HomeMy WebLinkAboutRP22-041PERMIT #�
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INSULATION
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VILLAGE OF RYE BROOK
MAYOR 938 King Street, Rye Brook,N.Y. 10573 ADMINISTRATOR
Jason A.Klein (914)939-0668 Christopher J. Bradbury
www.ryebrook.org
TRUSTEES BUILDING & FIRE INSPECTOR
Susan R. Epstein Michael J. Izzo
Stephanie J. Fischer
David M. Heiser
Salvatore W. Morlino
CERTIFICATE OF COMPLIANCE
October 26,2022
Michael Ryan
24 Tamarack Road
Rye Brook,New York 10573
Re: 24 Tamarack Road, Rye Brook,New York 10573
Parcel ID#: 135.67-2-49
Roof Permit#22-041 issued on 10/6/2022 to Re-Roof Existing Building
This certifies that the new roof,installed under the above captioned permit has been satisfactorily completed.
Sincerely,
Michael J. Izzo
Building&Fire Inspector
/to
DFor office u&e only:
DDBUILDN AkTMENT PERMIT# _ �
OCT 13 2022 VILLAGE OF RYE BROOK ISSUED:/ 0- -��
38 KING STREET,RYE BROOK,NEW YORK 10573 DATE: /Q 3-aa-
VILLAGE OF RYE BROOK (914)939-0668 FEE: 4 PAID
BUILDING DEPARTMENT www, ,rvebrook.erg
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
r►rr►r►►s►►rs►trrtwrw►►►r►►►rrwrwwrw►►►rrrtrrwr►►►►rrrrtwww►►rr►rrtrww►s►s►rrrrrrwr►w►►►►rrtrwr►r►rr►rrrrrwrwr►rs►rtrwwrrrss■
Address: .244 Ta rrkrack �� �? tZ�c '-3"ok A)-X ( D.- 7-T
Occupancy/Use: fri rA 6 Parcel ID#: /33- & 7 .2 - 4 9 Zone: le- 7
Owner: M iC1,ae l Ryr,►% Address: AY I m-i YA,4 '/O.f 73
P.E./R.A. or Contractor: /e/vef Any R�n+,�,�G��Address: DSO 1 S2 /3
Person in responsible charge: A tt fl e ri v f r
p g Cps�o 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:
X d R r being duly sworn,deposes and says that he/she resides at x 2Y TA M-4Y4 d( fa�c J
(Print Name of Applicant) (No.and Street)
in l� fir in the County of �� t s�� in the State of�X,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 equipm-e7nt,professional fees,and including the monetary value of any materials and labor which may
/have been donated gratis was:S / , a M• 60
for the construction or alteration of: d v /-0 P 2°
Deponent further states that he/she has examined the approved plans of the structure/work herein referred to for which a Certificate of
Occupancy/Compliance is sought,and that to the best of his/her knowledge and belief,the structure/work has been erected/completed in
accordance with the approved plans and any amendments thereto except in so far as variations therefore have been legally authorized,and
as erected/completed complies with the laws governing building construction.Deponent further understands that it shall be unlawful for an
owner to use or permit the use of any building or premises or part thereof hereafter created,erected,changed,converted or enlarged,wholly
or partly,in its use or structure until a Certificate of Occupancy or Certificate of Compliance shall have been duly issued by the Building
Inspector as per§250-10.A.of the Code of the Village of Rye Brook.
Sworn to before me this 3 Sworn to before me this
day of ,20-�c day of , 20
Signature of Property Owner v Signature of Applicant
/ll*6hae) Jam- i2yaH
Name of Property owner Print Name of Applicant
Notary Public Notary Public
SHARI MEULLO
notary Publlc,State of New York 8/12/2021
No-01ME6160063
Qualified in WWehester County
Co,tmtission Expires January 29,20 2S
QyE BRC�k•
1982 BUILDING DEPARTMENT
❑BUILDING INSPECTOR
r
SSISTANT BUILDING INSPECTOR VILLAGE OF RYE BROOK
ODE ENFORCEMENT OFFICER 938 KING STREET • RYE BROOK,NY 10573
(914) 939-0668 FAx (914) 939-5801
www ryebrook.org
- - - - - - - - - - - - - - - - - - - - INSPECTION REPORT - - - - - - - - - - - - - - - - - - - -
ADDRESS :— DATE.
