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HomeMy WebLinkAboutBP22-222��a DATE: 1 I a PERMIT # .�� SECTION TYPE OF WORK JOB LOCATION OWNER�,d�4 — CONTRACTOR �T. COST rl CO #� LOT TCO # FEE _ QATE INtortkuON RECORQ I DATE INSP FOOTING FOUNDATION FRAMING RGH FRAMING INSULATION PLUMBING C� RGH PLUMBING GAS O SPRINKLER ELECTRIC O LOWVOLT CJ ALARM O AS BUILT O FINAL 000or OTHER APPROVALS ARB BOT PS ZBA OTHER J tc4 4•°V�.t N JJJ �,W J 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 October 20,2023 Benjamin Chervin&Shira Chervin 19 Ridge Boulevard Rye Brook,New York 10573 Re: 19 Ridge Boulevard, Rye Brook,New York 10573 Parcel ID#: 135.60-1-20 Building Permit#22-222 issued on 11/17/2022 for Replacement Windows & Door This certifies that the four new windows and new patio door,installed under the above captioned permit has been satisfactorily completed. Sincerely, Steven E. Fews Building&Fire Inspector /to BUILD R NT For office use onlv: PERMIT VIL OF RYE OK ISSUED: //—/ 7 QCT — 2 2Q23 38 KING STRE YE BROOK, , YORK 10573 DATE: /U 9 -06 0 FEE: O - PAID 4' 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 *****sssts»ssssswtwtstssst*s»**sstssstssssts**s*ttw***sttstsstrtttsttttttw+++s+ssss*»***»*****+*s*+ssssss»*stastsssssssss+*ss Address: 19 Ridge Blvd, Rye Brook, NY 10573 Occupancy/Use: Residential Parcel ID#: 135.60-1-20 Zone: R-3 Owner: Benjamin Chervin & Shira Chervin Address: 19 Ridge Blvd, Rye Brook, NY 10573 P.E./R.A. or Contractor: Renewal by Andersen Address: 2041 West Main Street, Stamford CT 06902 Person in responsible charge: Kat Wood Address: 2041 West Main Street, Stamford CT 06902 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: Kat Wood being duly sworn,deposes and says that he/she resides at 2041 west Main Street (Print Name of Applicant) (No.and Street) in Stamford ,in the County of Fairfield in the State of CT that (City/Town/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: S 16,369 for the construction or alteration of. Installation of(4)replacement windows and New Patio Door 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-IO.A.of the Code of the Village of Rye Brook. Sworn to before me this �25 Sworn to before me this as day of !�jeatPo13�f,4 , 20 day of '-w / , 20 a� Signature of Property Owner & plicant ' "e �alwu►. ('i�cr✓ LPublic, Print Name o�P�operty Owner licantF BARAHONA Notary Public, State of Connect! E.My Commission Expires Dec 31, 2 StatExpire QyE BR(��, 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 :_ J 1 y V� DATE: l 2 2 PERMIT# z ISSUED: I NECT: BLOCK: LOT: LOCATION: N �✓� lU �w-^ ` � � OCCUPANCY: ❑ Violation Noted THE WORK IS... ASSED ❑ FAILED 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 ■ i i N a N N N ,,? a N c N b A � � • w D � ram-• ]�+� i ° �w CA W 1 .9 v ao a i C K G. ., .4 �1 L ' 1 o w � CG a, J 1—� Q p ( 4 y �' L Cn O e� O a U i y 1-� � A 0 > Z � ° 0 Q w .x W 00ON cq W ^ � ° � ° a V V z v p a F�1 G\ 1 M 1-4 o ,n pa ° 'Z ■ 00 . a � w U W � A �" � � v � o G � ■ z w �-+ z o c°aq � z V w p C7 , A Z O le m au o 4I as a a W z° � c �C ENE BUILDING DEPARTMENT VILLAGE OF RYE BROOK ` RNOV 14 2022 DD 938 KING STREET RYE BROOK,NY 10573 (914)939-0668 VILLAGE OF RYE BROOK wwwxyebrook.orz ; BUILDING DEPARTMENT 1 ADMINISTRATIVE EXTERIOR BUILDING PERMIT APPLICATION FOR EXTERIOR WORK WHICH DOES NOT REQUIRE VILLAGE ARCHITECTURAL REVIEW BOARD APPROVAL FOR OFFICE USE ONLY: v 5 2022 APPROVAL DATE: RMIT#: � �APPLICATION FEE:, APPROVAL SIGNATURE: PERMIT FEES: H.O.A.APPROVAL: DATE: DISAPPROVED: OTHER: ############*#****##**####�#7######t####tt#ttt###t######t#########t#####t#tt#ttttt*#######*##k*#%+############ 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 of building ,s etures,additions,alterations or for a change in use,as per detailed statement described below. 