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HomeMy WebLinkAboutRP23-056PERMIT # /� /- C) 056 DATE: �� �� c�J EM �//(v a �% SECTION �/ 3�5,_ T BLOCK I I Oj TYPE OF WORK P O JOB LOCATION 15 e� OWNER 1 o.r1__ SSA) 14 CONTRACT$w)R ,,(fo Ua& ES�T. COST TCO # FOOTING FOUNDATION FRAMING RGH FRAMING INSULATION PLUMBING I� RGH PLUMBING GAS SPRINKLER ELECTRIC LOW -VOLT CI ALARM F1 AS BUILT O FINAL r� OTHER APPROVALS l.Kui�d//!q ARB BOT IDS FEE DATE INSPECTION RECORD DATE INSP 12-12-7023 �_ SieI%(9/7)#lW 4AI/d�� ZBA OTHER DR190 �GG4°V JJv 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 December 12,2023 Lon Shue 15 Jennifer Lane Rye Brook,New York 10573 Re: 15 Jennifer Lane, Rye Brook,New York 10573 Parcel ID#: 135.58-1-19 Roof Permit#23-056 issued on 11/16/2023 to Re-Roof Existing Building This certifies that the new roof,installed under the above captioned permit have been satisfactorily completed. Sincerely, Steven E. Fews Building&Fire Inspector /to �_3 BUILDII'�d-&&TMENT For office use only: PERMIT# 3-Oslo M j VILLAGE OF RYE BROOK ISSUED: //4L QEC - 5 2023 �08 kING STREET,RYE BROOK,NEW YORK 10573 DATE:/ -5-d (914)939-0668 FEE: $ /p— PAIDa VILLAGE O !�Y_ L."OOK MM.rygbrv0 erg 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 tit►•tt►•►►tt►►#ttt#ni►ittiit►■f►►t►###►►#►ttttiitit■♦t•►►#►■ff►#►f###t#tiiiti■it►tt►tttttitti##t►ttttttttitttiii#►flit►►►it► Address: L' Occupancy/Use: �CC`>C�� Parcel M#: 3 Si 5 —I—I CJ` Zone: Owner: L en J t�//��� Address: 1 Inc•l N/ Lcan4, P.E./R.A. or Contractor:( 0U41kq C lw/0/ 6 i4)24�1QAddress: �l y rQ Ii sQ al��e Yor ee M V Person in responsible charge: :�FoLi/J ,yQ.Si 2/AO Address: ) 1 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: T Lr+ 6to, being duly sworn,deposes and says that he/she resides at (Print Name of Applicant) D (No.and Street)in ��1 !, Rra0k ,in the County of h l/ f $i fi( .�o' e� in the State of /v 7 ,that �1 (City/Town/Village) he/she has supervised the work at the location indicated above,and that the actual total cost of the work,including all site improvements, labor,materials,scaffolding,fixed equipment,professional fees,and including the monetary value of any materials and labor which may have been donated gratis was:$ 11,4S,96 / , for the construction or alteration of: r R �a. L&Y-fr 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 tbp Code of the Village of Rye Brook. Sworn to before me this Sworn to before me thisc) day o L ,20 day o c_ , 20 _ Signature of Property Owner Si tune of Applicant I �sh'-z L/N �h�e Pon,Name of Owner Print Name of Applicant / of blic otaE Cn0LYN MA=CANMSTRARO CAROLYN MARLS CAM STRARO A>�YlpBU(%,8TA184FNBWYt sARYMMM,SMEOFNEWY s/tz/zort )R�e�ietndioaNa CA061710�0 �R1 CA"177M Qa�6e3W �Y � � �yE(3RC�k. cu � 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 - - - - - - - - - - - - - - - - - - - - ' lam. ADDRESS :-2-5 .f r ILIA.) � t�l ,�Q�J'e DATE: PERMIT# ► 1` � `w (0 ISSUED: SECT: -3 ,Sv BLOCK: / LOT: LOCATION: �� � � HkAse OCCUPANCY: lV ❑ Violation Noted THE WORK IS... a PASSED ❑ FAILED REINSPECTION ❑ SITE INSPECTION REQUIRED ❑ FOOTING ❑ FOOTING DRAINAGE ❑ FOUNDATION ❑ UNDERGROUND PLUMBING NOTES ON INSPECTION: ❑ ROUGH PLUMBING ❑ ROUGH FRAMING ❑ INSULATION ❑ Natural Gas A-v ❑ L.P. Gas ❑ FUEL TANK ❑ FIRE SPRINKLER ❑ FINAL PLUMBING ❑ CROSS CONNECTION FINAL ❑ OTHER s a x s M N a LL q W ■ �'' 4 ~ s O a b O �] ■ A � Y ^r GL ■ w W V cu � ti W v a ~ In z 0 Fyl 00 x v n u a W �.J • a� � s � � � � 6 a � � � v � J s 3 : O W o ° a Ln ti h+l = ono $ d o 'a.