Loading...
HomeMy WebLinkAboutSP22-008PERMIT # SECTION TYPE OF WORK JOB LOCATION. /EST. COST CO #yam TCO #_ FEE DATE TIC DATE INSP FOOTING FOUNDATION FRAMING RGH FRAMING INSULATION PLUMBING SIGH PLUMBING �-�- GAS O �- SPRINKLER ELECTRIC LOW -VOLT O ALARM AS BUILT 0 AS p FINAL CQn� /dl/)93?'M1o3&a MR 0 Qy� DRC� CCCC4J�jJ ur CCCr.Lc,. 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 April 29,2024 Win Ridge Realty LLC c/o Alena Hakanjin 24 Rye Ridge Plaza Rye Brook,New York 10573 Re: 114 South Ridge Street, Rye Brook,New York 10573 Parcel ID#: 141.27-1-6 Sign Permit#22-008 issued on 10/28/2022 for a New Awning This certifies that the new awning,"Madison's Niche",installed under the above captioned permit has been satisfactorily completed. Sincerely, Steven E. Fews Building& Fire Inspector /to FEE C E � V E " t For B `ITTI.0 tip R1 lr PFJtM r M�D� APR 18 2024 x I5St3FU: 38 Km;ST E 1 VE-8 DAM VILLAGE OF RYE BROOK 9 -06 I-�:�1n IO — PA*• BUILDING DEPARTMENT APPLICATION FOR CERTIFICATE OF OCCUPANCY,CERTIFICATE OF COMPLIANCE, AND CERTIFICATI()N OF FINAL Com To 'M SililrttZTTM 0Mr UPON CCHPLETION OF ALL WORK, AND-PRIOR TO THE FIH]ItL INSPECTION ............................................................................................................................ ekcupancy t1. /Cis/ Pancl ID 4 / /, a 7—/— !_one:�1 Owner. I/1 42 L -Addt+css: P�ldWe P/G� Y.F/R.A.or Contractor. 0,.4l c , f , ,. Address: 3l 7 a!-�1� ✓t..l_ 1.�.,...� Pason in responsible ebarge: b ,.;jr il"I" Address. ie'7 Application is hereby much and submitted to the Building ftLVMwr Of the Vilingt: of'8yt: Brook for the i"wwz of a Grate of Occupancy/Certificate of Compliance for the suueturt:/construction/ahe��het rut m otxd is ttleevr><lffitre with law: _ STATE OF NEW YOM COUN-FY OF WESTCHESTER as lPr::a i�ma of A be ing dttly .dePo=WdsM that hr-Nhe tesi at--- (NO seed Sugar)in��? �i.�l..- /�-�� .to the Ccnatry of 5�t��f� tcityrrownr valarn r in the State ar that hrjshc h-"aupentiscd the work at flit location indicatedubovc:,and that the setual total roar Of the work.including all site itapruvcmcut�- labor.muterialll..catlitlding,Sneed equipntau,prufzssiOan!Goes,ww inchrding the moeatwy valor of am materials and inbur which mnv have helot donated gratis w,ts:S /ppd - for tbr-construction oralt of:_ Dcpoomt further states that hclyhc has examinel the appruvcd plans of the 3-Uvk1tLr6work herein refried to for which a Certificate of ()ccuFancY/CatupliROC a is Sought.and that to the best of hisrlw knowledge aW belle&the struemmiw(ukhrs been a r=ted aampkud in accordance with the approved plans and any it amettchttcnts thereto rxaelK in so for as varwions dunfow htn'e been IegallyautbM izrd,end as nertedlcemtplctedcompliecwith the laws governingbuildingi;tummcti='* DepnarntGathercmdmUmdythaitA=Hbeunkwfulforan Owner to UW or permit the use ofany building orpnaui�es or Part t kerevI hereatla crcatcdt aected.changed activated urcaLwSed, wholly Or Part1Y.in its use or structure utttila Certificate of oc amm c).or Certifie uc of Comoumce Stall have bcen duh issued by the Building tnspcctor as per 1230-10.A.of the Code of the VA1218e of Rvc Brook. Swarm it)befom me this 24,M- sworn to Wore me this. /7 3 Of- '✓ � '0 day of 41 'L; ,20 SW-of ACV Ll S 117 r ALENA HAKANJIN `ulai} NOTARY PUBLIC,STATE OF NEW