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HomeMy WebLinkAboutBP22-202PERMIT SECTION .1 d TYPE OF WORK JOB LOCAT�,OP' 4WNERjLLr.,4 cer INTRACTOF Yj� . COST "a DATE: Q =)6 LlXP: ,,:;4o% 7 BLOCK LOT I� 'a 3CbLoe o�ol 4 Ca 6evmZ 7 O/y)o---�%/ 3 i� rrr c1& / °'%jC fl MvfAT • DATE INSPECTION RECORD DATE FOOTING INSP OTHER APPROVALS ARB 4nt�P! c�0a1 Ii �oT I PB ! ZBA OTHER AS-BUILT1FiNAL SURVEY REQUIRED PRIOR TO FINAL MSPECTIPN1 , vPd .01203 Ct'+.Cca v'"+" VILLAGE OF RYE BROOD MAYOR 938 King Street, Rye Brook,N.Y. 10573 ADMINISTRATOR Jason A.Klein (914) 939-0668 Christopher J. Bradbury nww aebrook,or� TRUSTEES ACTING BUILDING& FIRE INSPECTOR Susan R. Epstein Steven E. Fews Stephanie J. Fischer David M. Heiser Salvatore W. Morlino CERTIFICATE OF COMPLIANCE February 7,2023 Bruce Rubenstein&Sandy Rubenstein 140 Country Ridge Drive Rye Brook,New York 10573 Re: 140 Country Ridge Drive, Rye Brook,New York 10573 Parcel ID#: 129.74-1-11 Building Permit#22-202 issued on 10/26/2022 For a New Partial Fence This certifies that the new four foot high partial fence,installed under the above captioned permit has been satisfactorily completed. Sincerely, Steven E. Fews Acting Building&Fire inspector /to Hirsch Fence Install & Design 747 Route 9W Valley Cottage, NY 10989 Customer'.Last Name,Fuss Name Sem.Add— EC E ME BUILD R MENT For office use only: PERMIT# q� JAN 20 2023 VIL OFRYE OK ISSUED: Q/ �(p 2 8KING STRE YE BROOK, YORK 10573 DATE: Q-% 9 -06 O� FEE: ' Q PAID Q' 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 wassssrwwwwrsssssrrrwwwaaaasssswwrrwaasssssrtw www waasasasrwwwwww saassssrwrrwwassssasrwrwwwwaaassrswrwwwwrasssssrrwr wwwwwasrts Address: 140 y(A(A��,,VI'�T Occupancy/Use: ////:; lq Parcel ID#: /Q 9,-7'V—//—�I/ Zone: -I S Owner: O Cafe P.E./R.A.or Contractor: r 6 6 L e 6� Address: 7 q Person in responsible charge: a 4,, 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 O COUNTY OF WESTCHESTER as: � vQ6 om,deposes and says that he/she resides at (Print Na�e o�f App icant �� ,,I,•L_e. l � (No.and Street) in rr1 �(7 (� I�1n the County of //U)l i"�e in the State of ,that (City wn/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:$ 60000 , for the construction or alteration of: Sm t?e— 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 V Sworn to before me this day of 204— day of ,20 Signature of Pro r Signature of Applicant d 0,5fel�] 3;;T; wner d Print Name of Applicant m Notary Pu c Notary Public GREGORY M.RIVERA Netary Public,State of New York 8/12/2021 No.01 R16441398 Qualified in Westchester County ' Commission Expires September 26,TO ���Rap. O Zm ( 1982 BUILDING DEPARTMENT ILDING 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 ygbrook.org - - - - - - - - - - - - - - - - - - - - INSPECTION REPORT - - - - - - - - - - - - - - - - - - - C� - 2 (n I 2o2-j ADDRESS:_ � ( `-�=�J� � � DATE: PERMIT# 202--- ISSUED:t SECT: -(BLOCK:LOT LOCATION: V r T��- � � OCCUPANCY: '-z �v ❑ VIOLATION NOTED THE WORK IS... ACCEPTE ❑ 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 ❑ ROSS CONNECTION FINAL OTHER : N \ \ w c a� y o y + a o 0 o w ° yob U W N Ln od 00 `�W1ou � � � •� �j = z ui Ln 'a � zo " e U rl `� ►7 N a p y "'w v a � o r h� G, I..