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HomeMy WebLinkAboutBP22-255PERMIT#�%d � DATE: P9(P:��'�LS7 SECTION BLOCK zQL LOT IY TYPE OF WOR / / P/7 4 JOB LOCATION Q � 'OyieiJ CONTRACTOR?? v �— EST. COST+&VoDon FEE ✓CO# - FEE dIRS-PA DATE TCO DATE DATE INSP FOOTING FOUNDATION FRAMING RGH FRAMING INSULATION PLUMBING RGH PLUMBING GAS O SPRINKLER �/ ELECTRIC 6z LOW -VOLT ALARM �L {1 AS BUILT FINAL /ABCo w 6 icy l riev f;� j OTHER APPROVALS ARB .'•T B LBA OTHER VILLAGE OF RYE BROOK WESTCHESTER COUNTY, NEW YORK NO: 4-099 (fertif ico.te of Occupancy 'This is to certify that (�)5 OVe of, R 7 having duly filed an application on (( 4 20 requesting a Certificate of Occupancy for the premises known as, Rye Brook,NY, located in a J?J- �7 Zoning District and shown on the most current Tax Map as Section: 1, Block: C;?- Lot: , and having fully complied with the requirements of the Building Code and the Zoning Ordinance under Building Permit No. , issued 20 o2�, such authority and permission is hereby granted to the property owner to lawfully occupy or use said premises or building or part thereof listed under the following New York State Classifications,Use: Construction: , for the following purposes: 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 exit fa ' ' tes shall be made,and no enlargement, whether by extending on any side or by increasing in hei all be made,n all the building be moved from one location to another until a permit to accomplish such change ha a om Building Inspector. Building Inspector,Village of Rye Brook: Date: AUG - 7 1014 DE `V� E N E r For office use only: BUILDIN+fs &EFARTMENT PERMIT# MAY 2 8 2024 VILLAGE OF RYE BROOK ISSUED: 938 KING STREET,RYE BROOK,NEW YORK 10573 DATE: VILLAGE OF RYE BROOK (9I4)939-0668 FEE: PAIDJW BUILDING DEPARTMENT wwwxyebrook.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 ti#rt#rtrtitii#t##i##ftiff#f##4##4f#i#i####t#tilt#tttrttiittif#######f####ff#iii##i##4##i###it#iii###iii#iifffrt#i##ii###i#ittrt#tf Address: z 5 1 v t( w 4✓e h u e- Occupancy/Use: Parcel ID#: / ��, 3 S— c�— q Zone: Owner: J udvi lure-n d Address: 3o 'L/UiNow at P.E./R.A. or Contractor: Address: 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: J vd n Nto re-»C' being duly sworn,deposes and says that he/she resides at 3 6 i' ! U/�o N S t (Print Name of Applicant) (No.and Street) in R- e Q,roo,V in the County of W r GIB e 5)1 L r in the State of�U �/ ,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:$�Z 60. 000 for the construction or alteration of: L41Cj1¢_7 d_j�j LQ04h,_6,C>2 J IZPhLa Ce-'7-LarA�� 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 D 9 Sworn to before me this day of \_ \C� , 20 day of , 20 ?ature of Property Owner Signature of Applicant I— 1 v)--,1 C `4 G-r�_71� �ameperty Owner Print Name of Applicant Nota ublic Notary Public Notary Public,State of New York No.OIME6160063 Qualified In Westchester County ti;l_, ,"I nommission Expires January 29,202 QyE BRC��. cu � 1982 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 : `� \ v 1 — DATE: PERMIT# (I� ISSUED: SECT: , /BLOCK'� LOT:I LOCATION: 1 N� CJ�`4\ �T `��(� OCCUPANCY: ❑ Violation Noted THE WORK IS... PASSED ❑ FAILED 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 �yE 4Rcb, Zm • 1982 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 - - - - - - - - - - - - - - - - - - - - INSPECTIONREPORT - - - - - - - - - - - - - - - - - - - - -21 ADDRESS . "u DATE: t 7 r � 1 PERMIT# ISSUED: SECT: BLOCK: LOT: j LOCATION: �J_. 1CY :� ` 1� OCCUPANCY: ❑ Violation Noted THE WORK IS... ❑ PASSED �1'J FAILED REINSPECTION ❑ SITE INSPECTION REQUIRED ❑ FOOTING ❑ FOOTING DRAINAGE ❑ FOUNDATION ❑ UNDERGROUND PLUMBING NOTES ON INSPECTION: ❑ ROUGH PLUMBING v ❑ ROUGH FRAMING ['INSULATION ❑ Natural Gas `�'�� �� '.,1 �r 'r (� i r / 1 �- ❑ L.P.Gas - O C 1 V CS ate, ❑ FUEL TANK ❑ FIRE SPRINKLER ❑ FINAL PLUMBING ❑ CROSS CONNECTION ❑ FINAL ) ( ✓\� CX ���� lY v ❑ OTHER �-1� QyE BR(��, O� Z� cu � • 1982 BUILDING DEPARTMENT F(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 : DATE: pJ PERMIT# J ISSUED: SECT: BLOCK: LOT: LOCATION: 1 OCCUPANCY: G ❑ Violation Noted THE ORK IS... j❑ PASSED ❑ FAILED REINSPECTION ❑ SITE INSPECTION G' v / REQUIRED ❑ FOOTING ❑ FOOTING DRAINAGE (7� ❑ 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 _G BRO 1982 BUILDING DEPARTMENT UILDING 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 : DATE: PERMIT# � ISSUED:1�'2-6 SECT: f f LOCK: LOT: I 1 LOCATION: ` n V-P' �� 6 L� V C'�1 0 N` OCCUPANCY: a ❑ Violation Noted THE WORK IS... ❑ PASSED ❑ FAILED REINSPECTION ❑ SITE INSPECTION ` �• \ ! REQUIRED ❑ FOOTINGS ❑ FOOTING DRAINAGE ❑ FOUNDATION ❑ ;UNDERGROUND PLUMBING NOTES ON INSPECTION: E ROUGH PLUMBING ❑ ROUGH FRAMING ❑ INSULATION �1 V Cv❑ Natural Gas ❑ L.P. Gas ❑ FUEL TANK ❑ FIRE SPRINKLER ❑ FINAL PLUMBING ❑ CROSS CONNECTION Y t i e V �, ❑ FINAL ❑ OTHER i tin = Ln �y o o 1 N N Q _ a� �� s N 4-4 N N W o .00. 0 -� y r•q rl � � � d y L� b w U x v !r"�� N Z q 0.0 o O45 = r4 bA � i o C D y •� s or W _ cc) A -4 w o z o � [ "o °" = CO ry V wa _ fl C z � C� 00 C)ts cn OT � I••i F+h M Itr 40, M, o .0 w 4 U A z O o c� ON oo a O z W A v W ` � O _ °X' o :z •� ° w z O © 0 E-1 & -U of to � v � W x zLn W � o w cn a 04 'y �a � _ p CC� EN BUILDING P"TMENT VILLAi E OF RYE,'RROOK DEC 2 2 2022 938 KING$TA$FT RYE BRq0x9 NY 10573 VILLAGE OF RYE BROOK {914)1939-066� BUILDING DEPARTMENT ADMINISTRATIVE EXTERIOR BUILDING PERMIT APPLICATION FOR EXTERIOR WORK WHICH DOES NOT REOUIRE VILLAGE ARCHITECTURAL REVIEW BOARD APPROVAL FOR OFFICE USE ONLY/ _ APPROVAL DATE: DEC 2 ' _ PERMIT M �)�-APPLICATION FEE:.