HomeMy WebLinkAboutBP19-060PERMIT #�
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Open Permit Letter Sent
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VILLAGE OF RYE BROOK
MAYOR 938 King Street, Rye Brook,N.Y. 10573 ADMINISTRATOR
Jason A. Klein (914) 939-0668 Christopher J.Bradbury
www.ryebrook.org
TRUSTEES BUILDING& FIRE INSPECTOR
Susan R. Epstein Steven E. Fews
Stephanie J. Fischer
David M. Heiser
Salvatore W. Morlino
CERTIFICATE OF COMPLIANCE
January 12,2024
Richard Burns
51A Avon Circle
Rye Brook,New York 10573
Re: 51A Avon Circle, Rye Brook,New York 10573
Parcel ID#: 135.75-2-31.1
Building Permit#19-060 issued on 4/16/2019 for Replacement Windows
This certifies that the three new windows,installed under the above captioned permit have been satisfactorily
completed.
Sincerely,
Steven E. Fews
Building& Fire Inspector
/to
f� ��. _ For office use onl�:
�JD C E � V11 E BUILD 3R ENT PERMIT# r-
�— VIL OF RYE' K ISSUED:
LOOCT —3 2019 ING STREE YE BROOK,, YORK 10573 DATE:
� (914)9 939-5801 FEE: PAID Orl
VILLAGE OF RYE BROOK
BLJILD!NG DEPARTMENT o .or
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
#tuft#i##itftfi#iif,,#/n�#fkkikkk#ii#•ki#kkki#k4i#itiikt#t#ti#ttifii###f#i#f#####f###t#iii■i#i##ti###tt##i####ft###t#•#k##iii;tfi
Address: ►-Cv ov-" Crj k
Occupancy/Use. Parcel ID#: Zone: RA_
Owner: ( 1`to v\Ck _�'L&r Y- Address: ( A C t r vt�- t C
P.Z./R.A.�,.Contractor:— ` cam Address: err' �{(a t,.4.e_GA
Person in responsible charge: Jckv\kA 01a Address:
Application is hereby made and submitted to the Building Inspector of the Village of Rye Brook for the issuance of a Certificate of
Occupancy/Certificate of Compliance for the structure/construction/alteration herein mentioned in accordance with law:
STATE OF NEW YOM COUNTY OF WESTCHESTER as: a
Pk a V'� �a S being duly sworn,deposes and says that he/she resides at T 1V J" C r r C '
(Prin Namc of'Applicant) (No.and Street)
in ao ,in the County of Wr- in the State of N J that
( 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:$ J)1 0
for the construction or alteration of 41Ar t L
�p
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 beet,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 Q� Sworn to before me this
day 20 \C� day"of , 20 (Cl
ure o erty MTV igna re of Applicant
mau�B()m 1� _
int arse of Property Owner Print Name of Ap icant
—
Notary Public NO
I
SHARI„AELILLO
g;j!Pt
Notary Public,State of New York 17FRANGES A CALDWELL
No.01ME6160063 otarq PuPicQualified in Westchester County Cc
Commission Exoires January 29. 20a , 21. 2020
QyE BRC��,
Zm
• �9°2 BUILDING DEPARTMENT
❑BUILDING INSPECTOR
QASSISTANT 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:_� /G� /7 / Q ill (.i l QC 6 DATE:
PERMIT# l3 9 - a6 v ISSUED: W SECT: 3 s 7r BLOCK: 2 LOT: .3 /
LOCATION: ��AJ �� /;P/ OCCUPANCY:
❑ Violation Noted THE WORK IS... ff PASSED ❑ FAILED /REINSPECTION
❑ SITE INSPECTION REQUIRED
❑ FOOTING
❑ FOOTING DRAINAGE
❑ FOUNDATION
❑ UNDERGROUND PLUMBING NOTES ON INSPECTION:
❑ ROUGH PLUMBING
❑ ROUGH FRAMING
❑ INSULATION
❑ Natural Gas /�if U�i✓�2 /�/� T A� C.
i/�u �� n�a �E
❑ L.P. Gas � f �(-/Z GVi ti(7/0
❑ FUEL TANK
❑ FIRE SPRINKLER
❑ FINAL PLUMBING
[ICROSS CONNECTION r` G f
Er FINAL
❑ OTHER
Alfredo DiVitto
From: Scott Doughman <scottdoughman@gopermits.org>
Sent: Friday, January 5, 2024 8:41 AM
To: Alfredo DiVitto
Subject: 51 Avon Circle
Good morning,
As per our conversation, the direct window replacement at the above address was completed in 2019. After
installation we made numerous attempts to contact the homeowner to schedule the final inspection. After we
exhausted our efforts we sent the homeowner a letter as well with instructions to either set it themselves on a
time and date that was convenient for them and or contact us and we would set it for them.
