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HomeMy WebLinkAboutSP23-010PERMIT it OCTION L TYPE OF WORK JOB LOCATION _ EST. COST VI O if(21 TCO I! 3_0 / O DATE o) % BLOCK_ EXP0 // /7 c y III w LOT it/ �e i h I I b 16. JOOS64a/ (10,v .�lqool uP onei C9/y)939 O FEE stif DATE121 2 V FEE DATE DATE INSP FOOTING FOUNDATION FRAMING RGH FRAMING INSULATION PLUMBING RGH PLUMBING GAS SPRINKLER ELECTRIC LOW -VOLT O ALARM AS BUILT 2oz FINAL BR(� O lVj V i�1. 1/ 190 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 February 27,2024 Win Ridge Realty LLC c/o Alena Hakanjin 24 Rye Ridge Plaza Rye Brook,New York 10573 Re: 112 South Ridge Street, Rye Brook,New York 10573 Parcel ID#: 141.27-1-6 Sign Permit#23-010 issued on 11/17/2023 for a New Sign This certifies that the new sign,DIG.Seasonal Comfort Food,installed under the above captioned permit has been satisfactorily completed. Sincerely, Steven E. Fews Building& Fire Inspector /to � For office use oolr:BUILDI}�T�:�E�,���f.MENT ffi PERMIT o/o VH1 \�OFRY>?�B"ox �AN 2 2 ZQ24 938 KING STREJlu BROOK,M. YORK 1QS?3 DIssUED: /a �3 �.._ VILLAt- PAtn!i BUI LD . � 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 r rrlr rr•r�r�r�rr��r r11►rrlr•rrr lrrrrsrrr rgrrrr Nrrlrrr rlr r•Nrr��rrr�♦wr�N�N�rwNINN�N�NN�Nrr Hrrrr♦rrlr rrr rrrr�rNr Address: Occupancy /Usdopnre/Uli:-/ Parcel ID#:-4t4 -21_I - (q Zone: Owner: e1 N -- -- Address: it k- © e I t t4y P.EJR.A.or Contractor: _-i J �Ca N-- Address: ki r ( 105�3 Person in responsible charge: _ 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: being duly sworn,deposes and says that he/she resides at y n,� 11 (1" I L'►� (I'r tNN:� - J (No.and`•treeq m .in the Courant. of -_I,(� j r} � in the State of that on-n'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:$ for the construction or ahembon of: OT Deponent further states that he/she has examined the approved plans of the structiaehvork herein referred to for which a Certificate of Occupancy/Compliance is sought,and that to the best of his/her knowledge and belief,the stntcturelwork 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 pan thereof hereafter created,erected,changed,converted or enlarged,whollv or partly,in its use or structure until a Certiftwic 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 Sworn to before me this v of (j ' ' ,- .20 2-4 Sday o —1 Zk f Apl--t co�ms' orPro Q"s sigmt �)26—PrmNmr Y 'rmN ant - Nobly Public Notary Public ALENA HAKANJIN 8122421 NOTARY PUBLIC,STATE OF NEW YORK LOIS NIETO Registration est h ester Count NOTARY PUBLIC, STATE OF NEW YORK Qualified in Westchester County My Commission Expires 9/1912027 NO. 01 N14899825 QUALIFIED IN WESTCHESTER COUNTY COMMISSION EXPIRES DECEMBER-3T2026 QyE BRC��, cu � 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: f 2 ,)L4 F e,AC.Q DATE: 2 Z (o PERMIT# '�S\ ISSUED: -/7- SECT: 7' Z7 BLOCK: l LOT: LOCATION: ST�a • OCCUPANCY: ❑ Violation Noted THE WORK IS... Ej---�PASSED ❑ FAILED /REINSPECTION ❑ SITE INSPECTION REQUIRED ❑ FOOTING ❑ FOOTING DRAINAGE ❑ FOUNDATION ❑ UNDERGROUND PLUMBING NOTES ON INSPECTION: ❑ ROUGH PLUMBING ❑ ROUGH FRAMING ❑ INSULATION n /} 1 ❑ Natural Gas (��Eb 5 - 1 v`t 1 '40 ❑ L.P. Gas ❑ FUEL TANK J ❑ FIRE SPRINKLER ❑ FINAL PLUMBING ❑ CROSS CONNECTION e—FINAL ❑ OTHER 4 = O N ° (U : v v O gg M W O ►�r W -no N F� 10 U A Cc: w o � �..