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HomeMy WebLinkAboutBP23-110PERMIT # 00 Q3 "J 0 DATE 70 43 SECTION TYPE OF WORK JOB LOCATION % imp T. COSTS UQ FEE DATE INcpECT10N RECORD I DATE I NSP FOOTING FOUNDATION FRAMING RGH FRAMING INSULATION PLUMBING RGH PLUMBING GAS C� SPRINKLER ELECTRIC 0 LOW -VOLT ALARM AS BUILT 0 FINAL of -pr 07/9) 7Qa- 5 � P 0, 3— V7s16x1v` tie'a Af 6fr!7 OTHER APPROVALS ARB BOT PB ZBA OTHER VILLAGE of RYE BROOK WESTCHESTER COUNTY, NEW YORK NO: 23-176 Certificate of ®ccupaurp This is to certify that )&d I - 1 of, , having duly filed an application on 20 requesting a Certificate of Occupancy for the premises known as, / Plaf Riotolip 'gnaj , Rye Brook,NY, located in a 'jl:;? Zoning District and shown on the most current Tax Map as Section: , 4) Block: Lot: and having fully complied with the requirements of the Building Code and the Zoning Ordinance under Building Permit No. - ) , issued �O 20 a3, 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: K- Construction: for the following purposes: Mkri a 4e� ha/Atzo ? 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 '�fi'acilities shall be made, and no enlargement, whether by extending on any side or by increasing in height shall b e,nall the building be moved from one location to another until a permit to accomplish such change has ee med fr ilding Inspector. NOV - 6 1013 Building Inspector,Village of Rye Brook: Date: '� ��" For office use only: BUILDINGFiTMENT pERMIFF# 11 U VILI AA*OF RYE B,iOOK ISSUED: SEP 15 2023 g NG STREi1T;41YE BROOK,fEW YORK 10573 DATE: - 15 '=2 3 VILLAGE OF RYE BROOKS FEE: -PAID BUILDING DEPARTMENT wK"0► r e kvr 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 srerru•ssrssss••sssss ssnsssessrsrrrrrrsrrsrrrsrsrrrsrrssrrrrrrrrrsrrr graarsursrsrrarssursrrrrrssasrsu usrssrs••rrrrrsr•s Address: 1 &, Occupancy/Use: gels Parcel ID#: V�5-+ - -` )q Zone: - Owner: Row U011 mer Address: -7 Pi he r I daQ Ro a— P.E./R.A.or Contractor: Address: Person in responsible charge: Address: l4 ►1 Application is hereby made an bmitted to the Building Inspector of the Village of Rye rook 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: being duly sworn,deposes and says that he/she resides at 7 Prrv"_ Print N e of Appli t ,,��p (No.and eet) in r _____,in the County of � �� j` in the State of,� ,that A (City Town/Village) he/she as 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 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 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§250-10A.of the Code of the Village of Rye Brook. Sworn to before me this I Sworn to before me this day of ) 20 �Il day of , 20 S of Signature of Applicant Print e o toperty Owner Print Name of Applicant Notary Pub# Notary Public GREGORY K RIVERA Notary Public,State of Now York No.01R"13li Qualified In Westchester County V. Commission Expires Septeen*f 26, QyE BRC��. 1932 BUILDING DEPARTMENT UILDING INSPECTOR ❑ASSISTANT BUILDING INSPECTOR VILLAGE OF RYE BROOK ❑CODE ENFORCEMENT OFFICER 938 King Street - Rye Brook,NY 10573 (914) 939-0668 FAx (914) 939-5801 www ryebrook.org - - - - - - - - - - - - - - - - -- - - INSPECTION REPORT - - - - - - - - - - - --- - - - - - - ADDRESS: DATE: PERMIT# ISSUED: ` SECT: BLOCK: LOT: LOCATION: r\ OCCUPANCY: ❑ Violation Noted THE WORK IS... [I--'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 ❑ MOSS CONNECTION �]/FINAL ❑ OTHER QyE BRC��. O� Zm 1982 BUILDING DEPARTMENT ❑BUILDING INSPECTOR ❑ASSISTANT BUILDING INSPECTOR VILLAGE OF RYE BROOK ❑CODE ENFORCEMENT OFFICER 938 King Street• Rye Brook,NY 10573 (914) 939-0668 FAx (914) 939-5801 www ryebrook.org - - - - - - - - - - - - - - - - - - - - INSPECTION REPORT - - - - - - -- - - - - - - - - - - - - \'�Q cal C-_ ))// ADDRESS : DATE: �i� PERMIT# q? -2 J— `1 D ISSUED: -63 