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HomeMy WebLinkAboutRP23-025PERMIT # — DATE. a 3 EXR, / 9 SECTION i BLOCK T TYPE OF WORK /S rcag JOB LOC TION C OWNER S / S o7 Q149 CONTRACTOR ,LLC - /) ,���/c� (9i'y)93°7- 7a79 ZoTamommom .COST3 %OFEE b FES11 I V 19CL DATE.433 TCO # FEE DATE DATE FOOTING FOUNDATION FRAMING RGH FRAMING INSULATION PLUMBING RGH PLUMBING GAS 0 SPRINKLER ELECTRIC 0 LOW -VOLT CJ ALARM 0 AS BUILT C] FINAL I NSP OTHEi2 APPROVALS ARB BOT P$ SBA OTHER tcb 4.°a J�V �L BR O VILLAGE OF RYE BROOK MAYOR 938 King Street, Rye Brook,N.Y. 10573 ADMINISTRATOR Jason A. Klein (914) 939-0668 Christopher J. Bradbury www.ryebrook.org TRUSTEES BUILDING& FIRE INSPECTOR Susan R. Epstein Steven E. Fews Stephanie J. Fischer David M. Heiser Salvatore W. Morlino CERTIFICATE OF COMPLIANCE September 21,2023 David Fields&Taylor Fields 51 Talcott Road Rye Brook,New York 10573 Re: 51 Talcott Road, Rye Brook,New York 10573 Parcel ID#: 135.58-1-27 Roof Permit#23-025 issued on 5/19/2023 to Re-Roof Existing Building This certifies that the new roof,installed under the above captioned permit have been satisfactorily completed. Sincerely, Steven E. Fews Building&Fire Inspector /to E C E G� BUILD ENT For office use onl PERMIT# P��S AN 2 9 2023 VIL OK ISSUED: - - . .. 9 8 KING STRE Y1Gi$ Q°dtt} YORK 10573 DATE: VILLAGE OF RYE BROOK 9 FEE: PAiD BUILDING DEPARTMENT w 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 ....................................�.�..(.}............................................ ........................................ Address: 51 T C,0+4- 'r o a-cX Ve 6av K `l f �� l n Occupa /Use: Parcel ID(!: 13 S, S^g — oZ1� r Zone: Owner: /I �C Address: Jam( (alGa�'�-�fogk Ake e/°°i< (6S q P.E./R.A. or Contractor: 0 0�bl e Address: Q3 JT vt- Pb T N� Person in responsible charge: J o Address; _ 3 �l I/>°i� 74✓Y' 0"ted4-tf 4; 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: D A V i h F1 f of being duly sworn,deposes and says that he/she resides at 1 7(11 GD' 4- r0 (Print Name of Applicant) ' ( (No.and Street) in in the County of cue k—C. - in the State of-L�v that (Citylrowry Village) lie/she has supervised the work at the location indicated above,and that the actual total cost of the work,including all site improvements, labor,materials,scaffolding, fixed equipment,professional fees,,and including the monetary value of any materials and labor which may have been donated gratis was: $ for the construction or alteration of, 0 0 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-I O.A. of the Code of the Village of Rye Brook, t 1 Sworn to before me this Sworn to before me this !�� ! U day of ��l � , 20 day of V 20 '� Si f Property owns Signature of Applicant DAV I P -f-CE&Ds 1JAu1 D F(EZ Print Name or Property Owner Prinl ame of Applicant No Public ANNA KiELBASA otnry Public Notary Public• State of New York ANNA KIELBASA Reg.No.01KI6378518 Notary Public• State of New York Qualified in Putnam County Reg.No.01 K16378519 8/12/202 t My Commisslon Expires July 30,2026 Qualified in Putnam County My Commission Expires July 30,2026 QyE BRC��• ID I 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# o�1j� ISSUED: A CT: ` LOCK: ( LOT: LOCATION: ' �1 ` OCCUPANCY: —' ❑ Violation Noted THE WORK IS... XPASSED ❑ FAILED REINSPECTION ❑ SITE INSPECTION REQUIRED ❑ FOOTING ❑ FOOTING DRAINAGE ❑ FOUNDATION ❑ UNDERGROUND PLUMBING NOTES ON INSPECTION: ❑ ROUGH PLUMBING ❑ ROUGH FRAMING i ❑ INSULATION ❑ Natural Gas �� : , ,J ❑ L.P.Gas ❑ FUEL TANK ❑ FIRE SPRINKLER ❑ FINAL PLUMBING ❑ CROSS CONNECTION FINAL ❑ OTHER i s O 'b N v c -° 4-4 V ,-y Ln ` N g, ITT 71 a = a m � ° cv .. w 4-4 L —ld C p O V) oc eQj64 N [ �' w .. .. 