� v v 41 o o a . A ■ � W `'' �., w � � � � � a o H c p r d "9 rr hh�� �D C p v V .� O �+ � as Ln O o � o 00o p ~A o �, Nwo ' p H oo c7 �Ln- W v b o � ` C7 w C7l w z �' cap kw uz � � ° o W � �j � ,�/ �, �i '�j►' M Q'i G7 t/1 �, a� ice, p �ULn ,, cq ~ U a w z 5: va � o Z o ] � � voo v ° 84 © w L s s A z � "� ® aki c Zoocv °3Q�Su : a O Z 0 V O ° � M (/) U V A Z 0 ;L- m � Q b y ■ W z O a D LAC MWFEF.. B[III,Dp�i: :D ARTMENT OCT 3 1 2023 V ILI f OF RYE BROOK 938KWGS ET RYE BRO,10 Y10573 VILLAGE OF RYE BROOK i4)939-tea`, BUILDING DEPARTMENT RR#RRRtRRt+RrRritRRfrR+RRii####rtRRitiR#iRr#RR#R## rps♦s•ra■ryr#s•sf##rr■sass••••i•+■•r•••••••••••#.••s#.•• FOR OFFICE USE ONLY: ^ Approi al Date. Pe i '' !V} (� -• Application# /1 _ --%— �� Approval signature: _-- ARCHI RAL REVIEW WARD• Disapproved: � � BOT Approval Date: Case# Cheitman PB Approval Date:-— - Case t1_ - - --— M'y Z13A Approval hate: —Case# Other: r Application Fees Permit Fees: U s'+rrsssrrr••rRssssarsRs•r••Rssr#ssrrssssrsRsasssrrsesRrsRRssrrlrasr - - sRRssRsrratsrRtrrrrrrirrRr#rrRR+RRRs♦rr SIGN PERMIT APPLICATION Application dated —L)—3/—C)3 is hoteby made to the Building inspector of the Village of Ryc Brook,NY,for the issuance eta Permit for the comstructionfinstallation eta aalsign in accordaame with Village Code5250-35 as per detaaled statement described below ) I Address: �� L OUA f) ' lC� 2. Property Use or Business Name:_ DD i 3- Yroposed Sign(s)(Describe in detail including number of signs,types.sizes,react localion(s),and illumination melhodls)if applicable.j ,'A separate Electrical Permit will be required for an associated electrical tiVork,) 4, Height from - gh Bade to highest point of sign: to t�Jowpst point of sign:yy ��y� 5. Property Owner: '►� l _K A P Qt� Y dress: � ry Phone#- .I# email: ,C lu 6. Applicant: aJi-r.► ,; ,J Adaross:t-ia •}�_� r�(�..e�, t„� may✓ Phone# Cell# 7. Architect/Engimeer: A dreas: Phone# Cell# — rr email: 8. Sign Contractor: 1 er1 -_Address: Phone# _—email SQ�='._o Lid -t- 9. Will the proposed sign require a Site Plan Rceiew by the Visage Planning Board as per§209 of Village Code? Yes: No:-)!�- (If yes.you must submit a Site Plan Application,&prop id detailed drawings) 10, Does the proposed sign involve a Hoime-Oceupation as per§250-35 of ViQage Code? Yew No:X—If yes,indicate: TIM 1•—TER II:—TIER III:w (If N es_a Home Occupation Permit Applica(on is required) 11. If building is located on a corner lot:which street does it front on: N Ito 12. Property frontage: 73 - 13. Property size:Sq.Ft: - — Acres: 14. What is the total estimated cast of construction: S 5,WO•a O (The estimated cost shall include all site impmeeruenta,labor.material-scaffolding.tiled equipment.professional fees_including any material and labor which may be donated gratis.) IS. Estimated date of completion: 12- 15 23 ...r..........t....................................+e...._.................................................. This application must include the notarized signature(s)of the legal owner(s)of the subject property,and the 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. .................................................