1. JobAddress: + f Iv 10 571 ? 2. Parcel ID#: / Q 3. Proposed Improvement(Describe in detail): a D(1 o r-1 W',CA A) otnd one (: ►LQa.-i o don{ ;� ,pox ; s� nu o 4. Property Owner: 'e'n 1. Ip(Vt n Address: 1 Cl Q )I v& Phone#Qj�»5 0 - �'tL S Cell# e-mail . Chuy",w2amex ,t e(r) List All Other Properties Owned in Rye rook: Applicant: Y�104- Pm Address: � _ 4 ' '� � Phone# ao5 WOa ': sl e-mail i'a wood a(b Awe5lc.lks-f P1.Cc— Architect: Address: Phone# Cell# e-mail Engineer: Address: Phone# Cell# e-mail General Contractor: QT7 IA/0_70 T Address: LIZ Phone# 203 ' & OS q, Cell# e-mail (I) 9/12'2021 5. Occupancy;(1-Fam.,2-Fam.,Commercial.,etc...)Pre-construction: rC1 CQ Post-construction: Mo CJJ e- 6. Area of lot: Square feet: 12,3(p Acres: 0 . 1 Z 7. Dimensions from proposed building or structure to lot lines: front yard: rear yard: right side yard: left side yard: other: 8. If building is located on a corner lot,which street does it front on: 9. Area of proposed building in square feet: Basement: 1"fl: 2"d fl: 31 fl: 10. Total Square Footage of the proposed new construction: 11. For additions,total square footage added: Basement: I"fl: 2"1 n: Yd fl: 12. Total Square Footage of the proposed renovation to the existing structure: 13. N.Y. State Construction Classification: N.Y.State Use Classification: 14. Construction Type&Location:()Typical Western Lumber Frame;O Timber Frame[TC];O Wood Truss[TT]; ()Pre-engineered wood[PW];Located;O Floor Framing[F];O Roof Framing[R];O Floor&Roof Framing[FR];Other: 15. Number of stories: Overall Height: Median Height: 16. Basement to be full,or partial: finished or unfinished: 17. What material is the exterior finish: 18. Roof style;peaked,hip,mansard,shed,etc: Roofing material: 19. What system of heating: 20. If private sewage disposal is necessary,approval by the Westchester County Health Department must be submitted with this application. 21. Will the proposed project require the installation of a new,or an extension/modification to an existing autog*tic fire suppression system?(Fire Sprinkler,ANSL System,FM-200 System,Type I Hood,etc...)Yes:_No: (ifyes.applicant must submit a separate Automatic lire Suppression System Permit application&2 sets of detailed engineered plans) 22. Will the proposed project disturb 400 sq.ft.or more of land,or create 400 sq.ft.or mor impervious coverage requiring a Stormwater Management Control Permit as per§217 of Village Code? Yes:_No: Area: T 23. Will the proposed project require a Site Plan Review by the Village Planning Board as per§209 of Village Code? Yes: No:_Iy� (if yes,applicant must submit a Site Plan Application,&provide detailed drawings) 24. Will the proposed project require a Steep Slopes Permit as per§213 of Village Code Yes: No: K (if yes,you must submit a Site plan Application, &provide a detailed topographical survey) 25. Is the lot located within 100 ft.of a Wetland as per§245 of Village Code? Yes: No: Ne (if yes, the area of wetland and the wetland buffer zone must be properly depicted on the survey&site plan) 26. Is the lot or any portion thereof located in a Flood Plane as per the FIRM Map dated 9/28/07? Yes: No: (if yes,the area and elevations of the flood plane must be properly depicted on the survey&site plan) 27. Will the proposed project require a Tree Removal Permit as per§235 of Village Code?Yes: No: (ifyes,applicant must submit a Tree Removal Permit Application) 28. Does the proposed project involve a Home-Occupation as per§250-38 of Village Code? Yes: No: Indicate:TIER 1: TIER II: TIER III: (if yes,a Home Occupation Permit Application is required) } 29. What is the total estimated cost of construction: $ 1 (P , 3(4 q Note:estimated cost shall include all site improvements,labor,material,scaffo/ding,fired equipment,professional fees, including any material and labor which may be donated gratis.If the final cost exceeds the ' ated cost,an additional fee will be require drrp��rior to issuance of the C/O. 30, Estimated date of completion: D alnU o-c Or (2) 8/1212021 ECENE BUILDING DEPARTMENT VILLAGE OF RYE BROOK �� y 202� 938 KING STREET RYE BROOK,NY 10573 1 VILLAGE OF RYE BROOK (914)939-0668 L BUILDING DEPARTMENT .s'ww.ryebrook.ort; AFFIDAVIT OF COMPLIANCE VILLAGE CODE §216 • STORM SEWERS AND SANITARY SEWERS THIS AFFIDAVIT MUST BEAR THE NOTARIZED SIGNATURE OF THE LEGAL PROPERTY OWNER AND BE SUBMITTED ALONG WITH ANY BUILDING OR PLUMBING PERMIT APPLICATION. ANY BUILDING OR PLUMBING PERMIT APPLICATION SUBMITTED WITHOUT THIS COMPLETED AND NOTARIZED FORM WILL BE RETURNED TO THE APPLICANT . STATE OF NEW YORK, COUNTY OF WESTCHESTER ) as: 3, �h�l( 4 t n ,residing at, being duly sworn, deposes and states that(s)he is the applicant above named, and further states that(s)he is the legal owner of the property to which this Affidavit of Compliance pertains at; "t dgt $�� �� OCR I'�-' V , Rye Brook, NY. Further that all statements contained herein are true, and that to the best of his/her knowledge and belief, that there are no known illegal cross-connections concerning either the storm sewer or sanitary sewer, and further that there are no roof drains, sump pumps, or other prohibited stormwater or groundwater connections or sources of inflow or infiltration of any kind into the sanitary sewer from the subject property in accordance with all State, County and Village Codes. lSignahncnfPr,q��ri, (Print N,nw of Properlc(i�cn�rf�ll Sworn to,jaefore me this nnh y of AO , 20 (3) 8/1 212 02 1 This application must be properly completed in its entirety by a N.Y. State Registered Architect or N.Y. State Licensed Professional Engineer & signed by those professionals where indicated. It must also 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. *****�,�*�***+:r,r*,�****��***,r******�**,r**,r*,r,r*,a,r*w*,rrc�r*re**,a�,r**,t,�*******,t�*,t,t,t�,t,t,t,t***,�**�****,r*,►,ttra,t***+r*,t* STATE OF NEW YORK, OUNTY OF WESTCHESTER ) as: Ja A- W po ,being duly swam,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 CAD to 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. By signing this application, the property owner further declares that he/she has inspected the subject property,and that to the best of his/her knowledge there are no roof drains,sump pumps or other prohibited stormwater or groundwater connections or sources of infiltration into the sanitary sewer system on or from the subject property. Sworn to before me this O? Sworn to before me this f day of , 20_02A day of , 20-4� Signature of Property Owner Si6ature of Applicant been &,e r Kul `vJ OQJ P int Name of Prope Owner t Name of Appli nt otary Public Notary Public (4) 8/12/2021 of Agreement Document and Payment Terms DBA:RENEWAL BY ANDERSEN OF WESTCHESTER AND FAIRFIELD COUNTY Ben Chervin Legal Name:Signature Exteriors/Vinylume Inc. 19 Ridge Blvd RENEWAL WC-27205-1-114,HIC0542457 Rye Brook,NY 10573 byANDERSEN 2041 West Main Street I Stamford,CT 06902 H:(914)589-8215 