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HomeMy WebLinkAboutBP23-101PERMIT # fJW SECTION ../: TYPE OF WORK JOB LOCATION CONTRALTO ✓Co # DATE: 3 iixP: Q Lz/ _ BLOCK LOT /0 �® o,o/aeAeo psi hi w_c r• TCO #� FEE DATE DATE FOOTING FOUNDATION FRAMING RGH FRAMING INSULATION PLUMBING Cl RGH PLUMBING GAS C] SPRINKLER ELECTRIC 0 LOW -VOLT O ALARM O AS BUILT O FINAL INSP �iy�93 ?�J/a7 9 DR . 19 VILLAGE OF RYE BROOK MAYOR 938 King Street, Rye Brook,N.Y. 10573 ADMINISTRATOR Jason A. Klein (914) 939-0668 Christopher J. Bradbury www.ryebrook.org TRUSTEES BUILDING& FIRE INSPECTOR Susan R. Epstein Steven E. Fews Stephanie J. Fischer David M. Heiser Salvatore W. Morlino CERTIFICATE OF COMPLIANCE August 17,2023 The Elena DeMasi Irrevocable Trust 2020 c/o Anna Maria Lankes,Trustee 563 Westchester Avenue Rye Brook,New York 10573 Re: 563 Westchester Avenue, Rye Brook,New York 10573 Parcel ID#: 135.83-1-10 Building Permit#23-101 issued on 7/12/2023 for 20 Replacement Windows This certifies that the twenty new windows,installed under the above captioned permit have been satisfactorily completed. Sincerely, Steven E. Fews Building&Fire Inspector /to Fc [� �wlr� ID R For office use only: BUILDINd DEPARTMENT PERMIT# O/ JUL 2 5 2023 VILLAGE OF RYE t 0OK ISSUED: 93 KING STREET;,RVE BROOK,NEW YORK 10573 DATE: VILLAGE OF RYE BROOK (914)9 -00W FEE: SAC //O-- PAID BUILDING DEPARTMENT wwa.ry rooL: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 rrr>r#r!•>//r''rrltarts!!r!> ►r>r>♦>rrltart>rl11!♦r►>♦tsars♦!•rlrr!>rrr tart r#r#rr!♦!r#r•rr#>!##!slat rlrrr>rrrrr##1#r11##t##!!!!#! .Address: 5t0J L''ef"11 6tt& ' A w, Occupancy/Use: 1'L,f° 1 Parcel ID#: 135. $3 " ' ( C Zone: Owner: Elenc& DeLI asi Address: SG3 _---_l J-f 1"VV--,, P.E./R.A. or Contractor: DD ti b f f Address: q3 Gl Person in responsible charge: ^n S 0 6� Address: t �� 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: L� �� ���p s4N iZ A&I being duly swom,deposes and says that he/she resides at�(3 wei �"�y f!' TC" P-- (Print Namc of Applicant) / _ _ (No.and Sire c) in 8�b in the County of (,�1y�""Jy'/� in the State of ,that (CityiTown,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:S (3 6— +l/ for the construction or alteration of- ' W 1 n w L4 N I rJ 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 ofhis/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-IO.A.of the Code of the Village of Ryc Brook. Sworn to before me this I �(J 1 Sworn to before Cc this day of �� I�/ , 20 D: day of T , 20,�_) 3 A. Signature of Property Owner Signature of Applicant / MELA IA Elm, p¢m4�� FRY OVSKY Of=NEW Y JoGh St�6c��o. Prim Name of Pro w r HR632415 Pri t Namc of A t Coun s 05/04/27 qNit., Public a tc 12 2u21 �E BRcb, w � .FO • 1982 BUILDING DEPARTMENT UILDING INSPECTOR 000000❑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: l G PERMIT# � ISSUED.7 12 SECT: /1 BL CK: LOT:�U Z E`� I LOCATION: (Vf Z'�` OCCUPANCY: ❑ Violation Noted THE WORK IS.. ASSED ❑ 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 s s a i4 y O W y 00 o,0. e QI n "O M O Ix �. w eq Q w o 0000 o Z Ln c1� H y v .. t• Z W p �> p Er PLI PLO CA 00 co W pp F" Gam• N Q �P' 6 aoi o v o Imo+ O W ° w dr Av0 � V (, s �j w T" r- � z V z p p ' M1 W Fi-�-� � n W w 0V, -a a M C7 W V 1-1 w � Q o Q " Z I w ° s " V - , . u m W cn O z z N •" V mt. Av "to � o O ' v a U 14 ~ W cr 14 W � N � �n en Z a' Vi G a 0 x A W z ¢ oA .. w cn o e ,5(4,�DL-o5 BUIC TMENT E C E� V VILRY OOK 938 KINGE BR ,NY 10573 JUL _ 2�23 9-©6 VILLAGE OP RYE BROOK BUILDING DEPARTMENT ADMINISTRATIVE EXTERIOR BUILDING PERMIT APPLICATION FOR EXTERIOR WORK WHICH DOES NOT REQUIRE VILLAGE ARCHITECTURAL REVIEW BOARD APPROVAL FOR OFFICE USE ONLY:jdf.