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HomeMy WebLinkAboutRP23-033PERMIT # - 03 J DATE: 7//7J,;,3 Exp; �?/J Y SECTION JQ 9, LOC T TYPE OF WORKor JOB LOCAT 0 / c.7%�O /P4$eJp// OWNE FYI Q r42/ C 4 00r�ljL! ✓�/ C lo�J lei 7 6%CXc CONTRACTOR P t — O LSO ' �t:? (919)937-YQ 79 EST. COSTA FEE vCO # c FEE D - DAT TCO # FEE DATE cif SPECTION F�EGORD i DATE INSP f FOOTING FOUNDATION FRAMING RGH FRAMING INSULATION PLUMBING 0 RGH PLUMBING GAS L� SPRINKLER ELECTRIC O LOW -VOLT L� 0 ALARM AS BUILT a �- FINAL OTHER APPROVALS ARB yE D 4 t�G4�J+Jv L . 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 16,2023 Adam Klareich&Carly Klareich 160 Brush Hollow Crescent Rye Brook,New York 10573 Re: 160 Brush Hollow Crescent, Rye Brook,New York 10573 Parcel ID#: 129.76-1-100 Roof Permit#23-033 issued on 7/17/2023 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 Dt)jB U I L D,?IN'd"iiI&T-M'- ENT FO— oi'fccu:aonly: PERMIT # _ �, -033 AUG ' 7 2023 VILLA EOF RYE1jOOK ISSUED: 7_s �r 938 KING STREI r' RYE BROOK, E`V YORK 10573 DATE: —�3 `,(9�4)9� -06 O`/ FEE: A //C-)— PAIU.� VILLAGE OF RYE BROOK �,.. fir ' �� BUILDING DEPARTMENT W---7.rye irooktor/g 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 ..............................................................,too.............,...,.........,,.,.,...........,.,.,....,.... Address: 160 61�-IA F��I�,.� e �e�, ��. .r��,< Y 1 aS 9 3 Occupancy/Usc: f-r-J;SfA-h 4 j Par�el ID #: � (� Gone: f�Ci1� Owner: /� �utr� 1<I cl r&;r Address: /-Mo") C ft,s� - 1'.L'./R.A, orContractor: 0at^b 11 je Address: ` L3� t � '� �V- PUMAG 64-21T Person in responsible charge: �„-1 <St i 6 e&\ Address: Application is hereby trade and sttbinitted to the Building Inspector of the Village of Rye Brook for the issuance of a Certificated Occupancy/Certificate of Compliance for the structure/construclion/aIteration herein mentioned in accordance with law: STATE OF NEW YORK COUNTY OF WESTCHESTER as: / )� 144a/�'I /Q/`('C being duly sworn,deposes and says that lic/she resides at / 6 `1 (t•/ V L j O f't ja'?f- (Print Namc of Applicant) II !! (No.and Strcet) Pa t-b 0 k in the County of V�S�" Cam"'� � _in the Slate of ,that (Cityrrownt Village) Itclshe has supervised the work at the location indicated above,and that the actual total cost of the work,including all site improvements, lubor,materials,scaffolding,fixed equipment,professional fees,and including the monetary value of any materials and labor which may have bccn donated gratis was: S ( ;z r (4 !g-U for iIre construction or alteration of: 60,w (- F Deponent l'urtlier states that he/she has examined the approved plans of the structure/work herein refen•ed to for which a Certificate of Occupancy/Compliance is sought,and that to the best of his/her knowledge and belies;the structure/work has been erected/completed in accordance with the approved plans and any anrendnrents thereto except in so far as variations therefore have been legally authorized,and as erected/conpleted complies with the laws governing building construction.Deponent furilier understands that it shall be unlawful foran owner to use or pemtit the use of any