SECT: BLOCK: LOT: LOCATION: \� >� c OCCUPANCY: ❑ Violation Noted THE WORK IS... ``PASSED ❑ FAILED REINSPECTION ❑ SITE INSPECTION REQUIRED ❑ FOOTING ❑ FOOTING DRAINAGE ❑ FOUNDATION ❑ UNDERGROUND PLUMBING NOTES ON INSPECTION: 911,ROUGH PLUMBING El ROUGH FRAMING ❑ INSULATION ❑ Natural Gas ❑ L.P.Gas ❑ FUEL TANK ❑ FIRE SPRINKLER ❑ FINAL PLUMBING ❑ CROSS CONNECTION ❑ FINAL ❑ OTHER i ■ e / l� M Q � � ■ � � r O N �a.o ■ rY � CV y � �T� ■ vi �. a p � ■ = H A � O O � � a� .o U M� ■ 17 o wx di n U. > H v o o cis AG s.a F t� �•'� c a � � o � ■ co IT a Cn ■ A �, w . � N z � � � O C W _ 00 A O A v ��' g U ■ Z � off' � z �,., � Pa z � , -5 � � v A•r G1_ „ {n c 7 c, fi`00 cq Q Z o _ a 9 u H c o � > a o o , a � � � A d Uqro 0 R v d � z RHG A W � O d .� �•� o-�, �,,,,� •. � nr W � � P4 ,� a, Ij �I a W _ � � BUILDING D19PARTMENT CEGC���'C� VILLAGE OF RYE,0-40 R OK JUL 14 2023 938 KING�TRE>E;T RYE BROOK,NY 10573 (914)939-0668 VILLAGE OF RYE BROOK vvrW ry"Me4k:erg BUILDING DEPARTMENT INTERIOR BUILDING PERMIT APPLICATION FOR OFFICE USE ONLY: 7Q` Approval Date:, t#: ,&/ d�—��o Application Fee:$ �00— Lip Approval Signature: Permit Fees:$ Q. Disapproved: Other: �lQ Application dated: ��� �� is hereby made to the Building Inspector ofthe 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, / �/ j� 1. Job Address: T i Y1G� '� SBL:/3�i 7' 1 5 7 Zone�'1 c 2. Proposed Improvement.(Describe in detail):_ 6 C* _ t...r c,( k P"-'M'-kC4 I it mLk sAgc 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 IL• TIER III: 4. Will the proposed project require the installation of a new,or an extension/modification to an existip 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;(1 fain.,2 fam.,comm.,etc...)Prior to Construction: Construction: ( -—., 6. N.Y State Construction Classification: N.Y.State Use Classification: 7. Property Owner: 4- ^ � A� � �.,- VoliyrAddress: S J' Phone# {`f�7 71- 6,'Ccll# email: L t�..s;-`'�! ��i4�d• Cb� 8. Applicant: Address: Phone# Cell# email: 9. Architect: Address: Phone# Cell# email: 10, Engineer: Address: Phone# Cell# email: 11. General Contractor:64120 ro''/p1W__7 �IP�NI.vf��7 ftefte4h LUI S 94C 0i.MQ rrC--e��lly. -# c Q &6 7 O 33 1 email: 12. Estimated cost of construction $ t1V, 00o (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) 6/l/2023 BUILDING DEPARTMENT VILLAGE OF RYE BROOK J U L 14 2023 938 KING JET RYE BROOK,NY 10573 VILLAGE OF RYE BROOK 7066�0V 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: ,, n I, L,0_"n , ,residing at, ? P � 'I f i k (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; r , ne— ` - M . A(,, _ &QV—.' PY ,Rye Brook,NY. (JobE_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. (Signature of Property Owner(s)) (Print Name of Property Owner(s)) Sworn to before me this f , 20 (Notary Public) SHARI MELILLO Notary Publle,State of New York No,01ME6160063 Qualified In Westchester County Commission Wires January 29.20Z%-7 (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: U D I/,in.e e-- ,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,attomey,etc.) That all statements contained herein are true to the best of his/her knowledge and belief, and that any work performed, or use conducted at the above captioned property will be in conformance with the details as set forth and contained in this application and in any accompanying approved plans and specifications, as well as in accordance with the New York State Uniform Fire Prevention &Building Code, the Code of the Village of Rye Brook and all other applicable laws, ordinances and regulations. By signing this application,the property owner further declares that he/she has inspected the subject property,and that to the best of his/her knowledge there are no roof drains, sump pumps or other prohibited stormwater or groundwater connections or sources of infiltration into the sanitary sewer system on or from the subject property. Sworn to before me this Sworn to before me this day of �\ , 20g day of ,20 Signature of Property Owner Signature of Applicant fM*ame of Property Owner Print Name of Applicant Notary Public Notary Public SHARI MELILLO Notary Public,State of New York ND.O1MM60063 qualified In Westchester County Commission Expires January 29,20L-1 (4) 8/12/2021 N i 0 N N W N N a , N � x ~ i E■ A a a a � °; a z o H s S V)ol F- N w z010 cn z w • v, c A as �, z C* W W H ob O w co Vr oo �..