PERMIT# `�Y (� ISSUED: I()`b Z CSECT: \ . BLOCK: LOT:
LOCATION: C W_ ` 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
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Buil,DlNc. DEPARTS EN'r SEP 2 8 2022
V:' - -xo m: R4,r BROOK VILLAGE OF RYE BROOK
S k S1 vi I i Wi I 1i 1--i o-- \Y 10573 BUILDING DEPARTMENT
i 9 14 j 9,�9-06,6 8
Apprui-W Dikilt: OCT t,"2 Rr o f r Applicalion sr
ApprnVoll ARCHITECTURAL REMWROARD:
I)rxalrgtratic¢I: bake:
80 1 Apvirlxf a]Wic, (48C q#
PH Arvirlival Mic� Caw a
ZRA AM- n-jval[)AU-:
Feirmit rev
Applicn0na W jib
R(,.)()F P E R 1IT A P P L I CATII ON
Apptkntwn d*ivd 8/4/2022 1 Bt NY.11M tik tilUffKe Of A I'LlMil W
Re Roof an Exating,baj,�tig,4,a pt.,c,-1,11 "'f'
24 Tamarack Road NY 10573 135.67-2-49
1. i(th Addmv- S141
Prnporty Ow-ner Michael Ryan A 24 Tamarack Road �� r, NY 10573
.dry"� i
PlIx-me it (614)580-0802 drmjryanggmail,com
Erik Brinkerhoff 2501 Seaport Dr.Chester PA 19013
2. Applicant. Akldrc'sk.
phow 0(610)874-5000 x6662 (203)400-0707 ctinstalls@powerhrg.com
3. Roofing ctxnmwl�)T:Power Home Remodeling Group 2501 Seaport Dr. Chester PA 19013
Mane�610)874-5000 x6652 ( k:A u (203)400-0707 o-livi ctinstalls@powerhrg.com
4. Jeb Dewription,last ntl Mr 71,w—s. .I ,,, I.,Remove and replace 18 sq roof w/50 yr GAF shingle, ice and water to code,
deck armor and taped seams. NO structural changes.
17288
5. U,-%tsmaltd Coif of Job:5 - {NUTE Theeialmawd it%hall incluad all'TIC
imvqr-cmen I*Wnyur,M himac'-w—n ff—aWing,f axed.opip—wttL—prof'e—*stmal rem—wl inArml and labpr whrch may dAmi lod grttl5.)
6. 1(vwxrVrrqwrty,iindicaitw=t
7. Omwiwlxin Type: VB NYS Co I aslu-uctiun(.'Iwr,%- R3
g"u betrig.rv-,r�m-jfml:N'U:I.0 '1 1 IA[Whcd N'u I'm, INUMber of'cars_
19, If,(1,4A peaked,hip,nwimm.f1j Peaked
Ill. Fjil;rnatcd datc nf completion�
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 NEW YOM COUNTY OF WESTCHESTER ) as:
Erik Brinkerhoff ,being duly sworn,deposes and states that he/she is the applicant above named,
(print mane of individual signing as the applicant)
and further states that (s)be is the legal owner of the property to which this application pertains, or that (s)he is the
Contractor 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.