& ! 6 APPROVAL SIGNATURE: PERMIT FEES: i i-' x 1 H.O.A.APPROVAL: DATE: DISAPPROVED: OTHER: Application dated:/� c1� is hereby made to the Building Inspector of the Village of Rye Brook,All',for the issuance of a Permit for the construction of buildings,structures,additions,alterations or for a change in use,as per detailed statement described below. 1. JobAddress: Z 5 14jall Vi<r W }l /,. 12 cC Uci A, 2. Parcel ID#: LIZ, 33 j Zone: 3. Proposed Improvement(Describe in detail): PS)-j-6 rco m -n c.v. t u'Y►(L 1 �p[��cc fGi 1[ c y� c?l1'�17c1�L, lJU; Yi�O:_.t.. ��PJLc3'mL►�1!f ' 4. Property Owner: _rtja—n 1AAo Address: �,n 111 t1iAi 1¢-rr P—# A r©O e N y 1 v 5 3 Phone#G14- ci3-3- ,!�614- Cell#91 e-mail T:jY10Z.gi$ kwiWWL. 4ryq List All Other Properties Owned in Rye Brook: Applicant: Address: Phone# Cell# e-mail Architect: Address: Phone# Cell# e-mail Engineer: Address: Phone# Cell# e-mail General Contractor: Address: Phone# Cell# e-mail (1} 8/12/2021 5. Occupancy;(1-Fam.,2-Farm,Commercial.,etc...)Pre-construction: Post-construction: 6. Area of lot: Square feet: Acres: 7. Dimensions from proposed building or structure to lot lines: front yard: rear yard: right side yard: left side yard: other: 8. If building is located on a comer lot,which street does it front on: 9. Area of proposed building in square feet: Basement: 1"fl: 21 fl: 3111 fl: 10. Total Square Footage of the proposed new construction: 11. For additions,total square footage added:Basement: 11 fl: 21 fl: 3'd fl: 12. Total Square Footage of the proposed renovation to the existing structure: 13. N.Y.State Construction Classification: N.Y.State Use Classification: 14. Construction Type&Location:()Typical Wester Lumber Frame;()Timber Frame[TC];()Wood Truss[TT]; ()Pre-engineered wood[PW];Located;()Floor Framing[F];()Roof Framing[R];()Floor&Roof Framing[FR];Other: 15. Number of stories: Overall Height: Median Height: 16. Basement to be full,or partial: finished or unfinished: 17. What material is the exterior finish: 18. Roof style;peaked,hip,mansard,shed,etc: Roofing material: 19. What system of heating: 20. If private sewage disposal is necessary,approval by the Westchester County Health Department must be submitted with this application. 21. Will the proposed project require the installation of a new,or an extension/modification to an existing automatic fire suppression system?(Fire Sprinkler,ANSL System,FM-200 System,Type I Hood,etc...)Yes:_No:_ (if yes,applicant must submit a separate Autom of atic Fire Suppression System Permit application&2 sets detailed engineered plans) 22. Will the proposed project disturb 400 sq.ft.or more of land,or create 400 sq.ft.or more of impervious coverage requiring a Stormwater Management Control Permit as per§217 of Village Code? Yes:_No:_Area: 23. Will the proposed project require a Site Plan Review by the Village Planning Board as per§209 of Village Code? Yes: No: (tfyes, applicant must submit a Site Plan Application,&provide detailed drawings) 24. Will the proposed project require a Steep Slopes Permit as per§213 of Village Code Yes: No: (if yes,you must submit a Site Plan Application, &provide a detailed topographical survey) 25. Is the lot located within 100 ft.of a Wetland as per§245 of Village Code? Yes: No: (if yes,the area of wetland and the wetland buffer zone must be properly depicted on the survey&site plan) 26. Is the lot or any portion thereof located in a Flood Plane as per the FIRM Map dated 9/28/07? Yes: No: (if yes,the area and elevations of the,Jlood plane must be properly depicted on the survey&site plan) 27. Will the proposed project require a Tree Removal Permit as per§235 of Village Code?Yes: No: (if yes,applicant must submit a Tree Removal Permit Application) 28. Does the proposed project involve a Home-Occupation as per§250-38 of Village Code? Yes: No: Indicate:TIER I: TIER II: TIER III: (if yes,a Home Occupation Permit Application is required) 29. What is the total estimated cost of construction: $ 3cz Oo o Note:estimated cost shall include all site improvements,labor,material,scaffolding,fixed equipment,professional fees,including any material and labor which may be donated gratis.If the final cost exceeds the estimated cost,an additional fee will be required prior to issuance of the CIO. 30. Estimated date of completion: "a rc l A Za 2 3 (2) 8n212021 BUILD = ---1 MENT 11R QmVED ' VIL DF OOK 938 KING ET-RVI BR ,NY 10573 EDEC2 2 2022 VILLAGE OF RYE BROOK BUILDING DEPARTMENT xwwxwxxwxwwxxxxxwwxwxxwxwwxw,tw*w*wxwwxxwwwwwwxxxwwwwwwxwxxwwwwwwwxxxwxw*wwxxxwxxw,rxx*wxxxwxxw*twx*wxwww AFFIDAVIT OF COMPLIANCE VILLAGE CODE 4216 • STORM SEWERS AND SANITARY SEWERS THIS AFFIDAVIT MUST BEAR THE NOTARIZED SIGNATURE OF THE LEGAL PROPERTY OWNER AND BE SUBMITTED ALONG WITH ANY BUILDING OR PLUMBING PERMIT APPLICATION. ANY BUILDING OR PLUMBING PERMIT APPLICATION SUBMITTED WITHOUT THIS COMPLETED AND NOTARIZED FORM WILL BE RETURNED TO THE APPLICANT STATE OF NEW YORK, COUNTY OF WESTCHESTER ) as: 3, A L) Yr C. N11&re ra u ,residing at, >,o h i✓,&cpti s1 R-g B , N x r oi U (Print name) (Address where you live) being duly sworn, deposes and states that(s)he is the applicant above named, and further states that(s)he is the legal owner of the property to which this Affidavit of Compliance pertains at; A r/c' , Rye Brook,NY. (Job Address) Further that all statements contained herein are true, and that to the best of his/her knowledge and belief,that there are no