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HomeMy WebLinkAboutSP23-004PERMIT SECTIO 7 C 10T TYPE OF WORK I? /a/ JOB LocAlnONjSe4fC �0 �- 61110mae MOM /T TCO # FEE DATE AD .;• DO TF .• FOOTING FOUNDATION FRAMING RGH FRAMING INSULATION PLUMBING O RGH PLUMBING GAS CJ SPRINKLER ELECTRIC C7 LOW -VOLT CI ALARM C) AS BUILT Cl FINAL OTHER APPROVALS FRB � �tl I9 BOT PB SBA OTHER DR O` bV . 19 t� O 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 Win Ridge Realty LLC c/o Alena Hakanjin 24 Rye Ridge Plaza Rye Brook,New York 10573 Re: 13 Rye Ridge Plaza, Rye Brook,New York 10573 Parcel ID#: 141.27-1-6 Sign Permit#23-004 issued on 8/1/2023 for New Awning This certifies that the new awning;Stretch Lab,installed under the above captioned permit has been satisfactorily completed. Sincerely, Steven E. Fews Building&Fire Inspector /to F �C E V LAUG:3 2023BUILD TMENT Fpr Met up on'Xi MITVIL OF RYE BROOK V OF: K BUILDING DEPARTMENT issuEt�: — c STRE YORx 10573 DATE: 000, — 9 FEE: PAID O APPLICATION FOR CERTIFICATE OF OCCUPANCY,CERTIFICATE OF COMPLIANCE, AND CERTIFICATION OF FINAL COSTS TO BE SUBMITTED ONLY UPON COMPLETION OF ALL woRR, AND PRIOR TO THE FINAL INSPECTION f NtNNf Nfff NfNftNff fflf NflNft/tNNlffNflNtN1l IItN NNtplttt tfttNtt Nll NfftNNt NtlfftN NNIf•If NffNtffff• Address: Rye- � 1uS7 '1 Occupancy/Use: Parcel ID#: /�1 , a 7 i 7,ame: Owner:. r Address: io(- P.EJR A.or Contractor: S I �Ste�nl �/G wnl;,clyAddress: 11 /(i573 Person in responsible charge- C.- Address: Y, i4Q I d-5 7 3 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:J o S h ZL being duly sworn,deposes and aaya that he/she resides at 404 V i I(eki n(JhsalWam e[AppH=* (No.and street) in I /d C 4 �1� y �' in the Cotmty of w e ' -L in the State of ,that (Cityrrownt vll ftr� 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 I have been donated gratis was:$ for the construction or alteration of eJao Deponent father stages that he/she has examined the approved plans of the ttrercture/work herein referred to for which a Certificate of Occupancy/Compliance is taught,and that to the best of his/her knowledge and belief,the struchuelwork has beau crected/completed in accordance with the approved plans and any amendments thereto except in so far as variations therefore have been legally authorized,and as erectulicompleted 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 we this Z Z Swom to before tine this )L J c0 da of 7 .20 Z3 Y of 20,Q tY _ n ce of ftwty essay kbwT to KAppNasat LO N L1J Z+a� P t r 0000 w atA sr ie en Pebbe Ov o w_ LC?1e not--rn J m TARY PUF' ''' snrne2YORK d Z Z W. �RLIFIEO INV. Ty QC WAISSION EXPIRES OEt;c►J;t3�R;,2026 O n Q - tJ QyE BRC�jk. O� Zm cu � • 1982 BUILDING DEPARTMENT i` 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.or - - - - - - - - - - - - --- - - - - - INSPE TION REPORT - - - - - - - - - - - - - --- -- - - a f ADDRESS : DATE. PERMIT# ISSUED' 1 �,SliCT: �4I' 1 BLOCK:LOT: y LOCATION: '✓ I AW(I M OCCUPANCY: ❑ Violation Noted THE WORK IS... 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 CROSS CONNECTION x1ro- FINAL OTHER ■ O " � N v � ■ oo v v u x � u • W 0 0 \ © W W 0 O W V o H en en ao _ C `1 as Q F . 