0. co i rh °Q ZeqA wvm0 Qo 001#4 f� O Fr'h \ W O� M i�r Z W i v a 7 N vo o � w ; z 00 �-+ gym- F^+ Q H 0.0 O r4 w so : BUILD MENT VI E :RYF- E OK © E C IE � 1yl 938 KING FTRO , NY 10573 �` MAY 16 2023 OFRYEBROOK FOR OFFICE USE ONLY: Approval Date: MAY 1 r t " � Application# Approval Signature: ARCHITECTURAL REVIEW BOARD: Disapproved: : Date: BOT Approval Date: Case# Chairman: PB Approval Date: Case# : Secretary: ZBA Approval Date: Case# Other: Application Fee: Permit Fees: oc)o/—'6V ROOF PERMIT APPLICATION Application dated: l D 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. T� 1. Job Address: J T Gt? ' - Ca q1 SBL: i - '/ ne:,e-lc Property Owner: —Tow or F >o l S vi �`; � ddress: 5-1 � I Go �_ Phone#: ��1i �a-`, r71—c,0 aq Cell#: email: OWL)i& �; e-( l! _�,�'•�� 2. Applicant: P°Lt b! to k Address: �13 W dle V-f— Qb/k C�,-J`k-r Phone#: `1 ' J Y <�WCell#: email: Ah s a.cLit,bye, a: rr7cv,1,re,rst 3. Roofing Contractor: 9 Address: • �( W i'//e- f1 v,\- - Phone#: '�f f " q.?nl q Cell#: email: /41"s 44.4 ,lift r E 9!2 1,r/.Gd n-7 4. Job Description, list all Methods&Materials: gemo t,y_ )(i;S4i'n S i f' �a� 52rn nn�y iC'P_1wg4cr A;&& 4 bco e.,.,(�&e E-S rb o ev Ins- neW GAF 5. Estimated Cost of Job: $ /U ,O O (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: PcJ j er--h,611 NYS Construction Class: 8. Number of stories: Height: 9. Is garage being re-roofed:No:V-Yes:{ )Attached No: ( )•Yes: ( )Number of Cars: 10. Is roof peaked,hip,mansard,flat,etc: 11. Estimated date of completion: -t- 811212021 Please note that this application must include the notarized signature(s) of the legal owner(s) of the above-mentioned property, in the space provided below. Any application not bearing the legal property owner's notarized signature(s) shall be deemed null and void, and will be returned to the applicant. I STATE OF NEW YORK,COUNTY OF WESTCHESTER -TV b , being duly sworn,deposes and states that lietshe is the applicant above named, (print name of individual signing as the applicant) and further states that (s)be is the legal owner of the property to which this application pertains, or that (s)he is the _ C C l" for the legal owner and is duly authorized to make and file this application. (indicate aechitect,contrac or4 gent,attorney,etc.) That all statements can Ined 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 I() Sworn to before me this 16 day of /, (.�h , 20 a3 clay of , 20 DT Sign ure of Property Owner Signature of Applicant b kv l b 1EL -JoL ,� ,-or �e&,_ Print Name of Property Owner Prin Name of Applicant tX otary Public o ry Public ANNA KIELBA9A ANNA KIELGASA Notary public. State of Now York Notary Public• State of Now York Reg.No,01 KI0318519 Reg,No.01KI6378519 Qualified In Putnam County Qualified In Putnam county My Commission Expires July 30,2024 My Commission Expires July 30,2028 .2. 8112/2021 p CCENE DD Talcott Woods Home Owners Association MAY 1 6 2023 OFFICE USE -------------- VILLAGE OF RYE BROOK ' BUILDING DEPARTMENT Revd By Date REQUEST FOR ARCHITECTURAL COMMITTEE REVIEW Document Check List Request From Survey/Plot Plan Specifications Date April 27, 2023 Bldg. Plans Permit Mr./Mrs.: Elevations V Photos Taylor and David Fields Details Other (noted) Address: 51 Talcott Road,Rye Brook,NY 10573 Phone No.: (347)271-2129 Brief description of addition, alteration, improvements, etc.: Repair roof and replace with GAF Timberline shingles(color Charcoal).Repair siding and stain to match existing(color Beachgrass) Contractor: Double RPBJ LLC HOMEOWNERS AFFIDAVIT Address: 439 Willet Ave I have read the covenants and restrictions Portchester, NY 10573 of my Associations and agree to abide by such covenants and restrictions. No work Cert. of Insurance Policy#2582-911-0 will be commenced without the approval of my Association. Certificate#257547 Date:: 04/27/2023 Signed: I Please check with Village of Rye Brook for Building Department Approvals FOR ASSOCIATI1 USE ONLY Approved by Homeowners Association Preliminary Approval Subject to Review J x� Insufficient Information Submitted- Resubmit i t A