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HomeMy WebLinkAboutRP23-035RIPAUT # SECTION, TYPE OF WORK _ JOB LOCATION 1 EST. COST VC0 #.Ll TCO # FEE DATE MmEtullu .oDATE INSO FOOTING FOUNDATION FRAMING RGH FRAMING INSULATION PLUMBING O FtGH PLUMBING GAS SPRINKLER ELECTRIC LOW -VOLT 0 ALARM AS BUILT 0 FINAL J OTHER APPROVALS QyE DR . 19 Gip � VILLAGE OF RYE BROOK MAYOR 938 King Street, Rye Brook,N.Y. 10573 ADMINISTRATOR Jason A. Klein (914) 939-0668 Christopher J. Bradbury www.ryebrook.org TRUSTEES BUILDING&FIRE INSPECTOR Susan R. Epstein Steven E. Fews Stephanie J. Fischer David M. Heiser Salvatore W. Morlino CERTIFICATE OF COMPLIANCE September 21,2023 Harriet Klein 4 Pine Ridge Road Rye Brook,New York 10573 Re: 4 Pine Ridge Road,Rye Brook,New York 10573 Parcel ID#: 135.41-1-18 Roof Permit#23-035 issued on 8/1/2023 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 D \� ' �3RC>EPMENT For office use only: BUILD C� 7 PERMIT# VILLOXE OK ISSUED: — 3 AUG 17 2023 38 KING STREV $Rb;OK ,l_.YORIc 10573 DATE: -1 a3 O-c FEE:�` //('7— PAID,I� VILLAGE OF RYE BROOK � BUILDING DEPARTMENT APPLICATION FOR CERTIFICATE OF OCCUPANCY, CERTIFICATE OF COMPLIANCE, AND CERTIFICATION OF FINAL COSTS TO BE SUBMITTED ONLY UPON COMPLETION OF ALL WORK, AND PRIOR TO THE FINAL INSPECTION rssssssasssssrssssssssssssssssrrrasrrsrsrrsassrssrrassrrrsrrrssssssssssrrsrrsrssssrssssrrrsasssssrrsrrssrsrsesssssrrarrrrssat Address: LF Rt rlA'a— IRrQ ,.-r_ 13,r 1- tJ7 Occupancy/Use: ,r e N,e_Lt.•n'i;u I Parcel ID#: / 3S� y�— /c Zone: Owner: 11 G,Y1c, r°_1— k 1 r_ Address: y 11G w,G cx� TY� 1-1 e_,.,r► S o,n I- / 10T3,5 P.E./R.A. or Contractor: ,f Address: tz r A,o P -, p1 eu sc:z -7 o Person in responsible charge: G,,,,,e y 1 a.„n Address: Application is hereby made and submitted to the Building Inspector of the Village of Rye Brook for the issuance of a Certificate of Occupancy/Certificate of Compliance for the structure/construction/alteration herein mentioned in accordance with law: STATE OF NEW YORK, COUNTY OF WESTCHESTER as: 1jr rr,P-4- being duly swom,deposes and says that he/she resides at -y 9�,,,, (Print Name of Applicant) (No.and Street) in 11 G r�i 5 h,n ,in the County of W�.,+r,l�e S I t✓ in the State of ,that (Cityrrown/Village) he/she has supervised the work at the location indicated above,and that the actual total cost of the work,including all site improvements, labor,materials,scaffolding,fixed equipment,professional fees,and including the monetary,value of any materials and Ir'_cc Nhich may have been donated gratis was:$_ (V'[o O. for the construction or alteration of y -vim Deponent further states that he/she has examined the approved plans of the structure/work herein referred to for which a Certificate of Occupancy/Compliance is sought,and that to the best of his/her knowledge and belief,the structure/work has been erected/completed in accordance with the approved plans and any amendments thereto except in so far as variations therefore have been legally authorized,and as erected/completed complies with the laws governing building construction.Deponent further understands that it shall be unlawful for an owner to use or permit the use of any building or premises or part thereof hereafter created,erected,changed,converted or enlarged,wholly or partly,in its use or structure until a Certificate of Occupancy or Certificate of Compliance shall have been duly issued by the Building Inspector as per§250-10.A.of the Code of the Village of Rye Brook. Sworn to before me this l(o Sworn to before me this day of �� S a- , 20 7-3 day of , 20 Signature of Property Owner Signature of