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HomeMy WebLinkAboutBP23-059TCO 8 FEE DATE u�PECTION RECORD I DATE INSP FOOTING FOUNDATION FRAMING RGH FRAMING INSULATION PLUMBING RGH PLUMBING GAS O SPRINKLER ELECTRIC 0 LOW -VOLT O ALARM � AS BUILT � fp /44 FINAL OTHER APPROVALS ARB BOT �l3S- 935s PB ZBA OTHER poa3-oy9/704e00rell; 1j1U*WAijj �7ea�'nJ VILLAGE OF 1?t�E BROOK WESTCHESTER COUIPY, NEW YORK No : 24-049 (Certificate of ®ccupaucp Zhis is to certify that rUl1C -wm cjapeyt-a c Vaj?.S' '( /yQyy�Z(Co GU of, having duly filed an application on ljOj 20_e requesting a Certificate of Occupancy for the premises known as, Rye Brook,NY, located in a _ / Zoning District and shown on the most current Tax Map as Section: 5 - & Alock: C-:;� Lot: and having fully complied with the requirements of the Building Code and the Zoning Ordinance under Building Permit No. 9,issued 5 ,5 20�3, such authority and permission is hereby granted to the property owner to lawfully occupy or use said premises o building or part thereof listed under the following New York State Classifications,Use: ks/ one /"ILI Construction: U 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 facilities shall be made,and no enlargement, whether by extending on any side or by increasing in height shall be made,n shall the building be moved from one location to another until a permit to accomplish such change has a ob me om a uilding Inspector. L Building Inspector, Village of Rye Brook: Date: 5 DR For office u e onl : BUILD ENT PERMIT 9 APR 16 2024 VIL OF RYE OK ISSUED: .'S— 938 KING STRE YE BROOKS YORK 10573 DATE: VILLAGE OF RYE BROOK 9 -06 O,c FEE: ,& C-- PAID BUILDING DEPARTMENT APPLICATION FOR CERTIFICATE OF OCCUPANCY,CERTIFICATE OF COMPLIANCE, AND CERTIFICATION OF FINAL COSTS TO BE SUBMITTED ONLY UPON COMPLETION OF ALL WORK, AND PRIOR TO THE FINAL INSPECTION sssssrarsrrssssssss►�sl►ssrss►*►►s►►ss««**«*r*»*ww*«**»•swt*»sss**»wt►»s►ws►rr►s►sssss►sssssrss*ttsss►sts►ssss►ssss►rsrssss►s►s Address: 2 V L��f 7 i � / n Occupancy/Use: /��1' Parcel ID#: /3� 6 — —1 7 Zone: loc— Owner: F*4yoo1 S Go SA'tY'Eo i2B- Address: Z reAt O� 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: 7 61f 40 S 1 1;6- being duly sworn,deposes and says that he/she resides at (Print Name of Applicant) (No.and Street) in l'� //h'DO�! -----,in the County of 44)1!�S_7�/L in the State of A/, X, ,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:$ 3{ for the construction or alteration of: 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 Sworn to before me this day of ��s ^f �� , 20 day of , 20 F Signa re of Pro a Signature of Applicant PilName of Property Owner Print Name of Applicant -60—L-11 �� LL Notary Public Notary Public SHARI MELILLO Notary Public,State of New York 8/12^021 No.OIME6160063 Qualified In Westchester Count`]-- Commission Expires January 29,20'!/ QyE BRC�v� cu � • 19312 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 : 1A L L ; DATE: r 2 2 C�2/ PERMIT# J -� �� ISSUED: S "� "lj SECT: Jz 5 •(o/7 BLOCK: LOT: / 1+ LOCATION: !F'C _� C IZ >.� Q Uy^ OCCUPANCY: ❑ Violation Noted THE WORK IS... 9 PASSED ❑ FAILED / REINSPECTION ❑ SITE INSPECTION REQUIRED ❑ FOOTING ❑ FOOTING DRAINAGE ❑ FOUNDATION ❑ UNDERGROUND PLUMBING NOTES ON INSPECTION: ❑ ROUGH PLUMBING ❑ ROUGH FRAMING ❑ INSULATION❑ Natural Gas ��f/ 4 /y-e 4 ❑ L.P. Gas SrcG c� ❑ FUEL TANK ❑ FIRE SPRINKLER ❑ FINAL PLUMBING ❑ CROSS CONNECTION ) Ja' FINAL I(�V FE� f� ^� b4 ❑ OTHER QyE BR(��, 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: DATE: PERMIT# ISSUED: SECT: BLOCK: LOT: LOCATION: 1 N c 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 / 1 r ❑ Natural Gas ❑ L.P. Gas 0 2 f r ,c' �..1c •, ;, _',, ?