Loading...
HomeMy WebLinkAboutBP19-077PERMIT # Jm SECTION TYPE OF WORK JOB LOCATION CO INSPECTION RECOIj� DATE EXP:. INSP FOOTING FOUNDATION FRAMING RGH FRAMING INSULATION PLUMBING 0 RGH PLUMBING GAS SPRINKLER ELECTRIC LOW -VOLT CJ Repro r Rear -al s 5�5? �- (as4 Tie H/C) � /*e? e Qv/C/ hrVP ,Su rVP t� a� ���lsu6IXe7,7' ,f do a/ C/o 'r�ea �4 c, ZBA OTHER • .. AS-BUiLTIFINAL SURVEY REQUIRED PRIOR TO FINAL INSPECTION J ju 19 VILLAGE OF RYE BROOK MAYOR 938 King Street, Rye Brook,N.Y. 10573 ADMINISTRATOR Jason A. Klein (914) 939-0668 Christopher J. Bradbury www.ryebrook.org TRUSTEES BUILDING& FIRE INSPECTOR Susan R. Epstein Steven E. Fews Stephanie J. Fischer David M. Heiser Salvatore W. Morlino CERTIFICATE OF COMPLIANCE September 22,2023 Srikanth Ambati&Pranitha Mantrala 7 Talcott Road Rye Brook,New York 10573 Re: 7 Talcott Road, Rye Brook,New York 10573 Parcel ID#: 135.58-1-36 Building Permit#19-077 issued on 5/1/2019 This certifies that the replacement of existing front tie wall with concrete masonry units and repair of rear tie wall,under the above captioned permit has been satisfactorily completed. Sincerely, Steven E. Fews Building&Fire Inspector /to RECENE MAR 14 2023 BUILDING DEPARTMENT For office use oni PERMIT# '077 VILLAGE OF RYE BROOK VILLAGE OF RYE BROOK ISSUED: BUILDING DEPARTMENT 938 KING STREET,RYE BROOK,NF,w YORK 10573 DATE: (914)939-0668 FEE: //b PAID ",A,rN ebrookm r(-, APPLICATION FOR CERTIFICATE OF OCCUPANCY, CERTIFICATE OF COMPLIANCE, AND CERTIFICATION OF FINAL COSTS TO BE SUBMITTED ONLY UPON COMPLETION OF ALL FORK, AND PRIOR TO THE FINAL INSPECTION Address: 7 l A l 1 o T T 6.0 E" 610 o K, N Y 10 ! 3 Occupancy/Use: J-r�I/&- Parcel ID#: / j� .5 8y �- 3(D Zone: Owner: Sy; kNlJd P-. ;T, tj Address: 7 'T,., ,,,J/t ���/ —141 N-"o r 73 P.E./R.A.or Contractor: Address: C Person in responsible charge: T� Address: f O 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: J r°k .t Gs, v►.6 �ra r. being duly swom,deposes and says that he/she resides at (Print Name of Applicant) (No and Street) in���,ruolL ,in the County of � L,s�"��st,(,c,� in the State of /U `J ,that t/ i(lh I(,k\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 eratis was:S 2 in n o for the construction or alteration of: �,,�# 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. 0 Sworn to before me this Sworn to before me this day of /I.Ae,h 9 �1� , 20 2---3 day of 202- S Signature of Property Owner Signature of Applicant f'I tis.t�l� Print�ofer Print a of t No ary Public Notary Public SCOTT J.GOWE NOTARY PUBLIC OF NEW YORK SCOTT J.GOWE I.D.f 01G063571I?Z NOTARY PUBLIC OF NEW YOIl1C� MY COMMISSION EXPIRES/ Z MY COMMISSIONO637EXPIRES! N 9="'/ �• �9�2 �' 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.or� - - - - - - - - - - - - - - - - - - - - INSPECTION REPORT - - - - - - - - - - - - - - - - - - - - ADDRESS . 77 ` Q'R- 1A DATE: PERMIT# � ISSUED: SLT: BLOCK: LOT: LOCATION: OCCUPANCY: ^\ 1 ❑ Violation Noted THE WORK IS... PASSED ❑ FAILED REINSPECTION ❑ SITE INSPECTION l �/� y( � 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 Q FINAL ❑ OTHER QyE BRC�k. �m 1932 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.ors - - - - - - - - - - - - - - - - - - - - INSPECTION REPORT - - - - - - - - - - - - - - - - - - - - ADDRESS: ,�L_C O ILL DATE: PERMIT#�?! C)- ISSUED:N SECT: -�S,-,!3eJBLOCK: LOT: LOCATION: �A-v7- Tl 2 A Ll,� CZO►-�� OCCUPANCY: f ❑ VIOLATION NOTED THE WORK IS... ACCEPTED ❑ REJECTED/ REINSPECTION ❑ SITE INSPECTION REQUIRED 0 FOOTING El 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 Building Permit Check List&Zoning Analysis Address: 7 '_—IA.L—C 07"I ' —�� . SBL: Zone: KZ— -2— Use: Z l-o Const.Type.