� ►mi l p4 cn z n W-400 1-4 il r••i . W O � � a � V 00 R. �0 CA I� V U x o Wp � u A w A W o zzb ` ° u a �j 0 a � � Ube ~ n. ZZ � z O c7 A z O : 9 ■ 44-44;4;444444;4;ago 44;aaa4;4U4;agog Q944410444;4;4;a4;4;a IED BUILD RTMENT D E C I M W r, VIL 4 OF R ROOK OCT -3 2022 938 KIN EET RYE B ,NY 10573 VILLAGE OF RYE BROOK �, 4 9- r BUILDING DEPARTMENT FOR OFFICE USE ONLY: Approval DateO P rmit#idle- c Q: - Application# 5 7 7(—D Approval Signature: ARCHITECTURAL REVIEW BOARD: Disapproved: : Date: 0 /f12--.V BOT Approval Date: Case# : Chairman: PB Approval Date: Case# Secretary: ZBA Approval Date: Case# Other: Application Feew Permit Fees: FENCE / WALL / GATE PERMIT APPLICATION Application dated: ©nt 3 ZO Z is hereby made to the Building Inspector of the Village of Rye Brook,NY,for the issuance ofa Permit for the installation,constructio ,repair or replacement of a Fence,Wall or Gate,in accordance with Section 250-6 B.(1)(g),of the Code of the V illage of Rye Brook,as per detailed statement described below. Swimming pool fences must conform to the State Code. 1. Job Address: 14-0 Colon ye , �qe_` I-cO 2. Occupancy/Use: I YC;4✓p1 S.B.L.#: Zone: S 3. Pro osed Fence/Wall/Gate(describe ' detail): / ��� d.k�.M drta.ns 6 r� 11 yJ"_M ;n o0 m tilt ei't /r' id P o a cG A'_ 4. Property Owner: -1' BrLtc le, n-.s -e 1 � L� Address~ u D -e_ rr oo Phone# Cell# d2(a 0'"q 0 email:_15ondott be n,5l e 10 Applicant: J"ra l b '�Tom' ti Address: j R �J Phone# Cell# email: Arch itect/Engineer: Address: Phone# Cell# email: Contractor: t✓ II" c '1 ,/ �y Address&Phone: t L le I — t i e QY/O O 5. If building is located on a corner lot,which street does it front on: 6. What is the estimated cost of construction &p 0.0O (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: 7 t 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 NEW YORK,COUNTY OF WESTCHESTER ) as: ,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 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.) 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 a d Sworn to before me this day of ,20_@D day of , 20 Signature of Property Owner Signature of Applicant Print Name of Property O er Print Name of Applicant Al_,� Notary Public Notary Public SHARI MELILLO Notary Public,State of New York No.OIME6160063 Qualified In Westchester County 11 Commission Expires January 29,20_ z 8/120021 Building Permit Check List&Zoning Analysis Address: SBL: Z�' 4f Zone ^I S Use Z I 0 Const Type: 11, Other Submittal Date: 3 Z Z Revisions Submittal Dates: Applicant: v3F N S i�c k e(-A rr Nature of Work �� N-<<a`�- Tt A C_ views:ZBA:OCT -- 4 2022 PB: BOT: Other. OK_ ( ( ) FEES:Filing: JS' BP: ( ` 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. Shore Fees: N/A; ( ) ( ) SITE PLAN:Topo: ite Pr tection: S/W Mgmt.: Tr e Plan: Other: SURVEY:Dated '-i I?