Phone:203-406-0545 Fax:203-406-0828 salesOrbawestchester.com Ben Chervin 09/14/22 BUYER(S)NAME CONTRACT DATE 19 Ridge Blvd , Rye Brook, NY 10573 (914)589-8215 BUYER(S)STREET ADDRESS PRIMARY NUMBER SECONDARY NUMBER b.chervin@gmail.com PRIMARY EMAIL SECONDARY EMAIL NOTES: Buyer(s)hereby jointly and severally agrees to purchase the products and/or services of Signature Exteriors/Vinylume Inc.d/b/a Renewal By Andersen of Westchester and Fairfield County("Contractor"),in accordance with the terms and conditions described in this Agreement Document and Payment Terms,any documents listed in the Table of Contents,and any other document attached to this Agreement Document,the terms of which are all agreed to by the parties and incorporated herein by reference(collectively,this"Agreement"). Buyer(s)hereby agrees to sign a completion certificate after Contractor has completed all work under this Agreement. TOTAL JOB AMOUNT• $16,369 By signing this Agreement,you acknowledge that the Balance Due,and the Amount Financed must be made by personal check,bank check,credit card,or cash. DEPOSIT RECEIVED: $5,455 BALANCE DUE: $10,914 We schedule installations based on the date of the signed contract and secondarily on the date in which we complete the technical measurements.The installation date that we are providing at AMOUNT FINANCED: $0 this time is only an estimate.We will communicate an official date and time at a later date. Rain and extreme weather are the most common causes for delay. METHOD OF PAYMENT: Credit Card NOTES: Buyer(s)agrees and understands that this Agreement constitutes the entire understandings between the parties and that there are no verbal understandings changing or modifying any of the terms of this Agreement. No alterations to or deviations from this Agreement will be valid without the signed,written consent of both the Buyer(s)and Contractor. Buyer(s)hereby acknowledges that Buyer(s)1)has read this Agreement,understands the terms of this Agreement,and has received a completed,signed,and dated copy of this Agreement,including the two attached Notices of Cancellation,on the date first written above and 2)was orally informed of Buyer's right to cancel this Agreement. NOTICE TO BUYER: Do not sign this contract if blank.You are entitled to a copy of the contract at the time you sign. YOU, THE BUYER, MAY CANCEL THIS TRANSACTION AT ANY TIME NOT LATER THAN MIDNIGHT OF 09/17/2022 OR THE THIRD BUSINESS DAY AFTER THE DATE OF THIS TRANSACTION, , WHICHEVER DATE IS LATER. SEE THE ATTACHED NOTICE OF CANCELLATION FORM FOR AN EXPLANATION OF THIS RIGHT. Y)0 SIGNATURE OF SALES PERSON SIGNATURE SIGNATURE Chuck Mcnulty Bun Chervin PRINT NAME OF SALES PERSON PRINT NAME PRINT NAME 09/14/22 Page 2/ 13 Itemized Order Receipt ....; `W,,, DBA:RENEWAL BY ANDERSEN OF WESTCHESTER AND FAIRFIELD COUNTY Ben Chervin VW- Legal Name:Signature Exteriors/Vinylume Inc. 19 Ridge Blvd RENEWAL WC-27205-1-114,HIC0542457 Rye Brook,NY 10573 byANDERSEN 2041 West Main Street I Stamford,CT 06902 H:(914)589-8215 Phone:203-406-0545 Fax:203-406-0828 i sales@rbawestchester.com ROOM: SIZE: DETAILS: PRICE: ow Misc, Misc. Miscellaneous Item, Miscellaneous, Rough out 0 H for door by others ow Misc, Misc, Miscellaneous Item, Lead Safe Work Practices 1 0 H to 5 Windows 001 basement 31 W Window, Gliding, Double, 1:1, Active / Passive, Base Frame, 14 H Exterior White, Interior White, Performance Calculator, Manual, PG Rating: 40 1 DP Rating: + 40 / - 40, Glass, All Sash: High Performance, No Pattern, Hardware, White, Standard Color Hand Pull, Screen, Fiberglass, Full Screen, Grille Style, No Grille, Misc, C.A.P. - Create-a-Pocket, Includes interior stops to match finish of new window, exterior stops finished with L-Trim or Aluminum. Painting by others if needed. 