-_ Other. Submittal Date: 3 I Revisions Submittal Dates: Applicant: Nature of Workc,�� Reviews:ZBA: MAR - g 2019 PB: BOT: Other. NEED OK ( ) FEES:Filing _S, BP: 140• �-3>-"- C/O: Legalization: ( ) (4"APP: Date Stamped: Properly Signed: " SBL Verified: -I.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 ✓ Seale ✓ Copies: Electronic: Other. (Jf ( ) License: i// Workers Comp: Liability V Comp.Waiver. Other. (_y (CODE 753#: Dated: N/A: ( ) ( ) HIGH-VOLTAGE ELECTRICAL:Plans: Permit N/A: Other. ( ) ( ) LOW-VOLTAGE ELECTRICAL:Plans: Permit: N/A: Other. ( ) ( ) FIRE ALARM/SMOKE DETECTORS:Plans: Permit: H.W.I.C.:_Battery:_Other. ( ) ( ) PLUMBING Plans: Permit: Nat.Gas: LP Gas: N/A/: Other. ( ) ( ) FIRE SUPPRESSION:Plans: Permit: N/A: Other. ( ) ( ) H.V.A.C.: Plans: Permit: N/A Other. ( ) ( ) FUEL TANK.Plans: Permit: Fuel Type: Other. O O 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. GARB mtg.date: `f tl approval: l notes: ( )ZBA mtg.date: approval;- notes: ( )PB mrg.date: approval• notes: REQUIRED EXISTING PROPOSED NOTES APPROVED Ares tee, A P R 2 3 2019 Circle: Fla Front: Front: Sides: Rear. Main Cov Accs.Cov: Ft.H Sb: Sd.H Sb: GFA: Tot : Ft.Im : P Height/Stories: notes: BUILDING D� TMENT CEMED VILI E OF RpOK G Y� 938 KIN ET RYE BRO(*NY 10573 MAR -8 2019 (914)968 FAX(914)939-5801 V�".M*rjok.org 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: �' W k7L Pcf Phone# Parcel ID#: Zone: Date of Submission: Proposed Improvement(Describe in detail): �i�r,IacP l'�ci Inx�r.P �i r - kiG I APPLICANT CHECK LIST: �! tt �J�� ��` The following items must be submitted to the Building W I-h n ( _S"�i r(( Depart ent with the application-no exceptions. 1. (7/completed Application 5 ri krr� 1 a b 2. (�hree(3)sets of sealed plans. (one full size{maximum Property Owner: / IM L c allowable plan size=36"x 42"1 and two 11"x17") Address: 7 /a4�7 �c( t k,e vr L)KC 3. ( )Three(3)copies of the property survey. 4. ( )Three(3)copies of the proposed site plan. Phone# 5. ( )One electronic/disc copy of the complete Applicant appearing before the Board: application materials. 6. (1/jFiling Fee. Sri (Cc.,n-�-11 �rr` k i 7. ( )Any supporting documentation. Address: 7 7-c lec,��7W rtnL) 8. ( )HOA approval letter. (ifapplicable) 9. ( )Photographs. Phone# 10.( ) Samples of finishes/color chart. (a sample board or model may be presented the night of the meeting) Architect/Engineer: r7 c, r L� �r 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. Swom to before me this Sworn to before me this day of N o-/ 2- 2018 day of , 20 aee�-- Signature of Property Owner Signature of Applicant ,ry i a4w�- Print Name of Property Owner Print Name of Applicant Notary Public Notary Public Rlchard C.Lem Nota Putdk,Sta3e KY Quaftd 1 w 4L11 Commis m Exolrm Fib.23, 6/1/18 MAR -8 2019 Talcott Woods (Home Owners Association VILLAGE OF RYE BROOK BUILD I G DEPARTMENT Rec'd By Date REQUEST FOR ARCHITECTURAL COMMffTEE REVIEW Document Check List Request From Survey/Plot Plan Specifications Date Bldg. Plans Permit Mr./Mrs.: S r I k.�.,�►, ,,.b�.