-q I Current ArchivaL •/ Sealed. Unacceptable: ( ) ( ) PLANS:Date Stamped Sealed: Cop Electronic: Other. ( V License: ✓ Workers Comp: r-// Liability: Comp.Waiver. Other. (0� ( CODE 753#: 10 )-UU) — 4//7—OG 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. ( ) ( ) 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. GARB mtg.date: i.o 19 approvaL• 1 2 notes: ( )ZBA mtg.date: approvaL notes: ( )PB mtg.date: approval: notes REQUIRED EXLSITNG PROPOSED NOTES A Date- OCT 2 .5 7ul - cir F � Front: Front sue: Main Cov Accs.Cov Ft.HS : S .H Sb: a Tot.Imp: F I : P Height/Stories: notes: p EC ENE BUILDING DEPARTMENT$ VILLAgt OF RYEaOOK 1 OCT — 3 2022 DD 938 KING � ET RYE BR arc,NY 10573 VILLAGE OF RYE BROOK > 4 9-0 -� 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: 11 0 l m 0 +T-\ Date of Submission: Parcel ID#: S)9,2q-/—// Zone: —�S /���/2'-z Proposed Improvement(Describe in detail): &1,) C Si APPLICANT CHECK LIST: _ MUST BE COMPLETED BY THE APPLICANT The following items must be submitted to the Building IL Department by the applicant-no exceptions. Property Owner: t f el�(�Completed Application 2. ( )Two(2)sets of sealed plans. (one full size (maximum Address: D (((� r' allowable plan size=36"x 42") and one 11"x 17") (3 3. ( )Two(2)copies of the property survey. Phone# Q 1 (� 4. ( ) wo(2)copies of the proposed site plan. Applicant appearing before the Board: 5. ( ne electronic/disc copy of the complete ur e" 1^/jo,6i r� plication materials. f� 6. (�'ng Fee. Address: (7 ��� idC; j 7. ( Any supporting documentation. Phone# q -6 d AV / 8. )HOA approval letter. (if applicable) 9. (photographs. Architect/Engineer: 10.( )Samples of finishes/color chart. (a sample board or Phone# 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. Swom to before me this 9 (1� Sworn to before me this day of �2 , 20 day of 20 Signature of ro rty Owner Signature of Applicant r- 4 7� M:'�nA� rty Owner Print Name of Applicant Notary Public Notary Public SHARI MEULLO �jotary Public,State of New York No.O1ME6160063 Quatltled In Westchester County mmission Expires January 29,20O?3 sn 2/2021 BR�u�\ Village of Rye Brook ML t/ MR n a FB SE Architectural Review Board Meeting AC SF Wednesday,October 19,2022 at 7:30 PM Village Hall,938 Ring Street IJM 1. ITEMS: 1.1. #5772(Consent Agenda) Bruce Rubenstein&Sandra Rubenstein 140 Country Ridge Drive 4'-0"high partial fence. 1.2. #5773 (Consent Agenda) Daniel Wurtzel&Helene Wurtzel 43 Meadowlark Road Rooftop solar array. 1.3. #5774(Consent Agenda) Michael Ross&Heidi Li 151 North Ridge Street Rooftop solar array. 1.4. #5775 (Consent Agenda) Richard Greenberg&Elizabeth Greenberg 1 Milestone Road Replace decking&railings on existing rear deck. 1.5. #5776 (Consent Agenda) Fernando Rosales&Leslie Rosales 68 Tamarack Road Replace wood tie wall w/masonry and add flagstone to existing steps. 1.6. #5672(Consent Agenda) G&G Homebuilders Corp 10 Arlington Place Change front and rear doors. (Amendment to Prior Approval) 1.7. #5784(Consent Agenda) Fabricio Denadae&Luciana Chieus do Amaral 110 Brush Hollow Close Legalize conversion of attic to living space-install skylights. Consent Agenda �'�1 Approvals: Motion ` Second INCn /'� abstention Aye; q Nay;�Z Adjournment; Notes Page 1 of 4 r.�. .' � _ :!. � .r .� f t.. �: ;4 3 r z����y ',.a > ,� �f +,� � 'ram-`�-- - •'iz .• A { n A> .y,N... Wt '�. � _{- , _ _ �����¢ tom_ :,�^ _,.ri-- S ."'R �.a. _ w�r� , ' ? '� ♦ \ • « irk oa Ao . 16 r i t t � •, ti �• ' � / '� '/ r :tom - • Win- - 1 ,-. '" •, -,,. 1 ` r� .�f�My,�� 1'S} � _ . `gym .�r' �+�,.�`' '�'�^_ •`1F�'$—� ,:rN.'s. �� "?�����. tom. ��'� - �xk-�ri�g •���. -�.-�-.- '-. t-r; ..... ..