building or premises or part Ihereof 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. Sworn to before me this t/� Sworn to before me this J'T� day of (A r' , 20 _ clay of �t' �V , 20a3 Siy a of Property Owner Signature or Applicant M 04124t Y�L„ sib 141 1'riut ,nc orPro cry Owner — Print Namc of Appli, a ry Public /ANNA KIEI_AASA otary PUbI1c ANNA KIELBASA Notary Public- 4404 of Nnw York Notary Public- Stale of New York Ron.No.01hh.3/851!I Reg.No.01K16378519 8.1212o21 Qur111180 t:n_ur,ty Qualified in Putnam County My Comndsstun Lxph• ;j J,.iy so,4'026 My Cornmisslon Explrss July 30,2026 Q�E BR(�k• O� Zm BUILDING DEPARTMENT XBUILDING 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 :— ( �/� \ ` y\ C� DATE: PERMIT# O / ISSUED: ' SIT: � '� BLOCK: LOT: LOCATION: OCCUPANCY: v ❑ 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 6 s ■ i ■ ■ a ■ M N N w y n 000001 a W o W 04 °� v h ■ ■ a a v 44 '..� O -o o W coo 4 �2 w ■ W w a., F c H ■ h+l 1 H W p '10co 04 � � � � a � c W W � � ov � •�: cn 00 v 00%b � CN en W +�+ FBI G1 w M , " W ow A E d (� ■ A CC w v C4 dew owo 7 Q o ' 4 o ECf ■ ;� 9 9 00 cn ■ CD z . w PG 1-4 y ~ F O v F p Z z Fow � .y a FBI I114 14 W b ME BUIL MENT E " IE V E OF RYE OK JUL 13 2023 938 KING ET RYE BR NY 10573 '0 VILLAGE OF RYE BROOK BUILDING DEPARTMENT FOR OFFICE USE ONLY: ,Q ? Approval Date: JUL 1 202 e it / �J'a 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: i 4?p b ROOF PERMIT APPLICATION Application dated: 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. ` 7� 1. Job Address: �® IN(�S �IO� ��l4- SBL: l b�(�]]� dd Zone:P141D Property Owner: 4 oil /< Cl re/C Address: 166 Sj-'-J� /40(10L-) G/tsce'fi y Phone#: J K.2 —&W ell#: email: 2. Applicant: 004,•6le. Address: Y-7"l© Phone#: L('� �� O`D1 Cell#: '/ email: Wf S 1k, &4)'>✓f C0� (V_ 0 07401 3. Roofing Contractor: D t L I l e, 9 Address: q-3q Phone#: ! /�" q3 9-4 D I Cell#: email: 4. Job Description,list 11 Methods&Materials: Rej-wo� `e t,33 9'� Sk9 s k,-j,_ r_U� 5 c*�. )V /� `r W 6t r}V S h►?� 1� C- f � a1/'Ql ice` cj 1�� rt - } n. tJ Frr r 1 n6t rI (b J `J y,f 4c, n CI J r` 5. Estimated Cost of Job: $ (NOTE:The estimated cost shall include all site improvements,labor,material,scaffolding,fixed equipm nt,professional fees,and material and labor which may be donated gratis.) 6. If corner property,indicate street frontage: N A 7. Construction Type: NYS Construction Class: 8. Number of stories: Height: 9. Is garage being re-roofed:No: (V,lr Yes:( )Attached( )•Yes: ( )Number of Cars: 10. Is roof peaked,hip,mansard,flat,etc: 11. Estimated date of completion: -t- 611/2023 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. r,rtrt*rtttttt*t+ttatiwttttr,rtttttttrttttttt,►rttttttttttttra►r*+ritt,rtttrrtt,rlrtt*tttttttelr*ttt*tttttttr*tte,► STATE OF NEW YORK,COUNTY OF WESTCHESTER ) as: -;'off,V) �6 r6e.) , 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 co/)Ou c or for the legal ownerand is duly authorized to make and file this application. (indicate architect,contractor,agent,ettomey,e1c.) 