HomeMy WebLinkAboutSP22-001PERMIT # '00 % DATE: c EXP: 4-o l)-,3
SECTION 10Ylo c 7 BLOCKL07 e
TYPE OF WORK A(ka) 0 r/C lCJ.�JO/�G S%�i.'� /
JOB LOCATION
OWNER /i'% /
EST. COST "
v/CO #
TCO #
FOOTING
FOUNDATION
FRAMING
RGH FRAMING
INSULATION
PLUMBING Cl
RGH PLUMBING
GAS 0
SPRINKLER
ELECTRIC O
LOW -VOLT m
ALARM m
AS BUILT O
FINAL
i�Iw/01/
o • �►
FEE DATE _--,
INSPECTION RECORD
DATE
INSP
�—
:r v
� ;4j � 7
/No/)1e3 Ylay
OTHER APPROVALS
•
�PyE DR
G tbG�'u�
n L
V L��t+�uJ i
VILLAGE OF RYE BROOK
MAYOR 938 King Street,Rye Brook,N.Y. 10573 ADMINISTRATOR
Jason A. Klein (914)939-0668 Christopher J.Bradbury
www.iyebrookny_gov
TRUSTEES BUILDING& FIRE INSPECTOR
Susan R. Epstein Steven E. Fews
Stephanie J. Fischer
David M.Heiser
Salvatore W.Morlino
CERTIFICATE OF COMPLIANCE
December 23,2024
Win Ridge Realty LLC
c/o Alena Hakanjin
24 Rye Ridge Plaza
Rye Brook,New York 10573
Re: 15B Rye Ridge Plaza,Rye Brook,New York 10573
Parcel ID#: 141.27-1-6
Sign Permit#22-001 issued on 2/28/2022 for New Fabric Awning Sign
This certifies that the new fabric awning sign,"Prosper IV",installed under the above captioned permit has
been satisfactorily completed.
Sincerely,
Steven E. Fews
Building&Fire Inspector
/to
®
`( BUILD R ENT For office use only:
DEC 19 2024 LV PI:Ran I # -cc /
VIL OF R )E OK ISSUED:
`.938 KING STRE VE BROOK, N'YORK 10573 D:\II::
VILLAGE OF BYE BROOK ,Y,k `1
BUILDING DEPARTMENT , 9 -06 Pmnm
ov
YO
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
sssssssas♦ssssssssrsssssrss��sss,/ssesrssssssssrsssssssssssssssssssssssasssessssssssssssaasassasassssssssssssssssassssssss��sas
Address: (Jr �y� 1" 'f
— 0
Occupancy// Used Parcel ID ��� z� �-—/ 6 Zone:
Owner: Wr-( 1Ct'14t r/ �' J ��C �n Address: le1ye (U4;'IV4, 177-e
P.E./R.A. or Contractor: 'rr 0a(4Wftr, Address: &t Iftr�r " NY/�J�c�
Person in responsible charge: 6(eryj,I q 3'61z-y/r' Address: IJ-9 /Z < r�'G f�4�• �� �t .rcA�
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 fir the structure construction/alteration herein mentioned in accordance
with law :
STATE OF NEW Y/O/RK, COUNTY OF WESTCHESTER as: a
being duly s��om.deposes and says that he she resides at 2�4-t5 aft A'e4 4 e-
Printt/Namee,off Applicant /, (No and Street)
in �(/ti'V we, in the County of 1,/jk4-e*r- in the State of that
(Cityrl'oµn/Village)
he'she has supervised the work at the location indicated above.and that the actual total cost of the tyork.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 vas:$ 1 YYC.
