HomeMy WebLinkAboutRP23-018PERMIT # A,1�
SECTION
TYPE OF WORK
JOB LOCATION .
OWNER �C e/ 5
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DATE: 3 0 q '� ®(p• /)9
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TCO # FEE DATE
INSPECTION RECORD
DATE
FOOTING
FOUNDATION
FRAMING
RGH FRAMING
INSULATION
PLUMBING O
RGH PLUMBING
GAS
SPRINKLER
ELECTRIC
LOW -VOLT O
ALARM
AS BUILT
FINAL
INSP
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19
VILLAGE OF RYE BROOK
MAYOR 938 King Street, Rye Brook,N.Y. 10573 ADMINISTRATOR
Jason A. Klein (914) 939-0668 Christopher J. Bradbury
www.iyebrook.org
TRUSTEES ACTING BUILDING&FIRE INSPECTOR
Susan R. Epstein Steven E. Fews
Stephanie J. Fischer
David M. Heiser
Salvatore W. Morlino
CERTIFICATE OF COMPLIANCE
March 30,2023
Keith Ackerson&Nelly Carreira
83 Greenway Close
Rye Brook,New York 10573
Re: 83 Greenway Close, Rye Brook,New York 10573
Parcel ID#: 129.84-2-72
Roof Permit#23-018 issued on 3/29/2023 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:
BUILD ��' �'MENT PERMIT# /8
VIL A I�)Ftr. OK ISSUED: :-,4y-,=�3
MAR 19 2023 938 KING STRE T YORx 10573 DATE: 3
FEE: 1/0 - PAID W
VILLAGE OF RYE BROOK i 1 To
BUII.�►^!r r,r-nnsaTpnr_n!T
APPLICATION FOR CERTIFICATE OF OCCUPANCYt CERTIFICATE OF COMPLIANCE
AND CERTIFICATION OF FINAL COSTS
TO BE SUBMITTED ONLY UPON COMPLETION OF ALL WORK, AND PRIOR TO THE FINAL INSPECTION
*trtttst+++sr*rr*tast+t+s+stt+****rrrtt+t+++++tsrttrttits+r+++ss+ssrsrrsttt+tts+ssrtttrttsttt+tsrrst*s*srsr+++++srrtt+tt++++s
Address: GPI vf-e
Occupancy/Use: 124'4 (A t Parcel ID#:1 9, - 74 Zone: P6
Owner: /�G �^ Address: P) G � Gk-l-z-
P.E./R.A. or Contractor: S6(1~ Address:
Person in responsible charge: &,A 11-el4rt( Address: PYG-v"-2 de-Q, 4e �'t1
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 OFNEW YORK, COUNTY OF WESTCHESTER as:
dle'7`r ✓/' 444 being duly swom,deposes and says that he/she resides at "
(Print Name of Applicant) ' / (No.and Street)
in o v'-t- - <0l"7 ,in the County of �Je rl ot^ai�' in the State of that
(City/Town/Vi lage)
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:$ , o cc
.,•'
for the construction or alteration of: K) ►.�Gc.��
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
ymee_this �q Sworn to before 2
me this
day of r �u�al� , 20 day of !V(►V�2Q r( , 20'Z--;>'_
/��/
Signatur fPropertyOwttq�'\\t 1j/// Sig natureofAppli tME
i
Prin a of ProPWt3 O 1 Prin am of=Appl' w
.,Y1 Y}y• - NU'If I f lC
Not lic �-0 //�` Notary Public
/(N F \\\ 8/12/2021
�E BRC�v�
o`` tim
BUILDING DEPARTMENT
ILDING 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: � V� DATE.
PERMIT# ` � " ISSUED: J SECT: 12-) ` ' BLOCK: - LOT:
LOCATION: '"( OCCUPANCY:
❑ 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
q'FINAL
/l❑ OTHER
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BUILDING PAItTMENT
VILLAGE OF RYE BROOK MAR - 6 2023
938 KING STREET RYE BROOK,NY 10573
914 939-0669 VILLAGE OF RYE BROOK
tAtjr-'� � ook. r 13UI1.DING DEPARTMENT
. _ _
FOR OFFICE USE ONLY:
Approval Date: crmit 37-0)-; Application#
IU23
Approval Signature: ARCHITECTURAL REVIEW BOARD:
Disapproved: Date:
BOT Approval Date: Case# Chairman:
PB Approval Date: Case# Secretary:
ZBA Approval Date: Case#
Other:
Application Feeft •.5` Permit Fees: 'A UE
ROOF PERMIT APPLICATION
Application dated: 3164-e7 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 Building,as per detailed statement described below.
