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HomeMy WebLinkAboutDP22-010PERMIT # �����J— � / � DATE: � /� �r� ®(P; � // of s�cTroN %a-�i. �5 eLocK _ / Los /� /a 3 TYPE OF WORK JOB LOCATION _ OWNER�� CONTRACTOR � ST. CO # TCO # FEE DATE INSPECTION RECORD DATE FOOTING FOUNDATION FRAMING RGH FRAMING INSULATION PLUMBING L RGH PLUMBING GAS I NSP SPRINKLER � �,� J� C" ELECTRIC -' LOW -VOLT 0 ALARM AS BUILT 0 FINAL OTHER APPROVALS 4 4t" Clrmd(lPJY+cS[aW 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 Michael J. Izzo Stephanie J. Fischer David M. Heiser Salvatore W. Morlino CLARIFICATION OF RECORD December 8,2022 SC Rye Brook Partners LLC c/o Watjatn Group LTD 4 West Red Oak Lane Suite 325 White Plains,New York 10604 Re: 2 Rose Lane, Rye Brook,New York 10573 Parcel ID#: 129.25-1-1.123 Demolition Permit#22-010 issued on 10/11/2022 to De-Construct Retail Sales Office This certifies that the above captioned permit has been closed out by Building Permit#17-024 issued on 2/10/2017 for an attached single family dwelling with a partial finished basement with Certificate of Occupancy#22-171 issued on 11/3/2022. Sincerely, Michael J. Izzo Building&Fire Inspector /to For office use onI NOV ' 9 2022 BUILDITA ARTMENT PERMIT# O VILY� OF RYE BROOK ISSUED: /p VILLAGE OF RYE BROOK 938 KING STREIFiT� YE BROOK,,NFw YoRK 10573 DATE: BUILDING DEPARTMENT (9l 9 -0648 FEE: PAID 13 r 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 ss.•s••••••r•s:s•ssas♦••s••••ssrs•s•s•••ss•r•s•s•s••r••s••s♦ssss•♦s•s••r••••ssrsss••s•s•sssss♦r►srrssrs►rs•••►•r•ss•ss•rssrr• Address: /— (49C 3� Occupancy/Use: IZ!kS Parcel ID#: !Zr-1,2G—l — 1 • 1 z3 Zone: -P uD Owner: 56 P-44-- l � 07,J , I _ tj Ad ress:4- 7 3 H D k -PLA 0, P.E./R.A.or Contractor: !SLA —1 .a j ►DkV t Pn1 kf' ( d�resss M 14 r% LAf t' S Person in responsible charge: W I LL-l 0W 1ZIIC N 1.. A dress m 5 N 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: W 1 l.0 AN al Diu L being duly swom,deposes and says that he/she resides at (Print Name of Applicant) � (No.antl Stint) in `amg a a—D� ,in the County of r P(f/�rr 1�L_o in the State of_ that (Citv'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 3 Z00- 00 for the construction or alteration of: t> - A OIJS�I.CCT Deponent further states that he/she has examined the approved plans of the structure/work herein referred to for which a Certificate of Occupancy/Compliance is sought,and that to the best of his/her knowledge and belief;the structure/work has been erected/completed in accordance with the approved plans and any amendments thereto except in so far as variations therefore have been legally authorized,and as erected/completed complies with the laws governing building construction.Deponent further understands that it shall be unlawful for an owner to use or permit the use of any building or premises or part thereof hereafter created,erected,changed,converted or enlarged,wholly or partly,in its use or structure until a Certificate of Occupancy or Certificate of Compliance shall have been duly issued by the Building Inspector as per§250-10.A.of the Code of the Village of Rye Brook. Sworn to before me this 1% Sworn to before me this day of I V D,e I'(tff ,2022 day , 20� o Signature of Property Owner Signature of Applicant t OL-)vh-1 Ar(-A i-A, 6,.)t t�+t lEsS' (.y 1,Lj_14a" PL1 F�}Z-- Print Name of Property Owner I SARAH A ARNDT Print Name of Applicant Notary Public-State of New York No.OIAR6435014 _ Qualified in Putnam County Lary lic My Commission Expires Jun 21,2026 Pjbi4owublic QyE 4Ro 1982 BUILDING DEPARTMENT ❑BUILDING INSPECTOR J,(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 -`� f`t P DATE: PERMIT# ' y�\ ISSUED: CT: IL l BLOCK: LOT: I �� LOCATION: ^ �� Q out Z i J �j / OCCUPANCY: ❑ VIOLATION NOTED THE WORK IS... El ,.ACCEPTED ❑ REJECTED/REINSPECTION ❑ SITE INSPECTION REQUIRED ❑ FOOTING ❑ FOOTING DRAINAGE ❑ FOUNDATION ❑ UNDERGROUND PLUMBING NOTES 04INSPECTION: ❑ ROUGH PLUMBING OUGH FRAMING INSULATION �- ❑ NATURAL GAS ❑ L.P. GAS ❑ FUEL TANK ❑ FIRE SPRINKLER ❑ FINAL PLUMBING ❑ CROSS CONNECTION ❑ FINAL ❑ OTHER o a N O elN a v a. Cn U o w N 0 PLO W ] v �.,� o LA °�° ao v 4 w � ;14 o � o � ° w U A 3 `�' a. " 4-4 Ln ■rT Q �` Aco Ln y 1-1 Wz �j vn a U q {p �+ MCI s Q U x .