10, V co Sri 0 v 4 4 o U {� CD 0-1 " 044 r��7jj I� W 9 41 CN 00 C/) Z Y 11 C^^J Uq � v W z V w © . ,oA°q �� } Oab o F a � 4 � b > M Z � A w � � d :� � � z d c may' _gam D BUILD TMENT VIL E Ok, `_ OOx FJUN:19:2023 938 K[NG ET RB ,NY 10573 ��Y ) VILLAGE OF RYE BROOK BUILDING DEPARTMENT FOR OFFICE USE ONLY: Approval Date 2 _�} ��23 Application# �� J��� Approval Signature: -' ARMTECTURAL REVIEW BOARD: Disapproved: : Date: BOT Approval Date: Case# Chairman: PB Approval Date: Case# Secretary: ZBA Approval Date: Case# Other: y Application Fee. ermit Fees: Ar\t /�-7 J5`huU� ###**#*t***s*itsrttrkkktki#*r#r#s;srswwsswi#ww##t!#sr#s#!!#!###f!;#!rt#ltwt!#!!!!*slwsstslw;wsrwsswrsww;klrt# v l SIGN PERMIT APPLICATION Application dated: f/7`r is hereby made to the Building Inspector of the Village of Rye Brook,NY,for the issuance of a Permit for the construction/installation of a sign in accordance with Village Code§250-35 as per detailed statement described below../ // 1. Address: 19 Rat i, Q, E�Jo / r SBL:�7/, c)7/—to Zone: 2. Property Use or Business Name: 3. Proposed Sign(s)(Describe in detail including number of signs,types,sizes,exact location(s),and illumination method(s)if applicable.) I A separate Electrical Permit will be required for any associated electrical work.) 4. Height from grade to highest point of sign: to lowest point of sign: 5. Property Owner: a� <= -----Address: 7 'I�ye 4,d i c P(,a {��It QI wK IU,' IrIS�3 Phone#_q t4-- Wi_ i Cell# email: A016 f ,1,4 -(� 5. Applicant: ( - b&51lIQL. Address: Phone# 1:4 14 - �3 l 4�Cell# email:,,Site&9tj J k 16tiI t7K 1(1.1.co rYti 7. Architect/Engineer: Address: Phone# Cell# email: 8. Sign Contractor: ea j Address: 4 6 1 [.f tO') 16, ? Phone# - Cell# email: LL . o�Q S 16L)11 a'4 A)• COO a- 8/12/2021 9. Will the proposed sign require a Site Plan Review by the Village Planning Board as per§209 of Village Code? Yes:_No: (If yes,you must submit a Site Plan Application,&provide detailed drawings) 19. Does the propos sign involve a Home-Occupation as per§250-38 of Village Code? Yes: No:X_if yes,indicate: TIER 1: TIER II: TIER III: (if yes.a Home Occupation Permit Application is required) 11. If building is located on a comer lot,which street does it front on: 12. Property frontage: 13. Property size:Sq.Ft.: Acres: 14. What is the total estimated cost of construction: $ Q Q Q 0 ("The estimated cost shall include all site improvements,labor,material,scaffolding,fixed equipment,professional fees,including any material and labor which may be donated gratis.) 15. Estimated date of completion: *******#***#****#*****k*#****#kkk•�k#*t***•'Rf4*#**•*k#*t#k********k*******##**********#*k**kk*k#**#***#**# This application must include the notarized signature(s) of the legal owner(s) of the subject property, and th • 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: _ gad t " h L n ,__ ,being duly swam,deposes and states that he/she is the applicant above named, (print namJ 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 fA r,ic..A=e_ 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. ' A,1 Sworn to before me this vZ~ Sworn to before me this �- 1 day of ,�j+t� 1 , 20 Z Nt�3 day of ✓ - )/ 20 - 7� l Cf— of (�perty Owner A"1�7 r Signature of Applicant 6K)c, trsi �l e4r)tt 1 Priat Name of Pr tlti�aer rR>xN► Print Name of A E No c No lie 2lQ -2_ 8/12/2021 Building Permit Check List & Zoning Analysis OB & C ONLY Address: OACA 9— SBL: 1 _ Zone: U e Const.T e: Other. Submittal Date: A Revisions Submittal Dates: 1 \ _ Applicant f-P V - � Nature of Work: \ l r Reviews:23A: JUL 0 5 2023 pB BP: other: NEED OK ` ( ) GEES:Filing. 