� ■ 0-4 a '`J r�-i W o To .2, CJ ` O W W v o r� 0-4 00 Jai co O °� z v o" can W m W c or b a 14 ^ v E v _ Cl Q A a s W sE � � o W I� U e-i P4 U �1 Z PLO z O � Ow u �i F 1C) O �' V z RE °° a d w Z O -Z- z d '� B a Z � A a a v 0 W W � " o A a � a BUIL DD TMENT D V VI :ET :RYE OK FWV 13 ��� 938 KING R ANY 10573 �L_— - =00K =� 'T r*****rr*r*rr*tttttt*r***�*�rrrtrrrsrrrtrttrsstttsrr*rrrrrrrr*r►+++.*r**r•s****+**�**�*���****+*.+*+s++++** FOR OFFICE USE ONLY- Approval Date: �� 1 # �' : 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: *►*r*rr«rss***e***s*rr*sr*►+ss***rr***r****r*sss*rr*r*rr*rr***r��*s*�******�«:*,��+�*e»r+++�**+**ss*s+r*a*s ROOF PERMIT APPLICATION Application dated: 4 I Y 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: /< . kjly _r t�K.-e< SBL: � �i S —� / Zone:P=-� Property Owner: Lein Chat Address: Phone#: t"l�`� ((��� � � Cell#: email: C 2. Applicant: Address: Phone#: + Cell#: email: 3. Roofing Contractor. 0,-A e,Jr,, 0 u[i dart le- 1 tit Address: 715 Pa 1 r Ca��_ kr llo,k6 y/y 2,3 Phone#: CellN-yldr? email: r lu a�i�Y1T �O� Wn 1 4. Job Description,list all Methods&Materials 1 r+il LIrk ?L Coo 4 5. Estimated Cost of Job: S w V�.3 (NOTE The estimated cost shall include all site improvements,labor,material,scaffolding.fixed equipment,professional fees,and material and labor which may be donated gratis.) 6. If corner property,indicate street frontage: 7. Construction Type: NYS Construction Class: 8. Number of stories: Height: 9. Is garage being re-roofed: No:(/1•Yes:( )Attached No: ( )•Yes: ( )Number of Cars: 10. Is roof peaked,hip,mansard,flat,etc: yy�'' 11. Estimated date of completion: ��km4I JIr et It+' &4) 106012023 Please note that this application must include the notarized signature(s) of the legal owner(s) of the above-mentioned property, in the space provided below. Any application not bearing the legal property owner's notarized signature(s) shall be deemed null and void, and will be returned to the applicant. STATE OF NEW YORK,COUNTY OF WESTCHESTER ► as: 0n 3:�bje� ,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 'n.4",, na Agw, a- for the legal owner and is duly authorized to make and file this application. (ingicate 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. 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Lrr•rrt! � : r� .i i .,pp�11i717ii�1++.ty�7i. tf �r,t, il�tfA. 1..1i 1y11,' � I�i.f it���f l:�rv'��,r•�,, •7„ 4f •'' )�) •:. _'t �o`. la..`. ::.o\\... �it "L 1 7 tt,r,,,t,J,jf tt /t ii dd`.}.,rl' ., t:djt+lir�iyr�h` .y,� 4i f,t:•'�`i'I�Ii�J�JL4 l ,�'}�,,�}�t���//fJ,r� rJ YJi 'i.�.1�`rLrytjrrl,:+'�J�`v� t;. ' � N'tt ti}..rr r.:��r tit -.'- r J'Ji�.��'s tx;, J'� ♦ �ifxwt\y5•�'� ,J.t� t���i r1I ky,�Yirt�fa iL t /. •._..+- 1 / �"� -.�t rr il_' .k f/�J'% tV. ;11+ w.. I ����' t./ t$ ,(t=..