known illegal cross-connections concerning either the storm sewer or sanitary sewer, and further that there are no roof drains, sump pumps, or other prohibited stormwater or groundwater connections or sources of inflow or infiltration of any kind into the sanitary sewer from the subject property in accordance with all State, County and Village Codes. (Si a of Property Owner(s)) �a7'► �: �:�[ Y1 : J (Print Name of Property Owner(s)) Sworn to before me this day of ��' , 20 1 (Notary Pu c) 1. GREGORY K RIVERA Nett Pabik,Shte of New York No.OI RSU1398- (6) IR Wnfthester County r Commission Expires September 2S,20 8/12/2021 I This application must be properly completed in its entirety by a N.Y. State Registered Architect or N.Y. State Licensed Professional Engineer & signed by those professionals where indicated. It must also include the notarized signature(s) of the legal owner(s) of the subject property, and the applicant of record in the spaces provided. Any application not properly completed in its entirety and/or not properly signed shall be deemed null and void, and will be returned to the applicant. Please note that application fees are non-refundable. STATE OF NEW 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 and regulations. By signing this application, the property owner further declares that he/she has inspected the subject property, and that to the best of his/her knowledge there are no roof drains, sump pumps or other prohibited stormwater or groundwater connections or sources of infiltration into the sanitary sewer system on or from the subject property. Sworn to before me this Sworn to before me this _ day of /` , 20r� day of , 20 (),U C4,44 �vGT ature of Property Owner Signature of Applicant Print Name of Property Owner Print Name of Applicant Wv- Notary Mfic Notary Public GREGORY M.RIVERA Notary Public,State of New York No.01 R16441398 QuaNrred In Westchester County i Commission Expires September 26,X_ (8) 8/12/2021 { $ M ' f OI N N W o � � w a y = it Q`ON W N • W � � � N W � h�7 CIO ' a y w (% CIAz a ao x �" o ►vl \ z �M Lo r) � ^ O Zfq o O Z Q z N 0-4 00 04 w - pxz O c� Wo C N (n z Uz z \ x ,,..a � � V A z ,. oo 0-0 w ; c°� z a� pq � z 2 A < a w x 3 N z z �fq 1 H w � N U v ue W W. o w z H c Z z N a • �? a Ln cz `n z A w o H O U tt44t4;QU t4:04w4044;4� C44444i4A4to446 9t4U4Cis U�6- U44U4mi44U yEd.Rnv� R F,CIE E, i BUIL E MENT VIL E OF RYE OK MAR 2 4 2023 938 KIN , ET RYE B ,NY 10573 VILLAGE OF RYE BROOK or BUILDING DEPARTMENT . ELECTRICAL PERMIT APPLICATION Westchester County Master Electricians License Required FOR OFFICE USE ONLY BP#: ��—��� EP Approval Date: Permit Fee: $ Approval Signature: Other: Application dated, 3( 11-((a3 is hereby made to the Building Inspector of the Village of Rye Brook NY,for the issuance of a Permit to install and/or remove electrical equipment,wiring, fixtures,or to perform other high or low voltage electrical work as per the detailed statement described below. By signing this document, the applicant & property owner agree that all electrical work performed will be in conformance with all applicable Federal,State,County and Local Codes. 1.Address: '95 V�N 5av%a) Cwf, SBL: S Zone: 2.Property Owner: o1.S VVN!h�yi CLJ cto ,fit_ . Address: Phone#: 93 7— 6 cP I J-1 Cell#: email: 3.Master Electrician/Licensed Installer: �� f,,o L,>r rt Address: )i!IU 2A f Lic.#: ahcN Phone#: Cell#:(q H)d(od-,lk(o 1 emaiL•('Usckf,nt�CeSc,�,r:% (--nlm gl-%�-LOZ Company Name: Cncst%r4t, Co NVkLA;nS t J]nC-, Address: M-9 G�,,�_ Q-A _ bre._as��t r�� l-050`) 4.Proposed Electrical Work/Fixture Count: 0-xyrK roor-M gzD © e o noXe oSe rS 5.31 Party Electrical Inspection Agency: Sk. \S STATE OF NEW YORK,COUNTY OF WESTCHESTER ) as: being duly sworn,deposes and states that he/she is the applicant above named,and does further (print name of individ 'a un .s the a pplic state that(s)he is the for the legal owner and is duly authorized to make and file this application. (Master Electrician Licensed Installer) The undersigned further states that all st tements 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 (Yxut�� day of 920 day of \L ,20_a3_ Jean M.Aliberto r Notary rk Public,state of New Yo C Signature of Property Owner No.01 AL6198763 Signature of pplicant Qualified in Westchester County G�My Commission Expires 01/05/202Y� Print Name of Property Owner �`;R`, Print Name of Afltplicant Notary Public Nota Public 3/3/2023 STATEWIDE • Service With hilcgrilY 121 Main Street,Fishkill, NY 12524 1 ennoil:• • SWIS JOBAPPLICATION tel845.202.7224 • • • 1• • SWISTraining.corn Office Use Elect.Permit# � �r'�.�'' 3� Date Bldg Permit# Utility ID# Final Certificate# City/Village Zip Township tJ!'l4ell, County , { r< Address Cross Street Section [Block Lot Owner Name/Address(if different than above) Contact Number ❑Basement ❑ 1 st Fl. ❑2nd FI. ❑3rd FI. ❑More Than 3 FI. ❑Garage ❑Attic ❑Outside Residential ❑Commercial Receptacles Special Recept GFCI AFCI Switches Dimmers Smoke Alarms Carbon Monox Hood Trash Compact Amt Amps Range(s) Cooktop(s) Oven(s) Dishwashers Refrigerator Disposal Microwave Warm Draw Incandescent Fluorescent SERVICE Amperage Voltage 1 P 3P #Meters #Disconnect ❑Underground ❑New ❑Reconnect ❑Overhead ❑Change ❑Visual Re-Inspection ❑ Safety Re-Inspection ❑ Re-Inspection Additional Information MAR 14 2023 VILLAGE OF RYE BROOK BUILDING DEPARTMENT This application is valid for one(1)year from the date received by SWIS,This application is intended to cover the above listed items to be inspected,if at