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HomeMy WebLinkAboutRP23-044PERMIT # _�D3-'U7 DATIE./ - / K Lr1ri�/ II•'P'�� �bL�IfG�IF�/�l!v - .mil -�_/l•�l IIr �� a I A• FOOTING FOUNDATION FRAMING SIGN FRAMING INSULATION PLUMBING O RGH PLUMBING GAS M SPRINKLER ELECTRIC CJ LOW -VOLT O ALARM A. BUILT �2o2J e.0 FINAL _ 1 7� 97/-5966 l03 OTHER APPROVALS ARB 80T PB zBA OTHER [•�yE DR . 19 L Li( 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.ryebrookny.gov TRUSTEES BUILDING & FIRE INSPECTOR Susan R.Epstein Steven E. Fews Stephanie J.Fischer David M. Heiser Salvatore W.Morlino CERTIFICATE OF COMPLIANCE July 16,2024 James Schutzer&Wendy Schutzer 43 Bonwit Road Rye Brook,New York 10573 Re: 43 Bonwit Road,Rye Brook,New York 10573 Parcel ID#: 135.41-1-44 Roof Permit#23-044 issued on 10/5/2023 to Re-Roof Existing Building This certifies that the new roof,installed under the above captioned permit has been satisfactorily completed. Sincerely, *;— 4 Steven E. Fews Building&Fire Inspector /to p EC IEWE ID BUILD R MENT For office use onl PERMIT# JUL - 1 2024 VIL OF RYE OK ISSUED: 938 KING STRE YE BROOK, YORK 10573 DATE: 5— VILLAGE OF RYE BROOK 9 -0 0 FEE: A Z d-- PAID PkBUILDING DEPARTMENT ov 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 ##fi#kiktkififikirtifiifiiiti#fifirt#rtrtrt#fi#fi##rtrt#rt#rtfi########4ikkkikik#iii#iifikiikfiiikiifiitiiittttiitfi#i#t#itittRiikiii#fiirtiti►fitii##rt Address: 43 Bonwit Road Occupancy/Use: Residential Parcel ID#: 135.41-1-44 Zone: Owner: James Schutzer Address: 43 Bonwit Road P.E./R.A.or Contractor: Perry Verrone, LLC Address: 12 Center St, Pleasantville Person in responsible charge: Perry Verrone Address: 12 Center St, Pleasantville 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: Perry Verrone being duly swom,deposes and says that he/she resides at 12 Center St (Print Name of Applicant) (No.and Street) in Pleasantville in the County of Westchester intheStateof NY that (City/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:$ 11,000.00 for the construction or alteration of. Roof replacement 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 i Sworn to before me this I day of , 20_ d ( , 20_M_ Signature of Property Owner 0 t James Schutzer ' T-;�l�''�; F N w Y0Perry Verrone PrintName of roperty Owner OF NEW t Na of Ap t ' YoRK\ _ NOigRY PUBL t NOTARY PUBLIC t ►o.unwT'."�. � 4 OIrAa3,7so2 blic ��J \ otM4u7so2 ��r s' c/ �� ♦ + tart blic EXP ' O � I It 0'1 ,n,-4 "101wokO QyE BRco Z(T% cu � 1. 1982 BUILDING DEPARTMENT ❑BUILDING INSPECTOR ASSISTANT BUILDING INSPECTOR VILLAGE OF RYE BROOK ❑CODE ENFORCEMENT OFFICER 938 KING STREET • RYE BROOK,NY 10573 (914) 939-0668 FAx (914) 939-5801 www.ryebrook.org - - - - - - - - - - - - - - - - - - - - INSPECTION REPORT - - - - - - - - - - - - - - - - - - - - ADDRESS : 3olJ l i 1 `A 1�. _� � DATE: Z Q L"1 PERMIT# 'L 2�- C) ,-1 '{ ISSUED: /0 SECT: IJS. j/r BLOCK: i LOT: LOCATION: t 00 OCCUPANCY: ❑ VIOLATION NOTED THE WORK IS... 12 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 Er FINAL ❑ OTHER s s = a H h v w s \ Ln N "' \ w a H 4-4 1 0 V) .r rj) U . F w W bA � \ 0 �0, 8 14A 40. o = a L 1 1 114'- v M «S ., '� O a N a wco O 0? q C 00 0 ,0 = Z O \ � 4 Z V z U ° v 0 (> 4 _ w Q 10 M z a h�y1 � Cd 14 ;.T., Q W 70 • Q ec �✓ ^ Ij zz � r� fg cn o . za. aatiav, ca • a � $ o N ca v W z � u o v O � A w z od = �I Lri R-i a1 Wl x � � BUILDING- �'"ARTMENT VILLAGE OF RYE OK OCT _ 4 2023 938 KING STET RYE BR NY 10573 14), -0 Y VILLAGE OF RYE BROOK BUILDING DEPARTMENT FOR OFFICE USE ONLY. 1 j�L� Approval Date: 0 5 it# ,=)3-07 I 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: 1��C ROOF PERMIT APPLICATION Application dated: �3 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 Bu ding,as per detailed statement described below. t 1. Job Address: � bon W+ km t4 SBL: //3sr q/-�/_ ,41 Zone: Property Owner: m cs &S -.h u t ze Y Address: 4 L-� 8b►'f xjf-- Pcod Ne- 8rl)m l Phone#: �_I -� l-�5 )FD Cell#: email: ,W S(,1I ut wr PO mat I.(orn 2. Applicant PeV Y� 1/e Y f C. Address: 12- PL ngnt I e, ry i Phone 49 74 7 -'Ve�0 3 Cell#: email: 1 (a) Ve rN Ve- nq 3. Roofing Contractor: S'MIe, as AAYWe Address: pu-yy W (; i- Phone#: Cell#: email: 4. Job Description, list all Methods&Materials: /n� 5. Estimated Cost of Job: $ (110011 (NOTE:The estimated cost shall include all site improvements,labor,material,scaffolding,fixed equipmenWP' ofessional fees,and material and labor which may be donated gratis.) 6. If comer property,indicate street frontage:_ 7. Construction Type: NYS Construction Class: $. Number of stories: eight: 7 9. Is garage being re-roofed: No: ( •Yes: ( )Attached No: ( }•Yes:VNurnber of Cars: L 10. Is roof peaked,hip,mansard,flat,etc: 11. Estimated date of completion: 61112023 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 OFNEW YORK,COUNTY OF WESTCHESTER ) as: k` i� ytW, ,being duly sworn, deposes and states that he/she is the applicant above named, (print name of in vidual 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 Con bm rhr 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 Sworn to before me this day ofr4v��_ 120 � da of 20 SijUaP&WfPropertyOwner oaeoeeiree Si nature of Applicant M VI-1 Print Name kTW6perty OivneE W Y Q��:il ���� Pnikijt Nam f plicant fsublic Otary Public 2\ $� e ° STA -2- 611023 Perry Verrone, LLC 12 Center Street Pleasantville, NY 10570 infoPl2errvverroneroofing.com Office:(914)747-7663 Fax:(914)747-7665 License WC 21701 H09 6/26/23 Prepared by Perry James Schutzer 43 Bonwit Rd Rye Brook NY 10573 (917)971-5965 jdschutzer@gmail.com PROPOSAL ROOF REMOVAL AND REPLACEMENT • All existing asphalt roofing removed and carted from job site • All rotted plywood replaced at$90.00 per sheet *If all the plywood needs to be replaced, the rate would be$70.00 per sheet for layover on entirefield of roof • GAF Weather Watch Ice and Snow barrier installed on all gutter edges,valleys and around skylights (6 feet up) • GAF TIGER PAW paper installed on the entire field of roof • GAF LIFETIME Timberline Architectural HDZ shingles installed on entire field of roof • GAF Cobra Ridge vent installed on all ridges of roof for attic ventilation • GAF TimberTex hip and ridge shingles installed on all ridges • Aluminum vent pipe boots installed over all vent pipes • WHITE Aluminum drip edge flashing installed around entire perimeter of roof • GAF Weather Blocker starters installed on all perimeter edges • Copper Chimney Flashing installed Page 1 of 5 Initial& Date: The price