1. Job Address: C Gam- SBL: 7,:):-Zone:
Property Owner: A'(C--Z-✓r—� Address: r Phone#: ?O 6 7 Cell#: 7 C 6'71t f email: /C�✓� �el-i C c 0--f-
2. Applicant: I-C, Ac Address:
Phone#: �`r�� 6 f_ Cell#: email: K-7-tf-(
3. Roofing Contractor: I r Address:
Phone#:_�/Y V--3'-0(9 Z S Cell#: email: 1 eT✓ cr ( 7
4. Job Description,list all Methods&Materials: ti t-A) -
5. Estimated Cost of Job:S �,GG.-. 'a v (NOTE.The estimated cost shall include all site
improvements,labor,material,scaffolding,fixed equipment,professional fees,and material and labor which may be donated gratis.)
6. If corner property,indicate street frontage:
7. Construction Type: �0�'~ NYS Construction Class:
r
8. Number of stories: Height:
9. Is garage being re-roofed:No: (-rc"Ves:( )Attached No: O•Yes: O Number of Cars:
10. Is roof peaked,hip,mansard,flat,etc:
11. Estimated date of completion: •� 1
-I-
W12/2021
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.
STATE OF NEW YORK,COUNTY OF WESTCHESTER ) as:
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 land regulations.
Swom to before me this Sworn to before me this b
day of M �\ , 2093 day of ,20-23
)ILZI ,
Signature of Property Owner Signature o pplicant
4tf4,�� v6c
J�int Name of Property Owner of Applicant r
Notary Public Notary Public
3NAR1 MELILLO SHARI MELILLO
Notary Public,State of New York
votary Publle,State of New York No.01ME61OW63
140.01MES160063 Qualified In Westchester County
In Westch"tet Count commission Expires January 28,20 ]
"�'fssrei)Explres January 29.202�
-2-
8112021
Laura Petersen
From: Keith Ackerson <kta9@aol.com>
Sent: Wednesday, March 29, 2023 10:07 AM
To: Laura Petersen
Subject: Re: 83 greenway Dec.
Yes, ice a water was installed. Pic attached of shingles used.
Y
Sent fromfrom my iPhone
On Mar 29, 2023,at 9:50 AM, Laura Petersen<LPetersen@ryebrook.org>wrote:
Good morning,
I will be working on the issuance of your roof permit today. Please indicate if ice
and water shield was installed and what type of shingles installed.
Thank you
Laura
Laura Petersen
Office Assistant
Village of Rye Brook
938 King Street
Rye Brook, New York 10573
Phone(914)939-0668 1 Ipetersen(a�ryebrook.orq
From: Keith Ackerson<kta9@aol.com>
Sent:Tuesday, March 28, 2023 2:26 PM
1
,s
To: Laura Petersen<LPetersen@ryebrook.org>
Subject: Re: 83 greenway Dec.
Thankyou.
Sent from my iPhone
On Mar 28, 2023, at 2:22 PM, Laura Petersen<LPetersen@ryebrook.ore>wrote:
Perfect. Thank you. I will let you know if anything else is needed
and/or when the permit is ready.
Laura
Laura Petersen
Office Assistant
Village of Rye Brook
938 King Street
Rye Brook, New York 10573
Phone(914)939-0668 1 Ipeterseneryebrook.org
From: Keith Ackerson<kta9@aol.com>
Sent:Tuesday, March 28, 2023 2:20 PM
To: Laura Petersen<LPetersen@rvebrook.ore>
Subject:83 greenway Dec.
La u ra,
As discussed- please see attached.