Swom to before me this 12th Sworn to before me this 12th
day of august , 202022 day of August 12022
I �C r--->
Signature of Propert�wner Signature of Applicant
Print Name of Property Owner Print Name of Applicant
Notary Pub ' Notary Public
srotL-..i_ Notary F'''.Jhj � ` -.::�C.�i l.. .flnnrTlCUt
[NotCaroYj pu�;',IC,Sig'•.>>of Cr.��rr,+eut My Con Iri Yi n E`,,; res,,K 112G23
Y ri)ISSion Expires 0'l3'112G23
-2-
tIFIYfM
National I fradqu:rlern
Michael Ryan
2501 $eaporl Drive,Cheater,PA 19013 35 99543
888-736-6335 July 21, 2022
WWW.POWERHRG.COM
144U//6-DCA
- CUSTOM REMODELING AND IMPROVEMENT AGREEMENT VVG25267.1i12
Buyer(s)'Information and Description of the Property: 7(,r(,
ject Number: 35-99543 July 21.2022
Michael Ryan
4)580-0e0z(Mirhaarl,5(>ft)
74 Tamarack Hnad drmiryan !tgmail com
i'ol t Chester,NY. 10573
County:Wr.-.tc:hr.!:tr.r
Township:
Buyer(s) listed above hereby jointly and severally agrees to purchase the goods and/or services of Power Home Remodeling Group
and its vendors ("Contractor") in accordance with the pricers and terrns described in this 5 page documtyrrt and the Product
Specifications, which are. Incorporated as part of the. Agreement (Collectively, this "AgreP.ment). This Agreement represents a Cash
sale of goods and services. Buyer(s) agrees to pay the cost of the goods and services purchased as described herein, regardless of
timing or approval of any financing Buyer(s) may seek for their purchase.
Purchase trice. $17.288.31 Pre Installation Inspection Dates.
Down Payment: S0.00 -1"n 1 " " 11",,,
Balance Dun on S17,288.31 Estimated Project Start: 3 to 4 weeks
Substantial Completion: Estimated Project Completion: 1 to 2 days
Method of Payment: Crodtt Card Huyer(s)aeknorwodgo that a definite start and compilation dates arc NOI of the essence Delays beyorc
C 4MrAcicx'A mnlroi rail irua a"I m r:AirrtlAhrl{i ilium brrrt,R% sstw n"ii y/tk,krxrwn Comfillnn"
Buyar(s) horoby arknowladgns rocelpt of a copy of tho p.7mphlot, "Tho Lnad-Sato Cortifind Guido to Ronovatn Right", informing
Buyor(s) of the potential risk of load hazard exposure from ronovation activity to be performed in or at Buyer(s)'Property, at the
address written above. Buyer(s) received this pamphlet on the date of this Agreement, before commencement of work.
`___Buyer(s)'Initials.
This Agreement constitutes the entire agreement arid understanding between the parties, and this Agreement replaces any and all
prior negotiations, representations, or agreements, either written or oral. No amendment, modification or waiver of this Agreement
shall be valid or effective unless in writing and signed by both parties. buyer(s) hereby acknowledges that Buyer(s) 1) has read the
entire Agreement and has recoivod a completed, signed, and dated copy of this Agreement, including the two accompanying Notice
of Cancellation forms, on the date first written above, 2) was orally informed of his/her right to cancel this transaction,3) has received
a ropy of New York's Consumer Bill of Rights on Contracting for Home Improvement, and 4) has received a Certificate of Workers'
Compensation Insurance before work has begun on the Property.
Buyer(s) also agrees and Understands that if Buyer(s)finances the work with a third-party, the terms of that financing will be
contained on separate documents, including any finance charge.
Future promotions not applicable.
I have read and received each page of this 5 page agreement.
Power Home Remodeling Group Buyer(s)
/07/21/22 107121122
Signature of Remodeling Consultant Signature
Kristen Dakin Michael Ryan
YOU. THE BUYER(S), MAY CANCEL THIS TRANSACTION AT ANY TIME PRIOR TO MIDNIGHT OF THE THIRD BUSINESS DAY
AFTER THE DATE OF THIS TRANSACTION, SEETHE ATTACHED NOTICE OF CANCELLATION FORM FOR AN EXPLANATION OF
THIS RIGHT.