2�a BP: O�'7S', WC C/O: Legalization: ( ) ( P.: Date Stamped Properly Signed: SBL Verified: Cross Connection: F.O.G.: ( ) Genic Roads: Steep Slopes: Wetlands: Storm Water Review: Street Opening: ( ) ( ) ENVIRO.: Long Shorn 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 rW 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: Grease Trap: Other. ( ) ( ) FIRE SUPPRESSION:Plans: Permit N/A: Other. ( ) ( ) H.V.A.C.: Plans: Permit: N/A Other. ( ) ( ) FUEL TANK: Plans: Permit: FUEL TYPE: Other. O O 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 ( B mtg.date approval notes: ( )ZBA mtg. date: approval: notes: ( )PB mtg.date: approval• _notes: APPRUVLU �. REQUIRED EXISTIIVG PROPOSED NOTES pate:JUl 2 5 2023 Circle: Frontage _ Front Front Sim: &W. FAIL Qm sAac� Stories. notes: D ECENE BUILD ! = "R. MENT VIL OOK J U N 19 2023 938 KING T R; ,NY 10573 VILLAGE OF RYE BROOK BUILDING DEPARTMENT ssssssssssssssssssssssssssssrsrsssssrsssssssssrssssssssssssssrsssssssssssssssssssssssssessssssrssssssssssss ARCHITECTURAL REVIEW BOARD CHECK LIST FOR APPLICANTS This form must be completed and signed by the applicant of record and a copy shall be submitted to the Building Department prior to attending the ARB meeting. Applicants failing to submit a copy of this check list will be removed from the ARB agenda. Job Address: 13 Rye 88y 00-4--, Rye &wk IVY 1OV3 Date of Submission: Parcel ID#: 1 , c)7-1—& Zone: Proposed Improvement(Describe in detail): 2 c e APPLICANT CHECK LEST: MUST BE COMPLETED BY THE APPLICANT S or c, c UlR ev c nt' The following items must be submitted to the Building 9/210✓e. ta.� d-z of n ca:t-\ Department by the applicant-no exceptions. Property owner: Ahr, klicreql e_L.L t� 1. (,4Completed Application 2. ( )Two(2)sets of sealed plans. (one full size (maximum Address: to Ryr k d�+ P.l k,,t &,A w-)3 allowable plan size=36"x 42")and one 11"x 17") Phone# �I y- y�$-7 3 oC r 3. ( )Two(2)copies of the property survey. 4. (i)Two(2)copies of the proposed site plan. Applicant appearin before the Board: 5. ( 'One electronic/disc copy of the complete application materials. {�— 6. Filing Fee. Adel ess:�D� I L t( 1J 7. ( )Any supporting documentation. Phone# 3 7 i 0 6 7� 8. ( }HOA approval letter. (f applicable) —'1`— ._ +/3 -- 9. j%j Photographs. .Architect/Engineer:_ 1 0.(>4 Samples of finishes/color char. (a sample board or Phone# model may be presented the night of the meeting) By signature below, the owner/applicant acknowledges that he/she has read the complete Building Permit Instructions&Procedures,and that their application is complete in all respects. The Board of Review reserves the right to refuse to hear any application not meeting the requirements contained herein. �'.� Swore to before me this 2-_ _ Sworn to bef a me this day of ,20 day of ,20 DNa f Property IA,ia= signature of Appl IMI F int Name of Property t Print Name of Nap—on-cant tin Wo b1i No Public LOIS NIETO NOTARY PUBLIC, STATE OF NEW YORK QUALIFIED IINOWESTCHESTER COOMY COMMISSION EXPIRES DECEMBER 3, 2026 Village of Rye Brook Agend 0 %.c t��''' y Architectural Review Board Meeting Wednesday,July 19,2023 at 7:30 PM Village Hall,938 King Street 1. ITEMS: 1.1. ARB23-064(Consent Agenda) DRJ West LLC 32 Lincoln Avenue 4'high white vinyl fence with driveway gate. 1.2. ARB23-065 (Consent Agenda) Brian Zelesky&Alexandra Zelesky 26 Hawthorne Avenue 4'high PVC picket fence,4'high black chain link fence,4'high white PVC driveway gate and 6'high black chain link fence. 1.3. ARB23-066(Consent Agenda) Alexander Sherman&Samantha Sherman 26 Lawridge Drive 4'high white vinyl fence and gates. 