-. yam•: �y�Yk�af�'4y�4'7p r .� •yam� ��yV Ff�y` �Ri R,. - '. .. ,. ' 'l.rl / a' .�. �;_ � . ,q��i ',„�@►�i _ gyp,., � �. �i �•. .. {fir .. e'Sre 4 } r' h Ar A� ��e.r Y✓ f � ` '?r.�•. � •l�,�, r,p�� ���'� ,4,, }rT � y ,, ♦�� ,z �r��ijy�A�, .'F'r r. 5 qq Q e r Ag- _ -�'\ �`� ��� tin,9•:� 1 _ ;L�sP ..� -�_ µ. `.ar'' ' i, hV i _7. t L G t "r tX �J l _ �Ln k x, 6. � auoydi Aw W04IUOS T O N • �. _ Y C3 a{{ * V U ^ � 1, F I r•r a�Oi C z ti a �okectiOn :d•"J. O � w "�E a �' � ' Q G 666 I� U r V w o f • O Z ^ W s y cm:: w -i '° F cr o `ficy�a►i�' I Gaj � � �'�`tslq►4. A )► � � fs r, C N .� z C-4 = N L T 1 .r Ir �ti I'M P'N,+�' � '� �.�fl14 li:1� �1�5 1 i � •-•r 1, �At F!t SN /.{111 1 iyr � , �! L •1f q �►I � i., � �, CERTIFICATE OF LIABILITY INSURANCE DATEIMM/DDYYYY) 9912612022 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 endorsements . PRODUCER CONTACT gill McCarthy McCarthy Insurance PHONE 914 769 0417 FAx 914 769-0609 378 Elwood Avenue E-MAIL gill mccarth insurance.net Hawthorne NY 10532 INSURERS AFFORDING COVERAGE NAIC C INSURER A: Preferred Mutual INSURED INSURER B Hirsch Fence Install&Design LLC INSURER 747 RT 9W-Cottage#4 INSURER D Valley Cottage,NY 10989 INSURER E 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. INSR TYPE OF INSURANCE DDL UBR POLICY EFF POLICY EXPLTR LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $1,000,000 A CLAIMS-MADE FX I OCCUR DAMAGE TO RIEa ENTED 50,000 X. BOP0100721375 11/12/2021 11/12/2022 MED EXP(Any oneperson) s5,000 PERSONAL&ADV INJURY S1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER. GENERAL AGGREGATE S2,000,000 POLICY❑PRO- ❑ JECT LOC PRODUCTS-COMP,OP AGG s2,000,000 OTHER S AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT S ANY AUTO BODILY INJURY(Per person) S ALL OWNED SCHEDULED BODILY INJURY(Per acudenl) S AUTOS AUTOS NON-OWNED PROPERTY DAMAGE S HIRED AUTOS AUTOS S UMBRELLA LIAR OCCUR EACH OCCURRENCE EXCESS LWB HCLAIMS-MADE AGGREGATE DEC RETENTIONS I S WORKERS COMPENSATION PER OTH- IR AND EMPLOYERS'LWBI LITY YY ll NN ANY PROPRIETORPARTNERrEXECUTIVE E.L.EACH ACCIDENT OFFICEWMEMBER EXCLUDED? u N I A (Mandatory In NH) E.L DISEASE-EA EMPLOYEE S If es.descnbe under OPERATIONS Wow J E.L.DISEASE-POLICY LIMIT S DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule.may be attached if more space is required) Fence Contractor Village of Rye Brook is Additional Insured Job Location: Rubenstein 140 Country Ridge Drive Rye Brook,NY 10573 CERTIFICATE HOLDER CANCELLATION Village of Rye Brook SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 938 King Street ACCORDANCE WITH THE POLICY PROVISIONS. Rye Brook NY10573 AUTHORIZED REPRESENTATIVE _ <CFP> � 2 ,. ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD c ' o"W Workers' Certificate of Attestation of Exemption STATE Compensation from New York State Workers' Compensation and/or Board Disability and Paid Family Leave Benefits Insurance Coverage **This form cannot be used to waive the workers'compensation rights or obligations 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 Hirsch Fence Install B Design LLC 747 Route 9%1'#4 From:Village a of Rye Brook Valley Cottage,NV 10989-2452 PHONE:845-304-8622 FEIN:X.XXXX0091 The location of where work will be