Sent from my iPhone
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1982 BUILDING DEPARTMENT
4 BUILDING INSPECTOR
r❑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. DATE:
PERMIT# ISSUED: SECT: BLOCK: LOT:
LOCATION: OCCUPANCY:
❑ 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 k
❑ FINAL PLUMBING ` ol❑ CROSS CONNECTION \\ 1 r\'I�
❑ FINAL �� ,� `1 Q__'�-►J �W\ W yC �_
❑ OTHER
LOG bA
BUILDING DEPAkDIENT
VILLAGE OF RYE i E K COMPLETION DATE:
938 KINR3 ,NY 10573
ASSIGNED TO:
198
ASSIGNED BY:
COMPLAINT#:
COMPLAINT FORM
DATE: 3 d 3 RECEIVED BY:
LOCATION: (5 93 f,-Pe,1 ttia C'�os-�
PARCEL I.D.#: Zone:IOU6 USE:
OWNER
Address&Phone: �/'2s/ �.fA !O S �r/-� 9®Q o/•CO✓h
SOURCE: 0.7 Q//IQ-it �/�,4 Q,I/C1R/J�phone/Lette othe Qrt-era/
Address& Phone: 91-,1- 7 J 7' C; `, qo
COMPLAINT: J;ee
POSSIBLE VIOLATION:
INSPECTORS LOG
DATE STATUS JNSPFCTOR
Laura Petersen
From: Steven Fews
Sent: Monday, March 6, 2023 9:30 AM
To: Laura Petersen
Cc: Tara Orlando
Subject: FW: 85 - STOP Roof work- no permit or application
Expires: Tuesday, July 4, 2023 12:00 AM
Laura can you please write up a complaint form and log this.
Thank You.
Steven E. Fews
Acting Building Inspector & Fire Inspector Office (914) 939-0668
-----Original Message-----
From: ADRIEN BLECH <adrienblech@gmail.com>
Sent: Saturday, March 4, 2023 11:46 AM
To: Arbors Property Manager <manager@arbors-ryebrook.com>
Cc: Adrien Blech <ablechwmw@gmail.com>; Katerina Blech <katerinablech@gmail.com>; Steven
Fews <Steve Fews@ryeb rook.org>
Subject: Re: 85 - STOP Roof work - no permit or application
This is not our house. I think it's 83 greenway close. Not 85. We have ordered no work to be done
Sent from my iPhone
> On Mar 4, 2023, at 11:39 AM, Arbors Property Manager <manager@arbors-ryebrook.com>
wrote
> Please be advised that work is being done without an A&G application or permits. All work
must stop immediately until a permit and application are furnished to the HOA.
> The village of Rye Brook has been included in this email.
> Our new property will be on site Tuesday if you need assistance.
> Dan Barnett
> AHOA President
i
Laura Petersen
From: Steven Fews
Sent: Monday, March 6, 2023 9:41 AM
To: Laura Petersen
Cc: Tara Orlando
Subject: FW: 83 - STOP Roof work - no permit or application
Expires: Tuesday, July 4, 2023 12:00 AM
FYI email thread between board and the Homewoner
Thank You.
Steven E. Fews
Acting Building Inspector& Fire Inspector
Office (914) 939-0668
From: Keith Ackerson <kta9@aol.com>
Sent: Saturday, March 4, 2023 8:29 PM
To: Daniel Barnett<arbors.d.barnett@gmail.com>
Cc: Arbors Property Manager<manager@arbors-ryebrook.com>; Board Members<BoardMembers@arbors-
ryebrook.com>; Steven Fews<SteveFews@ryebrook.org>
Subject: Re: 83 -STOP Roof work- no permit or application
Dan,
I plan on taking Legal action for harassment based on me personally in the last year. I will add this to the list. Thank you.
Sent from my iPhone
On Mar 4, 2023, at 7:41 PM, Daniel Barnett<arbors.d.barnettCCDgmail.com>wrote:
All applications are digital. A&G meets every week with the acting Property Manager, including this
week.
A $500 fine (plus possible more based on what we observe after inspection can be made) will be placed
on your account.
Steve, their closing is Thursday I believe if the Village intends to take action.
Dan Barnett
AHOA President.
On Sat, Mar 4, 2023 at 5:29 PM Keith Ackerson <kta9@aol.com>wrote:
Also no one onsite for A&D app. I don't have time to wait for you.
1
Sent from my iPhone
On Mar 4, 2023, at 5:26 PM, Keith Ackerson <kta9@aol.com> wrote:
Thanks. We are all done.
Sent from my iPhone
On Mar 4, 2023, at 12:04 PM, Arbors Property Manager
<manager@arbors-rvebrook.com>wrote:
Keith,
Please be advised that work is being done without an A&G application
or permits. All work must stop immediately until a permit and
application are furnished to the HOA.
The village of Rye Brook has been included in this email.
Our new property will be on site Tuesday if you need assistance.
Dan Barnett
AHOA President
<25B01DE5-A1DA-4639-807E-3017C4BDDAE5.jpeg>
Kind Regards,
Property Manager
The Arbors Homeowners' Association, Inc.
P: (914)939-2440
<I M G_3958.j pg>
Kind Regards,
Property Manager
The Arbors Homeowners' Association, Inc.