►.............e...................................r...e.w STATE OF NEA YORK,COUNTY OF WESTCHESTER ) as: -A being duly sworn,deposes and states that he/she is the applicant above named. (print noire of individual signing as the applicant) and fiuther states that (s)he is the legal owner of the property to which this application pertains, or that (s)he is the (mdreate urhrtocl,coatraeior,agmy attorney,etc.) for the legal owner and i s duly authorized to make and file this application. That al I statements contained herein are true to the best of his/her knowledge and belief,and that any work perforated,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 Z-L"r t^- //�� Sworn to before me this day of 20 � �`_ ` - > day of 6C14t y200� Sii,rra,.ire Of Pr,opr:tly OwNr�/.e�'A r.,. S, ' r t PriotName t PttiatNam ofAppGc�t Notary blic c.��N- Publi. NOTARY RUNA � MW y= LOIS NIETO I4 stratloe tYo. 013445 NOTAR ottu►0 Y PUBLIC, STATE OF NEW YORK Qu�aaC W*S Msar C NO. 01 N14899825 � QUALIFIED IN WESTCHESTER COUNTY COMMISSION EXPIRES DECEMBER 3,2C26 Building Permit Check List & Zoning Analysis OB & C ONLY Address: S� 1 SBL• (At Z 1— ` Zone: C—t ` Use: Cont.Type: VGl Other. Submittal Date: Revision Submittal Dates: Applicant: 1 k " +mil i Nature of Work ffl t c-�A Reviews:ZBA: , r 3 U2� PB BP: Other. NEED OK � FEES:F �J.J V`0' BP Z 0� C p — ( (''l / . Legah=tion: APP.: Date Stamped Properly Signed �SBL Verified Cross Connection F.O.G ( ) ( ) Scenic Roads: Steep Slopes: Wetlands: Storm Water Review Street Opening. ( ) ( ) ENVIRO.:Long Short Fees: N/A: ( ) ( ) SITE PLAN:Topo: Site Protection: S/W Mgmt: Tree Plan Other. ( ) ( ) SURVEY:Dated: Curren Archival• Sealed: Unacceptable: /P( ) ( LANS:Date Stamped Sealed Copies: Electronic. Other. ( ) ( ) License: Workers Comp: Liability Comp.Waiver. Other. ( ) ( ) Code 753#: Dated: N/A: ( ) ( ) HIGH-VOLTAGE ELECTRICAL:Plan: Permit: N/A: Other. ( ) ( ) LOW-VOLTAGE ELECTRICAL:Plan: Permit: N/A Other. ( ) ( ) FIRE ALARM/SMOKE DETECTORS:Plan: Permit: H.W.I.C.:_Battery:_Other. ( ) ( ) PLUMBING:Plan: Permit: Nat.Gas: LP Gas: Grease Trap: Other. ( ) ( ) FIRE SUPPRESSION:Plans: Permit: N/A: Other. ( ) ( ) H.V.A.C.: Plan: Permit: N/A Other. ( ) ( ) FUEL TANK: Plan: Permit: FUEL TYPE: Other: ( ) ( ) 2020 NY State ECCC: N/A: Other. ( ) ( ) Final Survey Final Topo: RA/PE Sign-off Letter. As-Built Plan: Other. ( ) ( ) BP DENIAL LETTER: C/O DENIAL LETTER: Other. Other. ( mtg.date: 11 YS �!L� pprovaL 'L Z es: e1�,23 /0'? ( )ZBA mtg. date: approvaL• notes: ( )PB mtg.date: approval• _notes: APPROVED REQUIRED EXISTING PROPOSED NOTES NOV 1 6 2023 Date: Ste: F� Emn� F.A.R.: Qgen Space: notes: RTC( IM BCIII.,DJN0,1)i P.