Thank you,
Scott Doughman, Owner
Go Permits LLC
105 Buttonball Lane, Glastonbury CT 06033
Ph: (860) 952-4112 t Fx: (860) 430-6719
Scottdoughman@qopermits.org - www.GoPermits.ora
1
Home Improvement Agreement: Pagel
Home Depot License #'s - For the most current listing www.Homedepot.com/LicenseNumbers
NY: Amherst HI-04712, Lockport 2395; Buffalo LT12-10023782, City Tonawanda 33257, East Hampton 4499, Long Beach
4917, N. Tonawanda 368.16, Nassau County H1171050000 - H1771053000, New York City 0900456-DCA, 900457-DCA,
0900458-DCA, 0910621-DCA, 0910622-DCA, 0920734-DCA, 0922474-DCA, 0968605-DCA, 1003822-DCA, 1003823-
DCA, 1003825-DCA, 1003828-DCA, 1003830-DCA, 1003833-DCA, 1026224-DCA, 1075580-DCA, 1129555-DCA,1129556-
DCA, 1129557-DCA, 1129562-DCA, 1129564-DCA, 1133444-DCA, 1152032-DCA, 1152034-DCA, 1152035-DCA, 1152036-
DCA, 1152038-DCA, 1152039-DCA, 1152040-DCA, 1178447-DCA, 1186042-DCA, 1212045-DCA, 1223272-DCA, 1251871-
DCA, 1318292-DCA , Niagara Falls 971, Putnam County PC 689, Rockland County H-06464, Southampton L002442,
Suffolk County 47874-ME, 55323-ME, 53429-H, 57713-H, 54888-MP, 50222-MP, Town of Tonawanda: 1854, Westchester
County WC18484H06, Yonkers 5675, 47874-ME
Rocco Deleo
Salesperson Name: Registration No. (if applicable):
Home Depot U.S.A., Inc. ("Home Depot") or Service Provider named below will furnish, install and/
or service the equipment listed below at the price, terms and conditions as outlined on this form.
Burns Alana Long Island 1-KXAS36V
Customer Last Name Customer First Name Store # / Branch Name Customer Lead/ PO#
51 Avon Circle A Rye Brook NY 10573
Customer Address City State Zip
(914) 714-4286 9149391782 alanaburns10@gmail.com
Home Phone# Work Phone# Cell Phone# Customer Email Address
NOTICE OF RIGHT TO CANCEL: YOU MAY CANCEL THIS AGREEMENT WITHOUT PENALTY
OR OBLIGATION BY DELIVERING WRITTEN NOTICE TO HOME DEPOT AT:
40 Oser Avenue Suite 17 Hauppauge NY 11788
Address City State Zip
Or Email: I customercancellationnortheast@homedepot.com
Service Provider Email Address
BY MIDNIGHT ON THE THIRD BUSINESS DAY AFTER SIGNING, UNLESS THE STATE
SUPPLEMENT PROVIDES A DIFFERENT CANCELLATION PERIOD. THE STATE SUPPLEMENT
CONTAINS A FORM TO USE IF ONE IS SPECIFICALLY PRESCRIBED BY LAW IN YOUR STATE.
YOUR PAYMENT(S) WILL BE RETURNED WITHIN TEN (10) BUSINESS DAYS AFTER HOME
DEPOT'S RECEIPT OF YOUR NOTICE. YOU MUST MAKE AVAILABLE FOR PICKUP BY HOME
DEPOT OR SERVICE PROVIDER, AT YOUR SERVICE ADDRESS, AND IN SUBSTANTIALLY THE
SAME CONDITION AS WHEN DELIVERED, ANY MERCHANDISE OR MATERIALS DELIVERED
TO YOU. OR YOU MAY CONTACT HOME DEPOT FOR INSTRUCTIONS REGARDING RETURN
SHIPMENT AT HOME DEPOT'S EXPENSE.