002 basement 31 W Window, Gliding, Double, 1:1, Active / Passive, Base Frame. 14 H Exterior White. Interior White, Performance Calculator, Manual, PG Rating: 40 1 DP Rating: + 40 / - 40, Glass, All Sash: High Performance, No Pattern, Hardware, White, Standard Color Hand Pull, Screen, Fiberglass, Full Screen, Grille Style, No Grille, Misc, C.A.P. - Create-a-Pocket, Includes interior stops to match finish of new window, exterior stops finished with L-Trim or Aluminum. Painting by others if needed. 09/14/22 Page 3/ 13 *° AIJV Itemized Order Receipt .. DBA:RENEWAL BY ANDERSEN OF WESTCHESTER AND FAIRFIELD COUNTY Ben Chervin Legal Name: Signature Exteriors/Vinylume Inc. 19 Ridge Blvd RENEWAL WC-27205-H14,HIC0542457 Rye Brook,NY 10573 byANDERSEN 2041 West Main Street I Stamford,CT 06902 H:(914)589-8215 Phone:203-406-0545 I Fax:203-406-0828 1 sales@rbawestchester.com ROOM: SIZE: DETAILS: PRICE: 003 basement 31 W Window, Gliding, Double, 1:1, Active / Passive. Base Frame. 14 H Exterior White, Interior White, Performance Calculator, Manual, PG Rating: 40 1 DP Rating: + 40 / - 40. Glass, All Sash: High Performance, No Pattern, Hardware, White. Standard Color Hand Pull, Screen, Fiberglass, Full Screen, Grille Style, No Grille, Misc, C.A.P. - Create-a-Pocket, Includes interior stops to match finish of new window, exterior stops finished with L-Trim or Aluminum. Painting by others if needed. 101 Room 1 95 1/4 W Patio Door, Gliding, 200 Series Narroline, 2 Panel. Active / 82 3/8 H Stationary, Exterior White, Interior White, Performance Calculator, Manual, Performance Data Unavailable, Glass, All Sash: Tempered High Perf., Hardware, Albany, White, Auxiliary Foot Lock Color Matched, Screen, Gliding, Full Screen, Grille Style, No Grille, Misc, Miscellaneous, Rough out by others for door 102 garage 36 W Window, Double-Hung (DG), 1:1, Slope Sill, Insert Frame, 50 H Traditional Checkrail, Exterior White, Interior White, Performance Calculator, Manual, PG Rating: 40 1 DP Rating: + 40 / - 40, Glass, All Sash: High Performance, No Pattern, Hardware, White, Standard Color Recessed Hand Lift, Screen, Fiberglass, Full Screen, Grille Style, No Grille. Misc, None WINDOWS: 4 PATIO DOORS: 1 ENTRY DOORS: 0 SPECIALTY: 0 MISC: Z TOTAL $16,369 Renewal b,v Andersen is comruitted to our customers'safety by 8E3j4 complying with the rules and lead-safe work pac•tices specified lip the EPA. 09/14/22 Page 4/ 13 Olt fto 00 Tr- PRO ' (Tr'41'�,�1j�1� {►�+l ,(,�If,h, !{ �; ,r4�lf,►> ! I. ►e/f,� ' l p•§ � `Y ,pis%t��'.:.�54�1�'�f!?s.:.:.+3i+�h'11.I/i�1.�'111...Nu�S°Ls...aas`e=1:'�1�11'.1�':�l�Ft:.�s:".�.w,.r�/llr_.� j�+!til///j!I� i►�1.\.. ry l.i•�yyLL J1ar r ,'�i(+�s)t � p c � 00 •items��, y m N L 0 6 r� > N o p, I C Y. =L O e y N a v U i c J UJ rl co» ►~. y Z (� .o` Q`O�gCtlOfl E ._ <c »i • � ry � � J C PIN O LL 1'r W oMINN j .� C , N X ` Z Q V TS 5G R is ` N LO ce) c c 4 L t .Ff _ <(0) ♦7r:�; 1•r I }§§s'[S"-ii:r.,.- s. --"- �" r+i 5pr.'I .'_ _.I�"•I �'- I'��'�`• �' I a• t�1� �` rr,►i�,I �s;_r! II?�iy ;.tlP/11,71 .,'ICI ly I I p, 'fir' J ly�lt�" 1"I 1�y +rt •i I I if/f r 1 I,I/Ilf,,l� 1 ylq II�1,1�,1 et �,. I,�I/I/lq f ji tlj,lf�ll 3 % ►+ �I'Pf 1, 1f ��1►•' �' ��sy. llw�t �4� fe;�t r.; t.1i, ..,�,;r ,tf r.�� tt.,,;� ��p'.t .,.• �t!w /1���� 6�: :?r 4�y'R � �. ' ''}'\r,� :� !�1J h!ly�.. `� , � _...¢J fr.`}�`. � f• h�i ^t►1+ U ao-.