July 21, 2022 15:12
IIIIIIIIIIIIIIIIIIIIIIII IIIIIIIIIIIIII IIII Page 1 of 5
III III
National headquarters Michael Ryan
2501 Seaport Drive,Chester,FA 18013 35-99543
888-736-6335 July 21,2022
WWW.POWERHRG.COM
1440176-UCA
4P. -.- PRODUCT SPECIFICATIONS wc-;iS2$67.H12
Buyer(-,)'Information and Description of the Property: Project Number: 35-99543 July 21,2022
Michael Ryan narPorn��,
74 Tamarack Roarf (614)5$0 0802 (Mrcha l:a Crrl) IrY 9
item anr1D mail.0ott1
Port GheStei, NY. 10573 E Mad Address 1
County:Wrstrhrsler
Township:
Buyers) listed above hereby jointly rand severally agrees to purcha!te the goods andtor services listed oil the accompanying-;pec;ificahon
sheets,In accordance with the prices and termq described in the Custom Remodeling and Improvement and the l4roduct Speci icationq
(colloctivoly,this-AgroomonC').
Pre. Installation Inspection Dato: Yrnir pro instal ation inspection is tonlativoly scheduled for Thu 8l4 betwtion 1:40p and 2 40p
Roofing-GAF Inclusions: For steep slope roofs, the application includes Fortitude Lifetime Shingles with 5q year non prorated labor
warranty. Also inciud(,,, removal of existing shingles, installation of f-slyle drip r�dge, Weather Watch ico and water shield. Deck Armor
breathable roof deck protection. Pro Starter starter strip, Snow Counhy ridge vent exhaust. I imbertex premium ridge cap shingles,
PowerVorit Intake ventilation, all flashing and chimney crickets where nooded and 6 nails per lull shingle. All applications used only whoro
applicable. Clean up and haul away of all job related debris.
Any wood replacement needed will be done at a cost to the homeowner of S3.94 per square foot. For Example: After the shingles have been
removed, if we find there is a need to replace 96 square feet of wood, it is the responsib lity of the homeowner to pay for the cost of the 96
gtluarp fr;rt of ieplarement at$3.94 per square loot, which �n this example is$378 24.
For low slope roofs, which aru roofs with a pitch bolow 2112, tho application includes a 15 yoar non pruratod labor and malerial warranty,
removal of all existing roofing materials. new decking, base and cap sheet, drip edge and flashing,where applicable. Roofs with cedar
shingle removal will include all new decking as part of the installation. Clean up and haul away of all job related debris.
It is a9tood and understood by and butwimen the parties that the Product Spix. ificalions, along with (tie Custom Remodoling and
Improvement Agreement, constitutes the entire understanding between the parties, and replace any and all prior negotlalionc,
representations. or agreements, either written or oral. The Product Specifications may not he changed, modified, or varied in Any way unless
such changes are in writing and signed by both Buyer(s)and Contractor. Buyers) hereby acknowledge that Buyor(;) has read the Product
Specifications.
I have read and received each page of this 2 page agreement.
Power Home Remodeling Group Buyer(s)
(1 ,JIAAtl/Y11 ? di h N*10 712 1 12 2 'Cy-- 107121122
Signature of Remodeling Consultant Signature
Kristen Dakin Michael Ryan
YOU,THE BUYER(S), MAY CANCEL THIS TRANSACTION AT ANY TIME PRIOR TO MIDNIGHT OF THE THIRD BUSINESS DAY
AFTER THE DATE OF THIS TRANSACTION. SEE THE ATTACHED NOTICE OF CANCELLATION FORM FOR AN EXPLANATION OF
THIS RIGHT.