-AR TI ENT OCT 31 2023 VILL OF RYi K VILLAGE OF RYE BROOK ' 00938 KING Sir* ET RYE BROok,N 10573 BUILDING DEPARTMENT �j fiftiitf tiiiifffiRRtifit#iiiiiittitlftifiiiiiftititiii fiflfifitiitlfiffftRiiiitttttfitttfttttiiff♦i#fttifit 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: 1 1 Z I p ✓rr Date of S issi : Parcel ID#:_ 1y� Z - _ Zone: L'k- Pr — oposed Improvement(Describe in detail): APPLICANT CHECK LIST—MUST BE COMPLETED BY THE APPLICANT The follrnvmg items must be submitted to the Building 0 fA�al1 ;1►�Pi.l 1\0115 $'H x 13IL. oepmlmcw by the applicant-no exceptions. Property Owner: j A R-eft,-'(�_kkC 1• (—T Completed Application Z Address. p, 2. (")'Two(2)sets of Sealed plans. (one full size(maamum _ allowable plan size-36''x 42-}and one 11"x17") Phone#_ q_ly' _ A` — 401S 3. ( )Two(2)copies of the property survey. 4. ( )Two(2)copies of the proposed site plan. Applicant appearing before the Board: 5. (,�One electronic/disc copy of the complete tit application materials. Address: 6. Q)+tlmg Fee. p t � 7• ( )Any SUPPortin$documentation. Phone# _ 0 3(-0 C) g• ( )HOA approval letter- V-Wirnabte) 9. (t/�Photographs. Architect/Engineer. _ 10_( )Samples of finishes/color chart (a sample board or Phone# mw&1 nw be pre-sewed dre m&of,he meejM) By signature below, the owner/applicant acknowledges that he/she has read the complete Building Permit Instructions&Procedures,and that their application is complete/n all respects. The Board of Review reserves the right to refuse to hear any application not meeting the requirements contained herein. ZL+� Swom to ffbefore me this Sworn to before me this 6 day of yGTc;6t;C Zoe day of ao(s9 3 D. Ow6el .err IN Appti—t 7 \ '� C LI'S r. i�rb=arrtt>pmrty:o.w i� �CJC�N 1 Print Name of A hunt L Nefary br f - Notary Pablic — ALEMAw►KAUN LOIS NIETO N�ARrt �STATE OFWNTM NOTARY PUBLIC, STATE OF NEW YORK Rp istra0"No.01NA0013645 OwiNItO In wtsichester to�ty NO. O 1 N14899825 Ml�atittiMwoeE.MrtsMit/ib2t QUALIFIED IN WESTCHESTER COUNTY COMMISSION EXPIRES DECEMBER 3, 2026 BR(�v�• Village of Rye Brook Ml, MR O� yAgend FB SE Architectural Review Board Meeting AC SF W Wednesday,November 15,2023 at 7:30 PM Q Village Hall,938 King Street JM 1. ITEMS: 1.1. ARB23-113 (Consent Agenda) Jesus Gonzalez&Beatriz Gonzalez 505 Franklin Street Rooftop solar array. 1.2. ARB23-123 (Consent Agenda) William Fasolino&Patricia Fasolino 252 Irenhyl Avenue Rooftop solar array. 1.3. ARB23-124(Consent Agenda) Ajai Venkatapur&Truti Patil 5 Heritage Court Rooftop solar array. 1.4. ARB23-125 (Consent Agenda) Or Barak&Meredith Barak 10 Mohegan Lane Black aluminum fence,gates and welded wire fence. 1.5. ARB23-126 (Consent Agenda) Alessio Colacino&Kelly Colacino 37 Tamarack Road Rooftop solar array. 1.6. ARB23-23-059 (Consent Agenda) (Amendment to Prior Approval) Srivatsan Raghavan&Janani Ranganathan 436 North Ridge Street 4'high black aluminum fence. Consent Agenda Approvals: Motion Second Abstention Aye; Nay; Adjournment; Notes Page 1 of 3 ' Architectural Review Board November 15,2023 1.7. ARB23-127 Anthony Paniccia 496 West William Street Reconstruct fire damaged two-family dwelling. Approvals: Motion Second Abstention Aye; Nay; Adjournment; Notes 1.8. ARB23-128(Amendment to Prior Approval) Steven Santiago&Amy Swift 3 Woodland Drive Rear one story addition. Approvals: Motion Second Abstention Aye; Nay; Adjournment; Notes 1.9. ARB23-129 Win Ridge Realty LLC 112 South Ridge Street New non-illuminated letter signage. "DIG.Seasonal Comfort Food" Approvals: Motion Second Abstention Aye; Nay; v Adjournment; Notes 1.10. ARB23-130 