THE LAW REQUIRES THAT THE HOME DEPOT GIVE YOU A NOTICE EXPLAINING YOUR RIGHT
TO CANCEL. PLEASE SI N BELOW TO ACKNOWLEDGE THAT YOU HAVE BEEN GIVEN ORAL
AND WRITTEN NOT C OF HT TO CANCEL.
Acknowledged by: 03/28/2019
usto i re Date
Contract Price and Payment Schedule : Payment of the Contract Price is due upon signing unless a
different payment schedule is required by law, specified below or in a payment addendum.
Contract Price: $ 12107.00 Includes all applicable taxes. Excludes finance charges.*
Sales Tax: $ 10.00 (If applicable)
*Maximum deposit ONL Y applicable in MD, MA, ME(33%), NJ, Wl (99%)
Dep. 125.0 % Deposit Amount $ 1526.75 Remaining Balance $ 1580.25
The Home Depot-2455 Paces Ferry Road, N.W. Bldg. B-3, Atlanta,Georgia 30339-Customer Care: 1-800-466-3337
460F1 HOE Customer Agreement(24 Jul.18) v 0.1,8
WINDOW SPECIFICATION SHEET - Spec.Sheet a —%A536V Sheet: 1 of I
Customer,Aiana Bums JDb k,1-%%AS36V Consultant.
Rocco Deleo Date: 03128/2019
New Window
Hinge Locations
E%isleq Window MeaSuromenls Grids Product Options Labor Ope— From outside.
Left to Right
Bays,Bows
Locali«f Color Rough Opening l of bars a of bars Csmnls.1 Pnl,
use L.RorS
Glass Mist Items
Hardware Code
Seen For Ows use
-@ Mulls 'S-=5181gndry«
LL
w Style Wraps 'x-=operallrq
TR- 1Io.1 Code (YIN) Style Code Series Cade 3 x5 to ii x x
STD,While, WRAP,LSR
t UY 1" OHy DH 6100 Wlf Wli 36.00 s0.00 86 GlassPack.Standard
STD,White, WRAP,LSR
2 LIV 1st DH Y DH 6100 WH WH 36,00 50.00 86 GlassPack-.Standard
STD.While, WRAP,LSR
3 LIV 1st DH I PW 6100 WH WH �--o
s0.00 87 GIassP,ck.Standard
SPECIAL CONSIDERATIONS.
1 While,2.While,3:White
ap Color
,few,Casing Type
Bay«Bow window:
e2lboard material(vml«Ily-Bin,h or Oak)
Bay Prolecl Angle(30«45)
Bay Flanker Type(CH.SH,or Csmnl)
Op of wir%low to soffit(inches)
t lied to soffit.color of sotto matenal I have reviewed end agree will,all the lob specifications aWYb and line
onseu[I Roof(Yes or No)' Special Terms and Conditions on the following page
Garden Window.
ealbowd Material(vinyl onfy While Pionite,Birch«Oak)
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, 'Vant,qoePointe�
-` Windows and Doors By OSIMONTON• Exclusively Installed Through
• r ♦ i ♦ r
�Vanta g ePointe �A.
-`Windows and Doors ByOOSIMONTUN•
■ Combines the best from two of America's leading companies:
Simonton"Windows and The Home Depot' "
t
* Features award-winning quality construction,
beauty,style options,value,and energy-efficiency
Learn more at vantagepointe.simonton.com
6100 Series Windows
■ Contoured window frame blends with any style of home
s Double Step Sloped sill drives water away from the window • .
■ Low gloss white or tan finish always looks like freshly painted wood .,
■ Dual panes of single strength glass create a strong thermal barrier
Glass package with Soft Coat Low E' � ,,,, • �—��
with Argon Gas meets ENERGY STAR
® quahflcations in most styles "
a.
y;n
Casement windows(above)provide maximum ventilation and add an air of contemporary style
Strong and Durable
Multi-chambered construction with Styles Colors Grids
nine separate air chambers create
Double Hung m��m
a much stronger window than '■■'
standard vinyl windows Slider
Picture
Interlocking meeting rail forms a tight Half Round
seal to virtually eliminate air and Casement �__•
White Flat White
water infiltration
Awning
■ Meets AAMA's standards for air Bay ■��■
and water infiltration,forced entry Bow
and energy efficiency Basement Hopper
Garden Window
Easy to Operate and Clean Patio Door Tan Flat Tan
fif Constant Force Balance System maintains the window
in any open position and never needs lubrication or adjustment
a Low profile tilt latches allow both Double-Hung window sashes Limited Lifetime Warranty"
to tilt in for easy cleaning Guaranteed protection for you and your home
Product
Peace Of Mind Double Lifeline warranty o1 vuryl bats covers peek�y,fiakirlg,
Chiporg,USLLYIrg&UYTO'SiOh
• We know you have a choice when it comes to home improvement Dade t;fer ne warranty o,hardware&pare Ikx:ks.fasters.rollers,
projects.That's why we're committed to providing quality balatices,ctc.icamrslxOnii&carosiorl
Double Lifedm a Screen warranty cogs the akirninlirn frame&the
products and installation services with our complete solution— fiwyassrrxsh against teas,p n>ctres&insect damage
from start to finish Craftsmanship
Uteti ie Craftsmanship warranty ensues the instalatron was done right
■ To ensure your peace of mind,we stand behind the entire fo as long asyouownytxrllorne
installation with Limited Lifetime Product and Craftsmanship
warranties.**
'Solt Coat Low E glass is required in some areas to meet energy code requirements. '-See actual warranties for details All installation services performed through The Home Depot performed by independent contractors.
License numbers held by or on behalf of THD AT-HOME SERVICES,INC.AL:10656,Sub S-43165:AZ:ROC193323.ROC218039.ROC223472,ROC254479,ROC254482:CA'Roofing!Fencing"B836021:CT:
HIC.0565522.DC Contract Only 6148,DE:1997 112310;FL:CRC046858.CGC1507093,CCC058327,ID:RCE-1852T.IA:C087256:KS:KS10.1239;IL.Roofing 104-014925,LA:HI.0550419,ME:CO2439:MD:52036.
MA'126893:MI'2104158225.MN:CR288257:MS:R05788;NV.0057766,0065773,065776;NJ'13VH01058300&L063478:NM: 351405:NC:64796:ND 29346 Class D;OR.158651:PA.PA002232:RI:16427;SC.
22647 and G115673:TN.59337,UT.5604067-5501,VA.2705073411A:WA:HOMED"972RQ:WV WV033268,Vvl:850869,Qualifier 1068645,Columbus.OH.HIC-4992 and G6519:Toledo,OH'BTR 05603HRC,OK.
80000018,Buffalo.NY.536871 Sub Contractor,Suffolk Cry 27587-H.Philadelphia,PA 21855:Rockland County,NY H-09403135-00-00:NYC 1201902,Nassau Cnry.NY H 18G1650DOO:Yonkers.NY 3802,Hammond.
IN Lic19030.Other license numbers available upon request.Services may not be available in all areas.Colors shown are reproduced by lithographic process and may vary from actual colors. Changes to product(s)may
have occurred since time of printing. Consult your THD At-Home Services representative prior to purchasing."AAMA'and the AAMA logo is a registered trademark of the American Architectural Manufacturers Association.
'NFRC"and the NFRC logo are registered trademarks(if the National Fenestration Rating Council.'The Home Depot is a registered trademark of Homer TLC,Inc.Cj200D-2014 Horner TLC,Inc.AN rights reserved.
THD-103(5/14)
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19
VILLAGE OF RYE BROOK
MAYOR 938 King Street, Rye Brook, N.Y. 10573 ADMINISTRATOR
Paul S. Rosenberg (914) 939-0668 Fax (914) 939-5801 Christopher J Bradbury
www.ryebrook.org
TRUSTEES BUILDING & FIRE
Susan R. Epstein INSPECTOR
Stephanie J. Fischer Michael J. Izzo
David M. Heiser
Jason A. Klein
January 6, 2020
Via 1" Class Certified Hail
Richard Burns c/o Alana Burns
51 A Avon Circle
Rye Brook, New York 10573
Re: 5 1 A Avon Circle, Rye Brook, New York 10573
Notice of$500.00 Fee for Expired Permits
Open Building Permit#19-060 Issued: 4/16/2019 - Expiration Date: 4/16/2020
Dear Property Owner.
Please allow this letter to serve as a reminder that your open permit(s) noted above, as is the case with all
Building Permits issued by the Building Department must be closed out with a Certificate of Occupancy
or Certificate of Compliance in accordance with §250-10.A. of the Code of the Village of Rye Brook.
Building Permits have a life of twelve (12) months and the expiration date is noted on the front of the
permit.
Please be advised that should you fail to properly close out your permit(s) in accordance with the law,
effective November 1, 2009 the Village will be imposing a $500.00 Administrative Fee in connection
with all open expired Building Permits issued after January 1, 2003. Please note that this Administrative
Fee applies to each individual permit and must be remitted in addition to any other required fees
associated with closing the permit(s), as well as any court imposed fines should a summons(es) be issued.
Thank you for your attention in this matter, and please feel free to contact this office should you require
any further information.
Michael J. Izzo
Building& Fire Inspector
mizzo dL Eyebrook.org
/ec
cc: Steven E. Fews, Assistant Building Inspector
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VILLAGE OF RYE BROOK
MAYOR 938 King Street, Rye Brook, N.Y. 10573 ADMINISTRATOR
Paul S. Rosenberg (914) 939-0668 Fax (914) 939-5801 Christopher J. Bradbury
www.ryebrook.org
.TRUSTEES BUILDING & FIRE
Susan R. Epstein INSPECTOR
Stephanie J. Fischer Michael J. Izzo
David M. Heiser
Jason A. Klein
January 6, 2020
Via I" Class Certified Mail
Richard Burns c/o Alana Burns
4202 Camelia Drive
Hernando Beach, Florida 34607
Re: 5 1 A Avon Circle, Rye Brook,New York 10573
Notice of$500.00 Fee for Expired Permits
Open Building Permit#19-060 Issued: 4/16/2019 - Expiration Date: 4/16/2020
Dear Property Owner,
Please allow this letter to serve as a reminder that your open permit(s) noted above, as is the case with all
Building Permits issued by the Building Department must be closed out with a Certificate of Occupancy
or Certificate of Compliance in accordance with §250-10.A. of the Code of the Village of Rye Brook.
Building Permits have a life of twelve (12) months and the expiration date is noted on the front of the
permit.
Please be advised that should you fail to properly close out your permit(s) in accordance with the law,
effective November 1, 2009 the Village will be imposing a $500.00 Administrative Fee in connection
with all open expired Building Permits issued after Januan 1, 2003. Please note that this Administrative
Fee applies to each individual permit and must be remitted in addition to any other required fees
associated with closing the permit(s), as well as any court imposed fines should a summons(es)be issued.
Thank you for your attention in this matter, and please feel free to contact this office should you require
any further information.
Michael J. Izzo
Building& Fire Inspector
mizzo(&rye brook.org
/ec
cc: Steven E. Fews, Assistant Building Inspector
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ACORO CERTIFICATE OF LIABILITY INSURANCE 02/1112019
Ii
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
PRODUCER NAME:
MARSH USA,INC. PHONE FAX
TWO ALLIANCE CENTER C N c No):
3560 LENOX ROAD,SUITE 2400 EMAIL
ADDRESS:
ATLANTA,GA 30326
INSURER(S)AFFORDING COVERAGE NAIL N
CN101642069-HomeD-GAW-19-20 INSURER A:Old Republic Insurance Co 24147
INSUREDHOME DEPOT U.S.A.,INC. INSURER B:New Hampshire Ins Co 23841
DIB/A THE HOME DEPOT INSURER C:HomeRisk Captive Insurance Company
2455 PACES FERRY ROAD INSURER D:
BUILDING C-20
ATLANTA,GA 30339 INSURER E:
INSURER F:
COVERAGES CERTIFICATE NUMBER: ATL-004353266-17 REVISION NUMBER: 3
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 Wffff_LTYPE OF INSURANCE INSD UBR POLICY NUMBER MO DDY E FF POLICY E YY M DD1 YY XP LIMBS
LTR I Ma
A X COMMERCIAL GENERAL LIABILITY MWZY314574 03/01/2019 03/01/2022 EACH OCCURRENCE S 1,000,000
DAMAGE TO RENTE15-CLAIMS-MADE M OCCUR PREMISES Ea occurrence $ 1,
X SIR:$1.000.000 MED EXP(Any one person) $ EXCLUDED
0
PERSONAL&ADV INJURY S 1'�'�
GENT AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 1'000'000
X POLICY PRO ❑ LOC PRODUCTS-COMP/OP AGG $ 1,000,000
1ECT
S
OTHER:
A AUTOMOBILE LIABILITY MWTB314573 03/0112019 03/0112022 EO aBINEDtSINGLE LIMIT $ 1.000,000
X ANY AUTO BODILY INJURY(Per person) S
OWNED SCHEDULED SELF INSURED AUTO PHY DMG BODILY INJURY(Per accident) $
AUTOS ONLY AUTOS
HIRED NON-OWNED PROPERTY DAMAGE $
AUTOS ONLY AUTOS ONLY Per accident
$
UMBRELLA LIAB OCCUR EACH OCCURRENCE $
EXCESS LIAB CLAIMS-MADE AGGREGATE $
DD RETENTIONS $
E _
B WORKERS COMPENSATION WC0127170991AKAH,NJ,VT) O H X STATUTE EER
B AND EMPLOYERS'LIABILITY Y/N WC 012717100(WI) 03/01/2019 03101/2020 5,000,000
ANYPROPRIETORIPARTNERIEXECUTIVE E.L.EACH ACCIDENT S
OFFICER/MEMBER EXCLUDED? N N/A 5,000,000
(Mandatory in NH) E.L.DISEASE-EA EMPLOYEE S
If yes,describe under Continued on Additional Page E.L.DISEASE-POLICY LIMIT S 5,000,000
DESCRIPTION OF OPERATIONS below
C Excess Auto 297110011002019 03/0112019 03/01/2020 Limit: 4,000,000
A Excess General Liability MWZX 314580 03101R019 03101R022 Limit: 8,000,000
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101.Additional Remarks Schedule,may be attached if more space is required)
VILLAGE OF RYEBROOK IS INCLUDED AS ADDITIONAL INSURED IF REQUIRED BY WRITTEN CONTRACT ON THE ABOVE GENERAL LIABILITY AND AUTOMOBILE LIABILITY POLICIES,BUT ONLY
WITH RESPECT TO LIABILITY ARISING OUT OF THE OPERATIONS OF THE NAMED INSURED.
CERTIFICATE HOLDER CANCELLATION
VILLAGE OF RYEBROOK SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
BUILDING DEPT. THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
938 KING STREET ACCORDANCE WITH THE POLICY PROVISIONS.
RYEBROOK,NY 10573
AUTHORIZED REPRESENTATIVE
of Marsh USA Inc.
Manashi Mukherjee �Lavcao►-� -►fit'
®1988-2016 ACORD CORPORATION. All rights reserved.
ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD
aK Workers' CERTIFICATE OF
srJ Compensation NYS WORKERS' COMPENSATION INSURANCE COVERAGE
Board __
Ia.Legal Name&Address of Insured(use street address only) 1b.Business Telephone Number of Insured
Home Depot USA,Inc. 770-433-8211
2455 Paces Ferry Rd., C-20 1c.NYS Unemployment Insurance Employer Registration Number of
Atlanta.GA 30339 Insured
76011130
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
58-1853319
2.Name and Address of Entity Requesting Proof of Coverage 3a.Name of Insurance Carrier
(Entity Being Listed as the Certificate Holder) New Hampshire Insurance Company
3b.Policy Number of Entity Listed in Box"1a"
Village of Ryebrook WC012717O98
Building Dept. 3c.Policy effective period
938 King Street 03/01/2019 to 03/01/2020
Ryebrook,NY 10573
3d.The Proprietor,Partners or Executive Officers are
M✓ included.(Only check box if all partners/officam 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 complyingwith 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: Lex Baugh -
(Print name of authorized representative or licensed agent of insurance carrier)
y 2l5/19
Approved by:
(Signature) (Date)
Title:
Authorized Representative
212-770-7000
Telephone Number of authorized representative or licensed agent of insurance carrier:
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.
www.wcb.ny.gov
C-105.2 (9-17)