July 21. 2022 1 a:12 IIIIIIIIIIIIIIIIIIII�III�IIIIIIIIIIII�I��Illll��l)
Nationa;I leadyuartm. Michael Ryan
2501 Seaport Dare.Chester. PA 19013 35,99543
888-736-6335
WWW.POWERtIRG.COM July 2i,2t122
1440r76-LXc A
Project Specifications WC-zsaa7-rlta
fluuhrU. Pis�u�r 1 18w.0'x1'0
ROOFING: Model GAF Style Form unc.. Type None Cnnhg None
OP 1 IONS' Color Cobblestone 1 Hemoval Standard Sh ngle l Drip Edge Color Waits I Instillation DOMIs
None
UP
COR"ATION
Cobblestone
Roofing: Attic: 1 160.0'xl 0'
H001-ING: Model OAF Style Heplace Wood type Sheathing Contlg None Qptons None I InstAttatoon
Ont,vh;None
CM MAT'EIR Al.3
CORPORATION
irk �
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July 21, 2022 15:12
Laura Petersen
From: Laura Petersen
Sent: Wednesday, September 28, 2022 3:18 PM
To: ctinstalls@powerhrg.com
Subject: Roof Permit Application - 24 Tamarack Road
Good afternoon,
The Building Department has received in the mail the roof application for 24 Tamarack Road.
At your earliest convenience, please send a valid Westchester County Home Improvement
license. The license received had expired on August 6, 2022.
Please also provide a contact name (first and last) for Power Home Remodeling Group.
Thank you
Laura 1 ` ,? Ive _1
Laura Petersen
�
Office Assistant
Village of Rye Brook
938 King Street
Rye Brook, New York 10573 04, CoS4�/O
Phone(914)939-0668 1 IaetersenOEyebrook.org J
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CERTIFICATE OF LIABILITY INSURANCE
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
CERTIFICATE DOES NOT AFFIRMATIVELY On 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 policOes) must have ADDITIONAL INSURED provisions or be endorsed.
It SUBROGATION 15 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 Ileu of such endorsement(S).
PRODUCER CUNTACI
Lacher&Associates insurance Agency r ncJnt - — -
L nnc�tr Itlklll!lY1CP. C�rc�up thG tta w 115 723 4. 7A ' FA 1 -59
632 East Broad Street AI DA'c Souderton PA 18964 eertl Cate lacherineurtsnce.cattl
tn5ulx1i(s)Arronvtnc cuvtnAcc NAIc r
INsunen A�Frnrt 1 anja Mar)uf)c.turcr• A rcui ttipn Insurance 12282
INswtCo POWERCL01 IN%IJRFR R MartcAl Amarlran In;Cr, -
Powrtr Ifornt) Rri tr tin Group, LLC 28932
2501 Seaport Drive,4th door munEN c:Enduratu a An, ritan prclau 41718
Chester PA 154()13 wsuaaao? ��_
INSURER E
P38URER F.
COVERAGES CERTIFICATE NUMBER: 1481041286 REVISION NUMBER:
IRIS IS 3U GLHtIFY IHAI THL POLICIES OF INSOHANCL LISIEU ULLC_)W HAVE 13LLN ISSUI_U IU IHL INSUHLU NAMLU AIJOVL F-OH IHE POLICY NLHIOD
INDICATEn NpTWiTHSTANDING ANY REOVIRFMFNT TERM OR CONDITION OF ANY CONTRACT OR OTHFR DOCUMENT WITH RESPECT TO WHICH THI4
CERTIFICATE MAY BE ISSULU OH MAY PERTAIN, HIL INSURANCE AFFORDED BY IHE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS Of SUCH POLICIES.LIM;TS SHOWN MAY HAVE BEEN RCDUCCC:BY PAID CLAIMS
1IMSR _ _...TAB_,__p �.....
TYPF OF INRURANCF - DALICV NUMpER POLICY EFF POLICY EXP I 1110111 R
A X (COMMCNCIAI GCNCITAI LIABILITY
1022771 ff:M q6 7 _
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# t.AC:tt(X:cul tilt Ntt $2,000,000
CLAIMS MADE tX; OCCUR
� E�_IE try- i t,000 U01i
I IUD EXP(Any vivo pwrmx)) >♦10,flO0
{>Yt! )NAI A AnV IN.AjfAY 12,(>a14,000
GEN'L AGGREGATE LIMIT APPLIES PER. (#EhIERAI ACit3RE0ATE A OOU 000
r(X i POLICY NHV
n .tl ..........I LOC PRO♦UCTS COMPfOP AGO 14 0W W0
OTHER, .__._....__..._._-..._..._,...-......_.____..____
A AUTOMORILELIASILITY 152275 66 20 QS 7A 111/202? 1/1/2023 .,IN L r .f 11,000,000
X 3 ANY At tm____
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CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
It1L LXPIHATION UAIL IIiLHLOF. NOIICL WILL BL ULLIVLHLU IN
Village of Rye Brook ACCORDANCE WITH THE POLICY PROVISIONS.