for the aforementioned work,which includes labor and material (excluding any additional plywood),totals to the sum of: $11,000.00 (Includes Courtesy Discount) ADDITIONAL WORK OPTIONS Please check appropriate box for desired extra work ❑ Carpentry/handyman work calculated on a time and material basis,said work performed at$120.00 per man hour plus material ❑ Rye Brook Building Permit for an additional cost TBD PRICE EXPIRES 90 DAYS AFTER ESTIMATE DATE Payment schedule is as follows: 50% 3 Days Prior to Start 45% Due the day of substantial completion 5% Retention may be held for resolution of unresolved issues Payment is accepted via personal checks and certified bank checks (made payable to Perry Verrone LLC or Perry's Roofing), MasterCard,Visa,American Express,and Discover credit and debit cards.All card transactions over$2,000.00 are subject to a 3% service fee. Payments of$4,000.00 or more are accepted via ACH/wire transfer upon request. Any monies not paid as specified above will be subject to accrue interest at a rate of 1.5% monthly,and 18% per annum. All material is guaranteed to be as specified above. All work to be completed in a workmanlike manner according to the standard practices.Any alteration or deviation from the above specification involving extra costs will be executed upon a written change order and will become an extra charge over and above the proposal.All agreements are contingent upon strikes,accidents, or delays beyond our control. Page 2 of 5 Initial& Date: ■ 43 Bonwit Rd, Rye Brook, NY 10573 (1) QuickMeasure June 23, 2023 Roof Reports in Under an Hour Prepared For: Perry's Roofing A N Contents Measurements Overview 1 Roof Area 2,348 sq ft Top View 2 Roof Facets 5 Side Views 3 Predominant Pitch 5 / 12 Lengths 4 Ridges/Hips 83 ft Pitches 5 Valleys 35 ft Areas 6 Rakes 117 ft Summary 7 Eaves 125 ft Materials 8 A QuickMeasure Top View Roof Reports in Under an Hour 1 1 � .l• 04 to IV Aw VIP • r r .' l 1�R t w,' 1 �4• � Ir I } �` , IV k t vp ,' • r do iAMLAw Awl mot.•' Ay •. Prepared For: Perry's Roofing © 43 Bonwit Rd, Rye Brook, NY 10573 (1) QuickMeasure Side Views Roof Reports in Under an Hour OW RPM,-, i t j r � A. a� M X, ` r Y' a Prepared For: Perry's Roofing 43 Bonwit Rd, Rye Brook, NY 10573 (1) QuickMeasure Lengths Roof Reports in Under an Hour AFlash Step Drp N 22 ■ Eave ■ Rake ■ Ridge ■ Valley 125 117 83 35 Lengths in feet Prepared For: Perry's Roofing 43 Bonwit Rd, Rye Brook, NY 10573 (1) QuickMeasure Pitches Roof Reports in Under an Hour A N 5 5 3 7 7 Pitches in inches per foot Prepared For: Perry's Roofing © 43 Bonwit Rd, Rye Brook, NY 10573 (1) QuickMeasure Areas Roof Reports in Under an Hour A N 253 755 496 340 504 Areas in square feet Prepared For: Perry's Roofing 43 Bonwit Rd, Rye Brook, NY 10573 (1) Quickmeasure Summary Roof Reports in Under an Hour Pitch 3 5 7 Area 496 1,008 844 Percent 21% 43% 36% Suggested Waste 0% 2% 5% 7% 9% 12% 17% Area 2,348 2,395 2,465 2,512 2,559 2,630 2,747 Squares 24 24 25 26 26 27 28 Roof Area 2,348 sq ft ARoof Facets 5 N Pitch 5 / 12 Eaves 125ft Rakes 117 ft Ridges 83 ft Valleys 35 ft Flash 3 ft Step 21 ft Drip Edge 242 ft Leak Barrier 301 ft Ridge Cap 83 ft Starter 242 ft 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 