any time of inspection additional items have been installed,you are authorized to make the Inspection and adjust the fee for the additional Items inspected.The applicant declares that there is no open applications for the above address with any other Inspection company.The applicant,owner or authorized agent agrees to all the above terms and conditions as set forth for the application. Inspector Date Finalized Inspector# Company Name Date Signature Address — ,, -q City/State Zip Code License# Phone# State Wide Inspection Services CJC) 1080 Main Street Fishkill, NY 12524 Sw U S 845 202-7224 Phone 914-219-1062 Fax STATE WIDE INSPECTION SERVICES Email: office(@swisny.com Website: www.swisny.com Service With Integrity BY THIS CERTIFICATE OF COMPLIANCE STATE WIDE INSPECTION SERVICES CERTIFIES THAT: Upon the application of: Upon Premises Owned by: Cesarini Contracting, Inc. 25 Highview Avenue Inc. 136 Guinea Road 25 Highview Avenue Brewster, NY 10509 Rye Brook, NY 10573 Located at: 25 Highview Avenue, Rye Brook, NY 10573 Section: Block: Lot: Electrical Permit Number: EP23-073 141.35 2 19 Certificate Number: 2024-1964 Building Permit Number: 22-255/23-033 A visual inspection of the electrical system was conducted at the Residential occupancy described below.The electrical system consisting of electrical devices and wiring is located in/on the premises at: 25 Highview Avenue, Rye Brook, NY 10573 The First Floor,Second floor, Kitchen, and Bathrooms were inspected in accordance with the NYS and NFPA 70-2017 and the detail of the installation, as set forth below,was found to be in compliance on the 28th day of March 2024. Name Quantity Rating Circuit Type Kitchen Stove 01 Dishwasher 01 Recessed Luminaires 06 Bathrooms Receptacles 02 Exhaust Fans 02 Luminaires 02 HVAC System 01 A Visual Inspection of existing conditions was performed on March 28", 2024 of the First Floor, _ Second Floor, Kitchen,and Bathrooms and Conforms to NFPA 70-2017 NEC. No Defects Were Noted. _ 4 Officer: Frank J. Farina r- This certificate may not be altered in any way and is validated only by the presence of a seal at the location indicated.This certificate is valid for work performed on the date of inspection only. � � N O fY a H a N k W • G` a z j tc x z M Oi H a L r CR z z ;� oce O A �, • z 00 u7 c�CN C7 00 1-1 0.-0CN U w W E N ~' GA zo w x a� U W a F w oa oo z off Q., ' w Ln V � $ x v O a aen oc QI as a a as w z _ = a p CC ENE JAN - 3 2023 BUILDING DEPARTMENT VILLAGE OF RYE BROOK VILLAGE OF RYE BROOK 938 KING STREET RYE BROOK,NY 10573 BUILDING DEPARTMENT (914)939-0668 www.ryebrook.org PLUMBING PER\\MIIT�T APPLICATION FOR OFFICE USE ONLY BP#: e��—c�� PP#: a 3--ao f Approval Date: AN - 4 Permit Fee: $ + v`� Approval Signature: Other: Disapproved: (fees are non-refundable) ************************************************************************************************** Application dated, 12/30/2022 is hereby made to the Building Inspector of the Village of Rye Brook NY,for the issuance of a Permit to install and/or remove Plumbing as per detailed statement described below.The applicant&property owner,by signing this document agree that said plumbing work will be in conformance with all applicable Federal,State,County and Local Codes.z9 1.Address: 25 Highyiew Ave SBL: Hj, 3S- �`I / Zone:dC�� 2.Proposed Work: Bathroom , Kitchen renovation 1 st& 2nd floors 3.Property Owner: Juan Carlos Moreno Address: 30 Division St Rye Brook NY Phone#: 914 484 5506 Cell#: email: Jcmo2989@hotmail.com 4.Master Plumber: John Pfeiffer Address: 669 Francis St Pelham NY 10803 Lic.#: 309 Phone#:914 738 3144 Cell#: 914 403 4434 email:lohn@abco-plumbing.com Company Name: ABCO P&H Address:530 Fifth Avenue Pelham NY 10803 INDICATE FIXTURES&LINES TO BE INSTALLED AS PER THE FOLLOWING SCHEDULE: Location Water Urinals Drinking Sinks Showers Bath Laundry Domestic Fire Sanitary Natural/ Other* Total Closets Fountains Tubs Tubs Service Service Sewer LP Gas Basement 1st Floor 1 2 1 2nd Floor 1 2 1 3'Floor 41 Floor 51 Floor Exterior 5.*List Other Equipment/Provide Details: (Notarized Signatures Required Next 2 Pages) 8/12/2021 1 BUILDING DEPARTMENT JAN - 3 2023 VILLAGE OF RYE BROOK 938 KING STREET RYE BROOK,NY 10573 VILLAGE OF RYE BROOK (914)939-0668 BUILDING DEPARTMENT ww�r�k�r� AFFIDAVIT OF COMPLIANCE VILLAGE CODE §216 - STORM SEWERS AND SANITARY SEWERS THIS AFFIDAVIT MUST BEAR THE NOTARIZED SIGNATURE OF THE LEGAL PROPERTY OWNER AND BE SUBMITTED ALONG WITH ANY BUILDING OR PLUMBING PERMIT APPLICATION. ANY BUILDING OR PLUMBING PERMIT APPLICATION SUBMITTED WITHOUT THIS COMPLETED AND NOTARIZED FORM WILL BE RETURNED TO THE APPLICANT . STATE OF NEW YORK,COUNTY OF WESTCHESTER ) as: Juan Carlos Moreno residing at, 30 Division St Rye Brook NY 10573 , (Print name) (Address where you lire) being duly sworn,deposes and states that(s)he is the applicant above named, and further states that(s)he is the legal owner of the property to which this Affidavit of Compliance pertains at; 25 Highview Ave Rye Brook NY ,Rye Brook,NY. (Job Address) Further that all statements contained herein are true,and that to the best of his/her knowledge and belief,that there are no known illegal cross-connections concerning either the storm sewer or sanitary sewer, and further that there are no roof drains, sump pumps, or other prohibited stonnwater or groundwater connections or sources of inflow or infiltration of any kind into the sanitary sewer from the subject property in accordance with all State, County and Village Codes. 