YOR CORN MAME-CO�:K73 Registration No.01HAO013645 Ouallried in Westchester County Notary P`��EofNow� Yy Commission Expires 911912027 No.010t3OM40 W1100-11 corn mbsdort Emsal-k"tows �yE BR(��. cu � 1982 BUILDING DEPARTMENT ❑BUILDING INSPECTOR D'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 : I �' SOc� 1 Af4, DATE: 7 ZS - Z 02 ` PERMIT# �� Z Z- 03 ISSUED: /0"Z;-ZZSECT: I/ l• Z 7 BLOCK: / LOT: LOCATION: J < l� , OCCUPANCY: ❑ Violation Noted THE WORK IS... PASSED ❑ FAILED /REINSPECTION ❑ SITE INSPECTION REQUIRED ❑ FOOTING ❑ FOOTING DRAINAGE ❑ FOUNDATION ❑ UNDERGROUND PLUMBING NOTES ON INSPECTION: ❑ ROUGH PLUMBING ❑ ROUGH FRAMING ❑ INSULATION ❑ Natural Gas F �v i N 2 a ►S /L�/C �+ ❑ L.P. Gas ❑ FUEL TANK ❑ FIRE SPRINKLER ❑ FINAL PLUMBING ❑ CROSS CONNECTION FINAL [�-OTHER V a N rq OQ N N C � 1 o 00CD no Rr oo � p" _ 104 O c +� _ o '+ ! h+i G r� u i N •• A cn a o 0 �, W �. . 'G-+ o r. _ �, � v 1,b O . � zr� Mom—, C/) �j � O d .; �,•� � � � s 00 rr 64 A u q a M A o . _ 00 cn �//�� VJ W W z c pq Oo �j v vw -d w x a � $ o � w © W V w p 0 C� U E" o 4. W 0 0d ... - Y u o H a �I a a w x � � b BUILDING DEPARTMENT VILLAGE OF RYE BROOK SEP 1 4 2022 938 KING STREET RYE BROOK,NY 10573 (914)939-Q668 VILLAGE OF RYE BROOK www.rNebrook•org BUILDING DEPARTMENT FOR OFFICE USE ONLY: \Approval Date: OCT 2 2022 ermit �+' Application# `jS 7 7a, Approval Signature: ARCHITECTURAL REVIEW BOARD: Disapproved: : Date: f BOT Approval Date: Case# : Chairman: PB Approval Date: Case# Secretary: ZBA Approval Date: Case# Other: Application Fee4 Permit Fees: z�s• VP SIGN PERMIT APPLICATION Application dated: is hereby made to the Building Inspector of the Village of Rye Brook,NY,for the issuance of a Permit for the construction/installation of a sign in accordance with Village Code §250-35 as per detailed statement described below. 1. Address: L( e(JI-eT I �c � SBL: �7�i 7 Z—lp Zone: 2. Property Use or Business Name: 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,) : Z l S f i 4f w,14 4. Height from grade to highest point of sign: to lowest point of sign: 5. Property Owner: i Address: K Q �� PK Of Phone# t� Cell# email: _ 6. Applicant: 1 Address: D ,/ /7V Phone# Cell# email: LIC 7. Arch itect/Engineer. (t in Address: it 11 Phone# — Cell# email: at fn 8. Sign Contractor;! ��Qf'? ��,5����� � dress_ Iyto)q k)1'1�2• . 1 Phone#_ 9/ -�/3 7-63��.�Cell# �"z�!f �jQ, —lNY t -I- 8/12/2021 9. Will the proposed gn 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) 10. Does the proposed sign involve a Home-Occupation as per§250-38 of Village Code? Yes: No: If yes, indicate: TIER I:—TIER IL—TIER HL— (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: 13. Property size:Sq.Ft.: Acres: 14. What is the total estimated cost of construction: $ ow (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.) r 15. Estimated date of completion: r+S - ' vu JL 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 PF,NEW Y` O ,COUNTY OF WESTCHESTER ) as: A 4�/L 19e 7 , being duly sworn, deposes and states that he/she is the applicant above named, (print name of ind vidual signing Is the applicant) and furt r state (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 b Sworn to before me this day of 51L= , 20 2,7_ day of 7 , 20 7- SIfnature of Propghy Owner Signature of Applicant g s _ 1CA Mal NwA of