- ' ❑ FUEL TANK ❑ FIRE SPRINKLER C�y ❑ FINAL PLUMBING t ❑ CROSS CONNECTION ` ❑ FINAL ❑ OTHER r , , � s �Nry N w 7 • N lLn iLn v cw� o ,_, Fq � O co'. e� Cl) a v ° x w r t;- 0.0 a 0 0 fs7 P�1 V �o o -g ti °A p to : Q 0�1 v ' p p 70 en p w 3 u C a 0 W OJ r-i r^ ^ 1+-1 ►Q1 C 0 T V J y W Z ° o ° � cn O Cc) � � p � � � � � � Q v tl�,•tipp cai� v" Mom! pco gc � A z 0 l O a o � owe � o 0 o p A W � 5 'C' o M� m � � r " � Cs] V oz v v = U ~ V P � ou : W ° Z R`` 96 Z O Cr.b uq w 0 '° c v E � �U a W o 3 z z " "` � v � W Qw Q n V wp Cf) � x o � . A 0 .. a BUILDING DEPARTMENT D VILLAGE OF RYE BROOK MAY - 3 2023 938 KING STREET RYE BROOK,NY 10573 (914)939-0668 VILLAGE OF RYE BROOK wwwxyebr_ook.org ; BUILDING DEPARTMENT INTERIOR BUILDING PERMIT APPLICATION FOR OFFICE USE ONLY: Approval Date: M A Y 5 ermit / d — Application Fee: $ eJ /— Approval Signature: Permit Fees: $ f C�7 _ 6 L Disapproved: Other: Application dated:s�3--�3 is hereby made to the Building Inspector of the Village of Rye Brook,NY,for the issuance of a Permit for the interior alteration of an existing building,or for a change in use,as per detailed statement described below. \ 1. Job Address: 2— V, 1 v— J/rJ Ce ; N /' SBL:/f J5i 6 7 Zone: — 2. Proposed Improvement. (De scri a in detail): Gil LW Rp OM Fkaf,- l i tgL< ll.4Y/ z_ Q/�F mr;&mNe /NsT aA aow . N-FW 7-1tk �z/o�& J11yK ve' r#N9 3. Does the proposed improvement involve a Home-Occupation as per§250-38 of the Code of the Village of Rye Brook? No: Yes: If yes,indicate: TIER I: TIER 11: TIER III: 4. 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...) :No: Yes: (If yes,please submit a separate Automatic Fire Suppression System Permit application&2 sets of detailed engineered plans) 5. Occupancy; (I fam.,2 fam.,comm.,etc...)Prior to Construction: I EA M. After Construction: S f M� 6. N.Y State Construction Classification: N.Y. State Use Classification: 7. Properly Owner: }r/1¢}/>CfS GD S,44 ilFP11A Address: 12 11,lu b� Tr Phone# y 3�' 9 3 s Cell# c�y!� j 'J SS email: T (ems 8. Applicant: 1'a2bVCiSL, 20 Address: Phone# Cell# i/ email: / 9. Architect: Address: Phone# Cell# email: 10. Engineer: Address: Phone# Cell# email: 11. General Contractor: Address: Phone# Cell# email:.��Ss 12. Estimated cost of construction $ �FE002 (NOTE The estimated cost shall include all labor,material,scaffolding,Fixed equipment,professional fees,and material and labor which may be donated gratis.) 13. Job Timetable: Start: Finish: (1) 8/12/2021 BUILDING DEPARTMENT F J v VILLAGE OF RYE]BROOK 938 KING STREET RYE BRQOK,NY 10573 MAY - 3 2023 (914 . 7066$ VILLAGE OF RYE BROOK r BUILDING DEPARTMENT 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: Ff /yC if ( SAS} l/E G' , residing at, (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; 'E Alp--C}C E 6 , 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. (Sig a of Property Owner( (Print Name of Property Owner(s)) n Sworn to before me this 20 (Not Public) SHARI MELILLO Notary Public,State of New York No.OIME6160063 Qualified In Westchester Coun (2) Commission Expires January 29,2� 8/12/2021 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. 