0 t nature of Propert Otiner(s)) Juan Carlos Moreno (Print Name of Property Owner(,)) Sworn to before me this '36-4, day of E C E tM13C- 20 22 vREENq A '�,' NOT�Y��'•,m (Notary Public) /C = 0� 0 p) 1p ro XPIREg',.� -3-,,�eele;lnl���o• 8/12/2021 STATE OF NEW YORK,COUNTY OF WESTCHESTER ) as: John Pfeiffer ,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 Contractor 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 3U Sworn two bbe�fo'r�e'_me this 34 day of 1�F }'l�C ,20_Z day oft *�ueU— 20 2Z /�7aoL", 20,Lbj S' nature of Property Owner ig ture otAp ' nt Juan Carlos Moreno John Pfeiffer Print Name of Property Owner Print Name of Applicant Notary Public tary Public This application must be properly completed in its entirety and must include the notarized signature(s) of the legal owner(s)of the subject property, and the applicant of record in the spaces provided. Applications not properly completed in its entirety and/or not properly signed shall be deemed null and void and will be returned to the applicant. EEIV,q, off BEN JQ; A.PFF'�%, -OVA STATE ' � �P• 0 OF NEW YORK N`, IAF�relr � : co NOTARY PUBLIC 106 Qualified in ,o -- "s o `Westcester County•N _2_ '�•.,,,�of�RE .•�' OIPF6034106 :�i,'•, hf- ",1� 8/12/2021 '�"'I" ON EXP\?���`�: IMP ip r _ a.96 a%. , 1w Wk. + . ' ,.. a j ♦ r ~ ` }am 4 Y AWM 04, sis . w X' I .� r _ Y y .. v j OF "wK Oft oll ..r rfr � Iwo AOk lit `. • � � t rcc -7 4 r ' ...+ I 1 N 742, � 1 � a Building Permit Check List&Zoning Analysis Address: S� G xW l F-W k"_�L SBL• 41 7� Zone�2 Use: _7—1 -> Const.Type: Other. Submittal Date: 2Z ZZ Revisions Submittal Dates: Applicant: VV 0QLF� 0 Nature of Work: t"-U;F� .0 —VRr--0--::,V 9►--� W VI ' Dt.J LAIC Reviews:ZBA: DEC 2 7 2022 PB: BOT: Other. OK( ( ) /FEES:Filing: 2.5-'1, BP: `t S'� C/O: Flood Plane: Legalization: ( ) (�APP: Dated:�✓ Notarized. ✓SBL: runs I.D. Cross Connection: H.O.A.: ( ) ( ) Scenic Roads: Steep Slopes: Wetlands: Storm Water Review: Street Opening: ( ) ( ) ENVIRO:Long. Short: Fees: N/A: ( ) ( ) SITE PLAN:Topo: Site Protection: S/W MgrnL: Tree Plan: Other. ( ) ( ) SURVEY:Dated: Current Archival:- Sealed: Unacceptable: ( ) ( ) PLANS:Date Stamped: Sealed: Copies: Electronic: Other. License: Workers Comp: Liability. Comp.Waiver. v"- Other. ( ) ( ) CODE 753#: Dated: N/A: (✓� ( ) HIGH-VOLTAGE ELECTRICAL:Plans: Permit: N/A Other. ( ) ( ) LOW-VOLTAGE ELECTRICAL:Plans: Permit: N/A Other. FIRE ALARM/SMOKE DETECTORS:Plans: Permit: H.W.I.C.:_Battery-_Other. (� ( ) PLUMBING:Plans: Permit: Nat.Gas: LP Gas: N/A/: Other. ( ) ( ) FIRE SUPPRESSION:Plans: Permit N/A: Other. ( ) ( ) H.V.A.C.: Plans: Permit: N/A Other. FUEL TANK:Plans: Permit: Fuel Type: Other. ,kf 2020 NY State ECCC-_7 N/A: Other. N Flj�=D u�i t,t bo t.- t+j M . r ( ) ( ) Final Survey Final Topo: RA/PE Sign-off Letter. As-Built Plans: Other. ( ) ( ) BP DENIAL LETTER: C/O DENIAL LETTER. Other. ( ) ( ) Other. ( )ARB mtg.date: approval: notes: ( )ZBA mtg.date: approval: notes: ( )PB mtg.date: approval:- notes: REQUIRED EX19IIN PROPOSED NOTES ckdv Fr n Front: From Sides Rom: Main Cov Accs.Cov Ft.HS : S .HS • Tot,Lm : Ft Imp: P Height/Stories: notes: N l UNITED WINDOW & DOOR 7400 5eries Replacement Window The 7400 Series with 3/4" warm-edge, insulated glass is3, designed to meet Energy Star ratings in all climate zones. With a bold bevel and stylishly designed frame, the 7400 Series comes with a lifetime, non-prorated warranty that covers both residential and commercial applications. A versatile and meticulously designed window, the 7400 boasts modern sightlines, solid performance, and a variety of styles and options to complete any project. STANDARD FEATURES OPTIONAL FEATURES 3/4"Warm-Edge Insulated Glass Energy Star Rated, Low-E&Argon Insulated Glass Commercial Grade Constant Force Balances Heavy Duty Full Screen or Extruded Aluminum Locking Half Screen Heavy Duty Half Screen Structural Mullions for Commercial Applications Continuous Head&Sill for Twins& Triples GBG and SDL Grids Watertight Full Capture Sill'/No Weep Holes Balance Covers Lifetime, Non-ProRated Warranty Exterior Coating Colors EXTERIOR COATINGS GRID PATTERNS El L=_LJ ULU Interbr Interi« In[erioJ _ Sable Brick Red Gray Interl« 'nterbr 'nterbr GRID OPTIONS Green Clay Bronze Black , . SDL G." Countour Flat - : APPEARANCE With a stylishly enhanced bevel designed for a bold appearance, the 7400 Series offers exterior j w coating p color options as well as =� i F. custom colors. �sg t . , OPERATION A corrosion resistant Teflon coated, } 2 stainless steel, constant force balance system allows for smooth and effortless operation, along with a sturdy lock and �- keeper system that exceeds forced entry requirements. EFFICIENCY � The 7400 is designed with a sloped, full = � capture sill for increased defense Z.— - ----- against air & water infiltration, and 3/4" warm-edge insulated glass for improved - Iflli�iari+�� thermal performance. Series Ratings -- SERIES .. . 