Applicant Print Name of Property Owner MILTON KLEIN Print Name of Applicant ' I Nary public,State of New York LC' Rea.No.021(L7295502 Notary Public Qualified in Westchester COMV Notary Public t ommisslon Expires 0=11202i 1,O"1,tS an 2n_o21 �E BRC�jk. • �9a2 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 - - - - - - - - - - - - - - - - - - - - INS ECTION REPORT - - - - - - - - - - - - -- - -- - - - ? I--' o N Q ADDRESS: � �'AQ � DATE' \ PERMIT# `► ISSUED: SECT: ' LOCK: LOT. LOCATION: a Vc-)� 1A W ,p OCCUPANCY: -Z� '-) ❑ Violation Noted THE WORK IS... Z 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 ❑ IPXOSS CONNECTION FINAL ❑ OTHER r- Y Ln N W ■ en N O � � yr ■ AA , 1�1 �00 � ft p N T� y ` m a p O x -o I1 cn CL v yi 0 a � a y m J o E G1 ^ s F1 ■ 0 4 ■ �" O �, v a r o W tw �-V ■ eo L O n c a {� A CA Z ■ a O o ow m co ■ r � H V] w N oo � � � g V ■ V W oO z et A O w U O0 O b ca cry 1+1 �n P-1C z W z b Q0 044 0-4 V1 ■ m � � � }. v O J. � V' ■ 1� Q 4 b f y 9 Ci) W H 0 Z 0 Z w O v O V v z g ?4 � x A z q u ob BUILD MENT P) ECENED V :ET :RYE:BR OK 938 KING W 1057 JUL 3 1 2023 VILLAGE OF RYE BROOK BUILDING DEPARTMENT FOR OFFICE USE ONLY: � Approval Date:AUG 0 1 2 P Application# Approval Signature: ARCHITECTURAL REVIEW BOARD: Disapproved: Date: BOT Approval Date: Case# Chairman: PB Approval Date: Case# Secretary: ZBA Approval Date: Case# Other: r Application Fee: Permit Fees: ') 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 BuildinJJg11 as p eer etailed statement described below. /� 1. Job Address: `T f IY1Ci td W SBL: L:Ki V1--�` Zone+ "-f Property Owner: Mi fto obt, Address: 4 Pine, QqL FxQd Phone#: 4I q -7]2-9 5 W Cell#: email: lJ7o6n( M1 i1L16n•CONY] 2. Applicant: M 1 I-hn Win Address: LF P l rI G 9*b ,mad Phone#:(qI'4) -772- QsJ 4 Cell#: email: MY-ldno6 Y]i4llcp. rayi 3. Roofing Contractor: C. Address: 17-CM4trS- . ,P( L9 Qn ty/j(Q IV Phone#:Lq LqL7yU--7(p(a Cell#: email: '�QZvrV VGYYa�G Y� CUl'p 4. Job Description, list all Methods&Materials: 9ginatz a 5. Estimated Cost of Job:$ 1 "I D D.OD (NOTE:The estimated cost shall include all site improvements,labor,material,scaffolding,fixed equipment,professional fees,and material and labor which may be donated gratis.) 6. If corner property,indicate street frontage: 7. Construction Type: rmml + M- "p-�( YS Construction Class: 8. Number of stories: ) F,O( -S Height: 9. Is garage being re-roofed:No: ( )•Yes: AA Attached No: ( )•Yes:DO Number of Cars: YV 10. Is roof peaked,hip,mansard,flat,etc: Q 11. Estimated date of completion: -1- 6/1/2023 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. STATE OF NEW YORK,COUNTY OF WESTCHESTER ) as: ,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,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. Sworn to before me this pC(� Sworn to before me this �}aw day of , 20 4,v of Sign tllre of Property Owner j,...&rpre u,Applican,/ L / �X.J a4 V O u✓J Yi-9 P in Name of r perty Owner Print Name of icant 1 t lju is ota Public Pto PAj,,t;;�•. sTArE`` OF NEW YORk\ / STATE /OF NEW YORKy NOTARY PUBLIC NOTARY PUBLIC Cps . '� OIPA6347542 ! � — �r 1 PsdBO;PA63 nss.C. 1 j7 SS1ON rillt�ptlss�. -2- 611/2023 Perry Verrone, LLC 12 Center Street Pleasantville, NY 10570 info@perryyerroneroofing.com Office: (914)747-7663 Fax: (914)747-7665 License WC 21701 H09 REVISED 7/26/23 3/3/23 Prepared by Todd Milton Klein 4 Pine Ridge Rd Rye Brook, NY 914-772-8554 mklein@mlklein.com OPTIONI: FULL ROOF REMOVAL AND REPLACEMENT • All existing asphalt roofing removed and carted from job site • All rotted plywood replaced at$95.00 per sheet • GAF Weather Watch Ice and Snow barrier installed