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HomeMy WebLinkAboutRP23-002PERMIT # c� DATE. C� !SECTION Z TYPE OF WORK JOB LOCH 1 OWNER /CG T. COST v # TCO # 13� %S r/U 1/�rrn�� LLI.: FEE DATE INSPECTION REC032 DATE FOOTI N G FOUNDATION FRAMING RGH FRAMING INSULATION PLUMBING C7 RGH PLUMBING GAS SPRINKLER 0 ELECTRIC LOW -VOLT O ALARM a AS BUILT FINAL 1 NSP p-//eO 7g1o3 OTHER APPROVALS OTHER Qy� DR C� t i vJ PLC,t� 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 ACTING BUILDING& FIRE INSPECTOR Susan R. Epstein Steven E. Fews Stephanie J. Fischer David M. Heiser Salvatore W. Morlino CERTIFICATE OF COMPLIANCE February 1,2023 Michael Kelly&Janet Kelly 10 Robins Roost Rye Brook,New York 10573 Re: 10 Robins Roost, Rye Brook,New York 10573 Parcel ID#: 135.27-1-29 Roof Permit#23-002 issued on 1/10/2023 to Re-Roof Existing Building This certifies that the new roof,installed under the above captioned permit has been satisfactorily completed. Sincerely, Steven E. Fews Acting Building&Fire Inspector /to For office use only: DBUILQBROOK, ENT PERMIT# -Opp JAN 2 3 2023 VILK ISSUED: —/ l 938 KING STREYORK 10573 DATE: —al3—ol3VILLAGE OF RYE BROOK FEE: J1 C7 PAIDJ� 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 ttssssrsssrsrsrrrrttsrssrrssrr*srrrsrawssrtsssssrrrrss*srttrwwtasrssssrsssrssrtttssssssr*s*srssrtrssssrsrs*r*wr*srerssrtsrrrs Address: t Y1 S Q-00 S �1 Occupancy/Use: Parcel ID#: Zone: /ep - Owner:µ�( Q L JQA�1S� �� Address: 1 u Z(bihS 9XL4, QQe 8Y L , Rq (6�3 P.E./R.A.or Contractor: "h 1P-*WYU r L—f f- Address: {}�{ (� Person in responsible charge: Poln Address: la attzleJ 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: T62a, VLrYi3��- being duly swom,deposes and says that he/she resides at f xar" C f-i' (Print Name of Applicant) (No.and Street) in ?\;*D a y40L l L2- in the County of (1)#' in the State of_��,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:$ Q l7 for the construction or alteration of: Y(Y)r' dLED (Zi0 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 beforeme this L 7 `011111111�1,//�,, Sworn t before me this TILA day of J , , 20 Z3 `----- ,, d o 20 411 STATE ' OF NEVV Yo e Igna o = 1`OmOw, �1 Ypiilc re of Applicant ` 01PA6347502 ^nt o p wn F eTATE�� //' ///'�,/oiN11p;R£5����`\ ri Ae,of I ant to Pub Ic — UBLIC I I (j Public Ii (J jo v � Qye BRCOuk 0 �m 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 " y "' DATE: PERMIT# � ISSUED: (63SECT: BLOCK: � LOT: � c LOCATION: , \ w sl- OCCUPANCY: 2- ❑ VIOLATION NOTED THE WORK IS... ACCEPTED ❑ REJECTED/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 x : a a _ M N \ W /�/ Y'N � V '✓ �+ v 0414 �h h W Z' � „ v .d `. � v � ■ U O 0 4-4 ~ A � � y, � y •� G o � I� a© dQ v o )rm' . C00 ob CO) .C) y} F� `�F-� aOtno� cqd' �'O °?'.aa.� o ►a Z V z a. _ C/) C� E, 3 w d I O a / n r T F+1 W a v T"A � Cam+ � (F/��){ --Ny.�.. w � �1 w/ A <n � o PP ce-go Q z z .0 V CJ� RX '� W O ran v U v R Q � ON v w = pq cn � z O U U How x ° u z z °` a x A o j--r w w o � - a � z IZ! u7 H A w z d 05 v � s r � BUILDj'N � It�MENT VI E OF RY OK �A� - 2�23 938 KrNG ET RYE BR NY 10573 _0 -�� VILLAGE OF RYE BROOK BUILDING DEPARTMENT FOR OFFICE USE ONLY: Approval Date:J AEI - 5 Permit# ,� 3-00�- Application# Approval Signature: N V ARCHITECTURAL REVIEW BOARD: Disapproved: : Date: BOT Approval Date: Case# Chairman: PB Approval Date: Case# : Secretary: ZBA Approval Date: Case# Other: Application Fee: Permit Fees: CD I OW 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 Existing Bu%ldiAg,as per detailed statement described below.,,` 1. Job Address: `� kiu SBL: (-2;3,al - I -2-9 Zone: �k�kAq Property Ow,n11 r: d Address: I I �U7�� Phone#: 4 Cell#: email: c� 3 V 2. Applicant: �� Address: �T• �t1 `�� Phone#: l� — Cell#JCgN J—W— —�q email:� V/�(NQ.YYUI 1 3 T l 3. Roofing Contractor: �o LL Address: cp .� Na^\A4V,M-0 1� Phone#:Lciy)1Lk'1 -')l_ug Cell#: - email: Y 4. Job Description,list all Methods&Materials: 1 i& rmk I r'r n �IIP r r, T a 1 lnlil r �W\0 5 t Ga Y (h mAtk ►h1 5. Estimated Cost of Job:$- t-k%A jC) Lit) (NOTE:The estimated cost shall include all site improvements,labor,material.scat of[dine.fixed equipment,professional fees,and material and bor which may be donated gratis.) G. If corner property,indicate street frontage:� 110Q '�1d L-`qw(A� 7. Construction Type: �k�- NYS Construction Class: 8. Number of stories: ` s Height: 9. Is garage being re-roofed: No:( )•Yes:W Attached No: O•Yes: Number of Cars: 10. Is roof peaked,hip,mansard,flat,etc: -WALL 11. Estimated date of completion: kmy n.L w a,4 a ep-yoock-� 4- 811212021 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. STPTE OF NEW YORK,COUNTY OF WESTCHESTER ) as: o tr r,4 V¢J y-✓U Y� ,being duly sworn,deposes and states that he/she is the applicant above named, (print name df 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 C v n �+c. ("� J r for the legal owner and is duly authorized to make and file this application. (indicate architect,contractor,agent,attorney,etc.) That all statements contained herein are true to the best of his/her knowledge and belief,and that any work performed,or use conducted at the above captioned property will be in conformance with the details as set forth and contained in this application and in any accompanying approved plans and specifications,as well as in accordance with the New York State Uniform Fire Prevention&Building Code,the Code of the Village of Rye Brook and all other applicable laws,ordinances and regulations. Sworn to before me this L'� Sworn to before me this day of , 201�__ d f j0n ,201a_ i I re o perty Owner Signature of Applicant • 2f ()CIr✓JnV__, rin ame to ner Pri t Namel ant t u i ry IC ,01111Pt I l I l// ♦ STATE // STIcTE ` — /Ol NEWYORIC� 1 1 1 1 { 01PA6WSM / ��/1111111t�� -z- 811212021 Perry Verrone, LLC 12 Center Street Pleasantville, NY 10570 infoOperryverroneroofing com Office: (914)747-7663 Fax: (914)747-7665 License WC 21701 H09 Janet Kelly 12 28 22 10 Robins Roost REVISED 1.3.23 Rye Brook, NY 10573 (914) 690-1180 Tomx2914(@gmail.com Prepared by Perry PROPOSAL ROOF REMOVAL AND REPLACEMENT • All existing asphalt roofing removed and carted from job site • All rotted plywood replaced at$95.00 per sheet- first four (4) sheets replaced at no charge • 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 the entire field of roof • GAF LIFETIME Timberline Architectural HDZ Charcoal shingles installed on entire field of roof • GAF Cobra Ridge vent installed on all ridges of roof for attic ventilation • GAF TimberTex hip and ridge shingles installed on all ridges • Aluminum vent pipe boots installed over all vent pipes • White aluminum drip edge flashing installed around entire perimeter of roof • GAF Weather Blocker starters installed on all perimeter edges • Copper chimney flashing fabricated and installed • Rye Brook Building Permit for an additional cost TBD GAF Golden Pledge Warranty The price for the aforementioned work,which includes labor and material (excluding any additional plywood), totals to the sum of: $13,900.00 Page 1 of 5 Initial & Date: 10 Robins Roost, Rye Brook, NY 10573 (1) QuickMeasure December 27, 2022 Roof Reports in Under an Hour Prepared For: Perry's Roofing A N 0 Contents Measurements Overview 1 Roof Area 2,658 sq ft Top View 2 Roof Facets 4 Side Views 3 Predominant Pitch 5 / 12 Lengths 4 Ridges/Hips 70 ft Pitches 5 Valleys 0 ft Areas 6 Rakes 1 16 ft Summary 7 Eaves 139 ft Materials 8 Bends 0 ft GAF 1 • • ' Ix �+. '�,� /�w 1!r • .�1 iT�•.`^fir � '► � �Y!/ v ,. r f i • dw 100001, w�. 94 10, �1 91 ` �' 1. •4 )` • • ,Q ` ~�\ J � lw tvo Of r '�� • �� � "•� �'rf ,.C'�� titer r —•• —• • •• • 2 1 •• 00 •• t '1 • GAF Ift • M C• i 4� `i r. \ r ♦ , op -oil -- QuickMeasure Lengths Roof Reports in Under an Hour AFlash Step Drip N O Eave Rake Ridge 139 i 16 Lengths in feet Prepared For: Perry's Roofing 10 Robins Roost, Rye Brook, NY 10573 (1) QuickMeasure Pitches Roof Reports in Under an Hour A N 5 5 5 5 O Pitches in inches per foot Prepared For: Perry's Roofing © 10 Robins Roost, Rye Brook, NY 10573 (1) QuickMeasure AreasRoof Reports in Under an Hour A N 219 289 874 1,275 O Areas in square feet Prepared For: Perry's Roofing 10 Robins Rocsi, Rye Brook, NY 10573 (1) QuickMeasure Summary Roof Reports in Under an Hour Pitch 5 Area 2,658 Percent 100% Suggested Waste 0% 1% 4% 6% 8% 11% 16% Area 2,658 2,684 2,764 2,817 2,870 2,950 3,083 Squares 27 27 28 29 29 30 31 Roof Area 2,658 sq ft ARoof Facets 4 N Pitch 5 / 12 Bends 0 ft Eaves 139ft Hips 0 ff Rakes 116ft Ridges 70 ft Valleys 0 ft Flash 5 ft Step 30 ft Drip Edge 255 ft Leak Barrier 290 ft Ridge Cap 70 ft Starter 255 ff Parapets 0 ft Notes 1)Measurements are rounded to the nearest whole number.2)Rakes are defined as sloped roof edges.3)Eaves are defined as level roof edges.4)Flashing pertains to level roof edges and excludes valleys.5)Step flashing pertains to sloped roof edges and excludes areas around penetrations.6)Drip edge=eaves+rakes.7)Waste table excludes additional materials needed for ridges,hips,valleys,etc.8)Suggested waste factor is based on the roof complexity and is provided for guidance purposes only. you should confirm the appropriate waste factor prior to ordering. Prepared For: Perry's Roofing i 0 Robins Roost, Rye Brook, NY 10573 (1) QuickMeasure Roofing Materials Roof Reports in Under an Hour Suggested Waste 0% 1% 6% 11% Shingle Products HDZ, Natural Shadow, ASII, Reflector, bundle 82 82 86 90 Royal Sovereign, and Cool Series Low-Slope Roofing System Liberty Base/Ply Sheet roll 0 0 0 0 Liberty Cap Sheet roll 0 0 0 0 Starter WeatherBlocker bundle 3 3 3 3 Pro-Start bundle 3 3 3 3 Quick-Start roll 8 8 9 9 Roof Deck Protection Deck-Armor, Tiger Paw, FeltBuster 10 sq roll 3 3 3 3 Shingle-Mate roll 7 7 8 8 VersaShield roll 8 8 9 9 Leak Barrier StormGuard, WeatherWatch 2 sq roll 5 5 5 5 WeatherWatch 1.5 sq roll 6 6 7 7 Ridge Cap Seal-A-Ridge, Seal-A-Ridge AS bundle 3 3 3 4 TimberTex bundle 4 4 4 4 Z-Ridge bundle 3 3 3 3 TimberCrest box 4 4 4 4 Attic Ventilation Cobra 4' Plastic Ridge Vents foot 36 Master Flow SSB960 Metal Slant-Black vent 11 Master Flow High-Capacity Dome Vent vent 5 Cobra IntakePro Rooftop Intake foot 71 Notes:1)These approximate quantities are based on estimated measurements and are for guidance purposes only. You should always confirm quantities prior to ordering and ensure you are following local building code requirements. 2)For Timberline.3 bundles=0.984 squares. 3)Starter=eaves+rakes. 4)Leak barrier=bends+eaves+flashing+hips+rakes+step+ valleys. 5)Ridge cap=hips+ridges.6)Estimated quantity of attic ventilation products based solely on exterior roof area and intended for estimating purposes only. Installer must verity attic floor square footage,roof design,local code requirements,quantity/type/approved roof pitch of recommended vent products.and conditioned space under the roof. Always have a balanced attic ventilation system. In no case should the amount of exhaust ventilation exceed the amount of intake ventilation.For more into.visit gaf.com/venicalculator.1)Low-slope products applied to 1/12 pitch areas.8)Timberline products applied to 2112 pitch areas and above. 'Installed coverage will be less and depend on quantity and width of side and end laps. Prepared For: Perry Roofing U 10 Robins Roost, Rye Brook, NY 10573 (1) 0 Timberline'HM" High Definition'Shingles ' 1 ilk dr n i f i .. - r } America's #1 -selling shingle just got better! The same shingle you know and love, now with LayerLock"' Technology which powers the industry's widest nailing area. 0 Timberline® H DZTM Shingles Benefits: Product details: ■ LayerLock"Technology—Proprietary durability, strength, and exceptional Product/System Specifics technology mechanically fuses the wind uplift performance. • Fiberglass asphalt construction common bond between overlapping ■ Dimensions(approx.):131/ x 39 V ■ StainGuard•Algae Protection— (337 x 1.000 mm) shingle layers. Exposure:5 Sr,'(143 mm) Helps protect the beauty of your ■ Bundles/Square:3 ■ Up to 99.9%nailing accuracy— roof against unsightly blue-green ■ Pieces/Square:64 The StrikeZone-nailing area is so algae discoloration. • StainGuard"Algae Protection 3 ■ Hip/Ridge:TimberTex";TimberCrest-; easy to hit that a roofer placed 999 ■ High Performance—Designed Seal-A-Ridge®;Z®Ridge;Ridgossl out of 1,000 nails correctly in our test. Starter:Pro-Start"';QuickStart6; with Advanced Protections,Shingle WeatherBlocker" ■ WindProven' Limited Wind Technology. Applicable Standards&Protocols: Warranty—When installed with is Seamless compatibility—The new ■ UL Listed to ANSI/UL 790 Class A the required combination of GAF ■ State of Florida approved Accessories,Timberline"HDZ" Timberline''HDZw Shingles are com- ■ Classified by UL in accordance with Shingles are eligible for an industry patible with traditional Timberline HD" ICC-ES AC438 g g y Shingles for the same look and feel ■ Meets ASTM D7158,Class H first: a wind warranty with no ■ Meets ASTM D3161,Class F maximum wind speed limitation.2 homeowners and contractors rely ■ Meets ASTM D3018,Type 1 on for beauty and endurance. ■ Meets ASTM D3462S is Our legendary Dural Grip"sealant ■ ICC-ES Evaluation Reports ■ Perfect Finishing Touch—For the ESR-1475 and ESP-3267 pairs with the smooth microgranule best look, use TimberTex w Premium ■ Meets Texas Department of Insurance surface of the StrikeZone"nailing Requirements area for fast tack.Then,an asphalt-to- Ridge Cap Shingles or TimberCrest- ■ ENERGY STAR"Certified(White Only) Premium SIBS-Modified Ridge (U.S.Only);Rated by the CRRC;Can asphalt monolithic bond cures for be used to comply with Title 24 cool Cap Shingles. roof requirements Colors & Availability: Results based on study conducted by Home Innovation Research Labs, an independent research lab,comparing installation of Timberline HD" Shingles to Timberline"HDZ"Shingles on a 16-square roof deck using _ standard 4-nail nailing pattern under controlled laboratory conditions _ Actual results may vary 15-year Wind?roven"limited wind warranty on Timberline"HDZ" Shingles requires the use of GAF starter ships,roof deck protection, ridge cap shingles,and leak barrier or attic ventilation.See GAF Roofing copperc System Limited Warranty for complete coverage and restrictions.Visit Biscayne Blue anyon got com/LRS for qualifying GAF products. r 'StainGuard"olgae protection is available only on shingles sold in �- packages bearing the StainGuard^logo.Products with StoinGuord" algae protection are covered by a 10-year limited warranty against l blue-green algoe discoloration See GAF Shingle&Accessory Limited Warranty for complete coverage and restrictions To be mixed on one root Timberline"HDZ`Shingles and Timberline HD° o •- _ Hunter Green Shingles must hove matching 6-digit codes found on me end of the bundle When mixed,always use Timberline HD"installation,nstruchons. 'Periodically,tested try independent and internal labs to ensure _ compliance with ASTM D3462 at time of manufacture Lifetime refers to the length of warranty coverage provided and means as long as the original individual owner(s)of a single-family detached residence[or eligible second owner(s)]owns the property where the - qualifying GAF products are installed.For other avners/stnatures.Lifetime o, • - - - = Shakewood coverage is nor applicable.Lifetime coverage on shingles requires use of GAF Lifetime shingles only See GAF Shingle&Accessory limited Nbnnorny o I for complete coverage and restrictions Lifetime coverage on shingles and accessories requites use of any GAF Lifetime Shingle and any 3 qualifying GAF accessories See G V Roofing System limited Warronty for complete o coverage and restrictions Visit got com/LRS for qualifying GAF products. Note:It is difficult to reproduce the color clarity and actual cola blends Sunset Brick Weatheredof these products.Before selecting your color please ask to see several •- tull-size shingles. a AMERICAN r� We protect what matters most' R (, •, r ,•I'+I,II,;!I it•!I.!• f i ! !1 ! kl!{ i i I'1i4l�rlljl{ [I'!1I i 1! I 1 I tt1 i!' ' I' i6 ji !�l1t1 i 11NI llii t� (tlltjt ! I lrlliii!''!I !1i.il J ! , , ! •I tl, +ail ii 1 Sh?) t; ! I ! ! ► II _ ii {it h { yil N yi i hi 1 t ,1 u; � tt �' ► t i• li'li I I,, , i!!1 'i', 1! ' � I t' t � !{jl ,! ! !M t t!,•' �1'i�!.. 1''�i i{I !, � t i t,l -, i " !� j'�;( y 7. I'� II,I il,('I►li; 1 J�f`,�iil•(!I�! {�• I` ! �11! i 1 ! '!' , !�, � G N iii l;'1{ �;(i!1 lu j!,t._ ,�uu,I'1���lil!11!!'lid+i .c16,, (!! r ( ! 1 �lir II +,i? I h�+ii il',I !;.r r %ly I• d � , t !t I i, ; 1�Irr i ,11{1 !1;; 11. @'•' i, ! !'!i•1'1' Gi 1 i !t 9{! pf�! � �S�� It!! 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I',7',!�M Itlf lllitili� it I! l+ti tll!i1j i!i ilili!`tl �1l. .!.t !1, !• e., il'�I'N(,1. �`! !, !•+nt•iur is � P i•; t6,1:1 L,d 11;. (.,k+li"1 ! ,. til - i!i O I , �,,�i 1 IN �1 ,J, t,l!{{ 11 � t ( n i ,I i'1 I! 1, ,p:•'t, 1 ! ri (1•i lf' i� tI, D1 i�+ t: i1 ° t I1 1 1 7 r ?r' Ji•• {II il11! rt'I !!� ,11!iII111 .1 i' O H i �3 1,•1 ri,it�a•,t.e�3�r1!j,! it ,.tkNl,l:,L �):1,!!lIII,Ii il,:7tl ail i��I"rl•tgU! :,.t.,!1..1l. I >) i• 11 t!,I itil „11111 !.i - 1 I � o2 ln _ \ j 4! / C O C \ CN 1 �r t( / C C W O e° ``• U l O tf) / .. w � O w � T lj 4. 0 }y H •- J (� W u w z °dam Q�o�ection 0ui J q H 70 �� )1 ^�/^ �I W !n y W V U oG O C" w a w o :N d4'�e ad C tu Y cc L rn m > > y z O r w d o N w U y d .. / I ��0 DATE(MM/DD/YYYY) A C CERTIFICATE OF LIABILITY INSURANCE 8/1/2022 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 NAME; Catherine DOlce Levitt Fuirst Associates, Ltd. PHOP: g14ine Dole F No:914-457-4220 520 White Plains Road Tarrytown NY 10591 EAo Bess: info levittfuirst.com INSURERS AFFORDING COVERAGE NAIL 0 INSURER A:Admiral Insurance Company 24856 INSURED PERRVER-01 INSURER a:Accident Fund Insurance Compan 10166 Perry Verrone LLC 12 Center Street INSURERC: Pleasantville NY 10570 INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:1229745749 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-BURR POLICPOLICY NUMBER MMIDDY EFF M LIXP D(E LIMITS LTR A X COMMERCIAL GENERAL LIABILITY 937258902375890 7!112022 7/1/2023 EACH OCCURRENCE $1,000,000 DAMAGE TO RENTED CLARAS-MADE OCCUR PREWSE$LEa occurrence) S 300,000 - MED EXP(Any one $5,000 PERSONAL 6 ADV INJURY $1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $2,000,000 X POLICY C dE O- LOC PRODUCTS-COMP/OP AGG S 2,000,000 OTHER: - S AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident ANY AUTO BODILY INJURY(Per person) S OWNED SCHEDULED BODILY INJURY(Per accident) S AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE S AUTOS ONLY HAUTOS ONLY I Per accident f UMBRELLA LIAB X OCCUR 9073490723490 7/1/2022 7/1/2023 EACH OCCURRENCE S5,00o,000 X EXCESS LIAB CLAIMS-MADE AGGREGATE _S5,000,000 DIED X RETENTION$ S WORKERS COMPENSATION PER H- AND EMPLOYERS'LIABILITY Y/N STATUTE ' ER _ ANYPROPRIETOR,'PARTNER/%EXECUTIVE E.L.EACH ACCIDENT = OFFICER/MEMBER EXCLUDED? ❑ N/A (Mandatory in NH) _E.L.DISEASE-EA EMPLOYEE,S If yes describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT S DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Certificate Holder and/or the entities listed below would be covered as an additional insured per attached endorsement.to the extent provided therein if required by written contract.on a primary non contributory basis on the general liability.Waiver of Subrogation applies.Primary and non contributory on the Umbrella Certificate Holder is included as additional insured when required by written contract 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 Street AUTHORIZED REPRESENTATIVF Rye Brook, NY 10573 ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD YORK Workers' CERTIFICATE OF STATE Compensation NYS WORKERS' COMPENSATION INSURANCE COVERAGE Board 1a. Legal Name&Address of Insured(use street address only) 1b.Business Telephone Number of Insured 914-867-1747 Perry Verrone LLC DBA Perry's Roofing 12 Center Street 1c.NYS Unemployment Insurance Employer Registration Number of Pleasantville,NY 10570 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 26-2754386 2 Name and Address of Entity Requesting Proof of Coverage 3a.Name of Insurance Carrier (Entity Being Listed as the Certificate Holder) Continental Indemnity Village of Rye Brook 3b.Policy Number of Entity Listed in Box"la" 938 King Street 46-884191-16 Rye Brook.NY 10573 3c Policy effective period 03/01/2022 to 03/01/2023 3d.The Proprietor,Partners or Executive Officers are included. (Only check box if all partners/officers included) Q all excluded or certain partners/officers excluded This certifies that the insurance carrier indicated above in box"3" insures the business referenced above in box"1a"for workers' compensation under the New York State Workers'Compensation Law. (To use this form, New York(NY)must be listed under Item 3A on the INFORMATION PAGE of the workers'compensation insurance policy). The Insurance Carrier or its licensed agent will send this Certificate of Insurance to the entity listed above as the certificate holder in box '2". 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: Steven Diamond(President) (Print name of authorized representative or licensed agent of insurance carrier) Approved by: 02/28/2022 (Signature) (Date Title: Licensed Insurance Broker Telephone Number of authorized representative or licensed agent of insurance carrier: 516-488-3040 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