for the construction or alteration of: aivi I t� re C e f2 X t f cif aou/Lt
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%%ith 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 pan thereof hereafter created.erected.changed.converted or enlarged.t%holly
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 ���—.. Swom to before me this �s
day of dV01 b k 9l . 7C ` day of J Y 11Q1)1(GCi . 20
I
Srgrriatu f Prorrn Owrtet ,{.w' Signature of Alicant /
Print Name ro rn t Print Name of:\I cznt
No Public Notary Puh rc
RICHARD A.YARMY 11 MEESAK MAR
Public State of New�O" g ,2Ct24
NOTARY PUBLIC,STATE OF NEW YORK C
ary No.otKU6azz235
Westchester cou b
25
Registration No.OIYA0013323 omisSion Expires Sep �Qualified in Westchester County
Commission Expires September 08,2027 ) l l LS ����
�yE BR(b,
cu �
ID
-c
1982•
BUILDING DEPARTMENT
❑BUILDING INSPECTOR
❑ASSISTANT BUILDING INSPECTOR VILLAGE OF RYE BROOK
❑CODE ENFORCEMENT OFFICER 938 KING STREET • RYE BROOK,NY 10573
(914) 939-0668 FAx (914) 939-5801
www ryebrook.org
- - - - - - - - - - - - - - - - - - - - INSPECTION REPORT - - - - - - - - - - - - - - - - - - - -
ADDRESS : ? Iti DATE:
PERMIT# ISSUED: -Z 9'11 SECT: 411,27 BLOCK: LOT:
LOCATION: -�r—V 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 v
❑ F EL TANK e2 U
❑ FIRE SPRINKLER
❑ FINAL PLUMBING
❑ CROSS CONNECTION
FINAL
13 OTHER
~ H
N p
ONo v '
a
a 0
a
p v a�i
o
0-4
o Z .0 A
WhmV IS W .
'C7
p"
> a
�+ � O O o O o � o eu � CO
o ■
• (� ULnLn
o
F .�
/� v
O W F--I A W z A U a
�] z 1 ° � v�, 2 'o 04%
l O `�' ►�+ " I .. o � G , to N � �-+
1 A Wz � � .yroo N • W
FBICNo < b v
104
w 5 -d o °
rn
� w U
0
H i-r Q 0 Cl
o O. C vG! P v to
I U p V o f g3v to
G4 a+ w O v a U 44
w o � Q 'A
Z 8 w ao pq c1�
�I U o V �• � Q; -a � o �i
4-4
,1 T
Bum MENT
VI E OF RYE OK FEB - 1 2G?_2
938 KING ET R)r BR ,NY 10573
(914)9 S (9 39-5801 VILLAGE OF RYE BROOK
o r BUILDING PFRARTMENT
FOR OFFICE USE ONLY: q
Approval Date: E8 2 3 401� ermit#� �1��}�! Application#
Approval Signature: ARCHITECTURAL REVIEW BOARD:
Disapproved: : Date: F E B _ 2021
BOT Approval Date: Case# Chairman:
n11r
PB Approval Date: Case# ; Secretary: M
ZBA Approval Date: Case# PC
Other:
Application Fee• ermit Fees:A 075/�)yE
SIGN PERMIT APPLICATION
Application dated: t r�AWC&& is hereby made to the Building Inspector of the Village of Rye Brook,NY,for the issuance of a Permit for the
construction/installation ofya�sign in aaccordance with Village Code§250-35 as per detailed statement described below.. /
1. Address: Py{ r"�( � �� u Y I Ds?Y SBL: /y/• c /'—/—CD Zone:��
2. Property Use or Business Name: rro aGr
3. Proposed Sign(s)(Describe in detail including number of signs,types,sizes,exact location(s),and illumination method(s)if applicable.)
(A separate Electrical Permit will be required for any associated electrical work.)
J jf*1I!t kjj Jf&r A40I - 'a&t
4. Height from grade to highest point of sign: ,to lowest point of sign: �Q� �^n �' ,,,/
5. Property Owner:_W/K got- a►� ac Address: io ►c1v luj�� �^�. ���+""�;,vYIOV-3
Phone# !! Cell# email: ��,,p _
6. Applicant: J1�ICf�4&(44u Vj' $f&jQuG� Ayole-Address: .947A[A,{�►ci AAC-�, �041 &&M"10930
Phone# ���.32d'•�f Cell# 2®l• �?3{ • � G� email: tLiiC �S � 4'Qa
�P
7. Architect/Engineer: Address:
Phone# f Cell""#�� � ��""��em/a�i_l:
8. Sign Contractor: 7f 4�(•4[ /d/"�JuLut Address:APIJ (agc�ue/49- h�hllf.'� l�. fl
Phone# �� •d •���� Cell# t'� —email: f�S%' �''¢' �19f��`�'•
3/21/19
9. Will the proposeVgn require a Site Plan Review by the Village Planning Board as per§209 of Village Code?
Yes: No: - (If yes,you must submit a Site Plan Application,&provide detailed drawings) v
10. Does the proposed sign involve a Home-Occupation as per§250-38 of Village Code? Yes: No: h If yes,indicate:
TIER L•_TIER IL_TIER III:_ (If yes,a Home Occupation Permit Application is required)
11. If building is located on a corner lot,which street does it front on:
12. Property frontage_/�k kq�
13. Property size:Sq.Ft.: r '` Acres:
14. What is the total estimated cost of construction: S 6 4f1 K
(The estimated cost shall include all site improvements,labor material,scaffolding,fixed equipment,professional fees,including any material and
labor which may be donated gratis.)
15. Estimated date of completion: — 3 wee r Si fk
This application must include the notarized signature(s) of the legal owner(s) of the subject
property, and the applicant of record in the spaces provided. Any application not properly
completed in its entirety and/or not properly signed shall be deemed null and void, and will be
returned to the applicant. Please note that application fees are non-refundable.
STATE OF NEW ORK,COUNTY OF WESTCHESTER ) as:
MI'CAAd a(2 ,being duly sworn,deposes and states that he/she is the applicant above named,
(print name of individual si ing as the applicant)
and further states ghat (s)he is the legal owner of the property to which this application pertains, or that (s)he is the
Sig H C914 fyCOX for the legal owner and is duly authorized to make and file this application.
dicate 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 Sworn to before me this !CJ
l
day of [ , 20� day of 4q
20
St ature of Pro rty Sigrtat a of A plicant
AID l.i$ Q 'fIQ,S AlichaaI iv
Print Name of Property Print Name of Applicant
K I - kmrd
Notary Public t ublic
KFI Iy Snn+r,l ER JANINE M KOGEt
I` " my York ENotcry PUhllc •Stoti of Ne•.v YM
NO,O1K06160107
^fiY uallfled lt1 Weatclter C rrty
orramlaslon expltea
-z-
3/21/19
Building Permit Check List&Zoning Analysis
Address: • l S�_G3 y�� l� aZ o4 SBL:
Zone: C k— Use: Const.Type: Other.
Submittal Date: Z " -Z Revisions Submittal Dates:
Applicant �A 1 _I:L Ll.> E
Nature of Work: i— � LIC _ ��.I�.►t,\I G -C"(e N
Reviews:ZBA: F F R - 2 7 0 2 2 PB: BOT: Other.
OK
( ( ) FEES:Filing 3.�- ' BP: � 07 7� ��C/O: Legalization:
( ) (.YAPP: Dated. ✓ Notarized: SBL: —"'Truss I.D. Cross Connection: H.O.A.:
( ) ( ) Scenic Roads: Steep Slopes: Wetlands: Storm Water Review: Street Opening.
( ) ( ) ENVIRO:Long. Short Fees: N/A:
( ) ( ) SITE PLAN:Topo: Site Protection: S/W Mgmt.: Tree Plan: Other.
( ) ( ) SURVEY:Dated: Current: Archival: $ealed. Unacceptable:
( (+ LANS:Date Stamped Sealed. ✓ Cop; "Z Electronic. ; Other.
( ( License: Workers Comp:_Jj��Liability ✓ Comp.Waiver. Other.
( ) ( ) 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.
( ) ( ) 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.
( )ARB mtg.date: 2- L Z Z approval: 2 notes:
( )ZBA mtg.date: approval:- notes:
( )PB mtg.date: approval:- notes:
REOUIRED EXISEN PROPOSED NOTES APPROVED
Ate: FZB-2--3 20V
Cir :
Front:
Front
Sides:
Main Cov.
Accs.Cov
Ft.HS :
Sd.H S :
Tot.!my:
Et-Imp:
PP
Ham"/Stories:
notes:
BUILD
VIL�1 E of Rv oOK T FEB - 1 2022
938 KING cu >KT Rl`E BR NY 10573
E OF RYE
(914)9 � 8. 9 39-5801 BIUILD NG DEPARBMENGT
i
o r
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
�apcopy of this check list will be removed from the
/ARB agenda.