P: (914)939-2440
2
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�N QFRr Property Description Report For: 83 Greenway Close,
Municipality of Village of Rye Brook
Lit
Status: Active
Roll Section: Taxable
Swis: 554805
-' Tax Map ID #: 129.84-2-72
7 Property Class: 210 - 1 Family Res
Site: RES 1
IdIn Ag. District: No (250 Units)
Site Property Class: 210 - 1 Family Res
Zoning Code: 02
Neighborhood Code: 01100 - Arbors Condo
Total Acreage/Size: 0.04 School District: Blind Brook-Rye
Land Assessment: 2022 - $247,700 Total Assessment: 2022 - $505,700
Full Market Value: 2022 - $505,700
Equalization Rate: ---- Property Desc:
Deed Book: 55191 Deed Page: 3016
Grid East: 719259 Grid North: 800822
Area
Living Area: 1,287 sq. ft. First Story Area: 657 sq. ft.
Second Story Area: 630 sq. ft. Half Story Area: 0 sq. ft.
Additional Story Area: 0 sq. ft. 3/4 Story Area: 0 sq. ft.
Finished Basement: 0 sq. ft. Number of Stories: 2
Finished Rec Room 0 sq. ft. Finished Area Over 0 sq. ft.
Garage
Structure
Building Style: Townhouse Bathrooms (Full - Half): 1 - 1
Bedrooms: 2 Kitchens: 1
Fireplaces: 1 Basement Type: Slab/pier
Porch Type: 0 Porch Area: 0.00
Basement Garage Cap: 0 Attached Garage Cap: 0.00 sq. ft.
Overall Condition: Normal Overall Grade: Average
Year Built: 1979 Eff Year Built: 1992
Owners
Keith Ackerson Nelly D Carreira
83 Greenway Close 83 Greenway Close
Rye Brook NY 10573 Rye Brook NY 10573
Sales
Property Value Arms Addl. Deed Book
Sale Date Price Class Sale Type Prior Owner Usable Length Parcels and Page
7/10/2015 $418,500 210 - 1 Land & Donovan, Yes Yes No 55191/3016
Family Building John J
Res
11/7/2013 $1 210 - 1 Land & Donovan, No No No 53309/3534
Family Building John
Res
Utilities
Sewer Type: Comm/public Water Supply: Comm/public
Utilities: Gas&elec Heat Type: Hot wtr/stm
Fuel Type: Oil Central Air: Yes
Improvements
Structure Size Grade Condition Year
Shed-machine 68.00 sq ft Average Normal 1979
Patio-concr 80.00 sq ft Average Normal 2010
Special Districts for 2022
Description Units Percent Value
CS481-VRB Sewer 0 0% $505,700
SW481-Solid Waste All 0 0% $505,700
Vlgs
Exemptions
Year Description Amount Exempt% Start Yr End Yr V Flag H Code Own %
Taxes
Year Description Amount
2019 County $1,880.43
* Taxes reflect exemptions, but may not include recent changes in
assessment.
Laura Petersen
From: Keith Ackerson <kta9@aol.com>
Sent: Monday, March 6, 2023 3:21 PM
To: Laura Petersen
Subject: Re: Roof Permit Application - 83 Greenway Close
I did it myself.
Sent from my iPhone
On Mar 6, 2023, at 1:28 PM, Laura Petersen<LPetersen@ryebrook.org>wrote:
Good afternoon,
Please send the following information for the review of your roof permit application;
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. The proposal for the work from the contractor
Thank you
Laura
Laura (Petersen
Office Assistant
Village of Rye Brook
938 King Street
Rye Brook, New York 10573
Phone(914)939-0668 1 Ipetersen(Wrvebrook.org
1
IhC
Hanover
Insurance Group"
06 AMENDED DECLARATION # XS
EFFECTIVE 05/07/22
H O M E O W N E R S P O L I C Y