� Elevations Photos Details Other(noted) Address: 7 Pc vk ye 1�rr2 c K tv'4 I OS 7 3 Phone No.: Brief description of addition, alteration, improvements, etc.. "�tl 2'tiiah X Si' lunw Contracto : rao c 1 r� HOMEOWNFRS AFFIDAVIT Address: 3 5 ,ce , Qa I have read the covenants and restrictions of my Associations and agree to abide by such covenants and restrictions. No work Cert.of Insurance will be commenced without the approval of my Association. Date: 0 3fl 2c1g /} Signed: ' Please check with Village of Rye Brook for Building Department Approvals FOR ASSOCIATION USE ONLY Approved by Homeowners Association Approved Preliminary Approval Subject to Review Insufficient Information Submitted- Resubmit Not Approved Approved with the Following Conditions George K George Chairperson,Architectural Reviev Date: 2-26-2019 VILLAGE OF RYE BROOK BUILDING DEPARTMENT 938 KING STREET, RYE BROOK,NY 10573 (T) 939-0668 (F) 939-5801 ARCHITECTURAL REVIEW BOARD Wednesday, April 17, 2019 NAME&LOCATION TYPE OF APPLICATION MOTION SECOND APPROVED REJECTED APPL.# 35 Country Ridge Dr New 6Ft Cedar Privacy Consent 4700 (Kaufman) Fence Agenda 2 Bonwit Road Amendment to prior Consent 4701 (Campbell) Approval (Change to Agenda Hardeplank Siding& Extend Eaves) 21 Long Ledge Dr New Windows 4702 (Little) 181 North Ridge St 1 Story Detached Garage 4703 (Conover/Figuera) Addition 44 Rock Ridge Dr Amendment To Prior 4704 Approval (Windows) 9 Elm Hill Drive New Windows,Front Door, 4705 (Sykes) Interior Alterations 37 Hillandale Road Front Two Story Addition, 4706 (Fischer) Rear Open Veranda& Porch, Rear Deck, Patio, & Walks 7 Talcott Road Replace Existing RR Tie 4707 (Ambati) Wall w/Stone CMU (� 9 Maywood Ave New Rear Deck 4708 (Hyle) 18 Ridge Blvd Amendment to Prior 4709 (Pugilese) Approval (Portico) 6 Hunter Dr (Mutis) Rear 1 Story Addition& 4710 New Rear Deck 31 Longledge Dr Expand Upper Rear Deck& 4711 (Lazarus) Renovate Lower Deck ML NM MR SE JM SF AC MI JB r 5 Garibaldi Place( Legalize Deck Expansion& 4711 Quiles) Concrete Walk Side Of House To Rear 80 Windsor Road Replace &Expand Existing 4712 (Breen) Rear Deck ML NM MR SE JM SF AC MI JB Check List For Release of Building Permits Address: 7Takz�f [� Owner/Applicant: (-1 aln Alln4ro o, Phone #'s: 79�7� /R-5f59 Dates Attempted To Contact Owner/ Applicant: 4�R 3/i-9 Comments: n o+f fieA,' oir,ow�w Comments: no 7- ec . GC Comments: NEED uilding Permit Fee $ vie itapi O # VersComp. mpr=m - 0 ( ) General Contractor's Contact Information ( ) Fire Sprinkler Plans (2) ( ) Fire Sprinkler Application ( ) Fire Sprinkler Permit Fee ( ) Estimated Cost $ ( ) SWO Fee $ ( ) Legalization Fee $ ( ) Other � ������� ,} •; ,���I,�1 .M ♦�1j �r `+ /�1�// �{n�'�i T j1��•1 1�1•1 0 ,1111 / '+w�lfF . ,/�'11 - �`Vfl� /111��� �! �,1/11,�., 'S. '`* ,NI/. 111,/ c.j1 gip• (( p '. i cC NLz O i -��� a GL. •f�. N *a. W N ya r. ��OVf•• Q) O ��A) ���•� G C � ate.+ � � �. L s U t » U 0 3 : NLO 0 4. on to cn `j '' rA ~ :D Q . 