on all gutter edges,valleys and around skylights (6 feet up) - Special attention cricket • GAF TIGER PAW paper installed on the entire field of roof • GAF LIFETIME Timberline Architectural HDZ CHARCOAL shingles installed on entire field of roof • GAF Cobra Ridge vent installed on all ridges of roof for attic ventilation, as needed • GAF TimberTex hip and ridge shingles installed on all ridges • Aluminum vent pipe boots installed over all vent pipes • Replace existing power fan • Aluminum WHITE drip edge flashing installed around entire perimeter of roof • GAF Weather Blocker starters installed on all perimeter edges *TARP DORMER ROOM BEFORE WORK COMMENCES The price for the aforementioned work,which includes labor and material (excluding any additional plywood), totals to the sum of. $11,900.00 Page 1 of 5 Initial & Date: QuickMeasure 4 Pine Ridge Rd, Rye Brook, NY 10573 (1) March 1, 2023 Roof Reports in Under an Hour Prepared For: Perry's Roofing A N Contents Measurements Overview 1 Roof Area 2,138 sq ft Top View 2 Roof Facets 7 Side Views 3 Predominant Pitch 6 / 12 Lengths 4 Ridges/Hips 80 ft Pitches 5 Valleys 45 ft Areas 6 Rakes 152 ft Summary 7 Eaves 99 ft Materials 8 Bends 9 ft a t04 s M 1 • •. 001. - /•, •. •r �• 1 i �ti 1 • • -.• -• QuickMeasure Side Views Roof Reports in Under an Hour ! t 4 •lilt' � / 'r. r ' t w t� Prepared For: Perry's Roofing © 4 Pine Ridge Rd, Rye Brook, NY 10573 (1) QuickMeasure Lengths Roof Reports in Under an Hour AFlash Step Drip N 21 1 i 21 Bend Eave Rake Ridge Valley 99 45 Lengths in feet Prepared For: Perry's Roofing U 4 Pine Ridge Rd, Rye Brook, NY 10573 (1) QuickMeasure Pitches Roof Reports in Under an Hour A N 6 6 4 6 6 6 b Pitches in inches per foot Prepared for: Perry's Roofing © 4 Pine Ridge Rd. Rye Brook, NY 10573 (1) QuickMeasure Areas Roof Reports in Under an Hour A N 476 339 117 285 281 189 450 Areas in square feet Prepared For: Perry's Roofing 4 Pine Ridge Rd, G-ye Brook, NY 10573 (1) QuickMeasure Summary Roof Reports in Under an Hour Pitch 4 6 Area 117 2,021 Percent 5% 95% Suggested Waste 0% 2% 5% 7% 9% 12% 17% Area 2,138 2,181 2,245 2,288 2,331 2,395 2,502 Squares 22 22 23 23 24 24 26 Roof Area 2,138 sq ft ARoof Facets 7 N Pitch 6 / 12 Bends 9 ft Eaves 99 ft Rakes 152 ft Ridges 80 ft Valleys 45 ft Flash 7 ft Step 24 ft Drip Edge 251 ft Leak Barrier 335 ft Ridge Cap 80 ft Starter 251 ff Notes:1)Measurements are rounded to the nearest whole number.2)Rakes are defined as sloped roof edges.3)Eaves are defined as level roof edges.4)Flashing pertains to level root edges and excludes valleys.5)Step flashing pertains to sloped root edges and excludes areas around penetrations.6)Drip edge=eaves+rakes.7)Waste table excludes additional materials needed for ridges,hips valleys.etc.8)Suggested waste factor is based on the roof complexity and is provided for guidance purposes only. you should confirm the appropriate waste factor prior to ordering. Prepared For: Perry's Roofing 4 Pine Ridge Rd, Rye Brook, NY 10573 (1) QuickMeasure Roofing Materials Roof Reports in Under an Hour Suggested Waste 0% 2% 7% 12% Shingle Products HDZ, Natural Shadow, ASII, Reflector, bundle 66 67 70 74 Royal Sovereign, and Cool Series Low-Slope Roofing System Liberty Base/Ply Sheet roll 0 0 0 0 Liberty Cap Sheet roll 0 0 0 0 Starter WeatherBlocker bundle 3 3 3 3 Pro-Start bundle 3 3 3 3 Buick-Start roll 8 8 9 9 Roof Deck Protection Deck-Armor, Tiger Paw, FeltBuster 10 sq roll 3 3 3 3 Shingle-Mate roll 6 6 6 6 VersaShield roll 7 7 7 7 Leak Barrier * StormGuard, WeatherWatch 2 sq roll 6 6 6 6 WeatherWatch 1.5 sq roll 7 7 8 8 Ridge Cap Seal-A-Ridge, Seal-A-Ridge