REASON FOR AMENDMENT : CHANGE MORTGAGEE
POLICY NUMBER POLICY PERIOD COVERAGE IS PROVIDED IN THE AGENCY CODE
HVE 9966628 05/07/2022-05/07/2023 MASSACHUSETTS BAY INSURANCE CO 150192300
440 LINCOLN ST
WORCESTER MA 01653
NAMED INSURED AND MAILING ADDRESS AGENT
KEITH ACKERSON PUTNAM INSURANCE AGENCY
83 GREENWAY CLOSE LLC
RYE BROOK, NY 10573 1152 E PUTNAM AVE
RIVERSIDE, CT 06878
TELEPHONE : 203-967-1550
POLICY PERIOD- 12:01 A.M. STANDARD TIME AT THE RESIDENCE PREMISES
THE RESIDENCE PREMISES COVERED BY THIS POLICY IS LOCATED AT:
83 GREENWAY CLOSE, RYE BROOK, NY 10573
CONSTRUCTION TERR. YR. SECTION I LOSS OCCUPANCY
CONST. DEDUCTIBLE
SIDING - WOOD WHC 1979 $1500 PER OCCURRENCE PRIMARY
COVERAGE INFORMATION
SECTION I COVERAGE LIMIT OF LIABILITY PREMIUMS
A. DWELLING $455, 000 $1, 526.00
B. OTHER STRUCTURES $45, 500
C. PERSONAL PROPERTY $341,250
D. LOSS OF USE $227, 500
SECTION II COVERAGE
E. PERSONAL LIABILITY $1, 000, 000 EACH OCCURRENCE
F. MEDICAL PAY TO OTHERS $50, 000 EACH PERSON $126.00
STANDARD POLICY PREMIUM $1, 652.00
OPTIONAL COVERAGES
EQUIPMENT BREAKDOWN $35.00
GUARANTEED REPLACEMENT COST PLUS $31.00
LIMITED WATER BACK UP & SUMP DISCHARGE OR OVERFLOW COV $76.00
PLATINUM OWNERS SELECT PREMIUM TRIM $200.00
TOTAL OPTIONAL COVERAGES PREMIUM $342.00
TOTAL POLICY PREMIUM $1, 994.00
PREV PREMIUM $1, 994.00 CHANGE $.00 CHANGE IN PREMIUM $.00
YOUR PREMIUM INCLUDES THE FOLLOWING DISCOUNTS AND PREMIUM ADJUSTMENTS:
ACCOUNT DISCOUNT
NEW HOME DISCOUNT
CONTINUED ON NEXT PAGE DIRECT BILLED
05/05/22 2136028710 PAGE 01 OF 03
231-6240 05 16 ORIGINAL/INSURED
06 AMENDED DECLARATION # XS
EFFECTIVE 05/07/22
H O M E O W N E R S P O L I C Y
REASON FOR AMENDMENT : CHANGE MORTGAGEE
POLICY NUMBER POLICY PERIOD COVERAGE IS PROVIDED IN THE AGENCY CODE
HVE 9966628 05/07/2022-05/07/2023 MASSACHUSETTS BAY INSURANCE CO 150192300
440 LINCOLN ST
WORCESTER MA 01653
NAMED INSURED AND MAILING ADDRESS AGENT
KEITH ACKERSON PUTNAM INSURANCE AGENCY
83 GREENWAY CLOSE LLC
RYE BROOK, NY 10573 1152 E PUTNAM AVE
RIVERSIDE, CT 06878
TELEPHONE : 203-967-1550
FORMS AND ENDORSEMENTS - The Declaration and the policy forms and endorsements
listed below form your Homeowners Insurance Policy:
HO 00 03 05 11 HOMEOWNERS 3 - SPECIAL FORM
231-6217 12 17 SPECIAL PROVISIONS - NEW YORK
231-0600 05 16 INFLATION GUARD
HO 24 93 05 02 WORKERS COMPENSATION
231-6323 10 17 PLATINUM HOME TOTAL HOUSEHOLD REWARDS
231-5767 05 16 EQUIPMENT BREAKDOWN
231-1937 08 17 IDENTITY FRAUD EXPENSE COVERAGE
231-6197 08 17 GUARANTEED REPLACEMENT COST PLUS
231-6279 08 17 LOSS ASSESSMENT COVERAGE
HO 04 77 10 00 ORDINANCE OR LAW INCREASED AMOUNT OF COVERAGE
231-6317 03 17 SERVICE LINE COVERAGE
231-5761 12 17 LIMITED WATER BACKUP & SUMP DISCHARGE OR OVERFLOW COV
HO 24 86 10 11 PERSONAL INJURY COVERAGE - NEW YORK
231-2331 05 16 LOCK REPLACEMENT COVERAGE
231-6282 08 17 OWNERS - SELECT PREMIUM TRIM
231-6283 08 17 PERSONAL PROPERTY REPLACEMENT COST LOSS SETTLEMENT
231-2341 05 16 REFRIGERATED PROPERTY COVERAGE
231-6204 05 16 REVISED DEDUCTIBLE - LARGE LOSS
MORTGAGEE
PHH MORTGAGE SERVICES
ISAOA
PO BOX 5954
SPRINGFIELD, OH 45501