36"x 75" Single Class R-PG35 0.10 7.52 i 36"x 60" Single Class R PG30 0.10 5.43 72"x 60" Twin Class R-PG35 0.10 7.52 72"x 75" Twin Class R PG30 0.10 5.43 7400 Series 108"x 60" Triple Class R-PG35 0.10 7.52 Test Results 108"x 75" Triple Class R PG30 0.10 5.43 108"x 60" Triple Class R-PG35 0.10 7.52 108"x 75" Triple Class R PG30 0.10 5.43 44"x 74" Picture Class R PG50 0.05 7.52 63"x 44" Slider Gass R PG30 0.05 7.52 108"x 48" 3 Lite Slider Class R PG35 0.08 4.59 Min/Max Sizing MIN/MAX SIZING Double Hung 15 5/8" 48" 27" 80" DH Twin CHS 315/8" 961/2" 27" 80" DH Triple CHS 47 3/4" 1071/2" 27" 80" 2 Lite Slider 231/4" 951/2" 141/2" 76" 3 Lite Slider 33" 120" 141/2" 76" 090000 Picture/Transom 111/2" 72" 17" 84" Picture/Transom 11 1/2" 84" 17" 72" To team more,visit us at unitedvindowmfg.com or on our social media UNITED Low E- Options WINDOW& DOOR LowE - 2 LowE - 2 Solar LowE - 3 LowE -4 EXT INT EXT INT EXT INT EXT INT �s 2 4 2 4 2 4 2 4 1 3 � 1 3 13 —A 3J , 1 70 36 55/27 72157 70136 plus IS2o Surface 2 Surface 2 Surface 3 Surface 2&4 Zone Zone Zone Zone North cC mgr al S®uath cCengral Northern (perspective) Northern Glass for all seasons. Allows natural light in the Incorporates a passive Engineered to lower the It insulates in the winter home while keeping solar heat concept to U-factor of standard and blocks heat in the much of the sun's heat provide a strong level of Low-E windows. summer. out. insulation against winter cold. (Formerly Smarter Low-E) (Formerly Solar HP) (Formerly IS20-4) WINDOWS CLIMATE U- t SHGC2 ZONE FACTOR iENERGY STARO for Doors, 1 Skylights s 0.27 Any Prescriptive i 029 a 0.32 CLIMATE ' • Equivalent =0.29 a037 Energy ' =0.30 a0.42 Performance North Central 50.30 50.40 s 0.30 s 025 � s 0.40 s 025 Northern Air Leakage s 0.3 cfm/ftr f! r Btu/h ft2.'F ❑ North-Central 2 Solar Heat Gain Coefficient PATIO DOORS z - '�` ❑ South-Central FACTOR SHGC= Northern 50.40 ■ Southern 0.30 North-Central s • Southern•-> South-Central s 0.25 Air Leakage for Sliding Doors s 0.3 cfnVft2 Air Leakage for Swinging Doors s 0.5 cfmrft' 10/1/2020 7400 SERIES Double Hung UNITED 7ViNDOW DOOR No Grids Flat or Sculpted Grids Glass Package IG Thick Interior Glass Exterior Glass Energy Star Energy Star U-Value SHGC VLT U-Value SHGC VLT 7400 Double Hung ;,. Clear 3/4" 2.3mm Clear 2.3mm Clear 0.47 0.63 0.65 0.47 0.57 0.58 LowE2 3/4" 2.3mm Clear 2.3mm 7036 0.33 0.31 0.56 0.33 0.28 0.50 LowE2, Argon 3/4" 2.3mm Clear 2.3mm 7036 0.30 0.31 0.56 NC 0.30 0.28 0.50 NC LowE3, Argon 3/4" 2.3mm 7257 2.3mm Clear 0.30 0.46 0.56 N 0.30 0.42 0.50 N LowE2 Solar, Argon 3/4" 2.3mm Clear 2.3mm 5527 0.29 0.22 0.44 NC,SC,S 0.29 0.20 0.39 NC,SC,S LowE4, Argon 3/4" 2.3mm IS20 2.3mm 7036 1 0.26 0.30 0.54 N NC 0.26 0.27 0.48 N NC Clear 3/4" 3mm Clear 3mm Clear 0.47 0.62 0.65 0.47 0.56 0.58 LowE2 3/4" 3mm Clear 3mm 7036 0.33 0.31 0.55 0.33 0.28 0.49 LowE2, Argon 3/4" 3mm Clear 3mm 7036 0.29 0.31 0.55 NC 0.29 0.28 0.49 NC LowE3, Argon 3/4" 3mm 7257 3mm Clear 0.30 0.46 0.56 N 0.30 0.41 0.50 LowE2 Solar, Argon 3/4" 3mm Clear 3mm 5527 0.29 0.22 0.44 NC,SC,S 0.29 0.20 0.39 NC,SC,S LowE4, Argon 314" 3mm IS20 3mm 7036 0.26 0.30 0.54 N,NC 0.26 0.27 0.48 N,NC Clear 3/4" 2.3mm Clear 2.3mm Clear 0.46 0.63 0.65 0.46 0.57 0.58 LowE2 3/4" 2.3mm Clear 2.3mm 7036 0.32 0.31 0.56 0.32 0.28 0.50 LowE2, Argon 3/4" 2.3mm Clear 2.3mm 7036 0.29 0.31 0.56 NC 0.29 0.28 0.50 NC LowE3, Argon 3/4" 2.3mm 7257 2.3mm Clear 0.29 0.46 0.56 N 0.29 0.42 0.50 N LowE2 Solar, Argon 3/4" 2.3mm Clear 2.3mm 5527 0.29 0.22 0.44 NC,SC,S 0.29 0.20 0.39 NC,SC,S LowE4, Argon 3/4" 2.3mm IS20 2.3mm 7036 0.25 0.30 0.54 N NC 0.25 0.27 0.48 N NC Clear 3/4" 3mm Clear 3mm Clear 0.46 0.62 0.64 0.46 0.56 0.58 LowE2 3/4" 3mm Clear 3mm 7036 0.32 0.31 0.55 0.32 0.28 0.49 LowE2, Argon 3/4" 3mm Clear 3mm 7036 0.28 0.30 0.55 NC 0.28 0.27 0.49 NC LowE3, Argon 3/4" 3mm 7257 3mm Clear 0.29 0.46 0.56 N 0.29 0.41 0.50 N LowE2 Solar, Argon 3/4" 3mm Clear 3mm 5527 0.28 0.22 0.44 NC,SC,S 0.28 0.20 0.39 NC,SC,S LowE4, Argon 3/4" 3mm IS20 3mm 7036 0.25 0.30 0.54 N,NC 0.25 0.27 0.48 N,NC Clear 3/4" 2.3mm Clear 2.3mm Clear 0.48 0.67 0.69 0.48 0.60 0.61 LowE2 3/4" 2.3mm Clear 2.3mm 7036 0.33 0.33 0.59 0.33 0.30 0.53 LowE2, Argon 3/4" 2.3mm Clear 2.3mm 7036 0.30 0.33 0.59 NC 0.30 0.29 0.53 NC LowE3, Argon 3/4" 2.3mm 7257 2.3mm Clear 0.30 0.49 0.60 N 0.30 0.44 0.53 N LowE2 Solar, Argon 3/4" 2.3mm Clear 2.3mm 5527 0.29 0.24 0.46 NC,SC,S 0.29 0.21 0.42 NC,SC,S LowE4 Argon 3/4" 2.3mm IS20 2.3mm 7036 0.26 1 0.32 0.57 N NC 0.26 0.29 1 0.50 N,NC Clear 3/4" 3mm Clear 3mm Clear 0.48 0.66 0.68 0.48 0.59 0.61 LowE2 3/4" 3mm Clear 3mm 7036 0.33 0.33 0,58 0.33 0.30 0.52 LowE2, Argon 3/4" 3mm Clear 3mm 7036 0.29 0.32 0.58 N,NC 0.29 0.29 0.52 NC LowE3, Argon 3/4" 3mm 7257 3mm Clear 0.30 0.48 0.59 N 0.30 0.44 0.53 N LowE2 Solar, Argon 3/4" 3mm Clear 3mm 5527 0.29 0.24 0.46 N,NC,SC,S 0.29 0.21 0.41 NC,SC,S LowE4, Argon 3/4" 3mm IS20 3mm 7036 0.25 0.32 0.57 N,NC 0.25 0.29 0.50 N.NC ENERGY STAR Cualifleation Criteria for Residential Windows,Doors,end Skylights Windows . pi« riper' Doors Northern --® My - - s 031 NaFcrpM L !q 4hpaP, Wow O.pe a0-W nomwm . North-Central .a�u, aamF�nn.c nw 90.40 j rwarm.na' 8�,m.ai,e., s on wam ka'a NLT,iIrBAfhpDeonsO.]dMl.- � � f0.30 so.fo �'�r LOMepf N,ewMgwp Oeonf 0.8 dnW South-Central a l so.w faz Southern ..]fopa AYL«bpf io3 evm i Bym M'F 901Y IMtO,Ir,C0p11Lrt 'Nw'f[fwfwbmf NOMWn Zae A�«ePf+F .