Job Address: `�ye �'�� l /� l�C/ Date of Submission: l tt1W
Parcel ID#: ��. 01 f—�r�p Zone
Proposed Improvement(Describe in detail): APPLICANT CHECK LIST:
0} MUST BE COMPLETED BY THE APPLICANT
P`f1 1� �ttil ,pk"(, � The following items must be submitted to the Building
8H exlj-� kf QUk-hH y uIC Department by the applicant-no exceptions.
1. (-1 Completed Application
�, 2. (.-1 Two(2)sets of suated"plans. (one full size(maximum
Property Owner: Alm Pue I2m `� allowable plan size=36"x 42") and one I 1"xl7")
�jr padg2 , #000 �j/ k Ny/�'J`�3 3 ( )Two(2)copies of the property survey.
Address: �Q e
4. ( )Two(2)copies of the proposed site plan.
Phone# 5. One electronic/disc copy of the complete
Applicant appearing before the Board: application materials.
6. (vj Filing Fee.
Mlwlgc� GQuf, J'1�'Ha � 7. ( )Any supporting documentation.
Address:YA)64#r 4l Aet 44J aW-C-�/yY/OkfdO 8. ( )HOA approval letter. (ifopplicable)
9. (•✓jPhotographs.
Phone# r�' «� 10.( ) Samples of finishes/color chart. (a sample board or
model may be presented the night of the meeting)
Architect/Engineer:
Phone#
By signature below, the owner/applicant acknowledges that he/she has read the complete Building Permit
Instructions&Procedures, and that their application is complete in all respects. The Board of Review reserves the
right to refuse to hear any application not meeting the requirements contained herein.
Sworn to before me this Sworn to before me this 74�
day of jm^') 20 2Z. day of,1aWZ4dU.1 , 20
e of Prope Ororner Signature of A icant
A61_wr
01
WID P06iUQ4 I V.P. QJ�EP-AT" !zI C6e,d W-
Print Name of Property f�pvrler f Print N f Applicant
NotlrPublic to ublic
f
Y JANINE M KOGEI 4
Notary Public - Stata of Ner.v York
/12 NO.01 K06150107
Qualified In Westche.;ter�C ,
My Commission Expires
VILLAGE OF RYE BROOK
BUILDING DEPARTMENT
938 KING STREET, RYE BROOK,NY 10573
(T) 939-0668 (F) 939-5801
ARCHITECTURAL REVIEW BOARD
Wednesday, February 16, 2022
ANNOUNCEMENT: PER THE GOVERNOR'S EXECUTIVE ORDER THIS MEETING WILL BE
HELD VIRTUALLY THROUGH THE ZOOM PLATFORM. THE PUBLIC CAN ACCESS THE
MEETING THROUGH THE FOLLOWING LINK: hops://us02web.zoom.us/o/81417970741
OR
BY OPENING ZOOM AND ENTERING THE MEETING ID: 81417970741
NAME& LOCATION TYPE OF APPLICATION MOTION SECOND APPROVED REJECTED APPL.#
15B Rye Ridge New Fabric Awning Sign 5674
Plaza(Win Ridge) "Prosper 1.V." ��,� 0
6 Whippoorwill 1&1/2 Story Addition, 5675
Road (Adelson) New Wood Deck& Flag
Stone Patio
9 Country Ridge Dr New Rear Deck, Siding, 5676
(Martino) Windows, Roofing &
Interior Alterations
5 Boxwood Place Replace Rear Deck And 5677
(Biderman) Patio Area With New Deck
2 Lee Lane (Kirsch) New Rear Retaining Wall, 5678
New Side Fencing and
Property Re-grading
980 Anderson Hill New Front Entry Gate 5679
Road (Blind Brook
Club Inc)
47 Hawthorne Ave New 1 Family Dwelling 5673
(Miller)
ML NM
MR SE
JM SF
AC MI
KC
_— 'as"'I WESTMAR-01 SHIEMAN
A�OR� CERTIFICATE OF LIABILITY INSURANCE DATE DIYYYY)