LOAN NUMBER: 7183427629
DISTANCE TO FIRE HYDRANT
LESS THAN OR EQUAL TO 1000 FEET
DISTANCE TO FIRE STATION
GREATER THAN 3 MILES BUT LESS THAN OR EQUAL TO 4 MILES
FINISHED LIVING AREA(SQ. FT) : 1287
NUMBER OF STORIES: 2
NUMBER OF FULL OR HALF BATHROOMS: 2
DESCRIPTION OF OPTIONAL COVERAGES
EQUIPMENT BREAKDOWN
LIMIT OF LIABILITY - $25, 000
IDENTITY FRAUD EXPENSE COVERAGE
LIMIT OF LIABILITY - $25, 000
CONTINUED ON NEXT PAGE DIRECT BILLED
05/05/22 2136028710 PAGE 02 OF 03
231-6240 05 16 ORIGINAL/INSURED
the
Hanover
Insurance Group"
06 AMENDED DECLARATION # XS
EFFECTIVE 05/07/22
H O M E O W N E R S P 0 L I C Y
REASON FOR AMENDMENT : CHANGE MORTGAGEE
POLICY NUMBER POLICY PERIOD COVERAGE IS PROVIDED IN THE AGENCY CODE
HVE 9966628 05/07/2022—05/07/2023 MASSACHUSETTS BAY INSURANCE CO 150192300
440 LINCOLN ST
WORCESTER MA 01653
NAMED INSURED AND MAILING ADDRESS AGENT
KEITH ACKERSON PUTNAM INSURANCE AGENCY
83 GREENWAY CLOSE LLC
RYE BROOK, NY 10573 1152 E PUTNAM AVE
RIVERSIDE, CT 06878
TELEPHONE : 203-967-1550
DESCRIPTION OF OPTIONAL COVERAGES
POLICY CONTAINS GUARANTEED REPL COST PLUS ON COV A
LOCK REPLACEMENT COVERAGE
LIMIT OF LIABILITY — $1, 000
LOSS ASSESSMENT COVERAGE
RESIDENCE PREMISES — AMOUNT OF INSURANCE — $10, 000
ORDINANCE OR LAW COVERAGE — 30%
REFRIGERATED PROPERTY COVERAGE
LIMIT OF LIABILITY — $500
SERVICE LINE COVERAGE
LIMIT OF LIABILITY — $20, 000
LIMITED WATER BACKUP & SUMP DISCHARGE OR OVERFLOW COVG
LIMIT OF LIABILITY — $30, 000
PERSONAL INJURY COVERAGE
WORKERS COMPENSATION
NUMBER OF EMPLOYEES — 01
TYPE OF HOUSEHOLD EMPLOYEE — OCCASIONAL SERVICES
DIRECT BILLED
05/05/22 2136028710 PAGE 03 OF 03
231-6240 05 16 ORIGINAL/INSURED
Hanover
Insurance Group
2136028710 HVE 9966628 15019230(
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3 1 0 5 7 3 1 5 0 5 8 3 2 3
KEITH ACKERSON
83 GREENWAY CLOSE
RYE BROOK, NY 10573
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KEITH ACKERSON
83 GREENWAY CLOSE
RYE BROOK, NY 10573
31057315058323
H The
aver
Insurance Group®
06 RENEWAL DECLARATION # 21 AC
RENEWAL OF POLICY HVE 9966628
H O N E O W N E R S P O L I C Y
POLICY NUMBER POLICY PERIOD COVERAGE IS PROVIDED IN THE AGENCY CODE
HVE 9966628 05/07/2023-05/07/2024 MASSACHUSETTS BAY INSURANCE CO 150192300
440 LINCOLN ST
WORCESTER MA 01653
NAMED INSURED AND MAILING ADDRESS AGENT
KEITH ACKERSON PUTNAM INSURANCE AGENCY
83 GREENWAY CLOSE LLC
RYE BROOK, NY 10573 1152 E PUTNAM AVE
RIVERSIDE, CT 06878
TELEPHONE : 203 -967-1550
POLICY PERIOD- 12:01 A.M. STANDARD TIME AT THE RESIDENCE PREMISES
THE RESIDENCE PREMISES COVERED BY THIS POLICY IS LOCATED AT:
83 GREENWAY CLOSE, RYE BROOK, NY 10573
CONSTRUCTION TERR. YR. SECTION I LOSS OCCUPANCY
CONST. DEDUCTIBLE
SIDING - WOOD WHC 1979 $1500 PER OCCURRENCE PRIMARY
COVERAGE INFORMATION
SECTION I COVERAGE LIMIT OF LIABILITY PREMIUMS
A. DWELLING $510, 000 $1, 690.00
B. OTHER STRUCTURES $51, 000
C. PERSONAL PROPERTY $382, 500
D. LOSS OF USE $255, 000
SECTION II COVERAGE
E. PERSONAL LIABILITY $1,000, 000 EACH OCCURRENCE
F. MEDICAL PAY TO OTHERS $50, 000 EACH PERSON $126.00
STANDARD POLICY PREMIUM $1, 816.00