1.4. ARB23-067 (Consent Agenda) Richard Billig&Kathleen Billig 16 Red Roof Drive Replace walkway and front steps. 1.5. ARB23-068(Consent Agenda) Sherree Amar 45 Lincoln Avenue Rooftop solar array. 1.6. ARB23-069 (Consent Agenda) Sujan Vasavada&Sujasha Vasavada 2 Heritage Court Rooftop solar array. 1.7. ARB23-070 (Consent Agenda) Michael Rackenberg&Stefanie Rackenberg 144 Country Ridge Drive Rear patio. 1.8. ARB23-071 (Consent Agenda) Karen Kuznetzow 267 North Ridge Street 6' stockade fence,post and rail fence along retaining wall and gate. Architectural Review Board July 19,2023 1.9. ARB23-072(Consent Agenda) Eric Gioseffi&Jacqueline Gioseffi 30 Lawridge Drive 4'-1/2"high black aluminum fence and gates. 1.10. ARB23-073 (Consent Agenda) Thais Cunha&Marcela Melgarejo 17 Lincoln Avenue Replace patio and walkway. Consent Agenda Approvals: Motion Second Abstention Aye; Nay; Adjournment; Notes 1.11. ARB23-074 Jose Sagastizado&Noemi Sagastizado 28 Division Street Rear deck. Approvals: Motion Second Abstention Aye; Nay; Adjournment; Notes 1.12. ARB23-075 Sheryl Brauman 12 Magnolia Drive Rear deck. Approvals: Motion Second Abstention Aye; Nay; Adjournment; Notes 1.13. ARB23-076 Joshua Kirsch&Kristen Kirsch 2 Lee Lane One-car attached garage and driveway parking court. Approvals: Motion Second Abstention Aye; Nay; Adjournment; Notes Page 2 of 4 Architectural Review Board July 19,2023 1.14. ARB23-077 Win Ridge Realty LLC 13 Rye Ridge Plaza New awning. "Stretch Lab" Approvals: Motion �\ Second "- Abstention Aye;—3xx Nay; 0 Adjournment; Notes 1.15. ARB23-078 Win Ridge Realty LLC 112 South Ridge Street New facade sign and awning. "DIG." Approvals: Motion Second Abstention Aye; Nay; Adjournment; Notes 1.16. ARB23-079 (Amendment to Prior Approval) 760-800 Owner LLC 760 Westchester Avenue Change from Betafence Guardian Dutyguard fence to black chain link with privacy green hedge inserts. Approvals: Motion Second Abstention Aye; Nay; Adjournment; Notes 1.17. ARB23-080 Jacob Gebrael&Marleine Ishak 1 Hunter Drive In-ground swimming pool. Approvals: Motion Second Abstention Aye; Nay; Adjournment; Notes Page 3 of 4 • Architectural Review Board July 19,2023 1.18. ARB23-081 Gregory Varone 47 Hawthorne Avenue New single-family dwelling with attached garage,in-ground swimming pool, spa, cabana, deck,patio and fencing. Approvals: Motion Second Abstention Aye; Nay; Adjournment; Notes 1.19. ARB23-082 Richard Gasparino&Bridget Gasparino 6 Jacqueline Lane Legalize 12x24 storage shed. Approvals: Motion Second Abstention Aye; Nay; Adjournment; Notes 1.20. ARB23-083 Srivatsan Raghavan&Janani Ranganathan 436 North Ridge Street Window and door changes. Approvals: Motion Second Abstention Aye; Nay; Adjournment; Notes 1.21. ARB23-084 Christopher Baildon&Tamzin Manning 72 Valley Terrace Legalize 10x23 rear paver patio. Approvals: Motion Second Abstention Aye; Nay; Adjournment; Notes NEXT MEETING: August 16,2023 Page 4 of 4 DATE(MMIDONYYY) ACOR" CERTIFICATE OF LIABILITY INSURANCE OS/31I2023 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 pollcy(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 Stacie Washington NAME: Borrelll Partners Insurance Agency A,ONNo Ext: (914)939-7900 FAX C No): (914)407-5088 287 Bowman Avenue E-MAIL swashington@borrellipartners com ADDRESS: Suite 406 INSURER(S)AFFORDING COVERAGE NAIC N Purchase NY 10577 INSURER A: Travelers Casualty Ins Co of America 19046 INSURED INSURER B: Travelers Indemnity Co 25658 Lanza Corporation D/B/a INSURER C: Phoenix Ins Co 