%FYl'�`\Y`y:',_''•`rA'r// �1�4t`t.v� t�CCs:> 7� 1� �}ti�Y �`t +`�>a7 ,Ftt�t+Yr" DATE(MM/DD/YYYY) AC n `..i CERTIFICATE OF LIABILITY INSURANCE 11/08/2023 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 oNTAC Patrick Quinn NAME: Champion Insurance Brokerage Inc PH CONENo. (718)547-7100 FAX. No): (718)547-7184 A/ Ext: A/C 1418 Williamsbrid a Rd E-MAIL g ADDRESS: Patrick@champloninsurance.org INSURER(S)AFFORDING COVERAGE NAIC a Bronx NY 10461 INSURER A: Utica First 15326 INSURED INSURER 8: Country Club Marble&Tile INSURER C: 719 Palisade Ave INSURER D: INSURER E: Yonkers NY 10703 INSURER F COVERAGES CERTIFICATE NUMBER: CL2311814342 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 TYPE OF INSURANCE POLICY EFF POLICY EXP LTR INSD WVD POLICY NUMBER MM/DD/YYYY MM/DD/YYYY LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE Fx�OCCUR PREMISES Ea occurrence S 50.000 MED EXP IAny one person) g 5,000 A Y ART3000622950 11/17/2023 11/17/2024 PERSONAL&ADV INJURY g 1.000,000 GENL AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE g 2.000,000 POLICY ❑PRO- ❑ 2,000,000 — JECT LOC PRODUCTS-COMP/OP AGG $ OTHER $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY(Per accident) g HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY Per accident UMBRELLA LIAB OCCUR EACH OCCURRENCE $ IEXCESS LIAB HCLAIMS-MADE AGGREGATE $ DED I I RETENTION$ $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY Y/N STATUTE ER ANY PROPRIETORPARTNER/EXECUTIVE ❑ NIA E.L.EACH ACCIDENT g D OFFICERIMEMBER EXCLUDE (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ If yes.describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space's required) Village of Rye Brook is listed as additional insured. 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 Rc!Ae'161: D 1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD NYSIF New York State Insurance Fund PO Box 66699,Albany, NY 12206 1 nysif.com CERTIFICATE OF WORKERS' COMPENSATION INSURANCE M^^ ^A A^ 061601773 '.� CHAMPION INSURANCE ;111 M' 1418 WILLIAMSBRIDGE RD r 1 BRONX NY 10461 E. i SCAN TO VALIDATE AND SUBSCRIBE POLICYHOLDER CERTIFICATE HOLDER JOHN MASIELLO D/B/A VILLAGE OF RYE BROOK COUNTRY CLUB MARBLE&TILE 938 KING STREET 719 PALISADE AVENUE RYE BROOK NY 10573 YONKERS NY 10703 POLICY NUMBER CERTIFICATE NUMBER POLICY PERIOD DATE VV1373125-2 868154 11/18/2022 TO 11/18/2023 11/8/2023 THIS IS TO CERTIFY THAT THE POLICYHOLDER NAMED ABOVE IS INSURED WITH THE NEW YORK STATE INSURANCE FUND UNDER POLICY NO. 1373125-2. COVERING THE ENTIRE OBLIGATION OF THIS POLICYHOLDER FOR WORKERS' COMPENSATION UNDER THE NEW YORK WORKERS' COMPENSATION LAW WITH RESPECT TO ALL OPERATIONS IN THE STATE OF NEW YORK. EXCEPT AS INDICATED BELOW. AND, WITH RESPECT TO OPERATIONS OUTSIDE OF NEW YORK. TO THE POLICYHOLDER'S REGULAR NEW YORK STATE EMPLOYEES ONLY. IF YOU WISH TO RECEIVE NOTIFICATIONS REGARDING SAID POLICY, INCLUDING ANY NOTIFICATION OF CANCELLATIONS, OR TO VALIDATE THIS CERTIFICATE,VISIT OUR WEBSITE AT HTTPS://WWW.NYSIF.COM/CERT/CERTVAL.ASP. THE NEW YORK STATE INSURANCE FUND IS NOT LIABLE IN THE EVENT OF FAILURE TO GIVE SUCH NOTIFICATIONS. THIS POLICY DOES NOT COVER THE SOLE PROPRIETOR, PARTNERS AND/OR MEMBERS OF A LIMITED LIABILITY COMPANY, THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS NOR INSURANCE COVERAGE UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICY. NEW YORK STATE SUR NCE FUND DIRECTOR.INSURANCE FUND UNDERWRITING VALIDATION NUMBER: 100595442 U-26 3 AC"R" DATE(08 20'YYVV) CERTIFICATE OF LIABILITY INSURANCE ,, (, `,,`,, 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 CONT NAMEA T