\Ark /� ?2 �j Q APPROVAL DATE: PERMIT #: / .�Ji v APPLICATION FEE:' �� APPROVAL SIGNATURE: PERMIT FE H.O.A.APPROVAL: D 4 �_ DISAPPROVED: OTHER: Application dated: T1 of is hereby made to the Building Inspector of the Village ofRye Brook,NY,for the issuance of a Permit for the construction of buildings,structures,additions,alt7;�Z:k foorra change in use,ass,per detailed statement described below. 1. Job Address: ��3 Ave- J` e- �6 Y- J"Y /k5—'-)3 2. Parcel ID#: 3S. p o Zone: c� 3. Pro osed Improvement(Describe in detail): 4 Pic,u- f XnI4Yn L,s ` '^' /Le/w y 4. Property Owner: J �r>✓n �i k/�m Address: 3 W ej+L t/ 'Fab � t b�9-3 Phone# "!n 6( - 13-)-L$ 20 Cell# e-mail List All Other Properties Owned in Rye Brook: 0D�Applicant: e- 0R�� _n Address: q3 Win! f�ref ;A -- 4+_ (- d J + Phone# q) - / `f o� Cell# e-mail 1 S 13 Architect:r-1 � A� 1 e- + �T n�.�� 4r, Address: J 3i 1 � of 13 Phone# t ! Cell# e-mail { Engineer: Address: Phone# nn Cell# e-mail General Contractor: Address: t Phone# 1 Cell# e-mail (ly 6/1/2023 5. Occupancy;(1-Fam 2-Fam.,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 corner lot,which street does it front on: 9. Area of proposed building in square feet: Basement: l`fl: 2nd fl: 31 fl: 10. Total Square Footage of the proposed new construction: 11. For additions,total square footage added:Basement: 11,fl: 2nd fl: 31d 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: O Typical Western Lumber Frame;O Timber Frame[TC];O Wood Truss[TT]; ()Pre-engineered wood[PW];Located;O Floor Framing[F];O Roof Framing[R];O 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: lu 11A Roofing material: 19. What system of heating: 11114 20, If private sewage disposal is necessary,approval by the Westchester County Health Department must be submitted with this application. 2 L 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: -k (if yes,applicant must submit a separate Automatic,Fire Suppression System Permit application&2 sets ofdetailed 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:A/Area: 23. Will the proposed project require a Site Plan Review by the Village Planning Board as per§209 of Village Code? Yes: No: (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: (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: Z (if yes, the area and elevations of the,flood 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: V (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: V 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: $ f 3 J�?v Note:estimated cost shall include all site improvements, labor, material,scafj'olding,fired equipment,professional fees, including any material and labor which may he donated gratis.If theffinal cost exceeds the estimated cost,an additional fee will be required prior to issuance of the CIO. 30. Estimated date of completion: (2) 6/l/2023 �-- o [EC IE Nc BUILD ► MENT VIL E OF RY"� OOK J U L - 6 2023 938 KING ET ItYE BR() ,NY 10573 4 -0 VILLAGE OF RYE BROOK BUILDING DEPARTMENT **k°kak**k***************k********#******k**k•k***********�F it*F*******k*F*******#•k##*******:k at************** 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: ,�1 , I, L'Ie 4 �'t'/y'a , residing at, 5Z;3 c�,al- mil- lip- Rye (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, Rv , ��ol; , 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 farther 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. 