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 specificadons,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 10 n Sworn to before me this JbA day of ^� ! �, 20c�3 day of l-+ ( 20_1�.3 Si re of Property Owner Signature of Applicant � th k_�4,d �J-a '5'w6eI Print N e of Property Owner Print Nat yte of Applicant •LG�t,ty- Not Public ANNAKIEE_BASA NO Public Notary Public- State of New York ` ANNA KIELBASA Rag.No.01KI6378519 Notary Public- State of New York Qualified In Putnam County Reg.No.01 Kt6378519 My Commisslon Expires July 30,2020 Qualified In Putnam County My commission Expires July 30,2026 -z- tll't12i123 The Arbors Homeowners' Association 173 1/2 Ivy Hill Crescent Rye Brook, NY 10573 i R[ECIEME DD J U L 13 2023 July 5th , 2023 VILLAGE OF RYE BROOK Adam and Carly Klareich BUILDING DEPARTMENT ---- Antonietta Vasaturo 160 Brush Hollow Crescent Rye Brook, NY 10573 Re: Entire Roof Replacement — 160 Brush Hollow Crescent Dear Adam and Carly, 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 LICENSE NUMBER "THE ORIGINAL'S Westchester WC36200H23 Family Owned And Connecticut 0668826 DOUBLE Operated Since 1960 All Home Improvements EST. 1960 439 Willett Ave. Port Chester,N.Y.10573 Tel#(914)937-4279 Fax(914)937-4172 htti)://www.DoubleRwindows.com Adam Klareich June 2,2023 160 Brush Hollow Crescent Rye Brook NY 10573 516-567-6706 Adam.kl are ichAgmaiLcom 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 entire house. • 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. l� • Install all new F- 5 brown aluminum drip edge. ZlmY—'00� • Install the new GAF Timberline roofing system in color of choice Q�� • Supply a dumpster to cart away job all related debris. • We are certified GAF roof installers 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 reconnecting existing alarm systems on windows and door. You the owner may cancel this transaction at anv time 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"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 Ten years from the date of installation. Approximate Start Date: Approximate Completion Date: Customer: $12,480.00 (Amount) Date: (Sales Tax) Double "R": $12,480.00 (Total Amount) Date: $6,240.00 (Deposit) $6,240.00 (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 Timberline HDZ® Specs •ABOUT •DOCS •VIDEOS SPECIFICATIONS (ALL DIMENSIONS ARE NOMINAL) AWARDS & RECOGNITION Good Housekeeping Rated 25-YEAR STAINGUARD PLUSTM ALGAE PROTECTION LIMITED StainGuard PlusTm Algae Protection Limited Warranty WARRANTY DURABILITY & TOUGHNESS Advanced Protection Shingle with GAF Dura Grip Adhesive EXPOSURE 5.625" (144 mm) EXTREME WEATHER IMPACT No RATED 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/SQ 256 CODES FBC State of Florida Approved ICC ESR-1475 SPECIFICATIONS (ALL DIMENSIONS ARE NOMINAL) 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 ENERGY RATING COOL ROOF RATINGS CRRC-rated(White only) COUNCIL (CRRC) MIAMI 21 (FLORIDA BUILDING Yes(White only) CODE) TITLE 24 (CALIFORNIA ENERGY Yes (two colors only) COMMISSION) SHIPPING AND PACKAGING APPROX. PIECES/SQ 04 APPROX. BUNDLES/SQ �A O 0 m N L N / ry• E U U 1`o- w c V Z ._ it M c rn r o ay .