Pawling Holdings LLC 261 North Ridge Street Attached two car garage and rear trellis. Approvals: Motion Second Abstention Aye; Nay; Adjournment; Notes Page 2 of 3 Architectural Review Board November 15,2023 1.11. ARB23-131 (Amendment to Prior Approval) 2 Elm Hill LLC 4 Elm Hill Drive Window,door and color changes. Front porch and deck extension. Approvals: Motion Second Abstention Aye; Nay; Adjournment; Notes NEXT MEETING: December 20,2023 Page 3 of 3 AC"R" CERTIFICATE OF LIABILITY INSURANCE DATE(M 05/31//2023Yy) 023 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS 'CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: Stacie Washington Borrelli Partners Insurance Agency A/CO No Ext: (914)939-7900 AX No: (914)407-5088 287 Bowman Avenue E-MAIL swashington@borrellipartners.com ADDRESS: Suite 406 INSURER(S)AFFORDING COVERAGE NAIC p Purchase NY 10577 INSURER : Travelers Casualty Ins Co ofAmerica 19046 INSURED INSURER B: Travelers Indemnity CO 25658 Lanza Corporation D/B/a INSURER C: Phoenix Ins Cc 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 AUIJL 5UtJK POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER MMIDD/YYYY MM/DD/YYYY LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE OCCUR DAMAGE ORIENTED PREMISES Ea occurrence $ 300,000 MED EXP(Any one person) g 5,000 A 6805J175092 06/05/2023 06/05/2024 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER. GENERAL AGGREGATE $ 2,000,000 JEa LOC PRODUCTS-COMP/OPAGG g 2,000,000 POLICY ❑X OTHER $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY(Per accident) 5 HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLYI P Per accident 5 UMBRELLA LIAR X OCCUR EACH OCCURRENCE $ 5,000,000 B X EXCESS LAB CLAIMS-MADE EX5J175240 06/05/2023 06/05/2024 AGGREGATE $ 5,000,000 DED I I RETENTION$ $ WORKERS COMPENSATION PER ORTH- AND EMPLOYERS'LIABILITY Y STATUTE E Q ANY PROPRIETOR/PARTNER/ECECUTIVE ❑ NIA U65J175160 06/05/2023 06/05/2024 E.L EACH ACCIDENT g 1,000,000 OFFICERIMEMBER EXCLUDED? (Mandatory in NH) E L.DISEASE-EA EMPLOYEE $ 1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E L DISEASE-POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS/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,At 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 N;RK Workers' CERTIFICATE OF '1TATE Compensation Board NYS WORKERS' COMPENSATION INSURANCE COVERAGE ` 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"la" 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"Y 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". /Vill 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: 05/31/2023 (Date) Title: Acct Mgr Telephone Number of authorized representative or licensed agent of insurance carrier: 914-939-7900 ?lease 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 o 03 I if 0 ........... .......... .......... IWO- 00 0O- N 00 Z n > rn W O O 0 v w D rn N Ul Vt m X z m O L J r N z O Lm X N O m x � n � o � z x cn OD O , O _. � Cl) F� O o O Q �Az — m .� --i -� > O -� z o < D r (D (/) = OZm =O c ccQD OCQ 0mzX =a -iZ =m � _ V cQ OZ� OD (D (D 9' - 5 3/4" 9' - 6 1 /4' irk - I -n _1!�, N m t� (D �. n _. 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