411-4,. (Signature of Property Owner(s)) PeA& D (Print Name of Property Owner(s)) Sworn to before me this day of :`-I 202L_ Fry ublicl FNOTARY A QUEZADA C,STATE OF NEW YORKn No.01QU6186064 (3) ESTCHESTER COUNTYpires April 28.2024 blt/2023 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,C?UNTY OF WESTCHESTER ) as: 0— ,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 C kv) L t'r 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. Swom to before me this 61 Sworn to before me this 64 day of J `^ `% , 20 day of ("l 1 , 20 All Signature of Property Owner Signature'of Applicant Rmq TL4 ke4 Print Name of Property Owner Print Name of Applicant of PublicJr Notary Public t67 IRMA QUEZADA NOTARY PUBLIC,STATE OF NEW YORK Registration No.01 OU6186064 Qualified in WESTCHESTER COUNTY Commission Expires April 28,2024 (4) 6/112023 Harvey Double Hung Vinyl Window Comparison r SLIMLINE CLASSIC TRIBUTE GOOD BETTER BEST U-Values(ENERGY STAR Glazing) 0.27 0.25 0.25-0.17 Air Infiltration .03-.06 .08- .14 .05-.07 Structural' DP30,DP45,DP50 DP40,DP45,DP50 DP35,DP50 Vinyl Thickness .065-.070 .070 .070 STC Ratings 26-35 27-35 29 TG,27 DG Triple Glazed N/A N/A Optional Vinyl Colors White White,Almond and Bronze White Painted N/A 28 colors available 28 colors available Lock Sweep style,double locks over 30-1/4", Cam style,double locks over 30-1/4" Dual action;double locks standard(all sizes) White only 5 finish options 3 finish options Limit Latch Two Two Two Screen Fiberglass full screen Fiberglass full screen VIEWS full screen Lift Rail Integral top and bottom Integral top and bottom Integral top;option on bottom for integral,applied,or none Balance Calibrated block and tackle Calibrated block and tackle Calibrated block and tackle Mull Option Common jamb Common jamb Common jamb Min.Size W x H 16-1/4"x 26-1/4" 16-1/4"x 24" 16-1/4"x 26" Max.Size W x H 45-3/4"x 77" 47-3/4"x 84" 47-3/4"x 84" 'Additional information available on harveybp.com 6 Energy • Options Harvey offers several glazing packages to take the guesswork out of the ordering process. The packages make it easy to decide on 017------- CE ........6 LOW-E the right window configuration for your customer's needs. ' °T°"+FOAM BASE This option is always the least expensive version of a particular product. In some cases, it is simply made up of clear insulated glass and does not qualify for ENERGY STAR. - CLASS�C/TRIBUTE ENERGY STAR .25 STPA,2XLaW-E.AIWM ----....4 ENERGY STAR glazing includes everything that is needed for a product to meet ENERGY STAR requirements. N LINE 27 ------ aiaw�.•ncdr+ ..........3.70 HIGH PERFORMANCE The High Performance package is available on our premium Tribute .30 NE/�CLLAISSIC 3.33 ---------• .....----- windows as well as select accessory windows. It incorporates triple glazing, two panes utilizing Low-E coating, foam-filled cavities and Krypton gas for maximum energy efficiency, The High Performance glazing package exceeds ENERGY STAR requirements. .47 . ...... FJCL.ASSiC ..... 2. 