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. i Sworn to before me this Sworn to before me this day of 174 7 , 20 1 day of 120 ySiglo"roo,qowner Signature of Applicant Mame of Property Owner Print Name of Applicant Notary Public Notary Public SHARI MEULLO Notary Public,State of New York No.01ME6160063 —7 Qualified in Westchester January 29,20 ! Commission Expires (`t) 8/12/2021 a M \ a 0 a v � aZON vi a z N Z s Zen rlenQ c cis C �i OZo w � M � o a O A � ' W00 O "s Z � C) 00 00 04 00 Z A Q ►� W W 1.4 Q wo a W o z O -. OR o � 3 W N N z � w z w Z Q o 0 i H � p v A w a � �I � a a � w z � �E �R BUIL G MENT MAY - 2 2023 VIL 6 OF RYE OK 938 KIN 'ET RYE B ,NY 10573 VILLAGE OF RYE BROOK 0r2 BUILDING DEPARTMENT W or PLUMBING PERNIIT AAPPLICATION 1 Q FOR OFFICE USE ONLY BP#: Q 3--0 S / PP#: Q 3-O 1 Approval Date: MAY 0 5 201Permit Fee: $1 ODL Approval Signature: Other: Disapproved: (fees are non-refundable) Application dated, 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 sai/d/plumbing work will be in conformance with all applicable Federal,State,County and Local Codes. 1.Address: /Z vA�/G' �,r�'� SBL:/��,6_7—v)4 9 Zone:/K_ 7 2.Proposed Work: 3.Property p rty Owner. �f l'/r(J %' SSA 14 yeo/eA Address:Phone#: _ Cell#: -email/ / ). 4.Master Plumber: J 02 T C G14 Address: 244 7+O 20 F'o+U .'l rt�.6 Lic.#: �C> Phone#:l C %`. ✓ Cell#: —t email: Company Name: oP i Address: INDICATE FIXTURES&LINES TO BE INSTALLED AS PER THE FOLLOWING LSCHEDULE: r Location Water Urinals Drinking Sinks Showers Bath Laundry Domestic Fire Sanitary Natural/ Other* Total Closets Fountains Tubs Tubs Service Service Sewer LP Gas Basement l st Floor 2nd Floor 3`d Floor 4'Floor 5"Floor Exterior 5.*List Other Equipment/Provide Details: N i (Notarized Signatures Required Next 2 Pages) STATE OF NEW YORK C9UNTY 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 Master Plumber for the legal owner and is duly authorized to make and file this application. 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. 0 7 Sworn to before me this o Sworn to before me this day of ,20 day of ,20 23 Nord •ZZ�r� XOn` Si tore of Property Owner w-n o Signatur of Applicant �m /�I,wesG� �if>a0[lG�2A o e Print Name of rope ner Print Name of Applicant y SCM d.00'IIVE Notary Publi&J NOTARY PUBLIC OF NEW YORK Public I.D.#01G06357188 ry DOREEN A SALVATI NOTARY PUBLIC,STATE OF NEW YORK Registration:NO,OISA6299217 Qualified in Westchester ur y This application must be properly completed in its entirety and must in wok m atur 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. -2- 3/3/2023 BUILD MENT D ECENE D VIL E 01FX OOK MAY - 2 2023 938 KING ET R "R NY 10573 4 1�l VILLAGE OF RYE BROOK BUILDING DEPARTMENT 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: �, �/j4&Ct s'� Si/�1de��A , residing at, Z �/ C e c (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; ✓✓ lel 2 , 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. g(Si.-naProperty Owner(s)) (Print Name of Property Owner(s)) Sworn to before me this l Sr day of , 20Z7j (Notary Public) SCOTT J.GOWE NOTARY PUBLIC OF NEW YORK I.D.#01GO6357188 MY r�nMMISSION EXPIRES?