�r W C o W � Za � c � ^ U z N w a� Q 8a. v �j c� CN 5 U ,.,., z q H ac o o `" -9 U �, W oo `-' M o W a am v 3 ogs . 1� � V r� O � A a WQ � � � � ° ►,� z z b ' V7 W N a u p � b f CZ V �ra � W Qu uc� z io0 W O N A z tx 4 CQ o b 0 r 5 BUEL c DEPAR MIENT OCT -5 2022 VILi�Oi OF RYE i OOK 938 KING SaREET RYE$Rocfk,NY 10573 (914 _-06W VILLAGE OF RYE BROOK -� BUILDING DEPARTMENT DEMOLITION PERMIT APPLICATION FOR OFFICE USE ONLY: Approval Date: T — Permit#: � Application Fcc; Approval Signature: Permit Fees:$ � Disapproved: Other' Application dated: 10--Sl- is hereby made to the Budding Inspector of the Villageed Rye Brook,NY,for the issuance of a Permit for the B dmg,or for a change in use,as per detailed statement described below. l n 1. Job Address: 2 e4JS4---1-At_Ik 2y¢ ReZZe N y SBL: /r�/ ol.S-/—/•/a3 Zone: /'y `' 2. Proposed Demolition.(Describe in detail): 5Tr2i e A Dvo�S -r wltiDocvS 3. Property Owner: sG C4iC 20;104 1�/a(Z/r�1�r LLL' A ess�WA�6- G7 Dry1 1 3L5 lei�k i'LA f ly Phone# �1 f�t Z2�J�-rp ty Cell# I.H -4 5l email:_J�1 u it•S�k IhM�1�i5Z,(? �p!7 Applicant: Address: Phone# Cell# email: Architect/Engineer: Address: Phone# Cell# email: General Contractor: Address: Phone# Cell# email: 4. Estimated cost of construction $ 32_Q D•Uv (NOTE:The estimated cost shall include all labor,material,scaffolding,5xed equipment,professional fees,and material and labor which may be donated !�be•) 5. Type of construction:(wood frame,masonry,steel,etc...) 6. Method(s)of Demolition: 7. Number&Location of Fuel Oil Tanks to be Removed: S. Number of Stories:. Height to Highest Ridge: To Highest Chimney: 9• Estimated date of completion: 1 Sl12=21 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. STATE OF NEW YOM COUNTY OF WESTCHESTER ) as: JIt4-40 y `D 4ci t s , being duly sworn,deposes and states that he/she is the applicant above named, (print name of individual signing as the applicant) and further states that (s)he is the legal owner of the property to which this application pertains, or that (s)he is the for the legal owner and is duly authorized to make and file this application. (indicate architect,contractor,agent,attorney,etc.) That all statements contained herein are true to the best of his/her knowledge and belief, and that any work performed, or use conducted at the above captioned property will be in conformance with the details as set forth and contained in this application and in any accompanying approved plans and specifications,as well as in accordance with the New York State Uniform Fire Prevention& Building Code,the Code of the Village of Rye Brook and all other applicable laws, ordinances and regulations. 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 r Sworn to before me this ?� � Sworn to before me this -_� day of , 20 2-2 day of r 20 2-2_ C Signature of Prope Owner Signature of Applicant Wit-LIAM rVW ulNr'rS'S lu-IAM 41CHL. Print Name of Property Owner Print Name of Applicant a ublic Na 1any Public SARAH AARNOT SARAH AARNDT Notary Public-State of New York Notary Public-State of New York 40, O1 AR64350 t 4 NO.01AR6435014 Qualified in Putnam County Qualified in Putnam County My Commission Expires Jun 21, 2025 My Commission Expires Jun 21,2026 (8) 3 21'19 Gfi:fi:�firfil A944totitfi 4cc;t t4V- :9t44t 4444;(ibfi;fi:fi + � r N r N \ 00 � W o oc v 0-0 r w v v Q ZLr) O QCA r+ 1 O � zo A N Ln o 11 � ' H NO r z V F o W .� 04 00 w a' x ►.. o �, o � � w a o � CX r W s j w c z CAp„ < V) O z � < g y r Q V W z p EC EWE BUILDING DEPARTMENT OCT 13 2022 VILLAGE OF RYE BROOK 938 KING STREET RYE BROOK,NY 10573 VILLAGE OF RYE BROOK (914)939-0668 BUILDING DEPARTMENT www.ryebrook.org ELECTRICAL PERMIT APPLICATION Westchester County MasterElectricians License Required �7 FOR OFFICE USE ONLY 0 EP#: c;)Q)—e� Approval Date: OCT 18 202 Permit Fee: $ Approval Signature: Other: Application dated, 10-7-22 is hereby made to the Building Inspector of the Village of Rye Brook NY,for the issuance of a Permit to install and/or remove electrical equipment,wiring,fixtures,or to perform other high or low voltage electrical work as per the detailed statement described below. By signing this document, the applicant & property owner agree that all electrical work performed will be in conformance with all applicable Federal,State,County and Local Codes. 