proved pro ed with the F owing C nditions hair son, Archit ctural Re�w B d • PIDO Date: 2pZag LICENSE NUMBER "THE ORIGINAL" Westchester WC-8561-H97 p O U B LE Operated Since 1960 All Home Improvements EST. 1960 439 Willett Ave. Port Chester,N.Y. 10573 Tel#(914)937-4279 Fax(914)937-4172 http://www.DoubleRwindows.com Mr. David Fields April 12, 2023 51 Talcott Rd Rye Brook,NY 10573 Insurance: All work involved within the following proposal is covered by Workmen's compensation,Public Liability,and Completed Operations Insurance. Roof Contract Supply Labor& Material for the following • Remove existing shingled roof from area of house that has not been recently done. • If any rotted plywood is found it will be an additional cost. • Supply and install ice and water shield over the eaves 6' up. • Install a synthetic Base sheet on remainder of roof. • Install all new F- 5 aluminum drip edge. • Install new roof boots • Install the new GAF Timberline roofing system in owners choice color. • Valleys will be weaved in • Supply a dumpster to cart away job all related debris. • We are certified GAF roof installers Roofing price $14,870.00 **Coupon mailer discount** -1,500.00 $13,370.00 total Terms: Painting,and windows cleaning to be done by others.Hidden rotten wood not included. Standard industry cash term,one half with the order,balance due upon completion. Terms may be modified to meet special conditions. Past due balances are subject to a monthly service charge of 1 1/2%(18%per annum). If the account becomes delinquent,you agree to pay any legal or collection fees expended by Double"R"arising from collection of the account.Permit&Application fees not included.Due to the fluctuating prices in plywood we reserve the right to adjust price. Double"R^is not responsible for reoonnectiag existing alarm systems on windows and doors. You the owner may cancel this transaction at anytime prior to midnight of the third business day. After the date of this transaction,such Cancellation must be made in person,at the offices of community improvements,or in writing postmarked prior to the fourth business day.We accept VISA or Mastercard with a 3%convenience surcharge on total amount being charged. Acceptance: The above prices,specifications and conditions are satisfactory and are accepted. Double"R"is authorized to do the work as specified. Contractor Performance Warranty: Double"W'proposes to furnish and install labor and material in accordance with above specifications in order that the above qualifies for the Manufacturer's Long-Term Warranty. In addition,all labor provided by Double"W is unconditionally warranted for a period of Ten years from the date of installation. Approximate Start Date: Approximate Completion Date: Customer: $13,370.00 (Amour Date: (Sales Tax) Double "R": $13,370.00 (Total Amount) Date: $6,685.00 (Deposit) $6,685.00 (Balance Due Upon Completion) Return original contract to Double"R", retain a copy for your records. Visit Our Showroom Located At 439 Willett Avenue Port Chester, N.Y. 10573 ir 46 46 .Ro tY` �e'r`c��• �: S .N e • y .is ,r f •f.•, • •!•,- v .j ��r,� 1 �� .1•i �� '.i : � aim � wa• AT IF �•' •; `�".•' •_ ..+.ter,.� '� .TJ',•t• �i- n�. ."L t A i W-_ 4/25/23,9:11 AM Timberline HDZ-America's best selling roof shingle I GAF Specifications Timberline HDZ° Specs ABOUT SPECS DOCS V11 (HTTPS://WWW.GAECOM/EN- (HTTPS://WWW.GARCOM/EN- (HTTPS://WWW.GAF.COM/EN- (HTTPS://WW' US/PRODUCTS/TIMBERLINE- US/PRODUCTS/TIMBERLINE- US/PRODUCTS/TIMBERLINE- US/PRODUC' HDZ) HDZ/SPECIFICATIONS) HDZ/DOCUMENTS) HDZ/1 SPECIFICATIONS (ALL DIMENSIONS ARE NOMINAL) AWARDS & Good Housekeeping Rated RECOGNITION 25-YEAR STAINGUARD PLUSTm ALGAE StainGuard PIusTm Algae Protection PROTECTION LIMITED Limited Warranty WARRANTY S - SSSS SS DURABILITY & Advanced Protection Shingle with TOUGHNESS GAF Dura Grip Adhesive EXPOSURE 5.625" (144 