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HomeMy WebLinkAboutRP23-043TYPE OF WORK TCO � FEE DATE DATE FOOTING FOUNDATION FRAMING RGH FRAMING INSULATION PLUMBING CJ RGH PLUMBING GAS O SPRINKLER ELECTRIC C� LOW -VOLT CI ALARM AS BUILT 0 FINAL • 0)9e ✓�/1' ; (9/7�593- S63? OTHER APPROVALS ARB BOT P8 ZBA OTHER DR t4.°e JjV t `it J `�`4Vvy VILLAGE OF RYE BROOK MAYOR 938 King Street, Rye Brook,N.Y. 10573 ADMINISTRATOR Jason A.Klein (914) 939-0668 Christopher J.Bradbury www.ryebrookny.gov TRUSTEES BUILDING & FIRE INSPECTOR Susan R. Epstein Steven E. Fews Stephanie J. Fischer David M. Heiser Salvatore W. Morlino CERTIFICATE OF COMPLIANCE September 23,2024 Fasih Ahsan&Talha Rathore 320 Betsy Brown Road Rye Brook,New York 10573 Re: 320 Betsy Brown Road,Rye Brook,New York 10573 Parcel ID#: 135.51-1-34 Roof Permit#23-043 issued on 9/25/2023 to Re-Roof Existing Building This certifies that the new roof,installed under the above captioned permit has been satisfactorily completed. Sincerely, Steven E. Fews Building&Fire Inspector /to D E C ENE For office use onl l BUILDING DEPARTMENT VILLAGE OF RYE BROOK PERMIT# $EP 16 2024 6 ISSUED: - 23 _ 138 KING STREET,RYE BROOK,NEW YORK 10573 DATE: r- VILL.A,Gc O� RY��B GOK (914)939-0668 FEE: PAID Cr"" Bul' CD!r!'=. ._iE:PAR_FMENT www.rvebrook.org APPLICATION FOR CERTIFICATE OF OCCUPANCY, CERTIFICATE OF COMPLIANCE, AND CERTIFICATION OF FINAL COSTS TO BE SUBMITTED ONLY UPON COMPLETION OF ALL WORK, AND PRIOR TO THE FINAL INSPECTION rr*t++»»rsst»ss»rt**sr*r+rr*»r**+**sst»ttttst»+****r»*t*+**ss»»t»s»*s»*»r»s*»»ssssstsssrstst*sst*»»rsr*sssr+*****r*st»ss*ss»t Address: 320 BETSY BROWN RD,RYE BROOK,NY 10573 Occupancy/Use: I- Parcel ID #: 05 .5 I l/ 2q Zone: R-12 Owner: TALHA RATHORE,FASIH AHSAN Address: 320 BETSY BROWN RD,RYE BROOK,NY 10573 P.E./R.A. or Contractor: AKSH QUALITY CONTRACTING CORP Address: 56201st Ave,First Floor, Unit#4,Brooklyn,NY 11220. Person in responsible charge: FASIH AHSAN Address: 320 BETSY BROWN RD,RYE BROOK,NY 10573 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: FASIH AHSAN being duly swom,deposes and says that he/she resides at 320 BETSY BROWN RD, (Print Name of Applicant) (No.and Street) in RYE BROOK in the County of WESTCHESTER in the State of NY that (Citv/Town/Village) he/she has supervised the work at the location indicated above,and that the actual total cost of the work,including all site improvements, labor,materials,scaffolding,fixed equipment,professional fees,and including the monetary value of any materials and labor which may have been donated gratis was:S 8000.00 for the construction or alteration of: New In-Kind Shingle Roofing System including Plywood as needed,Ice&water sheild,Flashing around Chimney,vent pipes 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-IO.A.of the Code of the Village of Rye Brook. Sworn to before me this ,(, Sworn to before me this day of S-e kQ , 20 2 — ) day of 120 /C7-� Signature o operty Ovmer Signature of Applicant 0,\L-kA A 1ArV He 9 F t Name of Property ner Print Name of Applicant 'Ilan � Notary Pu%atary Public,State of New York Notary Public No.01ME6160063 Qualified in Westchester County Ccmtnissitm Expires January 29,20L� �E BRC�k• 1937 BUILDING DEPARTMENT ❑BUILDING INSPECTOR 8.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 : 3 2 0 Q:�,,e— LA Q'tioc o,,j N . i n [ DATE: Z ` PERMIT# ISSUED: ' `'" e.J SECT:BLOCK:/LOT: LOCATION: `F— i' OCCUPANCY: ❑ VIOLATION NOTED THE WORK IS... D. ACCEPTED ❑ REJECTED/ 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 [f FINAL B OTHER W N � N � 1-i N Ca. A a 0 844 v 1 W w CL v G4 �"cog Ln en > O g w F--1 00 w $ O Q 1 G. o [ 4o Ln N d o D ■ O � j�y � � � A � .n C'C � � I' s °V p g *, oo z . �. co en A O A V , U 1.0 v Ln W rj) Q ``u � v a w � U w �" R■+ z z a� � o A z o P. LnD ° 0 N z w w P. � 44 M A z xv w a di I C4 C� 14 W ►� _ "� n EC EWE BUILDING WO'ARTMENT p VILLAGE OF RYE BROOD n JUN - 2 2023 938 DING STREET RYE BROOK,NY 10573 (914)939-0668 VILLAGE OF RYE BROOK wwWjy�brook.org. BUILDING DEPART ENT FOR OFFICE USE ONLY: Approval Date: SEP 2 ermit# -�"�� 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 Feet b Permit Fees: IV Oa— U ROOF PERMIT APPLICATION Application dated: 6"'-c=)—Q3 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. 