938 King t
Rye Brook NY 10573 qu*rtcJw:LDnLr+ILztNTAnvt
USA
1988-2015 ACORD CORPORATION. All rights reserved.
ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD
Nf,W
t YORK Workers' CERTIFICATE OF
—tart: Compensation NYS WORKERS' COMPENSATION INSURANCE COVERAGE
Board
t ct. t teal N.1fni:A Addra-m of Insured(use stieel address only) I b.Business Teieift"Number of Ins , .1
Nowar Home Ro modeling Group, LLC G 10-874-5000
2501 Seaport Drive, 4 ih Floor f c.NYS Unemployment Insura nco Employer RegistraWi Number of
Chester, PA 19013 Insured
Work t.oration of Ifi.urml(Orly mquired it coverage hi sperCirWI/y Nmiw to 1 d.Fedural Employer Idtvttif'x;aG(nn Nvinber of Insured of social Security
certain t wane in New York Slate,i.e..a wrap-Up Poik y) Number
23-3030708
2. Narne and Address of Entity Requesting Proot of Coverage 3a.Name of Insurance Camer
(Entity tieing Listed as the Certit�ate Holder) I E'rinn4ylvnr::, lwtur;jrwv Conip;rny
Village of Rye Brook 30. P'olicy Number of Entity Listed in Box•I a'
938 King St 202275-66-20-913-7
rtye f3rnok NY 10573 '3c. Policy effective period
01101/2022 to 01/01/2023
.irt The Propnator,P..utners or Citmuhve Officers are
T 1 Included (Only Owit r",-,it an AartnarsJnnrarc rrxiroc�f)
4 [✓I all excluded or certain partnersiolPicem excluded.
This certifies that the Insurance carrier indicated above in box"3" insures the bu•,rx;ss rolorenced aWv(-in t)ox"in"for workers
compensation under the Now York Statu Workers'Ccaiipensation 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 Il(xtitwd agent wlll send
this Certificate of insurance to the entity listed above as the curlitiG.3te 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 coverago 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 certific.ato holder, This;ccrtltlr;,oto does not amond,
extend or after the coverage afforded by the policy listed, nor does it confer any rights or responsibilities beyond those contalned In the
referenced policy.
This oertificate may be used as evi(JU110 of a Workers Compensation contract of insurance only while the underlying froiicy Ig In Affect.
Please Note: Upon cancellation of the workers'compensation policy indicated on this form, if the husinoss continues to be
named on a permit, license or contract issued by a certificate holder, the business must provide that certificate holder with it
new Certificate of Workers' Compensation Coverage or other authorized proof that the business i A complying with the
mandatory coverage requirements of the Now York State Workers' Compensation Law.
Under penalty of perjury, I certify that I Atli an authorized representative or licensed agent of the insurance carrier referenced
Above and that the named insured has the coverage m. depicted on this form.
Approvod by, Ashley Madormo
(14,vit riarne of:%.itt:v-u (i (0 lAAWAfVA CA AAA)
nw-341n.d hy:
Approvud by: I (11 y*b 10/ifs/2021 12:57:0-1 PM EDT
i�+ �43Ottov) ;Dale)
Title: Underwriter
Telephone Number of authorized representative or lic;unwLuJ agent of insurance rarner: 484.530.8.392
Please Note: Only Insurance cardom and their licensed agents are. aifIhorixed to Issue. roan C-105.2. Insurance brokers are NOT
authorized to Issue It. i
C-105.2 (9.17) www.wi.h.ny.gov