12 . .. We also manufacture windows and doors with a variety of glazing options to fit project needs: •50 2 • Low-E • Obscured or Bronze Tint U-FACTOR R-VALUE • Low-E/Argon • Tempered • Double Low-E/Argon • Double Strength Glass(DSB THERMAL PERFORMANCE FOR HARVEY DOUBLE HUNG WINDOWS U-Factor in accordance with NFRC-1 OD and based on vmole window values. Test results snovan are subject to mange ndho;n notice cue to periodic re-testing Air Infiltration Air infiltration is an important, yet widely overlooked, component of overall energy efficiency. Simply put, it's how much air can pass through a closed window. The lower the number the better, because rate of air exchange in a room has a big impact on energy use and comfort(draftiness). AIR INFILTRATION=CUBIC FEET PER MINUTE PER SO. FOOT WINDOWS AAMA INDUSTRY STANDARD 2X GLAZED DH WINDOW 0.03-0.14 0.30 •fl• cfm/sq.ft. Harvey's quality materials, advanced window design with integrated weatherseals, and the special care Harvey takes during the manufacturing process, all come together to yield resilient long-lasting performance that pays off year after year. To compare air infiltration values for Harvey vinyl windows, please see the previous page. • LICENSE NUMBER � `THE ORIGINAL" Westchester WC3620OH23 DOUBLE Family Owned And Connecticut 0668826 Operated Since 1960 All Home Improvements oo 439 Willett Ave. Port Chester,N.Y. 10573 Tel#(914)937-4279 Fax(914)937-4172 http://www.DoubleRwindows.com Elena and Joe Demasi 563 Westchester Ave Rye Brook,NY 10573 914-937-4870 mom# 857-891-2893 Joe Insurance: All work involved within the following proposal is covered by Workmen's compensation,Public Liability,and Completed Operations Insurance. REPLACEMENT OF WINDOWS SUPPLY LABOR& MATERIAL FOR THE FOLLOWING. HARVEY WINDOWS. A- REPLACE EXISTING WINDOWS WITH THE NEW HARVEY CLASSIC WINDOW SYSTEM. B- ALL WINDOWS ARE WHITE VINYL INSIDE/OUT C- ALL WINDOWS ARE FULLY WELDED AND ALL WINDOWS MEET THE ENERGY STAR RATING D- ALL DOUBLE HUNG WINDOWS COME WITH A HALF SCREEN E- ALL WINDOWS WILL COME WITH FOAM FILLED FRAMES. F- ALL WINDOWS WILL BE INSTALLED AS A REPLACEMENT APPLICATION FROM THE INTERIOR IF POSSIBLE.THE BATHROOM WINDOWS MAY GET INSTALLED FROM THE EXTERIOR. TOTAL AMOUNT OF WINDOWS IS AS FOLLOWS.20 UNITS G- ALL WINDOWS WILL BE SEALED,CAULKED,CLEANED AND INSULATED AT TIME OF INSTALLATION. H- ALL DEBRIS WILL BE CARTED AWAY AT THE END OF EVERY WORK DAY. I- REMOVE AND REINSTALL ALL EXISTING BLIND OR SHADES. REMOVE ALL STICKERS AND CLEAN GLASS. 3- REINSTALL MOLDING ON THE INTERIOR OF WINDOWS. K- LIFETIME WARRANTY ON WORKMANSHIP L- DOUBLE `R' TO CART AWAY ALL JOB RELATED DEBRIS. Terms: Painting,if necessary to be done by others. Hidden rotten wood not included. Standard industry cash term,one third 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,we agree to pay any legal or collection fees expended by Double"R"arising from collection of the account. Double"R"is not responsible for reconnecting 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. 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"R"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"R"is unconditionally warranted for a period of Two years from the date of installation. Approximate Start Date:4 TO 6 WEEKS Approximate Completion Date: 2 TO 3 DAYS $13,580.00 (Amount) Customer. Date: 0.00 • �� '� .a• •�` t'' ..j Y.a:; �! it �;.•• �: ,..:} �'� �� •a` i C 5: >, c G 2 c O O ,. ;l N O iL O W N l O b � � .v 6 r w w Qj L co C (A 5:• I V W � U �° Zn = O .. 0 J m W } o _ iptgGt1011 n- Of �- W H Q Lu O 17 J m JLU O Q O d p m 0 J = 3sw V � O U o r / Ya 11 4r O �e I A 1. p o O p v .. '01 C d > o ZX 4- i Q O N t \U y O i CA i k r+ 1�A / v BUILDING DEPARTMENT VILLAGE OF RYE BROOK 938 KING STREET RYE BROOK,NY 10573 (914)939-0668 RESIDENTIAL LOT AREA COVERAGE Address: Section: Block: Lot: PERMITTED COVERAGE RATIOS IN RESIDENTIAL DISTRICTS (Local Law 3-88) YOUR ZONE AREA IN MAIN ACCESS. DECK ZONE DISTRICT SQ. FEET BLDG. BLDG. MAX. CHECK MAX. R-35 35,000 14% 4% 5% R-25 25,000 14% 3.5% 4% R-20 20,000 14% 3.5% 4% R-15 15,000 16% 3.5% 4% R-15A 15,000 12% 3.5% 4% R-12 12,500 17% 4% 4% R-10 10,000 20% 4.5% 3.5% R-7 7,500 23% 4.5% 3.5% R-5 5,000 1 30% 1 5% 3.5% R-2F N 5,000 1 30% 1 5% 3.5% Existing: Proposed: 1. AREA OF LOT Sq. Ft. Sq. Ft. 2. AREA OF HOUSE a. Coverage of Main Building (Including Attached Garage or Accessory Building) Sq. Ft. Sq. Ft. b. Area of 1 sc Floor Divided By Area of Lot x 100 % % 3. AREA OF ACCESSORY BUILDING (Includes Detached Garages,Tool Shed, Playhouses) Ft. Sq. Ft. a. Coverage of Accessory Building Area of Accessory Building Divided By Area of Lot x 100 % % 4. AREA OF DECK Sq. Ft. Sq. Ft. a. Coverage of Deck Area of Deck Divided By Area of Lot x 100 % % I attest to the best of my knowledge and belief, the above information is correct. Architect's Signature (3) 8/12/2021 /17/2 ACOOR" CERTIFICATE OF LIABILITY INSURANCE DATE1D/YYYY) I/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 A enc PHONE 914 481-5599 RR8 371-9783 g Y A/C No E:t: AIC,No 338 Willet Ave ADDRESS: bettyreyesCthewillettinsurance.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: Port 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 r= POLICY NUMBER MMIDDIYYYY MMIDD/YYYY LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE 7 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 $ 1,000,0()0 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY JE� LOC PRODUCTS-COMP/OP 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 FIKOPtH I Y IJAMAUE $ AUTOS ONLY AUTOS ONLY Per accident) UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB HCLAIMS-MADE AGGREGATE $ DED I I RETENTION$ $ ORKERS COMPENSATION - ND EMPLOYERS'LIABILITY Y/N STATUTE ER NY PROPRIETOR/PARTNERIEXECUTIVE❑ N/A 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 f"NE YORK Workers' CERTIFICATE OF STATE Compensation Board NYS WORKERS' COMPENSATION INSURANCE COVERAGE 1a.Legal Name&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 1c.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 or 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 Carrier (Entity Being Listed as the Certificate Holder) NYSIF The Village of Rye Brook 938 King Street 3b.Policy Number of Entity Listed in Box"l a" Rye Brook,NY 10573 8910587 3c.Policy effective period 19194t9ro9 to ivtvcuom-i 3d.The Proprietor,Partners or Executive Officers are included.(Only check box if all partners officers included) Z 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"l a"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? ZYES ENO 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 uthonzed representative or licensed agent of insurance carrier) Approved by: (Sign ure) (Date) Title: Insurance representative Telephone Number of authorized representative or licensed agent of insurance carrier: 914 481-5599 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.wcbny.gov