Derformed is 140 Country Ridge Drive,Rye Brook.NY 10573. Estimated dates necessary to complete work associated with the building permit are from September 26.2022 to December 26.2022. The estimated dollar amount of project is SO-S 10,000 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: Bruce Hirsch 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)under 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.Bruce Hirsch,am the Member with the above-named legal entity. I affirm that due to my position with the above-named business I have the knowledge,information and authority to make this Certificate of Attestation of Exemption. 1 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 affairs that if circumstances change so that workers'compensation insurance and/or disability and paid family leave benefits coverage is required,the ove-named legal entity will immediately acquire appropriate New York State specific workers' compensation insurance and/or disability a p d family leave benefits coverage and also immediately furnish proof of that coverage on forms approved 'by the Chair of the Workers'Compensa rd to the government entity listed above. SIGN HEREI i�� Signature: Date: Exemption Certificate Number Received 2022-066221 September 26, 2022 NYS Workers'Compensation Board CE-200 01,2018 Laura Petersen From: Mike Izzo Sent: Wednesday, October 26, 2022 1:13 PM To: Laura Petersen; Steven Fews;Tara Orlando Subject: FW: Message from UDig NY From: UDig NY Exactix <tickets@exactix.udigny.org> Sent: Wednesday, October 26, 2022 1:12:50 PM (UTC-05:00) Eastern Time (US & Canada) To: Mike Izzo Subject: Message from UDig NY ****REGULAR**** DIG REQUEST from UDig NY for: VIL RYE BROOK Taken: 10/26/2022 13:11 To: VIL RYE BROOK PRIMARY Transmitted: 10/26/2022 13:12 00004 Ticket: 10262-001-417-00 Type: Regular Previous Ticket: ------------------------------------------------------------------------------ State: NY County: WESTCHESTER Place: RYE BROOK Addr: From: 140 To: Name: COUNTRY RIDGE DR Cross: From: To: Name: Offset: ------------------------------------------------------------------------------ Locate: WORKING AT THE BACK OF THE PROPERTY NearSt: ROCKINGHORSE TRL Means of Excavation: UNKNOWN Blasting: N Site marked with white: N Boring/Directional Drilling: N Within 25ft of Edge of Road: N Work Type: FENCE INSTALL Estimated Work Complete Date: 11/12/2022 Depth of excavation: Site dimensions: Start Date and Time: 10/29/2022 07:00 Must Start By: 11/15/2022 ------------------------------------------------------------------------------ Contact Name: SANDRA RUBENSTEIN Company: Addrl: 140 COUNTRY RIDGE DR Addr2: City: RYE BROOK State: NY Zip: 10573 Phone: 914-260-4013 Fax: Email: sandyrubenstein5@gmail.com Field Contact: SANDRA RUBENSTEIN i •Alt Phone: 914-260-4013 Working for: WORK TO BE PERFORMED BY: CONTRACTOR ------------------------------------------------------------------------------ Comments: CALLER ADVISED TO HAVE CONTRACTOR CALL UDIG NY Lookup Type: PARCEL ------------------------------------------------------------------------------ Members: CONED SUEZ WTR WESTCHESTER VIL RYE BROOK WESTCHESTER CTY SWR 2 ,(00 .. 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