mm) EXTREME WEATHER No IMPACT RATED FIRE RATING Highest Rating - Class A MATERIAL Fiberglass Asphalt Construction WIND RATING Eligible for the WindProvenTM use cookies to operU mded�1 End,Wmacdy,wheration and functionality,analyze site usage,and assist in our ;zing efforts. installed with four required GAF accessory products Manage Your Cookie Preferences SHINGLE STYLE Wood-Shake Look https:r/www.gaf.com/en-us/products/timberline-hdz/specifications 1/4 Timberline HDZ-America's best selling roof shingle I GAF Specifications SPECIFICATIONS (ALL DIMENSIONS ARE NOMINAL) SHINGLE TYPE Architectural Shingles APPROX.NAILS/SQ 256 AWARDS & RECOGNITION: Good Housekeeping Rated 25-YEAR STAINGUARD PLUSTM ALGAE PROTECTION LIMITED WARRANTY: StainGuard PIusTm Algae Protection Limited Wa rra my $ - $$$$: SS DURABILITY &TOUGHNESS:Advanced Protection Shingle with GAF Dura Grip Adhesive EXPOSURE:5.625" (144 mm) EXTREME WEATHER IMPACT RATED: No FIRE RATING: Highest Rating - Class A MATERIAL: Fiberglass Asphalt Construction WIND RATING: Eligible for the WindProvenTm Limited Wind Warranty when installed with four required GAF accessory products SHINGLE STYLE:Wood-Shake Look SHINGLE TYPE:Architectural Shingles APPROX.NAILS/SA: 256 CODES FBC State of Florida Approved ICC ESR-1475 ICC AC,438,cookies to ope6f i ,(y'lbsite,enhance site navigation and functionality,analyze site usage,and assist in our - MIAMI-DADE COUNTY Miami-Dade County Product Control Approved https: --n-us/products/timberline-hdz/specifications 2/4 ?'2 Timberline HDZ-America's best selling roof shingle I GAF Specifications CODES TDI Meets requirements of the Texas Department of Insurance FBC: State of Florida Approved ICC : ESR-1475 ICC AC438: ESR-3267 MIAMI-DADE COUNTY: Miami-Dade County Product Control Approved TDI: Meets requirements of the Texas Department of Insurance TESTING METHODS & APPLICABLE STANDARDS TAS 100-95 Yes TAS 100-95:Yes ENERGY RATING COOL ROOF RATINGS CRRC-rated (White only) COUNCIL(CRRC) MIAMI 21 (FLORIDA Yes (White only) BUILDING CODE) TITLE 24 (CALIFORNIA ENERGY Yes (two colors only) COMMISSION) COOL ROOF RATINGS COUNCIL (CRRC): CRRC-rated (White only) MIAMI 21 (FLORIDA BUILDING CODE):Yes (White only) COO i 'o opera+e r 6 e si'e enhanc sit nov ation and functionality,analyze site usage,and assist in our TITLE 24 (C, MIA ENER64��MMISSIOI�):des (Zo colors only) htips: products/timberline-hdz/specifications 3/4 �::-!� � �:�� ���• -_ "f At A F A �(d� Jt /� l�'� �%�f A ��5`A r�t yi . . . . . . . . . . . . . . . . . . a s. �•i 3 vOi �y,;• y co %� N M tt ••• �=ofas bi _la. • W : W U U � V: Come)), L0114 m w j. o ° 5 �o�ection a Q z a, �Q •�= t 511.1j O d W ¢ � U s. W � :.la (L pp:rr • V'lf 'r Cans ..u, O 'Pip. m J = a s s,. 4 CV) CC °r a. sd. �e m Clq p M 64 11 FdF .�� ^�s. .,. .1 �3i0• x r 1 1 �.�gr, Fe , r•�zs f�!�(0)> • DATE(MM/DDIYYYY) ACORO® CERTIFICATE OF LIABILITY INSURANCE F1 17/2023 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: Betty Reyes The Willett Insurance Agency PHONE. 914 481-5599 888 371-9783 g Y AIC,No E:t: A/C,No 338 Willet Ave ADDRESS: bettyreyes,(r thewillettinsurance.us INSURER(S)AFFORDING COVERAGE NAIC# Port Chester NY 10573 INSURER A: Westchester Insurance Company INSURED INSURER B: Double R PBJ,LLC INSURER C: 439 Willett Ave INSURER D: INSURER E Pon Chester NY 10573-3179 INSURER F COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER (MMIDD/YYYY) (MM/DD/YYYY) LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE ©OCCUR PREMISES Ea occurrence $ 100,000 MED EXP(Any one person) $ 5,000 A BP4904585Q2022 12 13/2022 12/13/2023 PERSONAL S ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY PRO- JECT LOC PRODUCTS-COMPIOP AGG $ 2,000,000 OTHER: $ AUTOMOBILE LIABILITY Ea accident $ ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS HIRED NON-OWNED DAMAGE $ AUTOS ONLY AUTOS ONLY Per accident) UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB HCLAIMS-MADE AGGREGATE $ DED I I RETENTION$ $ ORKERS COMPENSATION PER ND EMPLOYERS'LIABILITY Y/N STATUTE 1 11 ER NY PROPRIETOR/PARTNER/EXECUTIVE❑ NIA E.L.EACH ACCIDENT $ FFICER/MEMBER EXCLUDED? Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ f yes,describe under ESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN The Village of Rye Brook ACCORDANCE WITH THE POLICY PROVISIONS. 938 King Street AUTHORIZED REPRESENTATIVE Rye Brook NY 10573 ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD NEW Workers' sTRK A E Compensation CERTIFICATE OF Board NYS WORKERS' COMPENSATION INSURANCE COVERAGE 1a.Legal Name 8 Address of Insured(use street address only) 1b.Business Telephone Number of Insured Double R PBJ,LLC 914 937-2237 439 Willett Ave Port Chester,NY 10573 tc.NYS Unemployment Insurance Employer Registration Number of Insured Work Location of Insured(Only required if coverage is specifically limited to 1d.Federal Employer Identification Number of Insured a Social Security certain locations in New York State,i.e.,a Wrap-Up Policy) Number 92-1106938 2.Name and Address of Entity Requesting Proof of Coverage 3a.Name of Insurance Carver (Entity Being Listed as the Certificate Holder) NYSIF The Village of Rye Brook 938 King Street 3b.Policy Number of Entity Listed in Box"1 a" Rye Brook,NY 10573 8910587 3c.Policy effective period i9ngnmv to 1?i7cu?m:t 3d.The Proprietor,Partners or Executive Officers are included.(Only check box if all partners/officers included) all excluded or certain partners/officers excluded. This certifies that the insurance carrier indicated above in box"3"insures the business referenced above in box"la"for workers' compensation under the New York State Workers'Compensation Law.(To use this form,New York(NY)must be listed under Item 3A on the INFORMATION PAGE of the workers'compensation insurance policy). The Insurance Carrier or its licensed agent will send this Certificate of Insurance to the entity listed above as the certificate holder in box"2". Will the carrier notify the certificate holder within 10 days of a policy being cancelled for non-payment of premium or within 30 days if cancelled for any other reason or if the insured is otherwise eliminated from the coverage indicated on this certificate prior to the end of the policy effective period? EYES ONO This certificate is issued as a matter of information only and confers no rights upon the certificate holder.This certificate does not amend, extend or alter the coverage afforded by the policy listed,nor does it confer any rights or responsibilities beyond those contained in the referenced policy. This certificate may be used as evidence of a Workers'Compensation contract of insurance only while the underlying policy is in effect. Please Note: Upon cancellation of the workers'compensation policy indicated on this form,if the business continues to be named on a permit, license or contract issued by a certificate holder,the business must provide that certificate holder with a new Certificate of Workers'Compensation Coverage or other authorized proof that the business is complying with the mandatory coverage requirements of the New York State Workers'Compensation Law. Under penalty of perjury, I certify that I am an authorized representative or licensed agent of the insurance carrier referenced above and that the named insured has the coverage as depicted on this form. Approved by: Betty Reyes (Print nam uthorized representative or licensed agent of insurance carrier) Approved by: (Sig ure) (Date) Title: Insurance representative Telephone Number of authorized representative or licensed agent of insurance carrier: 914481-5599 Please Note: Only insurance carriers and their licensed agents are authorized to issue Form C-105.2.Insurance brokers are NOT authorized to issue it. C-105.2(9-15) www.wcb,nygov