AS bundle 4 4 4 4 TimberTex bundle 5 5 5 5 Z-Ridge bundle 3 3 3 3 TimberCrest box 5 5 5 5 Nails Cap Nails box 2 2 2 2 Coil Nails 1.25 in box 2 2 2 2 Step Flashing Step Flashing 10 ft piece 3 3 3 3 Step Flashing 8 ft piece 4 4 4 4 Drip Edge Drip Edge 10 ft piece 26 26 27 29 Drip Edge 8 ft piece 32 32 34 36 Attic Ventilation Cobra 4 ft Plastic Ridge Vents foot 29 Master Flow SSB960 Metal Slant-Black vent 9 Master Flow High-Capacity Dome Vent vent 4 Cobra IntakePro Rooftop Intake foot 58 Notes:1)These approximate quantities are based on estimated measurements and are for guidance purposes only. You should always confirm quantities prior to ordering and ensure you are following local building code requirements. 2)For Timberline,3 bundles=0,994 squares. 3)Starter=eaves+rakes. 4)Leak barrier=bends+eaves+flashing+hips+rakes+step+ valleys. 5)f8dge cap=hips+ridges.6)Estimated quantity of attic ventilation products based solely on exterior roof area and intended for estimating purposes only. Installer must verify attic floor square footage,roof design,local code requirements.quantity/type/approved roof pitch of recommended vent products,and conditioned space under the roof. Always have a balanced attic ventilation system. In no case should the amount of exhaust ventilation exceed the amount of intake ventilation.For more into,visit got.com/ventcalculator.7)Low-slope products applied to 1/12 pitch areas.8)Timberline products applied to 2/12 pitch areas and above. 'Installed coverage will be less and depend on quantity and width of side and end laps. U4 Pine Ricye Rd, R,e 5rook, NY 10573 (1) Ca....•4ki �1, Q �'ii4\ Y EE •. r. �ti 4' .•! :O 'O': r v/�yr JS..tG,'r'ySs r 'O '�., "'� l+ �^t b. x ti� •irI �31 h $' 4e `",e /�7f" 71 !• 'Ot yd�. 7,V' ". 'G3 - v. L /� v rt ' vri " ♦ r s- v r /r IL v T, /.�sT i�j� �• J• i/r 16 • 'L' i♦ 0 . ..�: • 11 1►1/1/11 _ ..1►1/11►{. i8 # y(1/1•,11 III.//111►I ` I►•,1'/, 111 \ � �#��. 1 'tl��# . 1// i��) •1• i I :' � i 1►,1+1►1 � s:� •..'rmn r''sr:'llil'�'li►1_sr:t'`- ;:+;:::INI111 c`?< ...=:.4111d's: << °t4NrP:i' yps<:_4111r1 +as' :.'NNI►:i{:ate o 'INU' s u• a% ' -- — . c Pt- 05> e o cLO N :1 o j( w CL N �C O k •• . T. O4. 1 ! \ •. ca CA is E O C O to to ftf v U U �- c � O � '• F O vl w 'i'r w ? o '� = otiection e-• .,. O (n LLJE F� G' �i• W LU > y _ ro a Z ai w J rn cL U o74-4 w a ICI X 41 O Z . ,. � sue:. ::�•,.t>� � � 4. w, NTH" U L a P� - r ' taw / •� O C% O i O — • rj En 0 1�ico)> fso='11++fir r '.` : >'? .'11 N��:-�'' �:���:-1r1�N1`=t`=?�_-'+:?..i►► NI`;}-=�',_z . •/ {I►Ilh`"� .:�_- �'t�lll�l',f''�,�;'s'=<'�1�'►►Ihi�:t• --,':r- •`"�.+� 1/1'/lll L -_ I{I/'1111 ��>^ 11111 1 .l 111111 s 1/1111 i 1 11 1 11 t� — 11/11 ��jg� 1 Q1,11/Ilr� t 11111 $ 34 1/1/IAY S�(1� 1/11► [F �lqL 11/1► a#F �1} 11/11 �i�$= �1 ♦��:YIT>fA�l�'i 'i�_A�� i.�i�A,��N �/�t°�FI�Atif� i ��/� .r�F(Ail r 1♦ Al '( �� ,.qIT �A� f�j"'i,� �/ tW'�jr ilA�'i�T •/• � 4• .+ t q 1 -r.. ' t �t n7 Y r: <:`�//+' cnr7,fh n r.d ` .1l v�,)1` r4}f%?r(^L.ti7D' ur��\v �'s., 2 a�!/� tt ;6 YIl�Z.•� � .trL�S�k., 0�... � •, `�� 3 �9ca2i°+Si`'�',.../v v •4 �,��wc�:u`�' .� �_� •�`���� asap ��.�'� �,������ DATE(MMIDDIYYYY) AcoR� CERTIFICATE OF LIABILITY INSURANCE 7/19/2023 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). CONTACT PRODUCER NAME: Catherine Dolce Levitt Fuirst Associates, Ltd. P"C0 .914-457-4200 ac No,914 457 4220 520 White Plains Road EMAIL info levittfuirst.com Tarrytown NY 10591 ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:Admiral Insurance Company 24856 INSURED PERRVER-01 INSURER B:Accident Fund Insurance Com an _ 10166 Perry Verrone LLC INSURER C:ShelterPOlnt 81434 12 Center Street Pleasantville NY 10570 INSURERD: INSURER E: INSURER F COVERAGES CERTIFICATE NUMBER:1704074886 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. 