2/2/2022
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 C cT Ana Shielmke
Hylant-Toledo PHONE FAx
811 Madison Ave.
Toledo,OH 43604 JM39.Ana.Shlemk lant.com
INSURE 8 AFFORDING COVERAGE NAIL t
_. INSURER A:Selective Insurance Co of SC 19259
INSURED INSURER B
Westchester Marketing Group,Inc.dba Signarama INSURERC:
28 North Central Avenue INSURER ID:
Hartsdale,NY 10530 -
INSURER E:
INSURER F:
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSRLTR TYPE OF INSURANCE ADDL SUB POLICY NUMBER POLICY EFF POLICY EXP LIMBS
A X COMMERCIAL GENERAL LIABLRY EACH CURRENCE 111 1,000,000
CLAIMS-MADE OCCUR DAMAGE TO RENTED
S 2209002 1/10/2022 1/10/2023Ono) 500,000
MED EXP(Any oneperson) 10,000
PERSONAL&ADV INJURY 1,000,000
GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE 3,000,000
POLICY JECT �X LOC PRODUCTS-COMP/OP AGG 3,000,000
OTHER
A AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT 1(EA accident) ,000,000
ANY AUTO S 2209002 1/10/2022 1/10/2023 BODILY INJURY Perperson)
OWNED SCHEDULED
AUTOS ONLY AUTOS
yy ED BODILY INJURY Per accident)
X ZVI;ONLY X AUTOS ONNLY era dent AMAGE
A X UMBRELLA LUIB M OCCUR EACH OCCURRENCE 1,000,000
EXCESSLI►B CLAIMS-MADE S 2209002 1/10/2022 IMW2023 AGGREGATE 1,000,000
DIED I X I RETENTIONS 10,000
WORKERS COMPENSATION PER OTH-
ER
AND EMPLOYERS'LIABILITY Y/N
ANY PROPRIETORMARTNER/EXECUTNE
OFFICER/MEMBER EXCLUDED? N/A E.L.EACH ACCIDENT
ndato n NFI)
It yes descr be under E.L.DISEASE-EA EMPLOYEE
DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT
A Property S 2209002 1/10/2022 1/10/2023 IContents 210,946
A Special Form/RC S 2209002 1/10/2022 1/10/2023 BUEE ALS
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space Is required)
Policy Includes blanket Additional Insured In respects to the general liability when required by written agreement,subject to policy provisions.
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
Village of Rye Brook THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
938 King Street ACCORDANCE WITH THE POLICY PROVISIONS.
Rye Brook,NY 10573
I AUTHORIZED REPRESENTATIVE
ACORD 25(2016/03) C 1988-2015 ACORD CORPORATION. All rights reserved.
The ACORD name and logo are registered marks of ACORD
INEWR Workers' CERTIFICATE OF
ATE Compensation
Board NYS WORKERS' COMPENSATION INSURANCE COVERAGE
1 a. Legal Name 8 Address of Insured(use street address only) 1 b. Business Telephone Number of Insured
(914)328-3111
WESTCHESTER MARKETING GROUP,
INC.DBA SIGNARAMA 1 c. NYS Unemployment Insurance Employer Registration Number of
28 N CENTRAL AVE Insured
HARTSDALE,NY 10530
Work Location of Insured(Only required if coverage is specifically limited to 1d. Federal Employer Identification Number of Insured or Social Security
certain locations in New York State,i.e.,a Wrap-Up Policy) Number
90-1020605
2. Name and Address of Entity Requesting Proof of Coverage 3a. Name of Insurance Carrier
(Entity Being Listed as the Certificate Holder) TRAVELERS CASUALTY INSURANCE COMPANY OF AMERICA
3b. Policy Number of entity listed in box"1 a"
VILLAGE OF RYE BROOK UB-1N586817-22
938 KING STREET
RYE BROOK,NY 10573 3c. Policy effective period
01/07/2022 to 01/07/2023
3d.The Proprietor,Partners or Executive Officers are
included.(Only check box if all partners/officers included)
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 "1 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 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 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: Michael James Mulligan
(Print name of authorized representative or licensed agent of insurance carrier)
Approved by: 'L -d U-#+— 02/02/2022
(Signature) (Date)
Title: 2VP BI Small Commercial Operations
Telephone Number of authorized representative or licensed agent of insurance carrier: (877)677-0428
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
N
00
�z
o °
:3CD
•• n
cfl
0c) D
�C
r+
L-91
X
0
0
-
CD
4�,,a)
1
o
c
n
(D
N
-7
p
Oo z
w
N �
�
w
c'
�D
m
CD
M%
v
m
. Ul
--
o
:37
O
cn
m
-(D
<
0
0
N
-0
N
LH
CD
cam'
ZY
m
-2
0
-0
CD
-lot
0
cam'
Q
CD
0
0'
CD
-t
CD
0
c
CD
OL
0
3
CD
0-
CD
Cu
0
0'
O
c�
3
0
cn
0'
T
c
r
M
Oft
m
rs.. ve•-- \m/
-T-=
...