25623 404 Willett Ave INSURER D: INSURER E: Port Chester NY 10573 INSURER F: COVERAGES CERTIFICATE NUMBER: CL235804613 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 AUUL1bUt5K POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER MM/DD/YYYY MMIDD/YYYY LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE 7 OCCUR PREMISES Ea occurrence $ 300.000 MED EXP(Any one person) $ 5,000 A 6805J175092 06/05/2023 06/05/2024 PERSONAL BADVINJURY $ 1,000,000 GEN'LAGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE $ 2,000,000 POLICY FX PRO- ❑ JECT LOC PRODUCTS-COMP/OPAGG $ 2,000,000 OTHER I $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea acudem ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY Per accident $ UMBRELLA LAB X OCCUR EACH OCCURRENCE $ 5,000,000 B X EXCESS LIAB CLAIMS-MADE EX5J175240 06/05/2023 06/05/2024 AGGREGATE $ 5,000,000 DEC I I RETENTION $ $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY YIN STATUTE ER C ANY PROPRIETOR/PARTNER/EXECUTIVE ❑ NIA UBSJ175160 06/05/2023 O6/OS/2024 E L.EACH ACCIDENT $ 1,000,000 OFFICER/MEMBER EXCLUDED? (Mandatory in NH) EL DISEASE-EA EMPLOYEE $ 1.000,000 If yes,describe under 1,000,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT E DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) BLANKET Al-OWNERS,LESSESS OR CONTRACTORS,AI-MANAGERS OR LESSORS OF PREMISES,AI-STATE OR POLITICAL SUBDIVISIONS PERMITS RELATING TO PREMISES,Al LESSOR OF LEASED EQUIPMENT,PRIMARY&NON-CONTRIBUTORY WORDING,WAIVER OF SUBROGATION-WC POLICY INCLUDES BLANKET WOS CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN 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 YORK Workers' CERTIFICATE OF STATE Compensation NYS WORKERS' COMPENSATION INSURANCE COVERAGE Board 1a. Legal Name&Address of Insured(use street address only) 1b. Business Telephone Number of Insured Lanza Corporation 914-937-6360 DBA Sign Design and J C Awning 1c. NYS Unemployment Insurance Employer Registration Number of 404 Willett Avenue Insured Port Chester, NY 10573 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 13-3525268 2. Name and Address of Entity Requesting Proof of Coverage 3a. Name of Insurance Carrier (Entity Being Listed as the Certificate Holder) Phoenix Insurance Company Village of Rye Brook 3b. Policy Number of Entity Listed in Box"l a" 938 King Street UB5J175160 Rye Brook, NY 10573 3c Policy effective period 06/05/2023 to 06/05/2024 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"S' 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". 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? YES ®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 Joanne SiricO (Print name of authorized representative or licensed agent of insurance carrier) Approved by: ��yLyL� �vau�B 05/31/2023 (Date) Title: Acct Mgr Telephone Number of authorized representative or licensed agent of insurance carrier: 914-939-7900 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 724 HOUR NOTICE REQWRED PRIOR TO ALL 15�% MANDATORY INSPECTIONS 11ft ol V0, :i3 . p.ti . . . . . . . . . . . rj -n -0 cm m 0 0 X (D 0 D (D > cn m 0 0 z z m 3 3 CD z ce > 0 0 m z 0 m w 7if 0 CD cn 0 =5 w "o 0 C Cr U -a 0 V0 -0 cl) Z3 Z3 00 c- > 0 U) r+ cr) =r 0 =r 0 a' cn N m L C � v�., ot) z ��z cn CD o"j 70 (D 0 000 Mir N r23RCM op CD o � o c� cl) (D rML I%mwoo 'AA m --o --y oc�., =r 0 3 x 0 4 "o m n tD (D o a LA (f) rmt ko rt r, .0, (D z r �6 -1 > e) < (D W z (D (A. 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