roof edges and excludes vallleys.5)Step flashing pertains to sloped roof 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 43 Bonwit Rd, Rye Brook, NY 10573 (1) QuickMeasure Roofing Materials Roof Reports in Under an Hour Suggested Waste 0% 2% 7% 12% Shingle Products HDZ, UHDZ, Natural Shadow, ASIL bundle 72 74 77 81 Reflector, Royal Sovereign, 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 Quick-Start roll 8 8 8 9 Roof Deck Protection Deck-Armor, Tiger Paw, FeltBuster 10 sq roll 3 3 3 3 Shingle-Mate roll 6 6 7 7 VersaShield roll 7 7 8 8 Leak Barrier * StormGuard, WeatherWatch 2 sq roll 5 5 5 6 WeatherWatch 1.5 sq roll 7 7 7 7 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 3 3 3 4 Drip Edge Drip Edge 10 ft piece 25 25 26 28 Drip Edge 8 ft piece 31 31 33 34 Notes:1)These approximate quantities are based on estimated measurements and are for guidance purposes only. You should always confirm quantities pnor to ordering and ensure you are following local building code requirements.2)For Timberline.3 bundles=0.984 squares.3)Starter=eaves+rakes.4)Leak barrier=bends+eaves+flashing+hips+rakes+step+valleys. 5)Ridge cap=hips+ridges.6)Low-slope products applied to 1/12 pitch areas.7)Timberline products applied to 2/12 pitch areas and above. 'Instated coverage will be less and depend on quantity and width of side and end laps. Prepared For: Perry's Roofing 13 Bonwit Rd, Rye Brook, NY 10573 (1) -M QuickMeasure Attic Vents Roof Reports in Under an Hour Static Quantity Units Cobra@ Rigid Vent 3T1^, SnowCountry@& SnowCountry®Advanced 32 ft Cobra@ Exhaust Vent Roll- Nail Gunnable 40 ft Cobra8 Exhaust Vent Roll- Hand Nailable 34 ft Cobra@ RidgeRunner'.R 46 ft Cobra® Hip Vent 63 ft Master Flow@ SSB960 Metal Super Slant-Back Roof Vents 10 vent Master Flow@ RV50/R50 Square-Top Roof Vents 12 vent Master Flow@ IR65 Plastic Slant-Back Roof Vents 9 vent Master Flow8 High-Capacity Dome Vents 4 vent Master Flow@ 10' Aluminum Ridge Vent 27 ft Cobra IntakePro,�j Rooftop Intake Vent 63 ft Master Flow it Undereave Intake Vents- 16" x 8" 12 vent Powered - Roof Mount Exhaust Cobra Master Flow 16x8 (vent) IntakePro (ft) Intake (vent) Master Flow@ ERV4 Power Attic Vents 2 107 20 Master Flow@ ERV5 Power& Wi-Fi Attic Vents 2 134 24 Master Flow@ ERV6 Power Attic Vents 1 80 15 Master Flow EZ Coollm Plug-in Power Attic Vents 2 112 21 Master Flow@ GreenMachinelm Solar/Dual-Powered Vents 3 84 16 Master Flow@ GreenMachinelm High-Power Solar/Dual-Powered Vents 3 120 22 Master Flow@ 12" Wind Turbines 4 105 19 Master Flow@ 14" Wind Turbines 3 112 21 Note.The estimated quantity of attic ventilation products in this report is based solely on the total exterior square footage of all roof planes and is meant for estimating purposes only. It is the responsibility of the installer to verity the correct quantity and type of attic ventilation products prior to commencement of work. Installer must always review job-specific attic ventilation needs such as local code requirements.attic floor square footage.roof design,and conditioned spaces under the roof. GAF recommends a minimum of 1 square foot of attic ventilation(evenly split between intake and exhaust)for every 300 square feet of othc floor space.The amount of exhaust ventilation at or near the ndge must never exceed the amount of intake ventilation at or near the soffit. See gaf.com/ventcalculator for details. Prepared For Perry's Roofing 43 Bonwit Rd, Rye Brook, NY 10573 (1) GAF 2021-03-20 2018-11-08 nor t y r �' j '•`vr'►,..1r ;.rt .