0 a p U c m Z p v 3 c v y Ci, U) (f) Q c� ZO > Lill r••► w o G� 4� L U CU \ CA <:a V o A ro ti E- , � U o 7 co LC w f LOi�'4;. / a, DATE(MM/DO/YYYY) ACOR" CERTIFICATE OF LIABILITY INSURANCE 04/30/2019 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 NAME: Melanie Rodriguez Forbes Agency,Inc. PHONE FAX a N : (914)232-7750 AIc No:(914)232-7226 135 Bedford Road E-""AIL melani orbesinsurance.com Katonah, NY 10536 AD Ss` License#: BR895421 INSURER 3 AFFORDING COVERAGE NAIL• INSURER A: Travelers Casualty Ins Co of America INSURED INSURERB: Progressive 14788 Fredys Contracting Inc INSURERC: Main Street America Assurrance 14788 3 Spice Hill Rd INSURERD: ShelterPoint Life Insurance Company Croton On Hudson, NY 10520-1130 INSURER E. INSURER F: COVERAGES CERTIFICATE NUMBER: 00000000-0 REVISION NUMBER: 21 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. INSR ADDL SUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD WVDPOLICY NUMBER MIDDIYYYY) (MMIDDNYYYI LIMITS A X COMMERCIAL GENERAL LIABILITY Y 680001 C415804 08/02/2018 08/02/2019 EACH OCCURRENCE S 11000,000 DAMAGE TO ENTED CLAIMS-MADE 41 OCCUR PREMISES Ea occurrence) $ 300,000 MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE f 2,000,000 X POLICY❑JET LOC PRODUCTS-COMP/OP AGG f 2,000,000 OTHER: f B AUTOMOBILE LIABILITY 07938533-0 08/02/2018 08/02/2019 Ea 2,an,SINGLE LIMIT E 1,000,000 ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per accident) t AUTOS ONLY X AUTOS HIRED NON-OWNED PROPERTY DAMAGE $ X AUTOS ONLY X AUTOS ONLY Per acadenl S A X UMBRELLA LIAR X OCCUR CUP001C742514 08/01/2018 08/01/2019 EACH OCCURRENCE $ 1,000,000 EXCESS LIAB CLAIMS-MADE AGGREGATE $ 1,000,000 DIED I I RETENTION $ C WORKERS COMPENSATION WCV2$757 12/31/2018 12/31/2019 PER OTH Y/N X - AND EMPLOYERS'LIABILITY STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 100,000 OFFICERIMEMBER EXCLUDED? y N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 100,000 Ii yyes,descnbe under DESCRIPTIONOF OPERATIONSbelow E.L.DISEASE-POLICY LIMIT $ 500,000 D Disability/PFL DBL264174 01/01/2019 01/01/2020 Statutory DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if mom apace In required) Village of Rye Brook as Additional Insured as per written contract. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN Village of Rye Brook ACCORDANCE WITH THE POLICY PROVISIONS. 938 King Street Rye Brook, NY 10573 AUTHORIZED EPRESENTATIVE (MGR) ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD Printed by MGR on April 30,2019 at 10:35AM YORK Workers' CERTIFICATE OF STATE Compensation Board NYS WORKERS' COMPENSATION INSURANCE COVERAGE 1a.Legal Name 8 Address of Insured(use street address only) lb.Business Telephone Nurnber of Insured Fredys Contracting Inc 3 Spice Hill Rd Croton On Hudson,NY 10520-1130 1 c.NYS Unemployment Insurance Employer Registration Number of Insured Work Location of Insured(Only required d coverage is specifically limited to 1d.Federal Employer Identification Number of Insured or Social Security i certain locations in New York State, i e a Wrap-Up Policy) Number 20-0725095 2.Name and Address of Entity Requesting Proof of Coverage 3a.Name of Insurance Carrier (Entity Being Listed as the Certificate Holder) Main Street America Assurrance Village of Rye Brook 938 King Street Rye Brook,NY 10573 3b.Policy Number of Entity Listed in Box"1a" WCV28757 3c.Policy effective period 12/31/2018 to 12/3112019 3d.The Proprietor,Partners or Executive Officers are included.