: GENERAL AGGREGATE i ZOW000 POLICY X .lE T __J LOC I PRODUCTS-COIMPrOPAGG s 2,000,000 X OTHER- �-- - S -------- AUTOMOBILE LIABILITY (Ea accident) 3 ANY AUTO BODILY INJURY(Per person) _S--ALL OWNED —1 SCHEDULED — __ -- ! AUTOS i1 AUTOS BODILY INJURY(Per nowt) s ---I NON-OWNED PROPERTY DAMAGE-- ---------------__..-.--- HIRED AUTOS AUTOS (Pu aoadant) $ $ UMBRELLA LIAR ( I EACHOCCURRENCE S EXCESS LIAB AGGR£(IATE S RETENTION S S WORKERS COMPENSATION - AND EMPLOYERS'LIABIUTY YIN -STAME ER .. ---------- ANYPROPRIFTOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT S --------------- ----... _.OFFICERrMEMBER EXCLUDED' MIA (Mandatory E.L.DISEASE-EA EMPLOYEE S !f yes.desurin NH)be under DESCRIPTION OF OPERATIONS below E-L.DISEASE•POLICY LIMIT S DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) CERTIFICATE IS SUBJECT TO THE TERMS,CONDITIONS AND EXCLUSIONS OF THE POLICIES CERTIFICATE REOUIRES ADDITIONAL INSURED TO HAVE A VALID WRITTEN CONTRACT IN PLACE AS DEFINED BY THE POLICY WAIVER OF SUBROGATION AND PRIMARY NON-CONTRIBUTORY COVERAGE APPLIES ADDITIONAL INSl1RED VILLAGE OF RYE BROOK 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,Building Department 938 KiN Street AUTHORIZED REPRESENTATIVE Rve Brook P57 ��lii,�c//L{llll�E�, ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD Certificate of Attestation of Exemption from New York State Workers' Compensation and/or Disability and Paid Family Leave Benefits Insurance Coverage "This form canmrt be used to waive the workers'compensation rights or obtigahions of any party." The applicant may use this Certificate of Attestation of Exemption ONLY to show a government entity that New York State specific workers'compensation and/or disability and paid family leave benefits insurance is not required. The applicant may NOT use this form to show another business or that business's insurance carrier that such insurance is not required. Please provide this form to the government entity from which you are requesting a permit,license or contract. This Certificate will not be accepted by government officials one year after the date printed on the form. In the Application of Business Applying For: (Legal Entity Name and Address): Building Permit Premier industry Group LLC From:Village of Ryc Brook 552 Kimball Ave Yonkers,NY 10704-2334 PHONE:914573-5355 FEIN:XXXXX9881 The location of where work will be performed is 7 Talcon road,Rye Brook,NY 10573. Estimated dates necessary to complete work associated with the building permit are from November 7,2018 to January 7,2019. The estimated dollar amount of project is $25,001-$50,000 Workers'Compensation Exemption Statement: The above named business is certifying that it is NOT REQUIRED TO OBTAIN NEW YORK STATE SPECIFIC WORKERS'COMPENSATION INSURANCE COVERAGE for the following reason_ The business is a LLC,LLP.PLLP or a RLLP;OR is a partnership under the laws of New York State and is not a corporation. Other than the partners or members,there are no employees,day labor,leased employees,borrowed employees,part-time employees,unpaid volunteers(including family members)or subcontractors. Partners/Members: Jail Faraj,MOHAMED FAITROUNI Disability and Paid Family Leave Benefits Exemption Statement: The above named business is certifying that it is NOT REQUIRED TO OBTAIN NEW YORK STATE STATUTORY DISABILITY AND PAID FAMILY LEAVE BENEFITS INSURANCE COVERAGE for the following reason: The business MUST be either: 1) owned by one individual, OR 2) is a partnership(including LLC,LLP,PLLP,RLLP,or LP)tender the laws of New York State and is not a corporation, OR 3) is a one or two person owned corporation,with those individuals owning all of the stock and holding all offices of the corporation(in a two person owned corporation each individual must be an officer and own at least one share of stock), OR 4) is a business with no NYS location. In addition,the business does not require disability and paid family leave benefits coverage at this time since it has not employed one or more individuals on at least 30 days in any calendar year in New York State. (Independent contractors are not considered to be employees under the Disability and Paid Family Leave Benefits Law.) I,Joel Faraj,am the Member with the above-named legal entity. I affirm that due to my position with the above-named business 1 have the knowledge, information and authority to make this Certificate of Attestation of Exemption. I hereby affirm that the statements made herein are true,that I have not made any materially false statements and I make this Certificate of Attestation of Exemption under the penalties of perjury. I further affirm that I understand that any false statement,representation or concealment will subject me to felony criminal prosecution,including jail and civil liability in accordance with the Workers'Compensation Law and all other New York State laws. By submitting this Certificate of Attestation of Exemption to the government entity listed above I also hereby affirm that if circumstances change so that workers'compensation insurance and/or disability and paid family leave benefits coverage is required amed legal entity will immediately acquire appropriate New York State specific workers' compensation insurance and/or disab' i and pal f 'ly leave benefits coverage and also immediately furnish proof of that coverage on forms approved by the Chair of the Workers'Co nsatio d the government entity listed above. SIGN I Signature: Date: //— HERE 7- Exemption Certi I e Number Received 2018-07,4506 November 7, 2018 d L NYS Workei+s'Compensation Board C E-200 0112018