1. Job Address: 320 BETSY BROWN RD,RYE BROOK, NY 10573. SBL:/3J_,5/—/—3�/ Zone: R-12 Property Owner: TALHA RATHORE,FASIH AHSAN Address: 320 BETSY BROWN RD, RYE BROOK,NY 10573. Phone#: 917-330-0296 Cell#: 917-330-0674 email: TALHARATHORE@GMAIL.COM 2. Applicant: TALHA RATHORE,FASIH AHSAN Address: 320 BETSY BROWN RD,RYE BROOK,NY 10573, Phone 4: 917-330-0296 Cell#: 917-330,--0674 email: TALHARATHOREOGMAIL.COM 3. Roofing Contractor u144 Co,-4-U c>�i-7 ' Address:56� PA/0—�-r�1C�ys7 Ally _ PhM7e-i�:c�Sha 1710/41' V� Cell#: 9f 7 J y3- 3�3-? email: - 4. Job Description, list all Methods&Materials: New In-Kind Shingle Roofing System including Ice&water sheild,30lbs Asphalt paper, Flashing around Chimney,vent pipes etc.Also In-Kind new putter installation S. Estimated Cost of Job:S 6000.00 (NOTE:The estimated cost shall include all site improvements.labor,material. scaffolding,fixed equipment,professional tees,and material and labor which may be donated gratis.) 6. If corner property,indicate street frontage: Not Applicable 7. Construction Type: SINGLE FAMILY HOUSE NYS Construction Class: VB 8. Number of stories: None Height: 9. Is garage being re-roofed:No:( )•Yes:(X) Attached No: ( )•Yes: (X)Number of Cars: One Car 10. Is roof peaked,hip,mansard,flat,etc: Hip 11. Estimated date of completion: 08/31/2023 -l- 8/12/2021 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 owners 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 C� Sworn to before me this day of ���v l\ , 20� day of , 20 Signature of Property Owner Signature of Applicant '1 (r P?mt Name of Property Owner Print Name of Applicant AL )�TA�, Notary Public Notary Public SHARI MELILLO Notary Public,State of New York No.01M E6160063 Qualified in Westchester county Commission Expires January 29.20z 7 -2- 8112/2021 r, AKSH QUALITY COPTACTING CORP. 5620 1st Avenue, FL 1, Unit#4, Brooklyn, NY 11220, Ph.:917-593-3638,929-255-5621,Email:info@akshqc.com,akshgccorp@gmail.com To July 19, 2023 Talha Rathore& Fasih Ahsan The Owner, 320 Betsy Brown Rd. Rye Brook, NY 10573 Ref.:New Shingle Roofing System: Project Location: 320 Betsy Brown Rd., Rye Brook, NY 10273 Dear Talha&Fasih, As per your instructions to provide cost proposal of furnishing& installation of new shingle roofing system. The new shingle roofing system will be installed at the plywood system.The cost of new shingle roofing system also includes 30%of the replacement of existing damaged/deteriorated plywood with new plywood system.The new plywood will meet the same thickness and style as existing. The new shingle roofing system will be GAF or approved equal system. The Total Cost of New shingle roofing system with labor, materials work will be$7,765 00* *Exclusions&Clarifications: 1. This work will be conducted without filing with Landmarks and DOB. It's the owner's responsibility to pay for filing in the event it is required. 2. Work to be completed without interruption.Additional cost will be applied if work, at the request of management or due to no fault of AKSH, is interrupted and made to spread out over several days. 3.Asbestos/lead testing or abatement:It is the owner's responsibility to test and ensure that work or work site are free of environmentally hazardous materials.AKSH is not licensed neither equipped to test or remove such materials with its own labor force and will hold the owner responsible in the event such hazardous materials, knowingly, unknowingly or due to negligence exist on this project. 4.Any alteration or deviation from the above-mentioned scope of work/project plans will extra costs and will be executed only upon written orders and will become an extra charge over and above the estimate. 5.Any item/items are not mentioned in scope of work will not be part of this cost proposal. 