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HomeMy WebLinkAboutRP22-052PERD SECI TYPE JOB Owr CON EST, vCO TCO # INSP� N REC03D 1 DATE I NSP FOOTING FOUNDATION FRAMING RGH FRAMING INSULATION PLUMBING C7 RGH PLUMBING GAS SPRINKLER ELECTRIC LOW40LT O ALARM AS BUILT C FINAL �e is/7elcly419y- 9eD9N OTHER APPROVALS ARB BOT PB ZBA OTHER 4U" a tftwmay# 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 CERTIFICATE OF COMPLIANCE December 29,2022 Karen Cherney Zaltz 47 Valley Terrace Rye Brook,New York 10573 Re: 47 Valley Terrace, Rye Brook,New York 10573 Parcel ID#: 135.59-1-56 Roof Permit#22-052 issued on 12/6/2022 to Re-Roof Existing Building This certifies that the new roof,installed under the above captioned permit has been satisfactorily completed. Sincerely, Michael J. Izzo Building&Fire Inspector /to [Ec [ E 0 " For office use onl R D [E IDBUILDING DEPARTMENT F 7 2022 VILLAGE OF RYE BROOK ! ISSUED: Mrr DEC is a 938 KfNG STREET,RYE BROOK,NEW YORK 10573 j DATE: VILLAGE OF RYE BROOK (914)939-0668 FEE: //p— YAM* BUILDING DEPARTMENT www.ryebrook.org 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 ittttiikktfiitiiiMfiMiftffffft►tktfittttttiiii4iikttiitittiftftittitftttffittitiitiiiiftiifititffittititttttiftitttisia�a. Addres_=:- I I y 1 e t- r a.cc �,c e Q rooK " cunancy/Use:1 Parcel ID#: �3 'si 59 —/— 5co Zone: _ Owner: if r-e n ��n t Y1rJ��1f Address: !!Y� u d. Zl��zaC P.E./RA.or Contractor: �lD'SINC� ►t�ta� rtoti Address: -YOOKijsj4cy,V '(�q/Vy/OS � Person in responsible charge: c,s'a 2 Address: t%ppucation is hereby made and submitted to the Building Inspector of the Village of Rye Brook for the issuance of a Eificate of Occupancy/Certificate of Compliance for the structure/construction/alteration herein mentioned in accordance with law: STATE OF NEW YORK.COUNTY OF WESTCHESTER as: K0_1-e h O rn �f 4e- being duly sworn,deposes and says that he/she resides at (Print Name of Applicant) Q o ark]Street) in tie. B t-oa K .in the County of Wu S �-_�C.s k P in the State of ,G'. Y that (C tt%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 // ,r1 pp9 S_U for the construction or alteration of: f- e0c=iN C4 6,<15 Deponent further states that he/she has examined the approved plans of the structure/work herein referred to for which a Certificate Occupancy/Compliance is sought,and that to the best of his/her knowledge and belief.the structure/work has been erected/comnleted it accordance with the approved plans and any amendments thereto except mi 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 Sworn to before me this ,..:y or , ec Q.+►6 n _, ova ' day of , 20 Cam. Signature of Property Owner 00 Signature of Applicant Ail ChW,n I t- Wint'N"of Propert j er Print Name of Applicant �Xq. (I-) No Notary Pubhz NOTAM NlMJO STATE CW NEW YYrTCljjS=0011NTIf c - �yE BRC��_ 1982 BUILDING DEPARTMENT ❑PUILDING 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.ors - - - - - - - - - - - - - - - - - - - - INSPECTION REPORT - - - - - - - - - - - - - - - - - - - - ADDRESS : 1 Vj \< DATE: PERMIT# �' �L ISSUED:1 SECT: �? BLOCK: LOT: LOCATION: OCCUPANCY: ❑ VIOLATION NOTED THE WORK IS...d❑ ACCEPTED ❑ REJECTED/REINSPECTION ❑ SITE INSPECTION �1 K�1. �y 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 a � a . a O 7 eq ■ \ '" cd W N N cr a.c z ON b a o bp H cu i P�, a .� vLn .