1.Address: 2 Rose Lane sBL: 129.25-1-1.123 Zone: 2.Property owner: SC Rye Brook Partners Address: 5 International Drive Phone#: 914-481-1531 cell#: email: 3.Master Electrician: Denis M Fortino Address: PO Box 713 Rye, NY 10580 Lie.#: E-51 Phone#: Cell#: 914-760-5226 email: dfortino(&enetrpriseelec.comRE Company Name: FnteMrise Electric C'onsul in�u Address: PO Box 713 R)e, NY 10590 4.Proposed Electrical Work/Fixmre Count: r Demolition wiring for existing office in garage, Lighting, Furnace and Condenser 5.31 Party Electrical Inspection Agency: Swls STATE OF NEW YORK,COUNTY OF WESTCHESTER ) as: Denis M. Fortino ,being duly sworn,deposes and states that he/she is the applicant above named,and does further (print name of individual signing as the applicant) state that(s)he is the legal owner of the property to which this application pertains,or that(s)he is the Contractor for the legal owner and is duly authorized to make and file this application. (indicate architect,contractor,agent,attorney,etc.) The undersigned further states 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 n this day of ,20 day of b 0 -.�L Signature of Property Owner Signature of Applicant Denis M. Fortino Print Name of Property Owner ame of A plican Notary Public Notary Public SHARI MELILLO Notary Public,State of New York No.01ME6160063 Qualified In Westchester County 6/23/2022 Commission Expires January 29,202j STATE WIDE INSPECTION SERVICES, INC.:! CAO Service Witli Integrily 0:0 • • APPLICATIONSWIS JOB 0. • Office Use Elect.Permit# 1 I; Date Bldg Permit# Sq Ft Plumbing Permit# Final Certificate # City/Village Zip/v�"'_= Building Dept. �!' �t County Address Cross Street Section` ;. j Block Lot�� R o-� Owner Name/Address(If different than above) js` � f.I�' ;l J71 !�.-�1 C; Contact Number ❑Basement ❑ 1st Fl. ❑2nd Fl. ❑3rd Fl. ❑More Than 3 Fl. ElGarage Attic ❑Outside ❑Residential [:]commercial Receptacles Special Recept GFCI AFCI Switches Dimmers Smoke Alarms C/O Detector Hood Trash Compact Amt Amps Range(s) Cooktop(s) Oven(s) Dishwashers Refrigerator Disposal Microwave Luminaires Generator Transfer Switch SERVICE Amperage #Panels 1P 3P # Meters # Disconnect ❑Underground ❑ New Reconnect Repair ❑Overhead ❑ Upgrade ❑ Disconnect Utility ID# ❑Con Ed ❑ NYSEG Central Hudson ❑ Orange/Rockland PHOTOVOLTAIC SYSTEM PV Modules Inverters AC Disconnect Junction Box Combiner Box Load Center PV Monitor Energy Storage System DC Disconnect ❑Legalization Safety Inspection consultation G �t % %if <I�L t ol'� �Y1 � p [ECE IE OCT 13 2022 DD VILLAGE OF RYE BROOK BUILDING DEPARTMENT This application is valid for one(1)year from the date received by SWIS.This application is intended to cover the above listed items to be inspected,if at anytime of inspection additional items have been installed,you are authorized to make the inspection and adjust the fee for the additional items inspected.The applicant declares that there is no open applications for the above address with any other inspection company.The applicant, owner or authorized agent agrees to all the above terms and conditions as set forth for the application. Email Address t7 r] ! - ,� o Name License# ~ Dater Signature t Address ;; FOX -�� �j City/State ,; a f Zip Code Company: ��r y L i i •`�` y' Phone# D E C EWE State Wide Inspection Services 1080 Main Street DEC - 5 2022 845 202-17224 Phone a 914-219-1062 Fax STATE WIDE INSPECTION SERVICES VILLAGE OF RYE BROOK Email: office@swisny.com Service With Integrity BUILDING DEPARTMENT Website: www.swisny.com BY THIS CERTIFICATE OF COMPLIANCE STATE WIDE INSPECTION SERVICES CERTIFIES THAT: Upon the application of: Upon Premises Owned by: Enterprise Electric Corp. SC Rye Brook Partners LLC PO Box 713 2 Rose Lane Rye, NY 10580 Rye Brook, NY 10573 Located at: 2 Rose Lane, Rye Brook, NY 10573 Section: Block: Lot: Electrical Permit Number: EP 22-247 129.25 1.123 