� z w F O oo $ V Vz Ln r.. ~ Oo ON Z H A w M w r l 5� yj� i WD 1� 1� .] 0 en z w N v og 0.0 a � °` x BRO, Im DD ' M BULL E MENT JUL 1 9 2023 VIL E OF RYE OK L----- 938 KIN ET RYE B ,NY 10573 VILLAGE OF RYE BROOK (914)9� 939-5801 BUILDING DEPARTMENT or PLUMBING PERMIT APPLICATION FOR OFFICE USE ONLY BP#: CD 3 _/ / 0 PP#: p),3- / Approval Date: ''JQL 1 9 1023 Permit Fee: $ Approval Signature: Other: Disapproved: ` (fees are non-refundable) Application dated, 7—/q—:)13 is hereby made to the Building Inspector of the Village of Rye Brook NY,for the issuance of a Permit to install and/or remove Plumbing as per detailed statement described below.The applicant&property owner,by signing this document agree that said plumbing work will be in conformance with all applicable Federal, State,County and Local Codes. 1.Address: 7 PINE RIDGE ROAD SBL: /,35 i zone: /C o� 2.Proposed Work: PLUMBING WORK FOR MASTER BATHROOM FIXTURES IN SAME LOCATION 3.Property Owner: LAURA & RAY VOLLMER Address: 7 PINE RIDGE ROAD Phone#: Cell #: 914-772-5925 email: LAURABV@YAHOO.COM 4.Master Plumber: Salvatore W Morlino Address: 1 Bonwit Road Rye Brook NY 10573 Lic.#: 725 Phone#: Cell #: 914-260-1592 email: salvatoreserious@gmail.eom Company Name: Westchester Plumbing & Heating Address: 1 Bonwit Road Rye Brook NY 10573 INDICATE FIXTURES& LINES TO BE INSTALLED AS PER THE FOLLOWING SCHEDULE: Location Water Urinals Drinking Sinks Showers Bath Laundry Domestic Fire Sanitary Natural/ Other* Total Closets Fountains Tubs Tubs Service Service Sewer LP Gas Basement 1 st Floor 2nd Floor 1 1 1 3 3 Id Floor 4 Floor 5 Floor Exterior 5.* List Other Equipment/Provide Details: INSTALL NEW FIXTURES IN SAME LOCATION Notarized Signatures Required Next Page -1- 2/26/18 BUILD MENT D E C IE � v VIL E OF RY OK DD 938 KING ET RYE Bit NY 10573 J U L 19 2023 (914)9 9 39-5801 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 YOM COUNTY OF WESTCHESTER ) as: 3, RAY VOLLMER , residing at, 7 PINE RIDGEE ROAD (Print name) (Address%%here 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; 7 PINE RIDGE ROAD , Rye Brook,NY. (.lob 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. x (Sign atur roperty Owner(s)) (Print N• m of Property 0%%ner(s)) Sworn to before me this 11 d of JULY , 2023 (Notary Public) SHARI MEULLO Notary Public,State of New York No.OIME6160063 Qualified In Westchester County-7 Commission Explms January 29,20 -3- 3/21/19 STATE OF NEW YOM COUNTY OF WESTCHESTER ) as: Salvatore W Morlino ,being duly sworn,deposes and states that he/she is the applicant above named, (print name of individual signing as the applicant) and further states that(s)he is the legal owner of the property to which this application pertains,or that(s)he is the Contractor for the legal owner and is duly authorized to make and file this application. (indicate architect,contractor,agent,attorney,etc.) That all statements contained herein are true to the best of his/her knowledge and belief,and that any work performed,or use conducted at the above captioned property will be in conformance with the details as set forth and contained in this application and in any accompanying approved plans and specifications,as well as in accordance with the New York