(Only check box d 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"l 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 earner 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: Melanie Rodriguez (Pnni name of ed representative or licensed agent of insurance camerl Approved by /4& 411 J 3,rZ/L (Signature) (Date) Title: Authorized Representative Telephone Number of authorized representative or licensed agent of insurance carrier: 914-232-7750 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 Ticket: 05019-900-091-00 Type: Regular Previous Ticket: ------------------------------------------------------------------------------ State: NY County: WESTCHESTER Place: RYE BROOK /V Addr: From: 7 To: Name: TALCOTT RD Cross: From: To: Name: Offset: ------------------------------------------------------------------------------ Locate: FRONT OF PROPERTY NearSt: /LINCOLN AVE/ Means of Excavation: HAND TOOLS Blasting: N Site marked with white: Y Boring/Directional Drilling: N Within 25ft of Edge of Road: Y Work Type: LANDSCAPING Duration: 5 DAYS Depth of excavation: 2 FEET Site dimensions: Length 50 FEET Width 1 FEET Start Date and Time: 05/04/2019 07:00 Must Start By: 05/20/2019 ------------------------------------------------------------------------------ Contact Name: JOSE ZHINGRI Company: FREDY'S CONTRACTING INC. Addr1: 3 SPICE HILL RD Addr2: City: CROTON State: NY Zip: 10520 Phone: 914-906-6284 Fax: Email: FREDYEZ7425@YAHOO.COM Field Contact: JOSE ZHINGRI Cell Phone: 914-906-6284 Working for: SRIKANTH AMBATI ------------------------------------------------------------------------------ Comments: REPLACING RAILROAD TIE WALL IN THE ENTRANCE : Lookup Type: PARCEL ------------------------------------------------------------------------------ Members: ALTICE USA 800-262-8600 CONSOLIDATED EDISON COMPANY OF NY 718-472-2304 SUEZ WATER WESTCHESTER 800-262-8600 VERIZON I VALHALLA WESTCHESTER 855-226-9564 VILLAGE OF RYE BROOK 914-939-0753 WESTCHESTER COUNTY 914-813-5419 880150 3S OA M3N ' S'-1 'NC) ` c� `dNV 7, g801s0 J% 4D r f; o 0 ��► d�s�� �� j0� ONIUT n 0 DDT' IA 6 Y � � Z0 ZLLL �- 3nN3Ab N�OONI7 01 6 z. _ L ` L Z 1 �3 njO 10 1 f nem oni 0 N Ul v no � dOJ\ M3N J0 3iViS 59 10-i 9c 107 IIS3HOiS3M T�J J0 kiNnoo AoMe L A00-18 3�d J0 NMO1 N01103S 8S'S2 L N01103S A OO�J 9 3/QJ J O 30V71A Z L 68 l dVW 03� 1J dvN Xdl W03'�Ib'W9@SNOIlmOS9NIdddWJlN :�It1W3 8CC1-5Z9 (Z--VC) 301JJ0 Oti011 AN '>18`dd 34.1H M3N LOZ '31S '3NIdN21f11 OH3la3f 00£ t '0 *d '0NI.l3n2if1S aNV� NOOiVS8Vd 'I VISViSVNV �zoz ` L z )\�jenNdr :03)OMns 31da a`d0(\j iio 3 vi , L 0*2 L ='l ,00'OL L —8 08VJI HOIH ,<:�Z3===Woo, IIVM ONINIV138 3NO1S $05' L -V 3 «-bZs1V2.0 L N 1lVHdSV J0 3003 08VA IIVM ONINIV138 8381411 do = Sd31S O 08VA z 1 0 z rn Hit D F 30V8V0 831NY Id . 831NV1d 0 v 831NV ld M 0 A 08VA A030 DOOM 3A08V N8031V1d L O-N - o1.J Z aavx 011dd N IV80 QNVA IIVM ONINIV138 838W11 IIVM ONINIV138 838Y411 I I IIVM ONINIV138 830N11 08VA HOIH / O � � 08VA HDIH 1090b5 M „-vZ,t2.Ol s z m ZJ 1N3lNi8Vd30 ONicriin8 >10088 3,k8 30 30VT11A . *01 (131�li�13:D m0 PD 14c)v' .16 �wN'-'Z O0�iNz�V)m�V►a�� ?� 0X0C- Dou Ac C ' N(A S C/)FNASO0�cC m' O No zrrn din ;m0�� �- m��rrl nnx uzi�mrn x5Dv OOD m =0il�m ;OGAOv-� 000C;mo o oz�- ors mN II ZZD C N � � O � n O moo; m z; rmgQ Z H ! � A 0 0 C) n 0Onmm r �o0 ;a0 _ Az�rn cz D Z N N m �� m m zZ om �. o Nm N �m v 0 91 �-n D r*► z O v Z m C -< r- v -� N C m D � r�* � m Z 0 do m -*� -1 d31S �' �, o z 0 C/) m om 00 D 0 c v n m m z O o c o Z� m OM c O r 0 c M c o o M �' 0 � O N r, o o m -v clio O v � C � C v z z _m n z N N v `• -< to m c m rn - A � 1 1 1 O � z O m CD rr m = z z �1 m 0 In C � g � M • O z r�* Z v o v c� m M 0 O m o �'' f O z 08VA z z . N _ 0 g m v 0 O z if O m ao c 6 z o N D v / o co v m v 08V,1 HOIH m o ;o c c 0 = 0 o z m K m