propemy e-sn[t Print Name of Applicant e::�C2- -41 1�;'� Na b1K ary l'u lle I 'Y gyp. -'7 "zi t3-+tar}N lew Eric Neittel C2 �1tif; _ NOTARY PUBLIC.STATE OF NEW YORK CU"rnisston E.xp:ros lrllts(` , =, ; RillausiosNo OINE 339)90 Qwtficd M Suffolk Cowl) CoTakissioe Expues Novembn M,202 S -2- 8/12/2021 Building Permit Check List&Zoning Analysis �ddress: 11 s -1�7 S� - SBL: 27 - t Zone: G ( 2 Use: Const.Type Other. Submittal Date: 11fT7Z Revisions Submittal Dates: Applicant: W% :—a ,� L Nature of Work (A W" l 0�/, 2 z , ` I /t Ab(c 0 "J "( "M(C.(� r Reviews:ZBA: S E P 1 4 2022 PB: BOT: Other. OK ( ( ) FEES:Filing . ' BP: Z C/O: Flood Plane: Legalization APP: Dated: Notarized. SBL: ✓Truss I.D. Cross Connection: H.O.A.: ( ) ( ) Scenic Roads: Steep Slopes: Wetlands: Stone Water Review: Street Opening. ( ) ( ) ENVIRO: Long Shore Fees: N/A.- SITE PLAN:Topo: Site Protection S/W Mgmt.: Tree Plan: Other. ( ) ( ) SURVEY:Dated: Current: Archival• Sealed: Unacceptable: ( ) GLANS:Datg Stamped: Sewed: Copies:3L Electronic: ✓ Other. ( ) ( License: ,/ Workers Comp: ✓ 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. G( ) ( ) Other. ARB mtg.date: l o�I �Z�approval notes: ( )ZBA mtg.date: approval• notes: ( )PB mtg.date: approval: notes: REQUIRED EXISTING PROPOSED NOTES APrPnRvvrwluj Arc& Date: OCT 2 5 2022 Circle: Fie Fr n Front: Main coy Accs.Cov Ft H Sd.H/Sb: s,E6: Tot,imp Hight/stories notes: BUILDING DEPARTMENT I �J VILLAGE OF RYE BROOK SEP 14 2022 �--1 938 KING STREET RYE BROOK,NY 10573 (914)9 9-0668 VILLAGE OF RYL BROOK wwwjwokwrg 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: I L i P( CJC f4. 9-f e 8r6j< Date of Submission: Parcel ID#: /`4//, Zone:C�-/n y�� Proposed Improvement(Describe in detail): R& I it., q�nir` M1 APPLICANT CHECK LIST: MUST BE COMPLETED BY THE APPLICANT The following items must be submitted to the Building YY Department by the applicant-no exceptions. Property Owner: �LI�. ae�q I• (-1 Qompleted Application 2. (�wo(2) sets of sealed plans. (one full size (maximum Address: allowable plan size=36"x 42")and one 11"x17") Phone# ( 3. ( )Two(2)copies of the property survey. 4. ( &- Two(2)copies of the proposed site plan. Applicant appearing before the Board: 5. (L-�6ne electronic/disc copy of the complete hIrmn15 a lication materials. 6. ( Fi 'ng Fee. Address:_ S �P 7. (--)Any supporting documentation. Phone# (rp — 1� Z- �j �S 8. ( )HOA approval letter. (ifapplicable) 9. (photographs. Architect/Engineer: M I` el 10.( ) Samples of finishes/color chart. (a sample board or Phone# L - q-Z;7 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. Sworn to before me this 46Sworn to before me this day of , 201� Y n� day of 20 405re'of Prope Owner st ure of Applicant Fnat NNW of PmpesgrMW L Print Name o Applicant i�vtsry bix za1i� Notary Public KFLLY SAR'hl ER N't-'•r}' P.'[ ., 'I r-W Y rk Eric Neittel N 1 ' NOTARY► LIC,STATE OF NEW YORK Q "Ii1 1 l y Regntiation No 01NEA139390 0k.