State Uniform Fire Prevention&Building Code,the Code of the Village of Rye Brook and all other applicable laws,ordinances and regulations. By signing this application,the property owner further declares that he/she has inspected the subject property,and that to the best of his/her knowledge there are no roof drains,sump pumps or other prohibited stormwater or groundwater connections or sources of infiltration into the sanitary sewer system on or from the subject property. Sworn to befo a me this Jq Sworn to before me this 18 day of -v .2023 day of JULY ,2023 rgnatur Property Owner Signature of Applicant Salvatore W Morlino Print N e of Property Owner Print Name of Applicant Notary PubligiARI MEULL0 Notary_Public Notary Public,State of Now York ID No.O1ME6160063 Qualified In Westchaster Csunty Commission Expires January 29.20L l ��������� This application must be properly completed in its entirety and must lnc u e the�totar-lzff signature s)of the legal owner(s)of the subject property, and the applicant of record in the spaces provided. Applications not properly completed in its entirety and/or not properly signed shall be deemed null and -oid and will be returned to the applicant. S m `40& -2- _26/18 w p U F. JIMPON ILI Qi Building Permit Check List&Zoning Analysis Address: 1' tl I SBL. Zone: �� Use: Con st ype: Other. Submittal Date: `-1 1 ions Submittal Dates: Applicant: V el Nature of Work.— Reviews:ZBA• JUL 1 9 7023 PB• BOT• Other XMQ OK n c/ (,_)-"FEES:Filing. \ P• \ _Qac�C/O• Flood Plane: Legalization:,( ) ( ) APP: Dated Notarized: SBL: Truss I.D. Cross Connection H.O.A.: ( ) ( ) Scenic Roads: Steep Slopes: Wetlands: Storm Water Review: Street Opening. ( ) ( ) ENVIRO:Long. Shore Fees: N/A: ( ) ( ) SITE PLAN:Topo: Site Protection S/W Mgmt.: Tree Plan. Other. ( ) ( ) SURVEY.Dated Current Archival Sealed: Unacceptable: ( ) ( ) PLANS:Date Stamped: Sealed Copies: Electronic: Other. ( � ( License: Workers Comp: Liability: Comp.Waiver. Other. ( ) ( ) CODE 753#: Dated. N/A: ( ) ( ) HIGH-VOLTAGE ELECTRICAL:Plans: Permit: N/A: Other. ( ) ( ) LOW-VOLTAGE ELECTRICAL:Plans: Permit: N/A: Other. (• , ( ) FIRE ALARM/SMOKE DETECTORS:Plans: Permit: H.W.I.C.:_Battery:_Other. (�( ) PLUMBING:Plans: Permit: Nat. Gas: LP Gas: N/A/: Other. ( ) ( ) FIRE SUPPRESSION:Plans: Permit: N/A: Other. ( ) ( ) H.V.A.C.: Plans: Permit: N/A Other. ( ) ( ) FUEL TANK:Plans: Permit. Fuel Type: Other. ( ) ( ) 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: REQLIIEtED EXISTING PROPOSED NOTES APPROVED Area: Ckdv FronWe Front: Front: Ste: Main Cov Accs.Cov Ft.HS : Sd.H S : Tot,Imp: F Im : ParkmQ Hdght/Stories: notes: 7, .wry:. 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C) t _ v \\ y _ . . . 1j1,1 ri °'�.,'11 11;.e4'sa'�4�i3;;�` 11 11�,:s s a:;;i`.11 11 •,'i-"'��;:;.11 11�:; �f..`.�(acs)f��/ 111111 ��14101/1011i'. 1`-d /1 IAi" �In10/.,AV (AFII IfN. �1 :iV 3Ard;, �• y'.i IP1A�■tt(';FL'' 0,117�1:)' ^4T`1"Y,r�10♦ ,�i ^�Sf,x. 01 ,;f:lj^ilF f.`i1(0/13{i$As:s: / 6 -.r,;;^ '71'7't14 dt; Ykj•,y h rt?p. '��" N y,� : y�,i {S§ I O'• +i �.+��}' •`O:. �+�.1iY�'• Off. "K?+ 1'�• O3� �i%7j�y'�•�''� o}� /f'S,';�j}�.��i',� ��` '.�j}'Jti<;51• Ogg "'%11,�.1�{451�;'1•* �� �' 3 - ��`Itl�r� :: - --'viVh:� -. ;•�v�'`;z r�v\� ' t�VidV" tI/`r�.`• t iji�v�{!i.� {(v 11 �_�e.._� � /"+&.Y.{�'v` +>'mow" .�`;.� ..• � nr� ... / ,��., >u, •'• �.