7CA000045827-02 POLICY EFF POLICY EXP LIMITS INSR TYPE OF INSURANCE POLICY NUMBER MM/DD/YYYY MWDD/YYYYLTRA X COMMERCIAL GENERAL LIABILITY 7/1/2023 7/1/2024 EACH OCCURRENCE $1,000,000 DAMAGE T R N 300,000 CLAIMS-MADE �OCCUR PREMISES Ea oxuvence $ MED EXP(Any one person) $5,000 PERSONAL&ADV INJURY $1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $2,000,000 PRODUCTS-COMP/OPAGG $2,000,000 POLICY�JECOT- LOC $ F1 OTHER: COMBINED SINGLE LIMIT AUTOMOBILE LIABILITY Ea accident $ BODILY INJURY(Per person) $ ANY AUTO OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS PROPERTY DAMAGE $ HIRED NON-OWNED Per accident AUTOS ONLY AUTOS ONLY $ B UMBRELLA LIAB X OCCUR#ADE GXL000147002 7/1/2023 7/1/2024 EACH OCCURRENCE $5,000,000 X EXCESS LIAB CLAIMS- AGGREGATE $5,000,000 DED X RETENTION$ $ PER OTH WORKERS COMPENSATION STATUTE ER AND EMPLOYERS'LIABILITY ANYPROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ OFFICE R/MEMBER EXCLUDED? E.L.DISEASE-EA EMPLOYEE $ (Mandatory in NH) If yes,describe under E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS below C i DBL358637 5/10/2022 5/10/2024 Statutory Limit DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101.Additional Remarks Schedule,may be attached if more space is required) Certificate Holder and/or the entities listed below would be covered as an additional insured per attached endorsement,to the extent provided therein if required by written contract,on a primary non contributory basis on the general lility.Waiver of Subrogation applies.Additional insured.primary and non contributory basis and waiver of subrogation on the Auto.Additional insured,primary aiabnd non contributory basis and waiver of subrogation on the Umbrella Certificate Holder is included as additional insured when required by written contract CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Village of Rye Brook 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 Workers' YOR K CERTIFICATE OF STATE Compensation Board NYS WORKERS' COMPENSATION INSURANCE COVERAGE la. Legal Name&Address of Insured(use street address only) 1b.Business Telephone Number of Insured 914-867-1747 Perry Verrone LLC DBA Perry's Roofing 1 c.NYS Unemployment Insurance Employer Registration Number of 12 Center Street Pleasantville,NY 10570 Insured Work Location of Insured(Only required if coverage is specifically limited to 1 d. Federal Employer Identification Number of Insured or Social Security certain locations in New York State. i.e..a Wrap-Up Policy) Number 26-2754386 2.Name and Address of Entity Requesting Proof of Coverage 3a. Name of Insurance Carrier (Entity Being Listed as the Certificate Holder) Continental Indemnity Village of Rye Brook 3b.Policy Number of Entity Listed in Box"la" 938 King Street 46-884191-18 Rye Brook,NY 10573 3c.Policy effective period 03/01/2023 to 03/01/2024 3d.The Proprietor. Partners or Executive Officers are included.(Only check box if all partners/officers included) QX 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 1a" 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: Steven Diamond (President) (Print name of authorized representative or licensed agent of insurance carrier) Approved by tQ_Wi Z/)4d,ZN.B.1td 03/28/2023 (Signature) (Date) Title: Licensed Insurance Broker Telephone Number of authorized representative or licensed agent of insurance carrier: 516-488-3040 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 (9-17) www.wcb.ny.gov