rnN
\r
D
z
r.:\L/
CAD
r
O
a
N
o
z
D
m
x
m
m
D
m
0
O
m
-v
x
O
C_
m
D
m
O
r
m
-v
O
-v
m
O
m
O
z
n
m
— n Cn
0
n
�. ° (a
3
>
°
CD
D
�-�
cn
to
0 .. CD
0
..
v
n
••
..
m
cn
C
O
V
:37
z
O
X
m
o C
1
\r\J0
o
V
V
V)
D
CD
r
O
�
m
x
�
O
U)
o
O
m
0-
0.
n
D
<71
..
'
migm
r16�.•R1iM.'.f.ZK9T:[(A
� r-
�ZMFM
CI)
T
V
ro
S _0 " 1(
■r�A� LPG I i
Punuj
z O
7-41
Village of Rye Brook
rch0ectural Review Board
Approval Dates a
Chairman:_
SMI� fir. r..i iM
•���.ixJ.•.ad9i•we\rt.l.vwx ufM�•(.+T�YM�
�. •..-s�q.�.�ysy+.1E.e.:N++s J'D�.I[cvt.M.a:.T:,t/
um
0
a�
Nplop
S
0
n
0
0
m
D
m
m
D
-v
m
O
x
m
c
z
r
rn
cn
(n
;-A
m
v
c
cn
z
z
--I
z
m
0
0
z
0
U)
C/)►
I
m
Z
.1%%
m
(/C/Dj
Y
D
0
__4
m
z
0
z
00
m
n
O
x
m
D
-v
O
r
V
r
m
D
m
n
m
C�
O
0
O
m
C)
i
u
m
r
r
z
-v
0
CD
z
07
W
C
V
m
V
Cl)
N
m
V
C
D
z
D
z
0
O
I
m
�o
0
m
D
U)
N
OD
�Z
=3" 0
o
CD
Ch �.
N - CD
oo cD
co CD
--` r-t
1 CD O
7rl LC
O
N
CL L 1<
t.0 -P O
CD I C
0 Co z
w�
N
N ror�� (1)
W_ "
o
r
—I D —I
u) n Un
�CDLn.
6,
CD
Q oCD �•
U) o CD
=7 Q
0 CD CD
-0 Z Q,
� m
''�^ • F
l� h
C)
o— C
p C-)C(9)
0
c�
QCD Q
0 CL
CD
Imo
�Q D CD
C C3
CD
^ �S•
73 (D
- O
C)
('D 0
CD
(n
CD
ou
CD
Z
v
rn
Cil
fS�
—
CD
C
0
0
•
N
M. 1 1001011
N
R
CD
V I
V ,
CD
O
CD%
I<
O
G'
CD
�.L
3
O
07
CD
—rS
CD
O
c�
O
f�'f•
"T
U)
CD
3.
CD
cu
0
�C
G
O
CD
O
D
•
•
•
�.
snacks
►
,
0
�r �;
►
. j (DSOOS�
Co
r
CD
,. ;
!
C
�
t
•
�e ..-.--
JI
1
jk
Cn
10.
j-
I
CCDyr,
`.�.- �_ �. _y:-�- .. _ - � n. _..�'.._ _�.�-�.�-....-_.-y._ .
`: :..,.a .-a..o_:;._r{t!-.c •-..".'-..
- _4"�'- . _}�...�. ' r,w�
_
mn
rT1
;7 _
T
I t t
J411�71►
• t
i
•
rn
- vi
fa
O
•
►
b 1 ?
{
lr
v'
s
'
i I i zi snack-,
j i
oo •-
• F r sL
1
!'-
►
14i Owl
, �j
�
�
is
n
'
�
• •i -
.