Patrick Quinn Champion Insurance Brokerage Inc IPHCNNEo, Ext: (718)547-7100 FAX,No (718)547-7184 1418 Williamsbridge Rd E-MAIL patrick@championmsurance.org ADDRESS: INSURERS)AFFORDING COVERAGE NAIC X Bronx NY 10461 INSURER A: Utica First 15326 INSURED INSURER B Country Club Marble&Tile INSURER C: 719 Palisade Ave INSURER D: INSURER E: Yonkers NY 10703 INSURER F COVERAGES CERTIFICATE NUMBER: CL2311814345 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 IN SR ADDLISUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER MM/DD/YYYY MM/DD/YYYY LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE S 1,000,000 CLAIMS-MADE FX OCCUR PREMISES Ea occurrence S 50.000 MED EXP(Any one person) S 5.000 A Y ART3000622950 11/17/2022 11/17/2023 PERSONAL&ADV INJURY S 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE S 2,000.000 POLICY PRO 2,000,000 JECT LOC PRODUCTS-COMP/OP AGG $ OTHER I I S AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accdent ANY AUTO BODILY INJURY(Per person) S OWNED SCHEDULED BODILY INJURY(Per accident) S AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE S AUTOS ONLY AUTOS ONLY Per accident $ UMBRELLA LIAR OCCUR EACH OCCURRENCE S EXCESS LIAB HCLAIMS-MADE AGGREGATE S DED I I RETENTION$ S WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY Y/NI STATUTE JER ANY PROPRIETOR.,PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE S If Yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT S DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Village of Rye Brook is listed as additional Insured. 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 Mdz6�w R&teia Oc 1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD NYSIF New York State Insurance Fund PO Box 66699.Albany, NY 12206 1 nysif.com CERTIFICATE OF WORKERS' COMPENSATION INSURANCE (RENEWED) A^^ AAA 061601773 I 'f CHAMPION INSURANCE 1418 WILLIAMSBRIDGE RD .1 BRONX NY 10461 SCAN TO VALIDATE AND SUBSCRIBE POLICYHOLDER CERTIFICATE HOLDER JOHN MASIELLO D/B/A VILLAGE OF RYE BROOK COUNTRY CLUB MARBLE&TILE 938 KING STREET 719 PALISADE AVENUE RYE BROOK NY 10573 YONKERS NY 10703 POLICY NUMBER CERTIFICATE NUMBER POLICY PERIOD DATE W1373125-2 868155 11/18/2023 TO 11/18/2024 11/8/2023 THIS IS TO CERTIFY THAT THE POLICYHOLDER NAMED ABOVE IS INSURED WITH THE NEW YORK STATE INSURANCE FUND UNDER POLICY NO. 1373125-2. COVERING THE ENTIRE OBLIGATION OF THIS POLICYHOLDER FOR WORKERS' COMPENSATION UNDER THE NEW YORK WORKERS' COMPENSATION LAW WITH RESPECT TO ALL OPERATIONS IN THE STATE OF NEW YORK, EXCEPT AS INDICATED BELOW. AND, WITH RESPECT TO OPERATIONS OUTSIDE OF NEW YORK. TO THE POLICYHOLDER'S REGULAR NEW YORK STATE EMPLOYEES ONLY. IF YOU WISH TO RECEIVE NOTIFICATIONS REGARDING SAID POLICY,INCLUDING ANY NOTIFICATION OF CANCELLATIONS, OR TO VALIDATE THIS CERTIFICATE,VISIT OUR WEBSITE AT HTTPS:/fWWW.NYSIF.COM/CERT/CERTVAL.ASP. THE NEW YORK STATE INSURANCE FUND IS NOT LIABLE IN THE EVENT OF FAILURE TO GIVE SUCH NOTIFICATIONS. THIS POLICY DOES NOT COVER THE SOLE PROPRIETOR, PARTNERS AND/OR MEMBERS OF A LIMITED LIABILITY COMPANY. THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS NOR INSURANCE COVERAGE UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICY. NEW YORK STAT SUR NCE FUND /l�Y� �V DIRECTOR,INSURANCE FUND UNDERWRITING VALIDATION NUMBER: 683576356 U-26.3