✓JjZ--2 8/12/2021 Alfredo DiVitto From: Alfredo DiVitto Sent: Friday, April 26, 2024 8:49 AM To: fsaprojects@gmail.com Cc: Steven Fews Subject: stop work order.. Good morning Mr. Saavedra As per our phone conversation and the discussion we had at the house during the bathroom inspection we will need a letter from the plumber stating all the work was done in accordance with the 2020 N.Y.S. plumbing code for us to close the building and plumbing permits for the second-floor renovation. Also, in speaking with steven Fews the building inspector he has stated you are going to need other permits for the new shed, fence, gazebo, and rear yard work.This was all stated on the stop work order and site inspection report. Any question give us a call at the Building Department. Thank you, Alfredo (Freddy) DiVitto Assistant Building Inspector Village of Rye Brook 938 King St. Rye Brook,N.Y. 10573 Office: 914-939-0668 i D � MAY p � 2024 VILLAGE OF RYE IBROO gU1LDING DEPAR 04/30/2024 Joe Carelli Plbg. & Htg. 2420 Boston Post Rd Larchmont NY 10538 Anthony Carilli-914-924-1066 Fax-914-630-1628 Building Inspector Village of Rye Brook 938 King St. Port Chester NY 10573 Re: 12 Valley Terrace Owner: Francisco Saavedra 2"`i floor bathroom Permit # PP23-049 To Building Inspector, This is to verify that all the plumbing work complies with the requirements of the Plumbing Code of New York State. From what I see, I verify that I have inspected the existing plumbing work and found it be in compliance with the plumbing code of New York State. Anthony Carilli-Master Plumber Joe Carelli Plbg. & Htg Liscense # 495 Anthony Carilli-VP i% � � r STOP WO RK OR 0 - E , R DULY ISSUED BY THE BUILDING DEPARTMENT, VILLAGE OF RYE BROOK, NY 938 KING STREET, RYE BROOK, NEW YORK 10573 • (914) 939-0668 • FAX (914) 939-5801 • www.rvebrook.org I� N T 1-4 '. YOU ARE HEREBY DIRECTED TO STOP ALL WORK AND TO OTHERWISE CEASE & DESIST ALL UNLAWFUL USE OF THIS PROPERTY/PREMISES AT, �c �- K a cg- RYE BROOK, NY. DA I E ISSUED: L11�Jj I � TIME ISSUED: \\.�15 (AC.M./P.M.) PERMIT #: �,30C�A' � QATION #: due Building Permit Check List&Zoning Analysis ^� Q Address:! I V e C,C SBL• ��� 4 & / Zone: l'� Use: , Const.Type: U Other. Submittal Date: l 3 Revisions Submittal Dates: Applicant: Nature of Works Reviews:2Bt - MAY 0 PB: BOT: Other. . y� t�FEES:Filing. 1 BP: �'C/O: �'—tom Flood Plane Legalization: c APP: Dated Notarized: SBL: �Truss I.D. Cross Connection: H.O.A. ( ) ( ) Scenic Roads: Steep Slopes: Wetlands: Storm Water Review: Street Opening. a ( ) ( ) ENVIRO: Long. Short: Fees: Nil ( ) ( ) SITE PLAN:Topo: Site Protection: S/W Mgmt.: Tree Plan: Other. ( ) ( ) SURVEY:Dated Current: Archival• Sealed Unacceptable: ( ) ( ) PLANS:Date Stamped. Sealed. Copies: Electronic tether ( ) (,, icense: Workers Comp: Liability: Comp.Waiver. �/ Other. ( ) ( ) CODE 753#: Dated N/A: ( ) ( ) HIGH-VOLTAGE ELECTRICAL.•Plans: Permit: N/A: Other. O O LOW-VOLTAGE ELECTRICAL Plans: Pemut: N/A: Other. (� ( ) YIRE ALARM/SMOKE DETECTORSPlaps: Permit H.W.I.C.:_,Battery:_Other. (� ( PLUMBING:Plans: Permit: i/ 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 2020 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. ( ) ( ) Other. ( )ARB mtg.date: approval notes: ( )ZBA mtg.date: approval notes: ( )PB mtg.date: approval: notes: REQUIRED EXISTING PROPOSED NOTFS l4P 'r `_'E© MAY 0 Frontag Fronc: Front: Si : &Cur- Main Q Accs.Cov Ft.HS : Sd,H/Sb: QFa Tot,Imp FG ImD: Pr HHdght/Stories: notes: Hanover Insurance Group", 1W RENEWAL DECLARATION # 21 AC RENEWAL OF POLICY HNY D100002 H O M E O W N E R S P O L I C Y POLICY NUMBER FROM POLICY PERIOD TO COVERAGE IS PROVIDED IN THE AGENCY CODE HNY D100002 12/21/22 I 12/21/23 THE HANOVER INSURANCE COMPANY 860807300 NAMED INSURED AND ADDRESS AGENT FRANCISCO SAAVEDRA TELEPHONE : 914-235-3144 VANESSA