6. -No work of exhaust pipe, chimney,skylight, gutter, downspouts included in the cost proposal 7.Any permit or permits requires and process will be additional cost. Page112 1 r� AKSK QUALITY COMMA CTING COP. 5620 1st Avenue, FL 1,Unit#4,Brooklyn,NY 11220, Ph.:917-593-3638,929-255-5621,Email:info@akshqc.com,akshgccorp@gmail.com Warranty: The warranty of new roofing system for Labor will be one year after complete installation and approval, and material warranty will be 20 years(which comes with the little cost from the manufacturer). Should you have any questions or requires additional information,please don't hesitate to contact the undersigns. Sincerely, AKSH Quality Contracting Corp. Shahid Altaf Vice President 917-593-3638 Page212 I • • • - • • • • I I I i I i I I Timberline HD° High Performance Peace of Mind Shingles Provide Designed with Advanced Protection` lifetime ltd. transferable warranty with Shingle Technology, which reduces the Smart Choice`'Protection (non-prorated These Unique Benefits: use of natural resources while providing material and installation labor coverage) Great Value excellent protection for your home for the first ten years3 (visit gaf.com/APS/to learn more) Architecturally stylish but Perfect Finishing Touch practically priced Stays in Place For the best look, use Timbertex Dimensional Look Dura Grip'Adhesive seals each Premium Ridge Cap Shingles or shingle tightly and reduces the risk of Ridglass' Premium Ridge Cap Shingles' Features GAF proprietary shingle blow-off. Shingles warranted color blends and enhanced shadow effect for a genuine to withstand winds up to 130 mph wood-shake look (209 km/h)' Highest Roofing StainGuard° Protection Helps ensure the beauty of your roof Fire Rating against unsightly blue-green algaez UL Class A, Listed to ANSI/UL 790 'This wine speed coverage regmres special mstallahuc.see GAF Shingie&Accessory Lfd Warr3nryfor details. "SlainGoard`Protection applies only to shingles with StairGuard�-labeled packaging.See GAF Shingle&AccessoryL:d Warranlvfor complete coverage and restrictions. 'See GAFSh;rgm&AcressvryLtd.Warranlyfor complete coverage and reslricfions.The word'Lifetime'refers to the leng?h o'coverage provided by the t-'AFSbirgle&Accessory Ltd.Warranty and means as long as the original individual owners)of a single-family detached•esidence[or the secono ewner(s)in certain circumsfancesl uwns the property where the shingles are installed Fin owners/structures not meetirg the above enteria. Liletime coverage is not applicable "These products are not available in all areas.See www.pat.cnn-dridgecapavaitahildy for details. .' I „ PatriotI Colors Availability Driftwood Fewter Gray Regional A • • . Northeast, -. and Central Fox Hollow111 1 Barkw 1 1 1 Birchwood Hickory Biscayne Blue Hunter Green f I 1 I CanadianDriftwood I I I ' ra Charcoalf I , Slate • Texas Department of Insurance listed Exposure: 5 5/8" 143 rnm Applicable Standards p ( ) • CSA A123.52 • Bundles/Square: 3 & Protocols • ENERGY STAR"Certified White Onl • UL Listed to ANSI/UL 790 Class A (U.S. Only) ( y) • Pieces/Square:• StainGuard" Protection: Yes° • Miami-Dade County Product Control • Rated by the CRRC • Hip/Ridge:Timbertex"' Seal-A-Ridge°; approved • Can be used to comply with Title 24 Z`-' Ridge; Ridglass" • State of Florida approved cool roof requirements • Starter: Pro-Start`'&Weathel-Blockee" • UL 997 modified to 110 mph • Meets the cool roof requirements of • Classified by UL in accordance the Los Angeles Green Building Code Installation with ICC-ES AC438 (Birchwood,Copper Canyon, Golden Detailed installation instructions • Meets ASTM D7158, Class H Amber, and White Only) are provided on the inside of each • Meets ASTM D3161, Class F Product/System S ifiCS3 bundle wrapper of Timberline HWI • Meets ASTM D3018,Type 1Shingles. Installation instructions may • Meets ASTM D34621 • Fiberglass Asphalt Construction also be obtained at gaf.com. • ICC-ES Evaluation Reports • Dimensions (approx.): 13 1/4" x 39 3/8" ESR-1475 and ESR-3267 (337 x 1,000 mm) 'Periodically tested by independent and internal labs to ensure compliance with ASTM C34U at time of manulactire. 