■r W LO 1� y ^'. a > z v off. Qc rA y ,M►� m C / 4�1 m = 3 s W it :D / 4i:' � 4•, p,, O o rn � � v o �Ga eye' .'y \1 cn e o �.y d X 0 O : O A ?j y cl yzcn \ N CN co p N C? \ 3 y I j � \ Z IA aC W LU ~ Q �; CD X N O O W p N G CN X Ci W �� U O a CN 0 W CD e W to _ mW rn H 0) 3 2 .. W C W (0W co O � p V sT N E H o C UA g a M InCc 3 ~ c N cco — U 0 Im O D to c cn En d Z C o x cu U / Z Co C w a d Q 3 C c (n ._ c E Z) E w O w O CNa* ao V a) 0 d C N O O LM � - X U W :_ w ; N ON E O d (n JH " L L � i 00 O O _j c m 0 3 3 Lo cn H O c fu E Z O +' c L O ' V mac .- O a > > Q 3 Ln 00 a c c a� W C W =_ ; a) (OJLL O C C .O ; m O O 'D i II O C Ol (D Q U �T .O. Q C ; > N px C N cu > > 1 OO W -i (n c p IL LL LL w ODCC) co LU a O O 5 � G C Of — C cn j a) O lA O � � c I m C L D X D X O dLO W co O �' Z U ' m j >_ c0 � c0'IT ip co O C (n - � Q O 7 M 7 M N 7 N r0 O i d s c Z U Z U va� 0U) E s � La � � QU a Dxa � � a aci Q ; co .0M __ a) U cp v� E rn E 0 I� Z N = y C y C ` ; M c W O O O m N w o 0 W _ � � t 3 � X W N W � U 04 O c,) m N O (n Cu CD co J dj ` C 'C C A? N N M Q +. O O N O CU Q CD m N � z a Qa � � L «. (n «. (n H _ Q X CL C M O M O i (n l0 } � rn > C V W C� _ N a� rn: Ft "t " } ; W G 7 � N n �t M c_ CD m m CO ' �.I O � CM � X w � p �_ 0) xo 0o L a II � _ � 0 � (n c (n c W I d O O .N m E Cb O �'M L o W lL d � w d m0 " cXo Q. N � � � o �a m 0 a 0 _ja- ofU E p CO m c c cu (n m (n 0) o O LL. � NL ° a� 3 6 3 5 = UEuno �a a) CD 5U) ccuucum � a = � _ � U 0 ; M M M � : O O O Wad I 000 Zm W O O a ~ •- I O CN Z per& LL i N N N i j :3 W 000 C o a O �* � c ; C7 9w•or • ® DATE(MM/DD/YYYY) A16- CERTIFICATE OF LIABILITY INSURANCE 1 17/2021 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 AIC No 888 371-9783 g Y A/C.No Ext: 338 Willet Ave MAIIE ADDRESS: bettyreyes a4thewillettinsurance.us INSURER(S)AFFORDING COVERAGE NAIC# Port Chester NY 10573 INSURER A: Westchester Insurance Company INSURED INSURER 8 Double R PBJ.LLC INSURER C: 439 Willett Ave I 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 WVD POLICY NUMBER (MMIDD/YYYY) (MM/DD/YYYY) LIMITS )C COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE ©OCCUR PREMISES(Ea occurrence) $ 100,000 MED EXP(Any one person) $ 5,000 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 7 jEC'T 7 LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: $ AUTOMOBILE EDIBILITY Ea accident) ccident $ ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS HIRED NON-OWNED 7RUPERT7=17GE $ AUTOS ONLY AUTOS ONLY Per accident) UMBRELLA LIAB OCCUR FACH OCCURRENCE $ EXCESS LIAR HCLAIMS-MADE AGGREGATE $ DED I I RETENTION$ $ ORKERS COMPENSATION ND EMPLOYERS'LIABILITY YIN STATUTE ER %NY PROPRIETOR/PARTNER/EXECUTIVE❑ NIA E.L.EACH ACCIDENT $ FRCER/MEMBER EXCLUDED? Mandatory in NH) E.L.DISEASE-FA 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' 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 td.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'i a" Rye Brook,NY 10573 8910587 3c.Policy effective period 1vngivnl?? to wn4i9m� 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? ZYES []NO 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: / / 7/c�Cc,� (signature) (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,wcb.ny.gov