S IRARRAZABAL MARENCO INSURANCE AGCY INC 12 VALLEY TER 2525 PALMER AVE RYE BROOK, NY 10573 NEW ROCHELLE, NY 10801 POLICY PERIOD- 12:01 A.M. STANDARD TIME AT THE RESIDENCE PREMISES THE PREMISES COVERED BY THIS POLICY IS LOCATED AT THE ABOVE ADDRESS. CONSTRUCTION PREM. NO. OF TERR. PROT. YR. SECTION I LOSS SEAS/SEC GROUP FAM. CODE CONST. DEDUCTIBLE FRAME 57 1 40 04 41 $1000 PER OCCURRENCE NO COVERAGE IS PROVIDED WHERE A PREMIUM OR A LIMIT OF LIABILITY IS SHOWN SECTION I COVERAGE LIMIT OF LIABILITY PREMIUMS A. DWELLING $486, 000 $3, 906.00 B. OTHER STRUCTURES $48, 600 C. PERSONAL PROPERTY $364, 500 D. LOSS OF USE $145, 800 SECTION II COVERAGE E. PERSONAL LIABILITY $300, 000 EACH OCCURRENCE F. MEDICAL PAY. TO OTHERS - $1, 000 EACH PERSON $20.00 TOTAL BASIC PREMIUM - - - - - - - - - - - - - $3, 926.00 ADDITIONAL PREMIUMS PLATINUM HO-3 SELECT PLUS $293.00 TOTAL ADDITIONAL PREMIUMS - - - - - - - - - - - - - $293.00 RATING CREDITS OPTIONAL DEDUCTIBLE $469.000R TOTAL RATING CREDITS $469.00CR VALUED CUSTOMER CREDITS CREDIT FOR PROTECTIVE DEVICES $195.000R NON-SMOKER DISCOUNT $39.00CR 25% CREDIT FOR INSURING BOTH YOUR AUTO AND HOME WITH US $977.000R TOTAL VALUED CUSTOMER CREDITS $1,211.000R TOTAL CREDITS - - - - - - - - - - - - - - - - - - - $1, 680.00CR TOTAL PREMIUM ADJUSTMENTS - - - - - - - - - - - - - $1, 387 .000R TOTAL ANNUAL PREMIUM - - - - - - - - - - - - - $2,539.00 MORTGAGEE M&T BANK ISAOA LOAN # 0031395924 PO BOX 5738 SPRINGFIELD, OH 45501 CONTINUED ON NEXT PAGE DIRECT BILLED 11/07/22 2109192227 PAGE 01 OF 02 ORIGINAL/INSURED 1W RENEWAL DECLARATION # 21 AC RENEWAL OF POLICY ENY D100002 H O M E O W N E R S P O L I C Y POLICY NUMBER FROM POLICY PERIOD TO COVERAGE IS PROVIDED IN THE AGENCY CODE HNY D100002 12/21/22 I 12/21/23 THE HANOVER INSURANCE COMPANY 860807300 NAMED INSURED AND ADDRESS AGENT FRANCISCO SAAVEDRA TELEPHONE : 914-235-3144 VANESSA S IRARRAZABAL MARENCO INSURANCE AGCY INC 12 VALLEY TER 2525 PALMER AVE RYE BROOK, NY 10573 NEW ROCHELLE, NY 10801 FORMS AND ENDORSEMENTS - H00003 04/91, H02343 04/91, 231-0600 04/83, 231-6073 03/13, 231-6217 11/15, 231-2364 06/06, 231-2745 09/09, 231-2323 06/06, 231-2324 06/06, H00453 04/91, 231-2326 06/06, 231-2325 06/06, 231-2328 06/06, H00435 04/91, 231-2235 12/05, H00490 04/91, 231-2341 06/06, 231-2331 06/06, 231-1937 01/01, 231-6026 03/12, H00477 06/94, 231-5761 03/12, 231-6317 03/17, 231-2407 03/17*, H00320 12/94, H02493 02/00, 391-0565 01/83. DESCRIPTION OF ADDITIONAL COVERAGES HURRICANE CATASTROPHE PERCENTAGE DEDUCTIBLE = 2% OF THE COVERAGE A LIMIT: DOLLAR EQUIVALENT = $9720 EMPLOYERS LIABILITY NUMBER OF EMPLOYEES IS 1, COVERAGE FOR OCCASIONAL SERVANT. CREDIT FOR PROTECTIVE DEVICES PERCENTAGE IS 05 11/07/22 2109192227 DIREC PAGEL 02 OF 02 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 appropriate box): ❑ 1 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 thq building permit. r1. L (Signature of Homeowner) (Date Signed) F19�17l/(!i i S z-o SA,�VFP124 Home Telephone Number 9f'Y t13 2 3 j�r (Homeowner's Name Printed) • Sworn to before me this day of Property Address that requires the building permit: (Co4—in­ty__C1_erk or Notary Public) -- jjr1.OAIX SHARI MELILLO Notary Public,State of New York No.OIME6160063 Qualified In Westchester County Commission Expires January 29,20T-7 o- Once notarized,this BP-1 form serves as an exemption for both workers'compensation and disability benefits insurance coverage. BP-1 (12/08) NY-WCB