2Retersto shingles sold in Canada only. 'Refer to complete published installation mstw.lions. 'StainGuard`Protection applies only to shingles with StainGuard'-labe ed packaging.See GAF Shwp'e d,4ccessofy lm Warranty'ur ccr,plete coverage and restr;rioas. Note:It is difficult to reproduce the color clarity and actual color blends of these products.Before selecting your color,please ask to see several full-size shingles. ©2017 GAF 12117#875 � ��"'� [u N y�t, .,� - ..� .A�. k1� yf! ^ �.r...y`^N�k�.Q�i�"- QA "•. , -a «9^ q�}}h�, {rd Q +�� {, Q ,,w°r` Q 74+ rf Qt,•�a�Y "pWNW k, •e I� i'1•/►Slio ' rTrr O •� y LLJ lu p p c Of C K \ LL .E okeCtiory «ems» \ on O , V Q Y a aua Mall N LO • i� O Q ¢ C. •I1tF`F FFF 16 Ad c M04 qw ; L= b E t 00 co 'I AbOy Y Its t{ a!.1. . . .�... ... . . . :7i.�el� r:i�C��e}.-��. 1 ^_� 7';�,•�I�h ' �dl�/l1h\ .�—•-� /il/llll /11�11 •\ ^- ill/,llii —'— .l�il, / 'It •,'lNws /� •�w�I , ,1Yl,r om !1',/►1►••4" '� U >/► + , 1 t i/<Iy1j /1+11/►�/1+ ,++IIY'�1►11++ w� "� - 'k T4 •(.° v :1,%�•a"': � �t Y } � � � �air " w � AC�® DATE(MMIDDIYYYY) CERTIFICATE OF LIABILITY INSURANCE 07/26/2023 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTANAME:CT Aamlr Sheikh S & A Insurance Agency, Inc. PHONN . 718-210-3397 a N,:844-348-0669 110-01 101 st Avenue E-MAIL RESS: aamir snainsa enc .com South Richmond Hill, NY 11419 INSURERS AFFORDING COVERAGE NAIC# INSURER A:Acceptance Indemnity Insurance 20010 INSURED INSURERS: Aksh Quality Contracting Corp INSURERC: 5620 1 st Ave, First Floor, Unit#4 INSURERD: Brooklyn, NY 11220 INSURERE: 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 INSD WVD POLICY NUMBER _LMMIDDNYYYI IMMIDDIYYYY) LIMITS t/ COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 AMA RENTED CLAIMS-MADE C, OCCUR PREMISES Ea occurrence $ 100,000 MED EXP(Any one person) $ 5,000 X BND0001829-02 7/09/23 �/O9/24 A PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY Z PRO- JECT LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident 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 LIAB OCCUR EACH OCCURRENCE $ EXCESSLJAB HCLAIMS-MADE AGGREGATE S DED RETENTION $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY Y/N STATUTE I I ER ANYPROPRIETOR/PARTNER/EXECUTIVE ❑ NIA E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? --— (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under —---- DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ Disability DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached If more apace Is required) The Certificate holder is named as Additional insured. CERTIFICATE HOLDER CANCELLATION BUILDING DEPARTMENT 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 STREET, ACCORDANCE WITH THE POLICY PROVISIONS. RYE BROOK, NY 10573 AUTHORIZED REPRESENTATIVE ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD NEW YORK Workers' CERTIFICATE OF STATE Compensation Board NYS WORKERS' COMPENSATION INSURANCE COVERAGE 1 a.Legal Name&Address of Insured(use street address only) 1 b.Business Telephone Number of Insured AKSH QUALITY CONTRACTING. 929-255-5621 5620 1 STAVE,1 ST FLOOR 1c.NYS Unemployment Insurance Employer Registration Number of UNIT 4 BROOKLYN, NY 11220 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 47-1071405 2.Name and Address of Entity Requesting Proof of Coverage 3a.Name of Insurance Carrier (Entity Being Listed as the Certificate Holder) National Liab&Fire Ins Co BUILDING DEPARTMENT 3b.Policy Number of Entity Listed in Box"la" VILLAGE OF RYE BROOK V9WC477387 938 KING STREET, RYE BROOK, NY 10573 3c.Policy effective period 05/18/2023 to 05/18/2024 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"3"insures the business referenced above in box"1 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: Mike Mathews (Print name of authorized representative or licensed agent of insurance carrier) Approved by: �� 0/apl 07/24/2023 IV iSignivi,rr, (Date) Title: President of Workers'Compensation Telephone Number of authorized representative or licensed agent of insurance carrier: 718-210-3327 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