��' ��..t' <• t r A' ... ,mow ' w �..� . '. :K�•,•. � ,may' •o .L 2016-03-26 r• --it '�' 2014-09-23 ,. ' .. It ' r •` � (�� r � �� 1� _ -�►� ���� � ►�� �► ` a•.,,,_i►.a%��— _ut_L:. ,:.�.a� ..::.`.e�':.lr '`:.H'.aS� _;c ., l(sal)f1, rti• O U ^ Ows ES p ,!!•�1 , p F) O : _. o u ..r U h- o U n r J z W y •° section ZLl z (j L=. lQ�oTc'�sl ,ae Q cn E Q F2 o2 r� LU Cl) W R7 :ts �- I .0 V O du Lu ZLij N W a. CL 4 -�•. 2 Yam„ • N Ow ago* V 0. e o CD % U N o d • .J .ACORO® CERTIFICATE OF LIABILITY INSURANCE FDATE(MM/DD/YYYY) 9l28/2023 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 CONTACT Levitt Fuirst Associates, Ltd. NAME: Catherine Dolce PHONE g14-457-4200 520 White Plains Road A/c No:914-457-4220 Tarrytown NY 10591 E-MAILSS: info levittfuirst.com INSURERS AFFORDING COVERAGE NAIC A INSURER A:Admiral Insurance Company 24856 INSURED PERRVER-01 INSURER B:Accident Fund Insurance Com an 10166 Perry Verrone LLC 12 Center Street INSURER C:ShelterPoint 81434 Pleasantville NY 10570 INSURERD: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:1287048576 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 SUER - - POLICY EFF POLICY EXP- LTR TYPE OF INSURANCEINSQ VVVOPOLICY NUMBER MM/DD/YYYY MM/DD/YYYY LIMITS A X COMMERCIAL GENERAL LIABILITY CA000045827-02 7/1/2023 7/1/2024 EACH OCCURRENCE $1,000,000 CLAIMS-MADE X G JR TAME To PREMISES EaEoccurrence) $300,000 MED EXP(Any one person) $5,000 PERSONAL&ADV INJURY $1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $2,000,000 POLICY I " E� 1�1 LOC PRODUCTS-COMP/OP AG G $2,000,000 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ ANY AUTO Ea accident OWNED SCHEDULED BODILY INJURY(Per person) $ AUTOS ONLY AUTOS BODILY INJURY(Per accident) $ HIRED NON-OWNED PROPERTY DAMAGE AUTOS ONLY AUTOS ONLY Per accident $ $ B UMBRELLA LIAR X OCCUR GXL000147002 7/1I2023 7/1/2024 EACH OCCURRENCE $5,000,000 X EXCESS LIAB CLAIMS-MADE AGGREGATE $5,000,000 DED X RETENTION$ $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY Y/N ANYPROPRIETOR/PARTNER/EXECUTIVE STATUTE ER OFFICER/MEMBER EXCLUDED? NIA E.L.EACH ACCIDENT $ (Mandatory In NH)If E.L.DISEASE-EA EMPLOYEE $ yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DBL358637 5/10/2022 5/10/2024 Statutory Limit I 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 liability.Waiver of Subrogation applies.Additional insured,primary and non contributory basis and waiver of subrogation on the Auto.Additional insured, primary and 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 Village of Rye Brook ACCORDANCE WITH THE POLICY PROVISIONS. 938 King Street 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 YORK ' 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 914-867-1747 Perry Verrone LLC DBA Perry's Roofing 1c.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"1a" 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) X❑ 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: t2w� 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