OPTIONAL COVERAGES
EQUIPMENT BREAKDOWN $35.00
GUARANTEED REPLACEMENT COST PLUS $31.00
LIMITED WATER BACK UP & SUMP DISCHARGE OR OVERFLOW COV $41.00
PLATINUM OWNERS SELECT PREMIUM TRIM $207.00
TOTAL OPTIONAL COVERAGES PREMIUM $314 .00
TOTAL POLICY PREMIUM $2, 130.00
YOUR PREMIUM INCLUDES THE FOLLOWING DISCOUNTS AND PREMIUM ADJUSTMENTS:
ACCOUNT DISCOUNT
NEW HOME DISCOUNT
CONTINUED ON NEXT PAGE DIRECT BILLED
03/24/23 2136028710 PAGE 01 OF 03
231-6240 05 16 ORIGINAL/INSURED
06 RENEWAL DECLARATION # 21 AC
RENEWAL OF POLICY HVE 9966628
H O M E O W N E R S P 0 L I C Y
POLICY NUMBER POLICY PERIOD COVERAGE IS PROVIDED IN THE AGENCY CODE
HVE 9966628 05/07/2023-05/07/2024 MASSACHUSETTS BAY INSURANCE CO 150192300
440 LINCOLN ST
WORCESTER MA 01653
NAMED INSURED AND MAILING ADDRESS AGENT
KEITH ACKERSON PUTNAM INSURANCE AGENCY
83 GREENWAY CLOSE LLC
RYE BROOK, NY 10573 1152 E PUTNAM AVE
RIVERSIDE, CT 06878
TELEPHONE : 203-967- 1550
FORMS AND ENDORSEMENTS - The Declaration and the policy forms and endorsements
listed below form your Homeowners Insurance Policy:
HO 00 03 05 11 HOMEOWNERS 3 - SPECIAL FORM
231-6217 12 17 SPECIAL PROVISIONS - NEW YORK
231-0600 05 16 INFLATION GUARD
HO 24 93 05 02 WORKERS COMPENSATION
231-6323 10 17 PLATINUM HOME TOTAL HOUSEHOLD REWARDS
231-5767 05 16 EQUIPMENT BREAKDOWN
231-1937 08 17 IDENTITY FRAUD EXPENSE COVERAGE
231-6197 08 17 GUARANTEED REPLACEMENT COST PLUS
231-6279 08 17 LOSS ASSESSMENT COVERAGE
HO 04 77 10 00 ORDINANCE OR LAW INCREASED AMOUNT OF COVERAGE
231-6317 03 17 SERVICE LINE COVERAGE
231-5761 12 17 LIMITED WATER BACKUP & SUMP DISCHARGE OR OVERFLOW COV
HO 24 86 10 11 PERSONAL INJURY COVERAGE - NEW YORK
231-2331 05 16 LOCK REPLACEMENT COVERAGE
231-6282 08 17 OWNERS - SELECT PREMIUM TRIM
231-6283 08 17 PERSONAL PROPERTY REPLACEMENT COST LOSS SETTLEMENT
231-2341 05 16 REFRIGERATED PROPERTY COVERAGE
231-6204 05 16 REVISED DEDUCTIBLE - LARGE LOSS
MORTGAGEE
PHH MORTGAGE SERVICES
ISAOA
PO BOX 5954
SPRINGFIELD, OH 45501
LOAN NUMBER: 7183427629
DISTANCE TO FIRE HYDRANT
LESS THAN OR EQUAL TO 1000 FEET
DISTANCE TO FIRE STATION
GREATER THAN 3 MILES BUT LESS THAN OR EQUAL TO 4 MILES
FINISHED LIVING AREA(SQ. FT) : 1287
NUMBER OF STORIES: 2
NUMBER OF FULL OR HALF BATHROOMS: 2
DESCRIPTION OF OPTIONAL COVERAGES
EQUIPMENT BREAKDOWN
LIMIT OF LIABILITY - $25, 000
IDENTITY FRAUD EXPENSE COVERAGE
LIMIT OF LIABILITY - $25, 000
CONTINUED ON NEXT PAGE DIRECT BILLED
03/24/23 2136028710 PAGE 02 OF 03
231-6240 05 16 ORIGINAL/INSURED
Hanover
Insurance Group®
06 RENEWAL DECLARATION # 21 AC
RENEWAL OF POLICY HVE 9966628
H O M E O W N E R S P O L I C Y
POLICY NUMBER POLICY PERIOD COVERAGE IS PROVIDED IN THE AGENCY CODE
HVE 9966628 05/07/2023-05/07/2024 MASSACHUSETTS BAY INSURANCE CO 150192300
440 LINCOLN ST
WORCESTER MA 01653
NAMED INSURED AND MAILING ADDRESS AGENT
KEITH ACKERSON PUTNAM INSURANCE AGENCY
83 GREENWAY CLOSE LLC
RYE BROOK, NY 10573 1152 E PUTNAM AVE
RIVERSIDE, CT 06878
TELEPHONE : 203-967-1550
DESCRIPTION OF OPTIONAL COVERAGES
POLICY CONTAINS GUARANTEED REPL COST PLUS ON COV A
LOCK REPLACEMENT COVERAGE