� r O O's 010 MM .y o A ; gib N 0.0 °o = o z OC A V F O h�—� M C� W W) 1ON � 11 Eft O Q N." o � M W = 00 WG � � � � � of a w W o w A A 0 °' � o v zoa "un. nv � H w O u u u v W O o a �°� a4 0 'a W F IE C E V BUILDING DEPARTMENT NOV 3 0 2022 VILLAGE OF RYE BROOK 938 KINo STREET RYE BRooK,NY 10573 VILLAGE OF RYE BROOK BUILDING DEPARTMENT (914}939-Ob68 FOR OFFICE USE ONLY: ` - Approval Data. DEC 1 z�z Permit Application Approval Signature: �/ � ARCHITECTURAL REVIE ARD: Disapproved: % Date: BOT Approval Date: Case# Ciatrinar, PH Approval Date: Case# % Secretary: ZBA Approval Date: Case# Other: Application Fee: Permit Fees: ROOF PERMIT APPLICATION Application dated: is hereby made to the Building Inspector of the Village of Rye Brook,NY,for the issuance of a Permit to Re-Roof an E?xisting Xilding.as per detaited statement described below. 1. Job Address; v E U,&C I-.SBL: /135i 59 �/—�6 Gone: Property owner: 400 C f r--L _ ll!- Address: 41 VALLO ILVIf 61-tC V &N J C 13 Phone#: yy _ Cell#: 1 rr,+ aj -L}i3- email: 2. Applicant 1 U 1 d S n no Q rate an Address: fl e rl - �"f/ Phone 9 q-9e d y Cell#: q [q-V 6!-4 get email: Ta -4--o a, a v iu�r rod .cQ 3. Roofing Conitractor. QU1 °i aAfi nq Address: L�dtl �� n d_ S �rr Phone#: q i q- y Q('_qU 4 q Cell#: Temail: t , s rod t Cv 4. Job Description.list all Methods&Materials: - l 1 N C l�r e 2 d o 5. Estimated Cost of Job:S aLl s g S o•OV (NOTT:The estimated cost shall include all site improvements,labor.material.scaffolding,fixed equipment.prolessional 1i:cs.and material and labor which may he donated gratis.) 6. If corner property,indicate street frontage: Construction Type: �oG� NYS Construction Class: 8. Number of stories: Height: 9. Is garage being re-roofed:No:(-I•Yes:( )Attached No:O•Yes: ( 1 Number of Cars: 10. Is roof peaked,hip,mansard,flat,etc: 11. Estimated date of completion: 81121Y021 Please note that this application must include the notarized signature(s) of the legal owner(s) of the above-mentioned property, in the space provided below. Any application not bearing the legal property owner's notarized signature(s) shall be deemed null and void, and will be returned to the applicant. ST TE OF NEW YOItK, UNTY OF WESTCHMER ) as: 4 ( +2— ,being duly sworn,deposes and states that4p;/she is the applicant above named, Umnt name of individual si4ning as the applicant) and fiuther states that (s)he is the legal owner of the property to which this application pertains, or that (s)he is the forthe legal ownerand 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 ' Sworn to before me this day of NO+q_m b0l- ,20 - day of , 20 Signature of Property(honer Signature of Applicant t-Name f Oviner Print Name of Applicant 1�)+i otary Ilic Notary Public S"y f16ASLJP #gTAF f pLWX STATE OF NEW YORK No.0i Y11EBirG GOl1HTY W2l2021 no so 1* ■• ■■ :: David's Roofing — & Restorations LLC — 400 King Street, Suite 2 Chappaqua,NY 10514 infoAdavidsroof.com 914-494-9094 LIC: WC-32748-H20 Karen Cherney Zaltz 11/25/22 47 Valley Terrace Rye Brook,NY 10573 914-830-4152 kcherneyz@gmail.com PROPOSAL ROOF REMOVAL AND REPLACEMENT • All existing asphalt roofing removed and carted from job site • All rotted plywood replaced at an additional $100.00 per sheet • GAF Weather Watch Ice and Snow barrier installed on all gutter edges,valleys and around skylights (6 feet up) • GAF Tiger Paw paper installed on entire field of roof • GAF Weather Blocker starter shingles installed on all perimeter edges • GAF LIFETIME Timberline Architectural HDZ shingles installed on entire field of roof • GAF Cobra Ridge vent installed on all ridges of roof for attic ventilation 1 • GAF TimberTex hip and ridge shingles installed on all ridges • Aluminum vent pipe boots installed over all vent pipes • Aluminum drip edge flashing installed around entire perimeter of roof • LIFETIME manufacturer's warranty on GAF materials • 10 year workmanship WARRANTY from David's Roofing & Restoration LLC • Cart away all debris from job site The price for the aforementioned work, which includes labor and material for the sum of: 11,850.00 (permit fee not included if applicable) PAYMENT SCHEDULE IS AS FOLLOWS 50% 3 Days Prior to Start 95% Due the day of substantial completion 5% Retention may be held for resolution of unresolved issues Any monies not paid as specified above will be subject to accrue interest at a rate of 1.5% monthly, and 18%per annum. All material is guaranteed to be as specified above. All work to be completed in a workmanlike manner according to the standard practices. Any alteration or deviation from the above specification involving extra costs will be executed upon a written change order and will become an extra charge over and above the proposal. All agreements are contingent upon strikes accidents or delays beyond our control. Notices to Owner Right to stop work: If any payment under this agreement is not made when due, David's Roofing and Restorations, LLC may 2 suspend work on the job until such time as all payments due have been made. The proposed sum above is valid for thirty (30)days and is based on prices of materials and equipment in effect as of the date of this proposal. The proposed sum is subject to increase because of tariffs,epidemics, import duties,trade policies,or market conditions. Notice of Lien: The contractor or subcontractor who performs on the contract and is not paid may have a claim against the owner which may be enforced against the property in accordance with the applicable Lien Laws. Cancellation: The owner has an unconditional right to cancel the contract without penalty until midnight of the third business day after he/she signs the contract. Cancellation must be done by giving David's Roofing and Restorations, LLC a written notice indicating the owner's intention not to be bound. Upon cancellation, any property traded in, or payments made under this contract will be returned within 10 business days following the receipt of the cancellation notice by David's Roofing and Restorations, LLC. Acceptance of Proposal: I have read the introductory packet along with this document and accept the specified conditions as stated,and the prices associated with such. I understand that upon signing this proposal,all documents presented becomes a binding contract. You are authorized to do the work as outlined. Payment will be made as indicated above. Signature November 25, 2022 Date 3 11/29/22, 1:12 PM Timberline HDZ-America's best selling roof shingle I GAF Specifications Timberline HDZ® Specs ABOUT SPECS DOCS VIDEOS (HTTPS://WWW.GAECOM/EN- (HTTPS://WWW.GAF.COM/EN- (HTTPS://WWW.GAF.COM/EN- (HTTPS://WWW.GAF.COM/EN- US/PRODUCTS/TIMBERLINE- US/PRODUCTS/TIMBERLINE- US/PRODUCTS/TIMBERLINE- US/PRODUCTS/TIMBERLINE- HDZ) HDZ/SPECIFICATIONS) HDZ/DOCUMENTS) HDZ/VIDEOS) SPECIFICATIONS (ALL DIMENSIONS ARE NOMINAL) AWARDS & Good Housekeeping Rated RECOGNITION 25-YEAR STAINGUARD PLUSTm ALGAE StainGuard PIusTm Algae Protection PROTECTION LIMITED Limited Warranty WARRANTY S - SSSS SS DURABILITY & Advanced Protection Shingle with GAF TOUGHNESS Dura Grip Adhesive EXPOSURE 5.625" (144 mm) EXTREME WEATHER No IMPACT RATED FIRE RATING Highest Rating-Class A MATERIAL Fiberglass Asphalt Construction WIND RATING Eligible for the WindProvenTm Limited Wind Warranty when installed with four required GAF accessory products SHINGLE STYLE Wood-Shake Look SHINGLE TYPE Architectural Shingles APPROX. NAILS/SA 256 AWARDS & RECOGNITION:Good Housekeeping Rated 25-YEAR STAINGUARD PLUSTU ALGAE PROTECTION LIMITED WARRANTY:StainGuard PIusTm Algae Protection Limited Warranty Cookie Preferences We use cookies to operate our website.enhanceade-naAgotion.analyze site usage.and assist in Souotjp"efforts.By clicking"Accept Cookies,"you agree to this use.For more information please visit our Cookie Notice(http .! www.gaf.com/emus/cookie-policy). Accept Cookies https://www.gaf.com/en-us/products/timberline-hdz/specifications 1'3 11/29/22, 1:12 PM Timberline HDZ-America's best selling roof shingle GAF Specifications SPECIFICATIONS (ALL DIMENSIONS ARE NOMINAL) DURABILITY & TOUGHNESS:Advanced Protection Shingle with GAF Dura Grip Adhesive EXPOSURE:5 625" (144 mm) EXTREME WEATHER IMPACT RATED: No FIRE RATING: Highest Rating-Class A MATERIAL: Fiberglass Asphalt Construction WIND RATING:Eligible for the WindProvenTm Limited Wind Warranty when installed with four required GAF accessory products SHINGLE STYLE:Wood-Shake Look SHINGLE TYPE:Architectural Shingles APPROX. NAILS/S6t: 256 CODES FBC State of Florida Approved ICC ESR-1475 ICC AC438 ESR-3267 MIAMI-DADE COUNTY Miami-Dade County Product Control Approved TDI Meets requirements of the Texas Department of Insurance FBC:State of Florida Approved ICC : ESP-1475 ICC AC438: ESR-3267 MIAMI-DADE COUNTY: Miami-Dade County Product Control Approved TDI:Meets requirements of the Texas Department of Insurance TESTING METHODS & APPLICABLE STANDARDS TAS 100-95 Yes TAS 100-95:Yes We use cookies to operate our website,enhance site navigation,analyze site usage,and assist in Cookie Preferences ENEjj( t gRAT j.j4Gcking"Accept Cookies,"you agree to this use.For more information please visit our Cookie Nofice[https://www.got.com/en-us/cookie-policy). Accepf Cookies https://www.gaf.com/en-us/products/timberline-hdz/specifications 2/3 11129/22,1:12 PM Timberline HDZ-America's best selling roof shingle GAF Specifications ENERGY RATING COOL ROOF RATINGS CRRC-rated (White only) COUNCIL(CRRC) MIAMI 21 (FLORIDA Yes (White only) BUILDING CODE) TITLE 24(CALIFORNIA Yes (two colors only) ENERGY COMMISSION) COOL ROOF RATINGS COUNCIL (CRRC): CRRC-rated (White only) MIAMI 21 (FLORIDA BUILDING CODE):Yes (White only) TITLE 24 (CALIFORNIA ENERGY COMMISSION): Yes (two colors only) SHIPPING AND PACKAGING APPROX. PIECES/SQ 64 APPROX. BUNDLES/SA 3 APPROX. PIECES/SA: 64 APPROX. BUNDLES/S6Q: 3 We use cookies to operate our website,enhance site navigation,analyze site usage,and assist in Cookie Preferences our marketing efforts.By clicking"Accept Cookies,"you agree to this use.For more information please visit our Cookie Notice(hops://www.gof.com/en-us/cookep- licy). Accept Cookies hftps://www.gaf.Gom/en-us/products/timberline-hdz/specifications 3 3 �y;0�;���+9� � t�. _ �� [.r, A •rnF' "' �^� yyn`Cq°' rA„ .:1£ �. -An �f.2d}? .�A p �„- ..:A� �•(y? '!(oii:. ).Jt • �1jN1♦I1�/•1♦1 jIi1l,:. f +^ 1�y1�+�♦�ls1l r[?. ?'�"Nt'y Il IiI¢vI.',.j.ayer• f : :IN�•+r1•�•1 1 ?Lf's =r• i,'i+�,•!♦ i� V♦ 5i�5�I ti r lit' V1Si ma �6} t 1 ry �1h��+♦I°I♦I�I/•frA�xnI R H"� vvQ f.f.e1s •c `` t _ tit 1111�4 IIk 1/111ti fir!• r- �, _ 74 Alt ._ O � a� r L 0 v •L "Fill?CA 0 o�ection a •�= � a '�'"^� cn 1 0 � � V J 1 U ui LU of CL (i v L v a t ;n r ►a�- ` IL Ive �.1 ~ O V O Z > :,..•,� . 3 c 70 40 / It, 1.0 e,.. 1 M = y v J U v: f �•s s '' 1 11`��+ ,1 1 L.`•k;s -- �1 1�III.ti° _...I 1�11( is ,I/,I11°`y a. IIIIIIy 11[ 11I)1/1♦1,1 ;111♦1/1♦111 (� 111)1/1♦II � 'i��l l�i [(� I II,1/1[1I1 I II)111♦1I A ♦♦ A R3 ♦II A I� Cj{iJA �1 •♦ A ♦I X .�p�� _ , p ,� y: p� ` �� '' °. ,�p� ���• �p� �h• ,gyp ���,� • gip, �. � ,Np, t,'•��V/�� .may V �,LV ", V V V� ;J/.Y�� 4yJ,�f.�. r:�4:�`" .sV/�' ��v..fY. "vvi'.` r C`�j\• r"rjV & 70ATE(MMIDD/YYYY) ACORN CERTIFICATE OF LIABILITY INSURANCE �� 1/28/2022 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT Erich Courant&Company PHONE FAX 25 East Spring Valley Ave Suite 270 �201-226-1200 IA/C.No):201-226-1201 Maywood NJ 07607 A DRIESS: INSURERS AFFORDING COVERAGE NAIC# _ License#:BR525310 INSURER A:Ategrity Special Speciafty Insurance Company 16427 INSURED DAVIROO-01 INSURER B: David's Roofing& Restorations LLC INSURERC: 400 King Street Suite 2 INSURERD: Chappaqua NY 10514 INSURERE: INSURER F: COVERAGES CERTIFICATE NUMBER:82477673 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 LTR TYPE OF INSURANCE ADDL SUBR POLICY NUMBER MMIDDfYYYY MPOLICY EFF M DDIIYEYXYY LIMITS A X COMMERCIAL GENERAL LIABILITY 01-P-GL-P70003222-0 3/30/2022 3/30/2023 EACH OCCURRENCE $1,000,000 CLAIMS-MADE FX]OCCUR PREMISES Ea occurrence $100,000 MED EXP(Any one person) $5,000 PERSONAL&ADV INJURY $1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $2,000.000 POLICY F JECT PRO ❑LOC PRODUCTS-COMP/OP AGG $2,000,000 OTHER: Deductible $2,500 AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY(Per accident) $ HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY Per accident UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB HCLAIMS-MADE AGGREGATE $ DED 1 1 RETENTION$ $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY Y/N STATUTE ER ANYPROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ OFFICER/MEMBEREXCLUDED? ❑ N/A - — (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under 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) Certificate holder is included as additional insured when required by written contract. The insurance afforded by the policies described herein is subject to all the terms,exclusions and conditions of such policies.This form does not constitute a contract between the issuing insurer(s),authorized representative or producer,and the certificate holder. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Village of Rye Brook 938 King St Rye Brook NY 10573 AUTHORIZED REPRESENTATIVE ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD 17-0--\111 I& NYSIF New York State Insurance Fund PO Box 66699,Albany, NY 12206 1 nysif.com CERTIFICATE OF WORKERS' COMPENSATION INSURANCE _ffmimam A^^^^A 850531987 !+ ERICH COURANT&CO INC 25 EAST SPRING VALLEY AVE SUITE 270 MAYWOOD NJ 07607 SCAN TO VALIDATE AND SUBSCRIBE POLICYHOLDER CERTIFICATE HOLDER DAVID'S ROOFING AND VILLAGE OF RYE BROOK RESTORATIONS, LLC 938 KING STREET 96 CAMPFIRE ROAD RYE BROOK NY 10573 CHAPPAQUA NY 10514 POLICY NUMBER CERTIFICATE NUMBER POLICY PERIOD DATE W2514 987-3 546531 05/29/2022 TO 05/29/2023 11/28/2022 THIS IS TO CERTIFY THAT THE POLICYHOLDER NAMED ABOVE IS INSURED WITH THE NEW YORK STATE INSURANCE FUND UNDER POLICY NO. 2514 987-3, COVERING THE ENTIRE OBLIGATION OF THIS POLICYHOLDER FOR WORKERS' COMPENSATION UNDER THE NEW YORK WORKERS' COMPENSATION LAW WITH RESPECT TO ALL OPERATIONS IN THE STATE OF NEW YORK, EXCEPT AS INDICATED BELOW, AND, WITH RESPECT TO OPERATIONS OUTSIDE OF NEW YORK, TO THE POLICYHOLDER'S REGULAR NEW YORK STATE EMPLOYEES ONLY. IF YOU WISH TO RECEIVE NOTIFICATIONS REGARDING SAID POLICY, INCLUDING ANY NOTIFICATION OF CANCELLATIONS, OR TO VALIDATE THIS CERTIFICATE,VISIT OUR WEBSITE AT HTTPS:/M/WW.NYSIF.COM/CERT/CERTVAL.ASP.THE NEW YORK STATE INSURANCE FUND IS NOT LIABLE IN THE EVENT OF FAILURE TO GIVE SUCH NOTIFICATIONS. THIS POLICY DOES NOT COVER THE SOLE PROPRIETOR, PARTNERS AND/OR MEMBERS OF A LIMITED LIABILITY COMPANY. THE POLICY INCLUDES A WAIVER OF SUBROGATION ENDORSEMENT UNDER WHICH NYSIF AGREES TO WAIVE ITS RIGHT OF SUBROGATION TO BRING AN ACTION AGAINST THE CERTIFICATE HOLDER TO RECOVER AMOUNTS WE PAID IN WORKERS'COMPENSATION AND/OR MEDICAL BENEFITS TO OR ON BEHALF OF AN EMPLOYEE OF OUR INSURED IN THE EVENT THAT, PRIOR TO THE DATE OF THE ACCIDENT, THE CERTIFICATE HOLDER HAS ENTERED INTO A WRITTEN CONTRACT WITH OUR INSURED THAT REQUIRES THAT SUCH RIGHT OF SUBROGATION BE WAIVED. THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS NOR INSURANCE COVERAGE UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICY. NEW YORK STATE SUR NCE FUND T �V DIRECTOR,INSURANCE FUND UNDERWRITING VALIDATION NUMBER: 743224361 U-26.3