•r-mission Expires March 5, 2,34L QrshfwdNoSutincow,). Comwissioo Exosres Norembei 30,2023 8/12/2021 4Rot Village of Rye Brook ML MR O� y end FB SE J Architectural Review Board Meeting AC SF Wednesday,October 19,2022 at 7:30 PM J Village Hall,938 Sing Street M 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 Approvals: Motion Second Abstention Aye; Nay; Adjournment; Notes Page 1 of 4 Architectural Review Board October 19,2022 1.8. #5767 (Re-Appearance) Pawling Holdings LLC 261 North Ridge Street New stone and clapboard siding,windows, front entrance and dormers. Approvals: Motion Second Abstention Aye; Nay; Adjournment; Notes 1.9. #5777 Breddy Alfaro 81 Hillcrest Avenue Legalize new flagstone walkways,rear patios and remove shed. Approvals: Motion Second Abstention Aye; Nay; Adjournment; Notes 1.10. #5674 Gregory Andronico&jaclyn Andronico 92 Windsor Road Addition to master suite. (Amendment to Prior Approval) Approvals: Motion Second Abstention Aye; Nay; Adjournment; Notes 1.11. #5778 Win Ridge Realty LLC New awning for"Madison's Niche" 114 South Ridge Street Approvals: Motion ,�1 Second Abstention 5 Aye; Nay; Adjournment; Notes Page 2 of 4 ACC CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDNYYY) lit, 06/2012022 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 2EPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: if the certificate holder is an ADDITIONAL INSURED,the policy(les)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 Stacie Washington Borrelli Partners Insurance Agency PHONE (914)939-7900 FAX A/c No): (914)407-5088 287 Bowman Avenue ADDRESS: swashington@borrellipartners.com Suite 406 INSURER(S)AFFORDING COVERAGE NAIC e Purchase NY 10577 INSURERA: Travelers Casualty Ins Co of America 19046 INSURED INSURER B: Travelers Indemnity Co 25658 Lanza Corporation INSURER C: Phoenix Ins Co 25623 dba Sign Design&J C Awning INSURER D: 404 Willett Ave INSURER E: Port Chester NY 10573 INSURER F: COVERAGES CERTIFICATE NUMBER: CL2252603715 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. LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER_ MM/DDIYYYY MML-V_- Y LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS MADE UWAGE ©OCCUR PREMISES Ee occ hence, It 300,000 MED EXP(Any one person) $ 5,D00 A 6805.1175092 06/05/2022 06/05/2023 PERSONAL&ADV INJURY $ 1,D00,000 GEN'LAGGREGATE LIMITAPPLIE9 PER: GENERAL AGGREGATE $ 2,000,000 POLICY1:1 JE,7 LOC 2,000,000 PRODUCTS-COI PLOPAGG E OTHER: $ AUTOM084LE LIABILITY BNEE Ea acddera N LE LIMIT $ ANY AUTO BODILY INJURY(Par person) $ OWNED SCHEDULED BODILY INJURY(Per acdae $ AUTOS ONLY AUTOS r'U HIRED NON-OWNED PR DAMAGE AUTOS ONLY AUTOS ONLY Per acaderd,I q— I I - . $ f UMBRELLA UAB OCCUR EACH OCCURRENCE $ 5.000,000 B EXCESS LIAB CLAIMS-MADE EX5J175240 06/05/2022 D6/05/2023 AGGREGATE $ 5,000,000 DELI I>< RETENTION$ 10,000 $ WORKERS COMPENSATION AND EMPLOYERS LIABILITY YIN STATUTE X ORH- C ANY PROPRIETOR/PARTNERIEXECUTIVE NIA UB5J175160 06/05/2022 06/0512023 E.L.EACH ACCIDENT $ 500,000 OFFICER/MEMBER EXCLUDED? FYI (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ 500,000 It yes,describe under DESCRIPTION OF OPERATIONS below _ _ E.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Add ltional Remarks Schedule,maybe attached N more space Is required) BLANKET AI-OWNERS,LESSESS OR CONTRACTORS,AI-MANAGERS OR LESSORS OF PREMISES,Al-STATE OR POLITICAL SUBDIVISIONS PERMITS RELATING TO PREMISES,Al LESSOR OF LEASED EQUIPMENT,PRIMARY&NON-CONTRIBUTORY WORDING,WAIVER OF SUBROGATION-WC POLICY INCLUDES BLANKET WOS 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 AUTHORIZED REPRESENTATIVE Rye Brook NY 10573 1 1 ' -- -- ©1888-2016 ACORD CORPORATION. All rights