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HomeMy WebLinkAboutBP23-087PERMIT SECTION TYPE OF JOB LOC/ T. COST UCJ # a -- 7 DATE: oQ 3 FEES _ TCO I FEE DATE uucoRrT10N REGOR� I DATE INSP FOOTING FOUNDATION FRAMING RGH FRAMING INSULATION PLUMBING RGH PLUMBING GAS SPRINKLER ELECTRIC LOW -VOLT ALARM AS BUILT FINAL 70 9 ,QviajQs C91Y)939- OTHER APPROVALS ARB BOT PB ZBA OTHER AS-BUILTIFINAL SURVEY REQUIRED PRIOR TO FINAL INSPECTION CCe�Ved /c�//o VILLAGE OF RYE BROOK WESTCHESTER COUNTY, NEW YORK 4 NO: 23-178 Certificate of Orcup ucp his is to certify that FF of, Y , /�- having duly filed an application on 7 20 requesting a Certificate of Occupancy for the premises known as, 7� L;1"e-sr-eaw Rye Brook,NY, located in a Zoning -J District and shown on the most current Tax Map as Section: Block: / Lot: _. and having fully complied with the requirements of the Building Code and the Zoning Ordinance under Building 19 Permit No.Of /, issued 11q20a25, 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: R /01)e--12a2ZZ1J 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 facilities shall be made,and no enlargement, whether by extending on any side or by increasing in height shall be made nor shall the building be moved from one location to another until a permit to accomplish such change has en obta' from a uilding Inspector.\11 NOV ' 6 1013 Building Inspector,Village of Rye Brook: Date: DLVALLit\%J "Cda Al\1ITA1 1I l PERM 4&c,),3,—OJCJ 7 VILLAGE OF RYE BROOK ISSUED: AUG 2 3 2023 38 KING STREET,RYE BROOK,NEW YORK 10573 DATE: a 3-d3 (914)939-0668 FEE: ,& //per PAID, VILLAGE OF RYE BROOK WW*,r rook.org BUILDInIr DFPARTk1!_-_ IT ,�,� APPLICATION t 4 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 srsssssssssssssswssssssessssrwwswwssrsssrrrrrrstrsrrrrrtrrwstwwwswssssrssssssssssssssssrss.s.■..................... Address: 179 Ivy Hill Crescent, Rye Brook, NY 10573 Occupancy/Use: / )S4A4—Parcel ID#: t2�.76-Y�=. Zone: - Owner: Matthew and Dana Perlstein Address: 179 Ivy Hill Crescent, Rye Brook, NY 10573 P.E./R.A. or Contractor: Barajas&Sons Landscaping Inc Address: P.O.Box 565 Port Chester, NY 10573 Person in responsible charge: Matthew and ban* Perlstein Address: 179 Ivy Hill Crescent, Rye Brook, NY 10573 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: Matthew and Gana Perlstein being duly sworn,deposes and says that he/she resides at 179 Ivy Hill Crescent (Print Name of Applicant) (No.and Street) in Rye Brook in the County of Westchester in the State of NY that (Cit% 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 mav" have been donated gratis was:$ 4,500 for the construction or alteration of: Stone paver patio 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 structuretwork 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-IO.A.of the Code of the Village of Rye Brook. tin Sworn to before me/t�h�is � Sworn to before me this 2-3 atgtature of rroperty owner atgnance of Appucant /I x- Pev L�6n ___00/v P, lj-lej� 1-7d�' �-(4" Print Name of Property Owne Print Name of Ap licant BALSAM S No p C,STATE OF NE NOT Registration No. 01 BA4994963 Registration No. 01 BA4994963 Qualified in Westchester County Qualified in Westchester County Commission Expires January, 31,2028 Commission Expires January, 31, 2028 QyE BRC�v� j' • 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.or8 - - - - - - - - - - - - - - - - - - - - INSPECTION REPORT - - - - - - - - - - - - - - - - - - - - ADDRESS:— t DATE: PERMIT# UED: SECT: ICJ ` BLOCK: ( LOT: 'v. LOCATION: �7 L OCCUPANCY:/ ❑ Violation Noted THE WORK IS... 0-1'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 ❑ OSS CONNECTION FINAL ❑ OTHER : : n 00 M N O d G 4-4 x a� t� a, CA = p w O ^ w o W © z N dIt 00 Cc, cu •a v� o let �4 94 a. LO w LO (n w � W � U C) � �-, A o 0 -a v V O p 1 Z a C: 0, z � z4 v a o �T MM d p : C� a z � �" w � z o � � \ Acc C � � � � : 1a y zrn w w -° CD U z 'w y .y Lr) H > ? O Z FMes! W tY F O 0 v U ZIL � U U U z °� -o r� WZ G1 A z O co R. W W W �.