LIMIT OF LIABILITY - $1,000
LOSS ASSESSMENT COVERAGE
RESIDENCE PREMISES - AMOUNT OF INSURANCE - $10,000
ORDINANCE OR LAW COVERAGE - 30%
REFRIGERATED PROPERTY COVERAGE
LIMIT OF LIABILITY - $500
SERVICE LINE COVERAGE
LIMIT OF LIABILITY - $20, 000
LIMITED WATER BACKUP & SUMP DISCHARGE OR OVERFLOW COVG
LIMIT OF LIABILITY - $30, 000
PERSONAL INJURY COVERAGE
WORKERS COMPENSATION
NUMBER OF EMPLOYEES - 01
TYPE OF HOUSEHOLD EMPLOYEE - OCCASIONAL SERVICES
DIRECT BILLED
03/24/23 2136028710 PAGE 03 OF 03
231-6240 05 16 ORIGINAL/INSURED
Affidavit of Exemption to Show Specific Proof of Workers' Compensation Insurance
Coverage for a 1, 2, 3 or 4 Family, Owner-occupied Residence
"This form cannot be used to waive the workers'compensation rights or obligations of any party.'•
Under penalty of perjury, I certify that I am the owner of the 1, 2, 3 or 4 family, owner-occupied residence
(including condominiums) listed on the building permit that I am applying for, and I am not required to show
specific proof of workers' compensation insurance coverage for such residence because (please check the
appropria box):
I am performing all the work for which the building permit was issued.
❑ I am not hiring,paying or compensating in any way,the individual(s)that is(are)performing all the work
for which the building permit was issued or helping me perform such work.
❑ I have a homeowners insurance policy that is currently in effect and covers the property listed on the
attached building permit AND am hiring or paying individuals a total of less than 40 hours per week
(aggregate hours for all paid individuals on the jobsite) for which the building permit was issued.
I also agree to either:
♦ acquire appropriate workers' compensation coverage and provide appropriate proof of that coverage on
forms approved by the Chair of the NYS Workers' Compensation Board to the government entity issuing
the building permit if I need to hire or pay individuals a total of 40 hours or more per week(aggregate hours
for all paid individuals on the jobsite)for work indicated on the building permit,or if appropriate,file a CE-
200 exemption form; OR
♦ have the general contractor, performing the work on the 1, 2, 3 or 4 family, owner-occupied residence
(including condominiums) listed on the building permit that I am applying for,provide appropriate proof of
workers'compensation coverage or proof of exemption from that coverage on forms approved by the Chair
2theS Workers' Compensation Board to the government entity issuing the building permit if the
es a total of 40 hours or more per week(aggregate hours for all paid individuals on the jobsite)for
ated on the building permit.
g
( /�naturenof Homeowner) (Date Signed)
k,. �l ) Home Telephone Number ��`� �i�-�� 71J
(Homeowner's Name Printed)
Sw rn to before me this Z day of
Property Address that requires the building permit:
� .� U/
ACC\
own y Clerk at --
14
! _ NOTA
1 --, ��erCoutY N
Once notarized,this BP-1 form sen es as an exemption for both workers'compensation and disability benefits insurance coverage.
BP-1 (12/08) NY-WCB