reserved. ACORD 26(2016103) The ACORD name and logo are registered marks of ACORD NEW YO K Workers' CERTIFICATE OF STATE Compensation Board NYS WORKERS' COMPENSATION INSURANCE COVERAGE 1a.Legal Name 8 Address of Insured(use street address only) 1b.Business Telephone Number of Insured Lanza Corporation 914-937-6360 CBA Sign Design and J C Awning 1c.NYS Unemployment Insurance Employer Registration Number of 404 Willett Avenue Insured Port Chester, NY 10573 Work Location of Insured(Only required if coverage is specifically limited to 1 d.Federal Employer Identification Number of Insured or Social Security certain locations to New York State,i.e.,a Wrap-Up Policy) Number 13-3525268 2.Name and Address of Entity Requesting Proof of Coverage 3a.Name of Insurance Carrier (Entity Being Listed as the Certificate Holder) Phoenix Ins Co Village of Rye Brook 3b.Policy Number of Entity Listed in Box'1a" 938 King Street UB5J175160 Rye Brook,NY 10573 3c.Policy effective period 06/0512029 to 06/05/2023 3d.The Proprietor,Partners or Executive Officers are ® included.(Only check box if all partnerslofrcen 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'1a*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". Will the carrier notify the certificate holder within 10 days of a policy being cancelled for non-payment of premium or within 30 days if cancelled for any other reason or if the insured is otherwise eliminated from the coverage indicated on this certificate prior to the end of the policy effective period? YES ®NO 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:,%' Stacie shington (P nt name of authori ed represen2 live or li nsed9genl or insurance carrier) Approved ti: 06/20/2022 (Date) CL anager Title: Telephone Number of authorized representative or licensed agent of insurance carrier: 914-939-7900 Please Note:Only insurance carriers and their licensed agents are authorized to issue Form C-105.2.Insurance brokers are NO authorized to issue it. C-105.2(9-15) www.wcb.ny.gov 2 {o -- 4 � i l m rnmx mmm >�a o n� q a m ,`0 o- rUJ - omm zr m _Cf),zo C)>X zrj2 0�- zoco -�C� MCM r cf) zm0 Xm O>m M>X r MOT r �Oo M-,- a m r" � x 0 cn p can X m c m 05 CI' n b z z a T a a =� c • 0 --� r � m Z M fi ems0 _ �.mn Cn c _/ o 3 "n* -n a -n 00 _/ O c' :3. rn� co0 (0 X -� �; —/ c 0 =3 rn x rMOL OWN -/ M n 0 (D cD � N as o� n' CL �•ac••As]�aQgR:a�er✓ F, m\I) , F �lll 1 m cm �. _ a �•� . v-n c:-') ,e ...,..o.�R.n....,,� !.J L� Li .+.r.�unanu•�swsy ..e:..�aw.+.....a..;.~ •+..wru...,.....nwa T m -v O MO O N (D O„ .n a) Cr 0 M m 0 O CD Mi N c O r► ■ O Q. 0 (D c r* W (D rMIL ■ O O Z ..i O F^�,y.n,.+o C7 O "M= "r A�� T Xr� rn co = 0 a 3 o Q o ' a) fT Q � 0 cr m a'w a 3 - -oo (A cn � O M xp o � roJa 0 CD (n C5 Q��� n n m � tlD �LOko 00 � E ����z CD ." �+�c 0 ZIA C7 CD Q- n _, d z N ? (n to r V C fn / ccnz tD D z �■ n �T lbdl W o a a- (D3 w rn c� M ^ D L m i w --i pm * co Uj m yD rnm� 0 -.� mImm X -i > U)n < O C7 COm� r- omm xmz viz© n>X >0- zmz O -i zOU) rncm M�m MmC) XMO 0 Go rn>� r- C-) 0 X mix 0�� o m jo 0 co 0 m C: K m C) D 2 z i a 0 X a Z D X 0 _< cnCD > ti (0 o<O z � " r ty �,�.�3 o < a � m Q, `� CD CDmO� CD � cs� CD CD D O a) �, n CDQ:3� -, SN n 0 > c� • N z m 0 vCA n � � � � v rn � T v c� 0 a� x a n� m _ i3 10 LS �2 �a `o w A n n N� K �. O �J Z fD 0 n O W O m ❑ o in ®� I` Ar V) ./ 0