�fPw'"4n1«wW PwMrrw qM.4 b.Y"bn Y "pp18 GATechnical Documents\NFRC\new United thermal chart 7400 series UNITE www unitedwlndowmfg.com WINDOW& DOOR 24-36 Fadem Road,Springfield NJ 07061 a 7400£ Double,.Hun g Window Product Performance: Window Size Confi uration AAMA Rating sf Air drn ft2 Water sf 7400 Series Window Test 44"x75" Single ClassR-PG2S 0.24 6.06 7400 Series Window Test 36"x75" Single ClassR-PG30 0.13 5.43 7400 Series 36"x 60" Single Class R-PGSO 0.16 7.52 Window Test 7400 Series Window Test 40"x80" Single ClassR-PG20 0.16 5.43 7400 Series Window Test 72"x60" Twin ClassR-PG35 0.13 7.52 7400 Series Window Test 72"x75" Twin ClassR-PG30 0.13 5.43 7400 Series Window Test 108"x 60" Triple Class R-PG35 0.10 7.52 7400 Series Window Test 108"x 75" Triple Class R-PG30 0.10 5.43 7400 Series Window Test 56"x 56" Fixed Class R-PG50 0.05 7.52 7400 Series Window Test 44"x74" Fixed Class R-PGSO 0.05 7.52 7400 Series Window Test 63"x44" Horizontal Slider ClassR-PG30 0.05 7.52 7,400 Series Window Test 108"x48" 3-Iite Horizontal Slider ClassR-PG35 0.08 4.59 Performance Grade is a numeric designator that defines the performance of a product upon the completion of three tests,structu ra I performance under wind load, resistance to water penetration and resistance to air leakage. The Performance Grade of a window unit is limited by the lowest performance rating of the three tests. The results apply to all window units smaller or equal to the window unit tested. Product Dimensions: Vinyl Wall Thickness: 0.065" Typ. Glass Thickness: 3/4" Jamb Depth: 3.6875" Mullion Adder: 1/2" Nail Fin Setback: NA I �` I p Rough Opening: i! Window Width + 1/2" } Window Height+ 1/2" i Size Restrictions: Min: Max: ' Y Width 18" 44" Height 25" 80" fi 1 (Max. United Inches 144") 'M.j. UNITE . , WINDOW& DOOR www.unitedwindowmfg.com 24-36 Fadem Road,Springfield NJ 07061 7400 Double Hung Window 16 416• 0 a�o - o 0 O C] 3/4"IG WINDOW HEIGHT 0 000 1i• 1 16 Series 740000 Vertical Series 7400 Intermediate Jamb Vertical Detail Detail ap 0 8- 34• Series 7400 Horizontal Diagram a D -Iti• T-3d 1. p 0 3j• 3jg — 0 CD ,8• ,8. WINDOW WIDTH .ate .� t: go � 'q r o chi r� `� 2 m n cs � U - b Q. O cs. U _ 3 cs O � > WE- Q > � c�i 3 b 7ocn u .� cnw y U � � to co� cl -ci U O. V7 r o Ems- ¢ W W a > o 3 3 o b '- cs cs r� °ai a n. U a M to cs cjj a Ca _ n ° " � � •� ` o wiz r r a 3 0 cl . U /I 0 Q Y r4 U U "D .� CJ 1+1 p c tom- U a > •� W O En -0 r=n 0 can •� w c7 w U o cn CA -0 .~� � c� ° W d � o W 0 W a u U � cv -- -0 -c� -, t t cn W "D U r- w, C, t%CL vOi cy _cl C) O In cl �> � � o ,cl a � wc, cn Zxx cis ti " o0 3 o rr W z Q o 3 wp cN u W W 71 to b 0 c M cn CI r c c`s u u r o *0 x j O -E u o b4 > u 7b .�' O chicj t a� o CD y 3 cs o b -- (D cs �, cis -e7 ❑ 3 Z c a 'A cn O y° cis clj cs cn p c c 0 .. n 's -Cc) 3 -- -- b - L = °o •° x � ww Y o o e�i n o .0 cs, w 3 c> > r� ¢ I'llp v� � i y «c o Z `. n ° cos � b o > �, J ¢ c L� 2Z W. o x :� ® cs E- O w a NEW United States Liability Insurance Company Direct Bill Policy Renewal of Number 1190 Devon Park Drive, Wayne, Pennsylvania 19087 POLICY DECLARATIONS A Member Company of United States Liability Insurance Group No. CP 1798936 NAMED INSURED AND ADDRESS: JUAN CARLOS MORENO 25 HIGHVIEW AVE RYE BROOK, NY 10573 POLICY PERIOD: (MO. DAY YR.) From: 10/20/2022 To: 10/20/2023 12:01 A.M.STANDARD TIME AT YOUR MAILING ADDRESS SHOWN ABOVE FORM OF BUSINESS: Individual BUSINESS DESCRIPTION: 1 to 4 Family Dwelling IN RETURN FOR THE PAYMENT OF . SUBJECT TO ALL THE TERMS OF POLICY, WITH YOU • PROVIDE THE INSURANCE AS STATED IN THIS POLICY. THIS POLICY CONSISTS OF THE FOLLOWING COVERAGE PARTS FOR WHICH A PREMIUM IS INDICATED. THIS PREMIUM MAY BE SUBJECT TO ADJUSTMENT. PREMIUM Commercial Liability Coverage Part $587.00 Commercial Property Coverage Part $3,349.00 TOTAL: $3,936.00 Coverage Form(s)and Endorsement(s) made a part of this policy at time of issue See Endorsement EOD (1/95) Agent: SCOTTISH AMERICAN(NY)(4902) Issued. 10/24/2022 10:16 AM 34-07 Steinway St,Suite 201 Long Island City,NY 11101 ;� � Broker: Genesis Insurance ` I�/ 171 Grand Street By: Authorized Represe ati e White Plains, NY 10601 THESE DECLARATIONS TOGETHER WITH THE COMMON POLICY CONDITIONS,COVERAGE PART DECLARATIONS, UPD(08-07) COVERAGE PART COVERAGE FORM(S)AND FORMS AND ENDORSEMENTS,IF ANY,ISSUED TO FORM A PART THEREOF, COMPLETE THE ABOVE NUMBERED POLICY. EXTENSION OF DECLARATIONS Policy No. CP 1798936 Effective Date: 10/20/2022 12:01 AM STANDARD TIME AT YOUR MAILING ADDRESS FORMS AND ENDORSEMENTS The following forms apply to multiple coverage parts Endt# Revised Description of Endorsements CGO104 12/04 New York Changes- Premium Audit CG2173 01/15 Exclusion Of Certified Acts Of Terrorism IL0017 11/98 Common Policy Conditions IL0023 07/02 Nuclear Energy Liability Exclusion Endorsement IL0183 08/08 New York Changes - Fraud IL0268 01/11 New York Changes- Cancellation And Nonrenewal IL0935 07/02 Exclusion Of Certain Computer-Related Losses IL0953 01/15 Exclusion Of Certified Acts Of Terrorism JACKET NY 12/19 Policy Jacket L-61ONY 01/07 Expanded Definition Of Bodily Injury- New York LLQ100 07/06 Amendatory Endorsement LLQ368 08/10 Separation Of Insureds Clarification Endorsement NTE NY 01/15 Notice Of Terrorism Exclusion The following forms apply to the Commercial Liability coverage part Endt# Revised Description of Endorsements CG0001 12/07 Commercial General Liability Coverage Form CGO068 05/09 Recording And Distribution Of Material Or Information In Violation Of Law Exclusion CGO163 07/11 New York Changes - Commercial General Liability Coverage Form CG2107 05/14 Exclusion -Access Or Disclosure Of Confidential Or Personal Information And Data-Related Liability-Limited Bodily Injury Exception Not Included CG2109 06/15 Exclusion - Unmanned Aircraft CG2136 03/05 Exclusion -New Entities CG2144 07/98 Limitation Of Coverage To Designated Premises Or Project CG2147 12/07 Employment-Related Practices Exclusion CG2621 10/91 New York Changes-Transfer Of Duties When A Limit Of Insurance Is Used Up JACKET NY 12/19 Policy Jacket L-697NY 11/07 Absolute Asbestos Exclusion With A Hostile Fire Exception L-698NY 11/07 Absolute Lead Exclusion With A Hostile Fire Exception L-699NY 11/07 Absolute Pollution Exclusion With A Hostile Fire Exception L-70ONY 11/07 Absolute Silica Exclusion With A Hostile Fire Exception L-783 02/14 Amendment Of Liquor Liability Exclusion Notice-Unmanned 05/16 Advisory Notice To Policyholders Aircraft—GL The following forms apply to the Commercial Property coverage part Endt# Revised Description of Endorsements EOD(01/95) All other terms and conditions remain unchanged. Page 1 of 2 EXTENSION OF DECLARATIONS Policy No. CP 1798936 Effective Date: 10/20/2022 12:01 AM STANDARD TIME AT YOUR MAILING ADDRESS FORMS AND ENDORSEMENTS CP 112 10/12 Equipment Breakdown Enhancement Endorsement CP 138 NY 02/11 Lead Exclusion CP 141 DEP NY 08/20 Changes-Actual Cash Value and Depreciation Definition CP 142 04/14 Protective Devices Or Services Provisions CP 146 NY 02/09 New York Changes CP 224 02/11 Asbestos Material Exclusion CP 226 02/11 Absolute Pollution Exclusion - Property CP 245 09/15 Earth Movement Exclusion CP0010 06/07 Building And Personal Property Coverage Form CP0030 06/07 Business Income (And Extra Expense) Coverage Form CP0090 07/88 Commercial Property Conditions CP0133 01/11 New York Changes CP0164 03/09 New York Changes - Fungus, Wet Rot And Dry Rot CP0178 08/08 New York- Exclusion Of Loss Due To Virus Or Bacteria CP1030 06/07 Causes Of Loss-Special Form CP1032 08/08 Water Exclusion Endorsement CP1077 12/20 Cyber Incident Exclusion - New York IL0953 01/15 Exclusion Of Certified Acts Of Terrorism JACKET NY 12/19 Policy Jacket Notice -Cyber 12/21 Cyber Incident Exclusion Endorsement-Advisory Notice to Incident Exclusion Policyholders CP NY EOD(01/95) All other terms and conditions remain unchanged. Page 2 of 2 COMMERCIAL PROPERTY COVERAGE PART DECLARATIONS Policy No. CP 1798936 Effective Date: 10/20/2022 12:01 STANDARD TIME DESCRIPTION OF PREMISES Prem Bldg Location, Construction, Occupancy and Other Information Territory Fire Code 1 1 25 Highview Avenue, Rye Brook, NY 10573 009 0197 Description: 1 to 4 Family Dwelling Covered Causes of Loss: Special Protection Class 3 Construction: Frame Number of Stories:2 Square Footage: 1700 Special Deductible: None Special Deductible Type: COVERAGES PROVIDED-INSURANCE AT THE DESCRIBED PREMISES APPLIES ONLY FOR COVERAGES FOR WHICH A LIMIT OF INSURANCE IS SHOWN Limits of Coinsurance %or Prem Bldg Coverage Insurance Deductible Monthly Indemnity + Valuation Premium 1 1 Building $600,000 $1,000 80% ACV $2,658 1 1 Business Income with Extra Expense $100,000 $0 100% $348 1 1 Equipment Breakdown Included $1,000 $343 MINIMUM PREMIUM FOR PROPERTY COVERAGE PART: $593 TOTAL PREMIUM FOR PROPERTY COVERAGE PART: $3,349 MP-minimum premium +Valuation:ACV-Actual Cash Value; RC-Replacement Cost;RC/ACV-Replacement Cost/ACV Roof FBV-Functional Building Value;AA-Agreed Amount;ALS-Actual Loss Sustained LOSS PAYABLE(S): NONE Coverage Form(s)/Part(s)and Endorsement(s)made a part of this policy at time of issue: See Endorsement EOD (01/95) THESE DECLARATIONS ARE PART OF THE POLICY DECLARATIONS CONTAINING THE NAME OF THE INSURED AND THE POLICY PERIOD. Includes copyrighted material of ISO Commercial Risk Services, Inc.,with its permission. CF 150 (01/03) Copyright, ISO Commercial Risk Services, Inc., 1983, 1984, 1988 Page 1 Of 1 COMMERCIAL GENERAL LIABILITY COVERAGE PART DECLARATIONS Policy No. CP 1798936 Effective Date: 10/20/2022 12:01 STANDARD TIME LIMITS OF INSURANCE Each Occurrence Limit $1,000,000 Personal &Advertising Injury Limit(Any One Person/Organization) $1,000,000 Medical Expense (Any One Person) $5,000 Damages To Premises Rented To You (Any One Premises) $100,000 Products/Completed Operations Aggregate Limit Included General Aggregate Limit $2,000,000 LIABILITY DEDUCTIBLE $0 LOCATIONS OF ALL PREMISES YOU OWN, RENT OR OCCUPY Location Address Territory 1 25 Highview Avenue, Rye Brook, NY 10573 009 PREMIUM COMPUTATION Rate Advance Premium Loc Classification Code No. Premium Basis Pr/Co All Other PNCo All Other 1 Dwellings-two-family 63011 1 Per Dwelling Included 586.712 Included $587 MINIMUM PREMIUM FOR GENERAL LIABILITY COVERAGE PART: $500 TOTAL PREMIUM FOR GENERAL LIABILITY COVERAGE PART: $587 (This Premium may be subject to adjustment.) MP-minimum premium Coverage Form(s)/Part(s)and Endorsement(s)made a part of this policy at time of issue: See Form EOD (01/95) THESE DECLARATIONS ARE PART OF THE POLICY DECLARATIONS CONTAINING THE NAME OF THE INSURED AND THE POLICY PERIOD. Includes copyrighted material of ISO Commercial Risk Services, Inc.,with its permission. CL150 (10/03) Copyright, ISO Commercial Risk Services, Inc., 1983, 1984, 1988 Page 1 Of 1 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 appropriate box): 0 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 of the NYS Workers' Compensation Board to the government entity issuing the building permit if the project takes a total of 40 hours or more per week(aggregate hours for all paid individuals on the jobsite)for work indicated on a building permit. G'l�1_21t�e2 9 (?zl 2-7/ ZvL Z (Signature of Homeowner) (Date Signed) 1 a7 C, Home Telephone Number g14- 4S¢ _5 (Homeowner's Name Printed) Sworn to before me this _ lay of Property Address that requires the building permit: �r_ a,pa.� Z anty Clerk o /t gry o/Z NYC) 3 Notary Fur iic, State of New York No.01 ME6160063 O!alifed in Westc.he,-ter County Cornmi-I-)n Exnire5,lanuary 29.20L I Once notarized,this BP-1 form series as an exemption for both porkers'compensation and disability benefits insurance coverage. BP-1 (12,08) NY-WCB