Certificate Number: 2022-8047 Building Permit Number: DP 22-010 A visual inspection of the electrical system was conducted at the Residential occupancy described below.The electrical system consisting of electrical devices and wiring is located in/on the premises at: 2 Rose Lane, Rye Brook, NY 10573 The Garage was inspected in accordance with the NYS and NFPA 70-2017 and the detail of the installation,as set forth below,was found to be in compliance on the 17th day of November 2022. Name Quantity Rating Circuit Type Incandescent Fixtures 03 Switches 02 Duplex Receptacles 02 GFCI 01 Officer: Frank J. Farina This certificate may not be altered in any way and is validated only by the presence of a seal at the location indicated.This certificate is valid for work performed on the date of inspection only. Building Permit Check List&Zoning Analysis Address: SBL: Zone:`Use 2 l Const.Type: �� Other. Submittal Date: l p 1 S' Z = Revisions Submittal Dates: Applicant: Nature of Work: iz��h4 (� S 4 L-G—f C(`.,c-[ce_ Reviews:ZBA: 0 C T - 5 2 0 2 2 PB• BOT• Other. OK( ( ) FEES:Filing. 7S BP: C/O: Flood Plane: Legalization: ( ) ( •�'APP: Dated:_L,-*" Notarized: ✓SB • ✓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:- Sealed: Unacceptable: ( ) ( ) PLANS:Date Stamped: Seale Copies: 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. O O 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: approval: notes: ( )ZBA mtg.date: approval: notes: ( )PB mtg.date: approval: notes: REQUIRED EXISTING PROPOSED NOTES APPROVED Ao: Circle — Fron e Front Front: Sides: RAW Main C P Ft H/Sb: Sd.H/Sb a . T°�: P HA"/Stories: notes: thNEw Workers' Certificate of Attestation of Exemption Ah Compensatlon from New York State Workers' Compensation and/or Board Disability and Paid Family Leave Benefits Insurance Coverage **This form cannot be used to waive the workers'compensation rights or obligations of any partjt** The applicant may use this Certificate of Attestation of Exemption ONLY to show a government entity that New York State specific workers'compensation and/or disability and paid family leave benefits insurance is not required The applicant may NOT use this form to show another business or that business's insurance carrier that such insurance is not required. Please provide this form to the government entity from which you are requesting a permit,license or contract. This Certificate will not be accepted by government officials one year after the date printed on the form. In the Application of Business Appplying For: (Legal Entity Name and Address): Building permit SC Rye Brook Partaen,LLC From:The Village of Rye Brook NY 1100 King St g y Rye Brook,NY 10573-1057 PHONE:914481-1531 FEIN:XXXXX6509 The location of where work will be verformed is 1100 King Street,Rye Brook,NY 10573. Estimated dates necessary to complete work associated with the building permit are from October 11,2022 to October 10,2023. The estimated dollar amount of project is over$100,000 Workers'Compensation Exemption Statement: The above named business is certifying that it is NOT REQUIRED TO OBTAIN NEW YORK STATE SPECIFIC WORKERS'COMPENSATION INSURANCE COVERAGE for the following reason: The business is a LLC,LLP,PLLP or a RLLP;OR is a partnership under the laws of New York State and is not a corporation. Other than the partners or members,there are no employees,day labor,leased employees,borrowed employees,part-time employees,unpaid volunteers(including family members)or subcontractors. Partners/Members: Robert Dale Disability and Paid Family Leave Benefits Exemption Statement: The above named business is certifying that it is NOT REQUIRED TO OBTAIN NEW YORK STATE STATUTORY DISABILITY AND PAID FAMILY LEAVE BENEFITS INSURANCE COVERAGE for the following reason: The business MUST be either. 