►
0
.
rn-
rn
(
•�
�� / I
�J �41ri
'rf
�
i
r
riE�-J.
�-r
I
i i _
•
fF
1
N
00
CA
�z
o °
�•
:3
CD, r
co
�D
-t
0000 D
I
s
<
O
O
V
4�,
I
o
C
!MGM
n
N
o
00 z
CA)
�_
N —L
O
D.
N �
�
O
z
X
oC �
r
( L
C) CQ
CD
W O CD
C)-
0 CD CD
- z0-
CD
s o
C:
1:3mcn
cn D
Q
� n —
07
o n
(DQ v
W
O Q C7
CD m
CD _T
V/ O J
Z :D7 O
CD
CD
QL) (D O
2' 3 MML
a i V/
�- C " O
CD
�.� CD
p
CD
VJ
0"
ZY
CD
'''0
V
CD
0
Cn
rF
CD
i�
3
Z)
0
07
CD
-1%
`D
O
CD
0-
0
3
CD
0-
CD
CD
0
l<
O
\V
3
VJ•
O�
D � _
Z 'h
r Z
O � �
� O
O ■■
Cn
7rl
ti o
m O O
00 k ����� '� ! .•1 S, ��`�.Y�n`�.r"k�i"ek��s I • .+3tm;�7+'+tf �j
J �� • rot N t h A !�"� 1 J� tl /+ i
/tom
rt .,
I Ow
• �' t Ciiyyyyy
yx� • �� , y'�1 �S l��r��t �Y �r��" � t r���/ t ,r ��rr . 1 � 1
m ,�r t���F''!'.,_ j�}�•j�J ,�,'�T�tO .:f/ c ,., _ -'
1 T 'f^� A kI fy Pt x7 Jf ]y « I -/ S( fl� l
-a -}y-fly, (�1 /��
''+�[,}"ktl�'�P•yG*"-`L•k ^`L � ,ill t / '� I,a: -ti • . � n
c �t�.,s��r;�i7i•'k f't'���'�"j'�1 r..�/yt�„ ..•t 'A ,1 y�r-t`,�� .� "
Pao ! i
Cn
m
rn n
mu r
x rn -
O
ggl
IF,
+; t• 4� �, 4 k �'1+ t,_ ✓e ti J � J%t�+'k,,�j�//� � Ali
t 4 h `• �a ��. ^ JI 4 w, ayh N,� �a4�/A����a���� �rI
w Z
i
Cl)
a r
� + ` µr 4NN rry{4 e' gt>!+ti � ••
. A
4
R.
p
C
1- .q M
m m
c �
z Cn
m CD N
Cn C CD rn
� CD�
C
D
O p Z
G") _ r-O- �
x (D -<
m D
m C-0 L sr,m —
-r.
'2
1`
C/ F r-7 O
m ..�,t —I
U) r�" 1 O _
-n��
Ul
mFa
�� ov
m
Cn
ri
r m
1 1 �-- I _ V
M
5.r,lW1Y�`m1![�G•.W.�InrYKKlL'[T.?FJAYf1t IT:fStSlIIadl..r• �.n� G-T LvTNs`2 4r
N
00
�Z
:37O
O ---%-
•
CD
`!
C
' ^ (D
Ct2
W �
Oo D
1 /
(D
s
Mill
`(D
W
CD
rt
O
V
X
N■
• r—f-
s0
C
�.2.
1<
CD
1
0
n
N CD
�
o
00 Z
(A)
N
N �O
U)
Q
oC
—I D —I
_ D
v, U/)
^- V�
)
Q_ CD .
U) o CD _
% = Q
CD CD
-0 z Q-
o
c�
0 0 cy
0- m U
rn
CD7 C7
0 0 C)
Q CD o
0-
cQ (D W
0Q n
_CD
o
�o::37
� (D
CD
T �_,)
`D `^ .T
� o
�-
� 73CD
KT�
c�
m
CD
v
rn
C31
—CD
�
C
o
o
N
0
vi
G'
U)
�f
IN
O
\V
0
C/)
G'
Q
0
c'
CD
CD
O
c-
m
O
cn
3
CD
0-
CD
m
O
1G
3
O
c
CD
1%
3
O
n