( p x IED BUILDING D'FPARTN ENT D [E C E Q VIL ,��,F OF RY OOK MAY 16 2023 938 KING i'r RYE BR ,NY 10573 14)939-05 VILLAGE OF RYE BROOK 1. 4 roof BUILDING DEPARTMENT �193 ADMINISTRATIVE EXTERIOR BUILDIN(I PERMIT APPLICATION FOR EXTERIOR WORK WHICH DOES NOT REOUTRE VILLAGE ARCHITECTURAL REVIEW BOARD APPROVAL FOR OFFICE USE ONLY: ^ry APPROVAL DATE. �LJ PERMIT##: LX3 APPLICATION FEE: APPROVAL SIGNATURE: PERMIT FEES: D 0—DUF H.O.A.APPROVAL: DATE: DISAPPROVED: OTHER: ***tt*t******t*tit***ttttttt********tt********ttttt**t***tt***t*tit*tt*********tit****ttttttttttttttttttttt Application dated:�J�! ._CP)3 is hereby made to the Building Inspector ofthe Village of Rye Brook,NY,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: 179 Ivy Hill Crescent, Rye Brook, NY 10573 2. Parcel ID#: 129.76-1-34 Zone: fill 3. Proposed Improvement(Describe in detail): we are applying to install a brick style paver patio in our backyard. The project will involve removing the current concrete patio that exists in our backyard(and small rocks by sliding door), and replacing It with a brick style paver patio. 4. Property Owner: Matthew Perlstein and Dana Perlstein Address: 179 Ivy Hill Crescent, Rye Brook, NY 10573 Phone# B45-325-1709 Cell# M-325-1709 e-mail matthew.perlstein@gmail.com List All Other Properties Owned in Rye Bm':: "/a Applicant: Matthew Peristein and Dano n Address: 179 Ivy Hill *rescent, r k, NY 10573 Phone# 84`-32' 709 Cell# W-325-1709 e-mail matthew.perlstein@gnwii.com Archite c: Address: Phone# Cell# e-mail Engineer: Address: Phone# Cell# e-mail General Contractor: From The Ground LOP 1 Corp ­,: O r g e Q�Ct IQS Address: 9 Drew Street#4, Part Chester, NY 10573 Phone# (914)939-IM Cell# e-mail Fromthegroundupicorp@gmail.com (I) i 8/12na21 5. Occupancy;(1-Fam.,2-Fam.,Commercial.,etc...)Pre-construction: Post-construction: 1-Fam 6. Area of lot: Square feet: Acres: 0•05 7. Dimensions from proposed building or structure to lot lines: front yard: rear yard: right side yard: left side yard: other: Backyard patio: from back right of proposed patio to back right of property- 2 ft, from back left of patio to back left of property- 10 ft, from left of patio to left of property- 12 ft 8. if building is located on a corner lot,which street does it front on: 9. Area of proposed building in square feet: Basement: 1'fl: 2nd fl: 3'd fl: 10. Total Square Footage of the proposed new construction: 11. For additions,total square footage added:Basement: I S'fl:, 2nd fl: 3'd fl: 12. Total Square Footage of the proposed renovation to the existing structure: 214.E sq ft stone pager patio 13. N.Y. State Construction Classification: N.Y. State Use Classification: 14. Construction Type&Location: O Typical Western Lumber Frame;{)Timber Frame[TC];()Wood Truss[TT]; i O Pre-engineered wood[PW];Located;O Floor Framing[F];O RoofiFraming[R];O Floor&Roof Framing[FR];Other: stone paver patio I 15. Number of stories: Overall I ieight Median height: 16. Basement to be full,or partial: finished or unfinished: 7. What material is the exterior finish: WA 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 extens{on/modification to an existing automatic fire suppression system?(Fire Sprinkler,ANSL System,FM-200 System,Type I Hood,etc...)Yes:_No: x (ifyes,applicant must submit a separate Automatic Fire Suppression System Permit application&2 sets of 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: x Area: 23. Will the proposed project require a Site Plan Review by the Village Planning Board as per§209 of Village Code? Yes: No: x (if yes,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: x (f 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: x (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: x (if yes,the area and elevations of theflood 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: x (►f yes,applicant must submit a Tree Removal Permit Application) 28. Does the proposed project involve a Home-Occupation as per§250-3$+f Village Code? Yes: No: x Indicate: TIER 1: TIER 11: TIER III: (ifyes,a Home Occupation Permit Application is required) 29. What is the total estimated cost of construction: $ 500o 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.!f the final cost exceeds the estimated cost,an additional fee will be required prior to issuance of the C/O. 30. Estimated date of completion: 9/1/2023 I i (2) 8/12/2021 Bum 1V1ENT VIL E OF RY'. OOK MAY 16 2023 938 KING ET RYE B ,NY 10573 d „-a ' VILLAGE OF Rl'E BROOK BUILDING DEPARTMENT AFFIDAVIT OF COMPLIANCE VILLAGE CODE �216 e STORM SEWERS,AND SANITARY SEWERS THIS AFFIDAVIT MUST BEAR THE NOTARIZED SIGNATURE OF TAE 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: x, Matthew Perlstein , residing at, 179 Ivy Hill Crescent, Rye Brook, NY 10573 (('lint name) (Address wh,re Nvu liec) 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; 179 Ivy Hill Crescent, Rye Brook, W 10573 Rye Brook,NY. �)E�h�lddru5:) 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. (fiigitauir of llrop rl� Om nc:r(s)) Matthew Perlstein Dana Perlstein Wrint Name ufl'ropertg Ot+ncr(s!i r Sworn to before me this J day of �"' , 20 otarti l'u61ic1 JOSHUA E. BALSAM NOTARY PUBLIC;STATE OF NEW YORK Registration No. 01 BA4994963 (3) Qualified in Westchester County Commission Expires January, 31, 2028 s)l znoz l 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(§) 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 shpil be deemed null and void, and will be returned to the applicant. Please note that application fees are non-refundable. STATE-OF NEW Y RK,COUNTY OF WESTCHESTER ) as: ��' � Pe--,js irrr-N ,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 ewflf 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. 01 Sworn to before me this Sworn to before me this day of , 20 Z day of ,20 Signature of Property Owner Signature of Applicant Print Name of operty Owner Print Name of Applicant Notary Public Notary Public JOSHUA E. BALSAM i NOTARY PUBLIC,STATE OF NEW YORK Registration No. 01 BA4994963 Qualified in Westchester County Commission Expires January, 31,2028 io (4) I 8/1 212 02 1 The Arbors Homeowners' Association 173 1/2 Ivy Hill Crescent Rye Brook, NY 10573 D - C DO May 24, 2023 JUN - 5 2023 VILLAGE OF RYE BROOK Matthew Perlstein BUILD114G DEPARTMENT Dana Perlstein 179 Ivy Hill Crescent Rye Brook, NY 10573 Re: Paver Patio Dear Matthew and Dana This letter serves as confirmation that the Architecture & Grounds (A&G) Committee has reviewed and accepted your application for the above-named work. This approval is valid for six (6) months from today's date. If any changes need to be made to the original plans submitted to A&G either before or during construction, the Committee must be notified in writing and your application must be amended. Work must stop and cannot proceed until you receive written approval for those changes. A permit from the Village of Rye Brook must be presented to the property manager before work begins. You are also required to inform the Property Manager when work begins. When the project is complete, the Property Manager must again be notified so that an inspection may take place. Please include a photograph of the work as well. Failure to comply with these procedures will result in fines and/or work stoppage. If you have any questions, contact me at: Property Manager. Nicholas Salzarulo Property Manager Tara Orlando From: :Matthew Perlstein<matthew.perlstein@gmail.com> Sent: Monday,June 5,2023 2:26 PM To: Tara Orlando Subject: Fwd:Perlstein-HOA Approval 179 Ivy Hill Attachments: 179 Perlstien Permit Letter Paver Patio 5 24.pdf Hello, We just spoke on the phone regarding our permit for 179 Ivy Hill Crescent. Thank you again for your help! Best, Matthew Perlstein ---------- Forwarded message--------- From: Matthew Perlstein<matthew.perlstein@gmail.com> Date:Wed, May 24, 2023 at 12:54 PM Subject: Perlstein- HOA Approval 179 Ivy Hill To:<stevefews@ryebrook.ore> Hi Steve, Please see attached HOA approval letter to accompany our permit application for our stone patio project at 179 Ivy Hill Crescent. Please let me know if you may need any additional information for our permit. Thank you! Best, Matthew Perlstein 845-325-1709 1 Sams d)M 0 21dW-j S4:. p �IdNrvj `p area of proposed patio in green 0T6 �b353 ro a- ► N�Z �aN� p O Ab3SY In O SNP tl3 O 13 HiY3 A83S3 ((� O � \ 9M79 -40 0 a/Y O X ti 5 �a 0 optYd e \\ Ox 6 a � � n63s3 ��, �a '4 a � � 1 �b3S3 •'^°� o �n \\ +, Xm L,� \ \ II U ` �0 �\\ \ AN.*W19 a( a `210 dSNI JNI IA9 r \\\\ \ A ddV VO AtV L ,S"W bad ---a r A= ' i f k , e n _ 1 _ IAO Aw fA ^ vn- IL AM Mail- Matthew.Perlstein@YNHH.ORG Page 3 of 7 Ell_.�-- Al " `• + "�,q,�ya rid" z Kai, . Al https:Howa.ynhh.org/owa/ 5/5/2023 Mail - Matthew.Perlstein@YNHH.ORG Page 4 of 7 �x Alp I f I I . 1 �i ' I https:Howa.ynhh.org/owa/ 5/5/2023 Mail - Matthew.Perlstein@YNHH.ORG Page 5 of 7 l a m r yi y t i i 'i i https://owa.ynhh.org/owa/ { 5/5/2023 *Mlll 12, AIR ....... ........ Jim, 7E aw C%J C6 LO Q 0 CY) U o4u qw rA CA 0 ........... C) C: ection uj CL. 0 a. w E F- F- in U) 0 LU MAI, LL. UJ ON O C) 0-4 o Cl. > 4— w g LL COMO 4- CL Ali -MR-2- WL ME t: ca AKE 0 co ca C14Z -3, 41 E 0 :3 z 6)go! rA 0 (Mbill Oem 11 41 ............... Tr. 4 . . . . . . . . . . . . ..... . . . . . . gyp 61. DATE(MM/DD/YYYY) AFRO® CERTIFICATE OF LIABILITY INSURANCE 5 19/2023 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 GUNTAUT NAME: Betty Reyes The Willett Insurance Agency PHONE. -2689 FAX 888 371-9783A/C No Ext: (203)570 (A/C,N 338 Willet Ave ADDR benyreyes@thewillettinsurance.us INSURER(S)AFFORDING COVERAGE NAIC# Port Chester NY 10573 INSURER A: Hiscox INSURED INSURER B: Progressive From The Ground Up 1 Corp INSURER C: P.O Box 1422 INSURER D: INSURER E: Port Chester NY 10573 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 CONTRACTOR 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 VWD POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYY) LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE Fit]OCCURPREMISES(Ea occurrence) $ 100,000 MED EXP(Any one person) $ 5,000 A P1004211843 07/28/2022 07/28/2023 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 X POLICY PRO- JECT F LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: $ AUTOMOBILE LIABILITY $ Ea accident 300,000 ANY AUTO BODILY INJURY(Per person) $ B y OWNED SCHEDULED 02323237-2 07/02/2022 07/02/2023 BODILY INJURY(Per accident) $ I<• AUTOS ONLY AUTOS HIRED NON-OWNED PRUPEK I Y UAMAUE $ AUTOS ONLY AUTOS ONLY Per accident) UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LAB HCLAIMS-MADE AGGREGATE $ DED I I RETENTION$ $ ORKERS COMPENSATION ND EMPLOYERS'LIABILITY Y/N ISTER ER NY PROPRIETOR/PARTNER/EXECUTIVE❑ E.L.EACH ACCIDENT $ FFICER/MEMBER EXCLUDED? N/A Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under ESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS/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 St AUTHORIZED REPRESENTATIVE fie,fh/ R"ej 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 "w Workers' Certificate of Attestation of Exemption STATE Compemation from New York State Workers' Compensation and/or Board Disability and Paid Family Leave Benefits Insurance Coverage **This form cannot be used to waive the workers'compensation rights or obligations of any party.** The applicant may use this Certificate of Attestation of Exemption ONLY to show a government entity that New York State specific workers'compensation and/or disability and paid family leave benefits insurance is not required. The applicant may NOT use this form to show another business or that business's insurance carrier that such insurance is not required. Please provide this form to the government entity from which you are requesting a permit,license or contract. This Certificate will not be accepted by government officials one year after the date printed on the form. In the Application of Business Applying For: (Legal Entity Name and Address): OTHER:Landscaping work From The Ground UP 1 Corp 9 Drew St Apt 4 From:The Village of Rye Brook Port Chester,NY 105734860 PHONE:914490-6919 FEIN:XXXXX8220 Workers'Compensation Exemption Statement: The above named business is certifying that it is NOT REQUIRED TO OBTAIN NEW YORK STATE SPECIFIC WORKERS'COMPENSATION INSURANCE COVERAGE for the following reason: The business is a one person owned corporation,with that individual owning all of the stock and holding all offices of the corporation. Other than the corporate owner,there are no employees,day labor,leased employees,borrowed employees,part-time employees,other stockholders,unpaid volunteers(including family members)or subcontractors. Disability and Paid Family Leave Benefits Exemption Statement: The above named business is certifying that it is NOT REQUIRED TO OBTAIN NEW YORK STATE STATUTORY DISABILITY AND PAID FAMILY LEAVE BENEFITS INSURANCE COVERAGE for the following reason: The business MUST be either: 1) owned by one individual; OR 2) is a partnership(including LLC,LLP,PLLP,RLLP,or LP)under the laws of New York State and is not a corporation; OR 3) is a one or two person owned corporation,with those individuals owning all of the stock and holding all offices of the corporation(in a two person owned corporation each individual must be an officer and own at least one share of stock); OR 4) is a business with no NYS location. In addition,the business does not require disability and paid family leave benefits coverage at this time since it has not employed one or more individuals on at least 30 days in any calendar year in New York State. (Independent contractors are not considered to be employees under the Disability and Paid Family Leave Benefits Law.) I,Heriberto Barajas,am the President with the above-named legal entity. I affirm that due to my position with the above-named business I have the knowledge,information and authority to make this Certificate of Attestation of Exemption. I hereby affirm that the statements made herein are true,that I have not made any materially false statements and I make this Certificate of Attestation of Exemption under the penalties of perjury. I finther affirm that I understand that any false statement,representation or concealment will subject me to felony criminal prosecution,including jail and civil liability in accordance with the Workers'Compensation Law and all other New York State laws. By submitting this Certificate of Attestation of Exemption to the government entity listed above I also hereby affirm that if circumstances change so that workers'compensation insurance and/or disability and paid family leave benefits coverage is required,the above-named legal entity will immediately acquire appropriate New York State specific workers' compensation insurance and/or disability and paid family leave benefits coverage and also immediately furnish proof of that coverage on forms approved by the Chair of the Workers'Compensation Board to the government entity listed above. 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