1) owned by one individual; OR 2) is a partnership(including LLC,LLP,PLLP,RLLP,or LP)under the laws of New York State and is not a corporation; OR 3) is a one or two person owned corporation,with those individuals owning all of the stock and holding all offices of the corporation(in a two person owned corporation each individual must be an officer and own at least one share of stock); OR 4) is a business with no NYS location. In addition,the business does not require disability and paid family leave benefits coverage at this time since it has not employed one or more individuals on at least 30 days in any calendar year in New York State. (Independent contractors are not considered to be employees under the Disability and Paid Family Leave Benefits Law.) 1,Janice Heusser,am the Office Assistant with the above-named legal entity. I affirm that due to my position with the above-named business I have the knowledge,information and authority to make this Certificate of Attestation of Exemption. I hereby affirm that the statements made herein are true,that I have not made any materially false statements and I make this Certificate of Attestation of Exemption under the penalties of perjury. 1 further affirm that I understand that any false statement,representation or concealment will subject me to felony criminal prosecution,including jail and civil liability in accordance with the Workers'Compensation Law and all other New York State laws. By submitting this Certificate of Attestation of Exemption to the government entity listed above I also hereby affirm that if circumstances change so that workers'compensation insurance and/or disability and paid family leave benefits coverage is required,the above-named legal entity will immediately acquire appropriate New York State specific workers' compensation insurance and/or disability and paid family leave benefits coverage and also immediately furnish proof of that coverage on forms approved by the Chair of the Workers'Compensation Board to the government entity listed above. SIGN HERE Signature: Date: Al • //• 2i Z.Z CE-200 01/201 a A� CERTIFICATE OF LIABILITY INSURANCE DATE`MM/D12/05/20222022 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(les) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain d J p y, policies may require an endorsement. A statement on c this Certificate does not confer rights to the certificate holder In lieu of such endorsements. c m PRODUCER NONTACT Aon Risk Services Northeast, Inc. Pq�p� Boston MA Office (A/C.No.E.* (866) 283-7122 fAYb.Ne.): (800) 363-0105 v 53 State Street VMS i Suite 2201 Boston MA 02109 USA INSURERIS)AFFORDING COVERAGE NAIC li INSURED INSURER A: Guideone National insurance company 14167 SC Rye Brook Partners, LLC INSURER B. 230 Park Ave. New York NY 10169 USA INSURER C: INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 570096686098 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, AppL g�gq pp��C EFL POLI E]� Limits shown are as requested IN SR TYPE OF INSURANCE a1SD yyyp POLICY NUMBER (MM/DU/1 I) (MMACpY/Y%) LIMITS TAR4COMMERCIAL GENERAL LIABILITY 099000069 06 30 2020 03 01 2023 EACH OCCURRENCE $5,000,000 CLAIMS-MADE OCCUR DAMAGE TO RENTED PREMISES(Ea occurrence) S100,000 MED EXP(Any one person) Excluded PERSONAL a ADV INJURY $5,000,000 w GENIAGGREGATE LIMITAPPLIES PER GENERALAGGREGATE $5,000,000 ao POLICY F_X�JECa LOC PRODUCTS-COMP/OP AGG $5,000,000 rn OTHER: a r` AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Ea accident) ANY AUTO BODILY INJURY(Per person) O OWNED SCHEDULED BODILY INJURY(Per accident) m AUTOS ONLY HIREDAUTOS NON-OWNED PROPERTY DAMAGE io ONLY AUTOS ONLY (Per xddent) Y m UMBRELLA LLAS OCCUR EACH OCCURRENCE U IXCE39 LIAB CLAIMS-MADE AGGREGATE DED RETENTION WORKERS COMPENSATION AND PER STATUTE pT}I EMPLOYERS'LIABILITY ER YIN PNY PROPRIETOR I PARTNER/ E.L.EACH ACCIDENT EXECUTIVE OFFICERIMEMBER N/A (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE DUse describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE?OUCY LIMIT DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101.AddlOonal Remarks Schedule,may be aeacMd if more space Is required) a?� CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION ,DATE THEREOFNOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. aa` village of Rye Brook AUTHORIZED REPRESENTATIVE 938 King Street Y Rye Brook NY 10573 USA ©1988-2015 ACORD CORPORATION.All rights reserved ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD