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HomeMy WebLinkAboutBP20-098PERMIT # TYPE OF WORKa��� JOB LOCATION INSPECTION RECORp DATE FOOTING FOUNDATION FRAMING RGH FRAMING INSULATION PLUMBING CI RGH PLUMBING GAS C1 SPRINKLER ELECTRIC F1 LOW -VOLT 0 ALARM E0000 AS BUILT FINAL INSP rear)/a./d �i3q-4/gbg .....OVALS rj f/ -"""-'�rINAL SURVEY REQUIRED PRIOR TO FINAL INSPECTION y VILLAGE OF RYE BROOK WESTCHESTER COUNTY, NEW YORK NO: 24-162 Certificate of ®ccupa.ucp 'This is to certify that U / C of, &]Ln1C_ f having duly filed an application on mv'PfflhPr /15�__20 requesting a Certificate of Occupancy for the premises known as, �bUrChlll ROO&_, Rye Brook,NY, located in a , -l5 Zoning District and shown on the most current Tax Map as Section: Sq Block: Lot: and having fully complied with the requirements of the Building Code and the Zoning Ordinance under Building Permit No. , issued c;)) 20;V , such authority and permission is hereby granted to the property owner to lawfully occupy or use id premises or building or part thereof listed under the following New York State Classifications, Use: - /' Construction: for the following purposes: 7-e r:y--0)G:A ])n-H n U-) �Y i \10r L4 10 veo r pia r Subject to all the privileges, requirements, limitations, and conditions prescribed by law, and subject also to the following: This certificate does not in any way relieve the owners or any person or persons in possession or control of the premises, building,or any part thereof from obtaining such other permits or licenses as may be prescribed by law for the uses or purposes for which the building or premises is designed or intended. Furthermore, it does not relieve such owners or persons from complying with any lawful order issued with the object of maintaining the premises or building in a safe and lawful condition. No changes or rearrangement in the structural parts of the building or in the a it facil' es s al�6 made,and no enlargement, whether by extending on any side or by increasing in heigW or all a bu Aft be moved from one location to another until a permit to accomplish such change has be the B it g pector. Building Inspector,Village of Rye Brook: ate: DEC 2 3 2024 D [E V E N E, � For office use onl : BUILDING IIE A tTMENT PERMa# a0-09� NOV 15 2024 VILLAGE OF RYE BROOK ISSUED — �/— U 938 KING STREET,RYE BROOK,NEw YORK 10573 DATE: V!LLAGE Lr k'y L! BROO,: (914)939-0668 FEE: 4� /SU PAM - BUILDI{N ' rrF?i�, ::=T�1_ www,rygbrog! 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 iiittit►tttt■►►►t►f►tflit-►►►►►t►►►tt►ltiiffliiit►tiRtttRttiifittRit►►t►►tt►►►►Rt►►itftftiifitfRittiit►it►t►t►Rit►tiiR►►ttttt►tt Address: I CInU��h I �� �U ����� ,�y I N 73 Occupancy/Use: OS IdIII Parcel ID#: / 3 y— — j(V Zone: —� 5 Owner: J-W hO y St. L d W&k U e. Address: � (A1 P.E./R.A.or Contractor: 0 ? 1 Address: L P C ti J Person in responsible charge: 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 YORK,,COUNTY OF WESTCHESTER as: lj Vd A 4 S-,U JV l,p[j t being duly sworn,deposes and says that he/she resides at (Print a of Applicant) l (No.and Street) in IK IJ 1,00 C (M 7 ,in the County of I S f 6 V'l,��4 in the State of ,that �— (City/Town/Vil ge) 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:$ for the construction or alteration of: rl u -hacXVad 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 j S Sworn to before me this day of �l �r� ,2C)"-t day of , 20 Ygnkurr of Prop O er Signature of Applicant hdsa Y Sf.. e- erne of operrtty/Owner Print Name of Applicant 7 - - LL Notary Public Notary Public SHARI MELILLO iu+.ary Public,State of New York Nc-.0.IME616006 8/12/2021 t :..IliicJ In Westchester County m tixpltes January 29,21029 BRC�v� o � W � BUILDING DEPARTMENT INSPECTOR VILLAGE OF RYE BROOK /BUILDING VILLAGE ENGINEER 938 KING STREET RYE BROOK,NY 10573 0 ASSISTANT BUILDING INSPECTOR (914) 939-0668 FAx(914) 939-5801 - - - - - - - - - - - - - - - - - - - - - INSPECTION REPORT - - - - - - - - - - - - - - - - - - - - - ADDRESS: Q, -cvv-� \ �, 1 DATE: � 2 �� � PERMIT# ��SSUE GIB' SECT: � � BLOCK: LOT: LOCATION: OCCUPANCY: 0 VIOLATION NOTED THE WORK IS... ACCEPTED ❑ REJECTED/REINSPECTION ❑ SITE INSPECTION REQUIRED ❑ FOOTING ❑ FOOTING DRAINAGE 0 FOUNDATION ❑ UNDERGROUND PLUMBING NOTES ON INSPECTION: ❑ ROUGH PLUMBING 0 ROUGH FRAMING ❑ INSULATION ❑ NATURAL GAS ❑ L.P.GAS Cl FUEL TANK ❑ FIRE SPRINKLER ❑ AL PLUMBING :FINAL ❑ ER c (2A VOD c\A cd�N000 y,e") (,�3 ►l cszxjc� ':) k _ 2 Ct Z�2 O _c Building Permit Check List&Zoning Analysis Address: t C�L..c.— SBL: Zone:-% Use: Const.Type: Other. Submittal Date: ?-D Revisions Submittal Dates: Applicant 'T i L-41-'C �CF— Nature of Work: L rr L_l'z F F o A. ``� L.L. LJ00r.. SC 2.cFi,._j =4�>" w00-tn' ::�z.kvdGH P�X_jC{— A Reviews:ZBA: MAR 1 0 2UL PB: BOT: Other. NEE OK ( ) FEES:Filing. 7 s-In> BP: C/O: Legalization: ( ) (✓Y APP: Dated: ✓ Notarized ./ SBL: Truss I.D. Cross Connection: H.O.A.: ( ) ( ) Scenic Roads: Steep Slopes: Wetlands: Storm Water Review: Street Opening. ( ) ( ) ENVIRO:Long. Shorn Fees: N/A: ( ) ( ) SITE PLAN:Topo: Site rotection: S/W Mgmt.: Tree Plan:�_Other. ( ) (,4 SURVEY:Dated l 2� Z-2 Current: ✓ Archival• Sealed: Unacceptable: ( ) (. S:Dat;,Bfamped: ✓ Sealed ✓ Copies:,Electronic Other. ( ( cense: ✓✓ Workers Comp:_ability: V Comp.Waiver. Other. ,( ( ODE 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 20I7 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. G( ) ( ) Other. ARB mtg.date: 3 AJ Z� approval• l notes: ( )ZBA mtg.date: approval• notes: ( )PB mtg.date: approval• notes: REQLMED EXISTING PROPOSED NOTES APPROVED Area: ! Circle: Fron�taee Front: Front: Sides: Rear. Main Cor. Accs.Cov. Ft.H Sb: Sd.H Sb: GFA: Tot : k Vi 15 Ft.Imp: Par ' . Height/Stories notes: BUILDING DEPARTMENT A VILLAGE OF RYE BROOK MAR - 4 2020 938 KING SWEET RYE BROOK,NY 10573 (914)939-0668 +. X(914) 939-5801 VILLAGE OF RYE BROOK wi v: olz;or� BUII..DING DEPARTMENT t.� ARCHITECTURAL REVIEW BOARD CHECK LIST FOR APPLICANTS This form must be completed and signed by the applicant of record and a copy shall be submitted to the Building Department prior to attending the ARB meeting. Applicants failing to submit a copy of this che'ckv list will be removed from the ARB agenda. Job Address: ,L{'� U{��{�I I I K ( A')k f 1 Date of Submission: JLi a O C) Parcel ID#: /;s 3Lj — g Zone: os13 Proposed Improvement(Describe in detail): APPLICANT CHECK LIST: Nit `.;l �1: 1_'4 i '1.1:"1l;f; m niF APPL1C'ANT The following items must be submitted to the Building —PAPP Department by the applicant -no exceptions. t7 Ge 1. (v)'Completed Application L 2. (i)'I'wo(2)sets of sealed plans. l ooc t� Property Owner: S A S I/�/re L e ::i \ ,,i "!/c ,,i Address: l/vl LI►�C l ��(v73 3. (✓jTwo(2)copies of the property survey. 4. ( 'Two(2)copies of the proposed site plan. Phone# 5. (L )'One electronic/disc copy of the complete Applicant appearingapplication materials.before the Board: 6. (Vf Filing Fee. LL1/)�S Q 7. ( )Any supporting documentation. Address: Y ��>L73 C r 8. ( )HOA approval letter. (i(applicable) l �1�1�G�I I I G( N Q Q�'D0� 9. (a'Photographs. Phone# 2 I i 2 5 10.( samples of finishes/color chart. (a Sample board or u model may be presented the night of the meeting) Architect/Engineer:—DA (/1 Phone# g l 9 5 y 8 -- )a 5 By signature below, the owner/applicant acknowledges that he/she has read the complete Building Permit Instructions&Procedures,and that their application is complete in all respects.The Board of Review reserves the right to refuse to hear any application not meeting the requirements contained herein. Swom to before me this t>/ Sworn to before me this i day of , 20 1 l) day of , 202-0 Si atu pe Owner re tAppj�gt s a S�. L-a w►r°Pc oe Ll yl 41 (A �� - wre 4 Print Name of Pro erty Owner Print Name of Appl ant Notary Public Notary Public Richard C.LaL25oi!:; NO r o.01LA 2 No y w,nmeMCIM 4,W;KX QuaMed in Westet est No onluz0032a rnmrrk¢i n Expires F � ON in- Fxpl Zg,ztl - 3/21/19 VILLAGE OF RYE BROOK BUILDING DEPARTMENT 938 KING STREET, RYE BROOK,NY 10573 (T) 939-0668 (F) 939-5801 ARCHITECTURAL REVIEW BOARD Wednesday, April 1, 2020 NAME & TYPE OF APPLICATION MOTION SECOND APPROVED REJECTED APPL.# LOCATION 15 Beacon Lane Roof Top Solar Array& Consent 4895 (Zubov) System Agenda 4 Wilton Road Roof Top Solar Array& Consent 4896 (Boruch) System Agenda 15 Carlton Rd Roof Top Solar Array& Consent 4897 (Amestoy) System Agenda 2 Hillandale Road Roof Top Solar Array& Consent 4898 (Oling) System Agenda 18 Red Roof Dr Roof Top Solar Array& Consent 4899 (Lungariello) System Agenda 23 Woodland Dr. Moving Window Over, at Consent 4900 (Silverman) Rear Nook Elevation Agenda 1 Churchill Road(St Legalize Front Patio, Cedar 4901 Lawrence) Privacy Fence, Stair Railing 47 Rock Ridge Dr (2)Rear 2nd Story 4902 (Nurik) Additions,New Deck,Front Addition&Portico 5 Brookside Way New Detached Accessory 4903 (Con Edison) Bldg,New 125K Natural Gas Generator,New Site Lighting& Security Equipment 20 Country Ridge Dr Demo Existing Deck,Build 4904 (Reiss) New Larger Deck. 20 Country Ridge New Front Porch,New 4905 Circle(Hannon) Gable Roof 177 North Ridge Two Story Addition 4906 Street(Lovallo) ML NM MR SE JM SF AC MI JB Buchanan Buchanan features 1" x 4" dog- • eared boards(pictured right), giv- ing the fenceline a very dramatic look. This j single-sided style easily en- < hances any prop- :.: erty, while addin 'acy. e pictures at left show scallop Buchanan with op tional routed edge pickets, and 1" x 6" boards, all of which are also available. Harrison Looking for something a little different? IMPOIFt Alternating slant pickets combine with �; y flat top pickets to result in our Harrison style single sided fence. A true beauty in any height. Johnson � F This variation of the ,.� Van Buren style adds a more formal look to a landscape. Johnson offers 1"x 4" boards. l Shown at left, Johnson is stained �r -- and in the inset, un- stained to weather to a natural silvery gray. i Nixon Nixon (shown stained brown) features dra- matic 1" x 6" round top boards in a cathe- dral configuration. 1 x 4" is standard. Custom Cedar 10 Single Sided Fence Fillmore Fillmore has become such a popular fence style, that it is offered in sev era[ configurations as part of our ri regular line. It comes standard as I '' s� pictured, with a midrail. Fillmore is 1 available with or without tongue-in- groove construction, and with 1" x - -" 4"or 1"x 6"vertical boards. Note: Sections without tongue-in-groove require a midrail. - Sections with tongue-in-groove require no midrail. i tmore can be special ordered without the midrail(not required with tongue-in-groove). When removed, an entirely different, yet - equally beautiful, look is achieved. Fillmore without ;. Midrail offers a solid double sided fence panel. This is the ultimate in privacy and se- curity. Inset shows Cedar Per- gola with Fillmore Scallop gate. Fillmore Crown is a solid double sided section with a crown top, as shown �. right in the drawing and left in the photographs. Note: Sections without tongue-in-groove require a midrail. Sections with tongue-in-groove require no midrail. — Fillmore is also available with or with out the middle rail, in Scallop configura- tion. Image to the left _-___ �! shows a line drawing with- --- out the midrail, while the _ram . _- --_- --------- - - photographs to the right have t th are very attractive fence ' panels. Note: Sections without tongue-in-groove require a midrail. Sections with tongue-in-groove require no midrail. Custom Cedar Double Sided Fence 9 Check List For Release of Buildiniz Permits Address: I ch Vl rch l I / Poo C Owner/Applicant: � Lo v\j ra.nC - Phone Ws: Dates Attempted To Contact Owner/ Applicant: no] V Comments: Jeri Loi led �Y v� �e a��.e� Comments: Comments: NEED: ( /Byu .' ding Permit Fee $ ( FO # (^ Home Improvement License ( ) ility ( rs Comp. / Comp Waiver ( Feral Contractor's Contact Information ( ) Fire Sprinkler Plans (2) ( ) Fire Sprinkler Application ( ) Fire Sprinkler Permit Fee ( imated Cost $K�O Fee $ Legalization Fee $ ( ) Other Tara O Tara Gerardi From: Tara Gerardi Sent: Wednesday, May 27, 2020 10:20 AM To: 'linzgr102@yahoo.com' Subject: Building Permit - 1 Churchill Road The building permit application has been approved by the Building Inspector, before I can issue the building permit the following items must be submitted to our office, 1. General contractor's contact name & phone number. 2. Copy of general contractor's valid Westchester County Home Improvement License. 3. General contractor's valid liability insurance (the Village Of Rye Brook must be the certificate holder) 4. General contractor's valid workers compensation on a NY State Board form (C105-2 or U26.3) 5. Building permit fee $158.00 (due once permit is issued and ready for pick-up) 6. Contractor must call Dig Safe NY and get a 10 digit ticket number. TARA A. GERARDI SECRETARY -- PLANNING BOARD, ZONING BOARD OF APPEALS & ARCHITECTURAL REVIEW BOARD VILLAGE OF RYE BROOK 938 KING STREET RYE BROOK, NEW YORK 10573 OFFICE (914) 939-0668 FAx (914) 939-5801 1 i i ao A a A L' ••O . ..OPi z L � N /'• P. N we E X cV «or> O Ln s U R co r � U � �'=Z t�-• O En z co =-y 0 PUN Z W ►- U sJ y . T� ��• .ems i . U r W lU _ code) z o y g w w 1� _ a) �J U O U = 3 r v • ^ Z W U Oto w w o o ° > rn a� a� U Cd «o)> U 1 otLO a 4 Y. U • Nay ^ Y, 1 ;? j 0 _ 'r b, Q ✓ V � :O Rio v .a � ,� ACO CERTIFICATE OF LIABILITY INSURANCE FDATEos/22/2020 Y)IMM/ ozo 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 poliey(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 Stacie Washington NAMEBorrelli Partners Insurance Agency PHONE (914)939-7900 FAX (914)407-5088 A/C No Ext: AIC,No 287 Bowman Avenue E-MAIL swashington@borrellipartners.com ADDRESS: Suite 406 INSURER(S)AFFORDING COVERAGE NAIC# Purchase NY 10577 INSURER A: Main Street America 29939 INSURED INSURER B: NGM Insurance Company 14788 COPERINE LANDSCAPING INC INSURER C: Old Dominion Insurance Co. 40231 206 LEICESTER ST INSURER D: INSURER E: PORT CHESTER NY 10573-2619 INSURER F COVERAGES CERTIFICATE NUMBER: 19-20 Cent 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 ADDL SU13H POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER MWDD/YYYY MMIDDIYYYY LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE ❑X OCCUR DAMAGE TO occurrenceRENTED 500,000 PREMISESS S MED EXP(Any one person) $ 10,000 A Y MPV44750 12/11/2019 12/11/2020 PERSONAL&ADV INJURY $ 1,000,000 GEN'LAGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY PRO- X JECT LOC PRODUCTS-COMP/OPAGG $ 2,000,000 OTHER Empl Practices Liab Ins $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000 Ea accident X ANYAUTO BODILY INJURY(Per person) $ B OWNED SCHEDULED 131V44750 12/11/2019 12/11/2020 BODILY INJURY(Per accident) S AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY Per accident Uninsured motorist s 500,000 UMBRELLA LIAR " OCCUR EACH OCCURRENCE S EXCESS LIAB CLAIMS-MADE AGGREGATE s DED RETENTION$ $ WORKERS COMPENSATION I PER OTH- AND EMPLOYERS'LIABILITY YIN STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACHACCIDENT $ 100,000 C OFFICER/MEMBER EXCLUDED? � NIA WCV44750 12/11/2019 12/11/2020 (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ 100,000 If yes.describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) CERTIFICATE HOLDER IS NAMED AS ADDITIONAL INSURED AS PER THE WRITTEN CONTRACT OR AGREEMENT CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN Village of Rye Brook ACCORDANCE WITH THE POLICY PROVISIONS. 938 King St AUTHORIZED REPRESENTATIVE 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 KR Workers' CERTIFICATE OF STATE Compensation Board NYS WORKERS' COMPENSATION INSURANCE COVERAGE 1a.Legal Name 8 Address of Insured(use street address only) lb.Business Telephone Number of Insured Coperine Landscaping Inc (914)939-4958 206 Leicester St 1c.NYS Unemployment Insurance Employer Registration Number of Port Chester, NY 10573 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 13-3998910 2.Name and Address of Entity Requesting Proof of Coverage 3a. Name of Insurance Carrier (Entity Being Listed as the Certificate Holder) Old Dominion Insurance Co. Village of Rye Brook 3b. Policy Number of Entity Listed in Box"I a" 938 King Street Rye Brook, NY 10573 WCV44750 3c.Policy effective period 12/11/2019 to 12/11/2020 3d.The Proprietor,Partners or Executive Officers are included.(Only check box if all partners officers 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"I 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". Will the carrier notify the certificate holder within 10 days of a policy being cancelled for non-payment of premium or within 30 days if cancelled for any other reason or if the insured is otherwise eliminated from the coverage indicated on this certificate prior to the end of the policy effective period? DYES ®NO 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: (611 G O ft C( ( i .arre of authorized re enta7E7 d t surance carrier) Approved by 2 2 Q (Date) Title: S 51 S <A C-Co -4` Gi Aa Telephone Number of authorized representative or licensed agent of insurance carrier: (914)939-7900 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. i C-105.2(9-15) www.wcb.ny.gov i Ticket: 06170-153-052-00 Type: Regular Previous Ticket: ______________________________________________________________________________ State: NY County: WESTCHESTER Place: RYE BROOK /V Addr: From: 1 To: Name: CHURCHILL RD Cross: From: To: Name: Offset: ______________________________________________________________________________ Locate: LOCATE FRONT YARD NearSt: WINDINGWDOD Means of Excavation: HAND TOOLS Blasting: N Site marked with white: Y Boring/Directional Drilling: N Within 25ft of Edge of Road: Y Work Type: REPLACING FRONT WALKWAY Duration: 1 WEEKS Depth of excavation: 12 INCHES Site dimensions: Length 15 FEET Width 6 FEET Start Date and Time: 06/22/2020 07:00 Must Start By: 97/07/2020 ____________________________________________ -____- Contact Name: PETER COPERINE Company: COPERINE LANDSCAPING Addrl: 206 LEICESTER ST Addr2: City: PORT CHESTER State: NY Zip: 10573 Phone: 914-403-3885 Fax: Email: COPERINELANDSCAPINr@WIL.COM Field Contact: PETER Cell Phone: 914-403-3885 Alt Phone: 914-939-49SS Working for: MICHAEL ___________________________________________________ __________ Comments: Lookup Type: PARCEL ------------------------------------------------------------------------------ Members: ALTICE USA 800-262-8600 CONSOLIDATED EDISON COMPANY OF MY 800-762-0592 x3 SUEZ WATER WESTCHESTER 800-262-8600 VILLAGE OF RYE BROOK 914-939-0753 WESTCHESTER COUNTY SEWER 914-813-5419 Service Area Code Service Area Name Contact ay Phone Emergency Phone Altphone UtilityType Response ALTICE USA ALTICE USA USIC VOICE 10 CLEAR,NO FACILITIES WITHIN 15 FT OF CALLS (800)262-8600 FIBER,CATV THE EXCAVATOR DEFINED WORK AREA 30 MARKED,THE APPROXIMATE CONSOLIDATED PROTEK ELECTRIC,GAS,GAS HORIZONTAL LOCATION OF UNDERGROUND CON-ED EDISON COMPANY USIC (800)762-0592 x 3 TRANSMISSION FACILITIES WITHIN 15 FT OF THE OF NY DISPATCH EXCAVATOR DEFINED WORK AREA HAVE BEEN MARKED SUEZ WTR SUEZ WATER USIC VOICE 10 CLEAR,NO FACILITIES WITHIN 15 FT OF WESTCHESTER WESTCHESTER CALLS (800)262-9600 WATER THE EXCAVATOR DEFINED WORK AREA VI.RYE BROOK VILLAGE OF RYE MICHAL STORM SEWER, 10 CLEAR,NO FACILITIES WITHIN I S FT OF BROOK NOWAK (914)939-0753 914)490-1628 CULVERTS,SANITARY SEWER THE EXCAVATOR DEFINED WORK AREA WESTCHESTER WESTCHESTER MARIAN CT SANITARY SEWER, lO CLEAR,NO FACILITIES WITHIN 15 FT OF Y SWR COUNTY SEWER POMPA (914)813-5419 WATER ITHE EXCAVATOR DEFINED WORK AREA