•M r AC"R"9 DATE(MM/DDrfYYY) � CERTIFICATE OF LIABILITY INSURANCE 06/23/2023 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 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 NELLA CARRICO _ NAME: TOP INSURANCE AGENCY,INC PLc No Ext1: 914-690-1440 _ 914-690-2875 18 PUTNAM AVE nDOREss• TOPINSNY@GMAIL.COM _ PORT CHESTER,NY 10573 INSURERS AFFORDING COVERAGE NAIL s INSURER A: UTICA FIRST INS CO INSURED INSURER B GREAT IMAGE HOME IMPROVEMENT LLC INSURERC: 22 HOMESTEAD LN INSURER 0:__ GREEN WICH,CT 06831 INSURER E: 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. INSR ADDL.SUBR_ POLICY EFF POLICY EXP LTR TYPE OF INSURANCE POLICY NUMBER MMIDD/YYYY MWDDIYYYY LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 P,COM�ERCIAL GENERAL LIABILITY ET NT SO,000 �� y � PREMISES Ea occurrence SMS-MADE �J OCCUR MED EXP(Any one person) $ 5,000 ART 3000827270 12/13/2022 12/13/2023 PERSONAL 8 ADV INJURY S 1,000.000 I GENERAL AGGREGATE $ 2,000,000 GENL AGGREGATE LIMIT APPLIES PER: I PRODUCTS-COMPIOP AGG S 2.000,000 POLICY F7 PRO• LOC $ AUTOMOBILE LIABILITY COMBINED SI L L M Ea accident ANY AUTO BODILY INJURY(Per person) $ A ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY(Per accident) S NON-OWNED i PROPERTY S HIRED AUTOS AUTOS (Per a S UMBRELLA LIAB OCCUR EACH OCCURRENCE _ S EXCESS LIAB HCLAIMS-MADE AGGREGATE $ DIED 5 $ WORKERS COMPENSATION WC STATU- OTH- AND EMPLOYERS'LIABILITY Y/N ANY PROPRIETOPiPARTNERIEXECUTIVE E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED' ❑ N/A - (Mandatory in NH) E.L.DISEASE-EA EMPLOYE $ 11 yyaas,Re desclribe under -- - DESC TION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT S DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space Is required) PAINTING INTERIOR/EXTERIOR/REMODELING/CARPENTRY EXCLUDES:ROOFING/TREE CUTTING AND REMOVAL/POLYURETHANE HARDWOOD REFINSH CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE VILLAGE OF RYE BROOK THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 938 KING ST ACCORDANCE WITH THE POLICY PROVISIONS. RYE BROOK,NY 10573 AUTHORIZED REPRESENTATIVE NELLA CARRICO ACORD 25(2010/05) ©1988-2010 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD 6/27/23,5:24 PM Certificate of NYS Workers'Compensation Insurance Coverage CERTIFICATE OF YORK Workers NYS WORKERS'COMPENSATION INSURANCE COVERAGE L—� STATE Compensation Board Insured Detail Ia.Legal Name and address of Insured(Use street address only) lb.Business Telephone Number of Insured Great Image Home Improvement LLC 914-481-1217 22 Homestead Lane Greenwich,CT 06831 le.NYS Unemployment Insurance Employer DBA:Great Image Painting Registration Number of Insured Id.Federal Employer Identification Number of Insured or Social Security Number 812202298 Work Location of Insured(Only required if coverage is specifically limited to certain location in New York State,i.e.a Wrap-Up Policy) 2.Name and Address of the Entity Requesting Proof of Coverage 3a.Name of Insurance Carrier (Entity Being Listed as the Certificate Holder) Wesco Insurance Company The Village of Rye Brook 938 King St. 3b.Policy Number of entity listed in bog"la": Rye Brook,NY 10573,NY 10573 WWC3606665 3c.Policy effective period: 9/10/2022 to 9/10/2023 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"I 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". The insurance carrier must notify the above certificate holder and the Workers'Compensation Board within 10 days IF a policy is canceled due to nonpayment of premiums or within 30 days IF there are reasons other than nonpayment of premiums that cancel the policy or eliminate the insured from the coverage indicated on this Certificate. (These notices may be sent by regular mail.)Otherwise,this Certificate is valid for one year after this form is approved by the insurance carrier or its licensed agent,or until the policy expiration date listed in box "3c",whichever is earlier. 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: Matt Zender (Print name of authorized representative or licensed agent of insurance carrier) Approved By: 6/27/2023 (Signature) (Date) Title: Senior Vice President https://wc.amtrustgroup.com/ANAWC/PolicyNYCertificateOfWclns.aspx?IndexId=441418&InstaneeId=1d8d9l02-1092-48d4-ae3c-db2500abc41d 1/2