• s - "'' r v `k. �+r . v c,; r � +y. - .,gyp. •51 C,. - _ C4,��� '{�,.�G,,,r(�•,t✓ �,f�+ �'i�,:r"�.�,. �r,:�r...,�•,y vt l:�.�,'r��C:. .,�v".C'.p?I.!n�\ FAIRCUS-01 TBRAND ACORO CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDIYYYY) �i 9/26/2022 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). CONTACT Theresa Brandon PRODUCER NAME: MBI Company Group LLC. PHONE 20FAX 280 State Street (AIC,No,Ertl: 3)288-3401 (A/C,No): North Haven,CT 06473 AD RIE :theresa.brandon@mbi-ins.com INSURERS AFFORDING COVERAGE NAIC 8 INSURER A:Selective Insurance Company of America 12572 INSURED INSURER B: Fairchester Custom Windows LLC dba:Renewal by Andersen INSURER C: Fairchester 2041 West Main Street INSURER D: Stamford,CT 06902 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. INSR TYPE OF INSURANCE ADDL SUER POLICY NUMBER POLICY EFF POLICY EXP LIMITS LTRA X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE ❑X OCCUR X S 2516791 8/12/2022 8/12/2023 DAMAGE TO RENTED n $ 500,000 pce)MED EXP(Any oneperson) $ 15,000 PERSONAL&ADV INJURY 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 3,000,000 POLICY[X]PRO- F_X]LOC PRODUCTS-COMP/OP AGG $ 3,000,000 JECT OTHER: $ A AUTOMOBILE LIABILITY COMBINdEeD SINGLE LIMIT $ 1,000,000 ANY AUTO S 2516791 8/12/2022 8/12/2023 BODILY INJURY Perperson) $ OWNED X SCHEDULED AUTOS ONLY AUTOS BODILY INJURY Per accident $ X HIRED X NOW WNEp P OPCER'ZI AMAGE $ AUTOS ONLY AUTOS ONLY $ A X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 4,000,000 EXCESS LIAB CLAIMS-MADE X S 2516791 8/12/2022 8/12/2023 AGGREGATE $ 4,000,000 DED I X I RETENTION$ 0 A WORKERS COMPENSATION X PER TA T X ORTH. AND EMPLOYERS'LIABILITY YIN WC 9099063 8/12/2022 8/12/2023 500,000 ANY PROPRIETOR/PARTNER/EXECUTIVE ❑ E.L.EACH ACCIDENT $ OFFICERIMEMBER EXCLUDED? NIA 500,000 (Mandatory in NH) E.L.DISEASE-EA EMPLOYE $ If yes,describe under 500,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached If more space is required) Village of Rye Brook is Additional Insured as required by written contract per the endorsements included with this certificate. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Village of Rye Brook ACCORDANCE WITH THE POLICY PROVISIONS. 938 King Street Rye Brook,NY 10573 AUTHORIZED REPRESENTATIVE ACORD 25(2016103) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD YORK Workers' CERTIFICATE OF STATE Compensation Board NYS WORKERS' COMPENSATION INSURANCE COVERAGE 1a.Legal Name&Address of Insured(use street address only) 1b.Business Telephone Number of Insured Fairchester Custom Windows LLC. 203-406-0545 dba:Renewal by Andersen Fairchester 1c.NYS Unemployment Insurance Employer Registration Number of 2041 West Main Street Stamford,CT 06902 Insured 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 in New York State,i.e.,a Wrap-Up Policy) Number 88-2855660 2.Name and Address of Entity Requesting Proof of Coverage 3a.Name of Insurance Carrier (Entity Being Listed as the Certificate Holder) Selective Insurance Company Village of Rye Brook 3b.Policy Number of Entity Listed in Box"'Ia" 938 King Street Rye Brook,NY 10573 WC9099063 3c.Policy effective period 08/12/2022 to 08/12/2023 3d.The Proprietor,Partners or Executive Officers are �X included.(Only check box if all pariners/offcers 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: Theresa Brandon (Print name of authorized representative or licensed agent of insurance carrier) Approved o1 p (Signature) ate) Title: Agent Telephone Number of authorized representative or licensed agent of insurance carrier: 203-288-3401 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