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HomeMy WebLinkAboutBP24-006PERMIT # SECTION Z TYPE OF WO JOB LOCATIC CONTRACTOR_/ EST. COST a V/CO# a�_ TCO # r 0942. DATE: 7 >-17 BLOCK / LOT, 4S24ef ooml 7 Zjjooc1'eoq7Q FEE W;Za` U-kok3 FEE DATE INSPECTION RECORD DATE INSP FOOTING FOUNDATION FRAMING RGH FRAMING INSULATION PLUMBING LYJ J z to toW -Foa-s�t� RGH PLUMBING 167 z ze r AWd GAS SPRINKLER ELECTRIC O LOW -VOLT O ALARM AS BUILT O FINAL Q GK GZ7� �I i�l G�- OTHER APPROVALS ARB BOT BPS ZBA OTHER VILLAGE OF RYE BROOK WESTCHESTER COUNTY, NEW YORK NO: 24-156 Certificate of Occupancy qa �This is to certify that Y /f/r lam/ / 1116 J'*YO,, of, pu? &wkj /V having duly filed an application on 20�requesting a Certificate of Occupancy for the premises known as, Rye Brook,NY, located in a p- /'5 Zoning District and shown on the most current Tax Map as Section: . ' Block: J— Lot: , and having fully complied with the requirements of the Building Code and the Zoning Ordinance under Building Permit No. "" , issued -7 2029 such authority and permission is hereby granted to the property owner to lawfully occupy or use said premises or building or part thereof listed under the following n � -0 New York State Classifications, Use: r-% /L Construction: , for the following purposes: holi boMvo6m Subject to all the privileges, requirements, limitations, and conditions prescribed by law, and subject also to the following: This certificate does not in any way relieve the owners or any person or persons in possession or control of the premises, building,or any part thereof from obtaining such other permits or licenses as may be prescribed by law for the uses or purposes for which the building or premises is designed or intended. Furthermore, it does not relieve such owners or persons from complying with any lawful order issued with the object of maintaining the premises or building in a safe and lawful condition. No changes or rearrangement in the structural parts of the building or in the exit facilities shall be made,and no enlargement, whether by extending on any side or by increasing in height shall be made,nor shall the building be moved from one location to another until a permit to accomplish such change has n obtai ed from Building Inspector. Building Inspector,Village of Rye Brook: Date: DEC 1 2 2024 BUILWBROOK, ENT For office use onl PERMIT# O O 6 DEC - 2 ZO24 VILOK ISSUED: /-j7-�1/ 938 KING STRE YORK 10573 DATE: /,D Q—3 FEE: �S(�— PAID ov APPLICATION FOR CERTIFICATE OF OCCUPANCY,CERTIFICATE OF COMPLIANCES AND CERTIFICATION OF FINAL COSTS TO BE SUBMITTED ONLY UPON COMPLETION OF ALL WORK, AND PRIOR TO THE FINAL INSPECTION Address: : O (� Occupancy/Use: //C,i'-( Parcel ID#: /3, , 3 - 7 Zone: le- Owner: �A�C4\.e c S1c� Y,►— Address: SCj M �VCS P.E./R.A. or Contractor: KT uc P TMp( jW)TAddress: 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: \C.1,._.e \�C S_�CA Y� being duly sworn,deposes and says that he/she resides at (e l W\'/\O— (Print Name of Applicant) (No.#d Street) in 2 V e b(VOL ____,in the County of ��S 1� in the State of 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:$Z-7 U (L—j d I , for the construction or alteration of- f n itic 1,C Ir }'Yc ski b `�Vt)c))'"1 � 1- _j1I1 6�V-O rl 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 L Sworn to before me this day of .I KQey))y , 20)_L4 day of , 20 C� Signature of Property Owner Signature of Applicant aotary me of Property Owner Print Name of Applicant U,�:s Public Notary Public SHARI MELILLO Notary Public,State of New York 6/l/2024 No.OIME6160063 Qualified in Westchester Countyy J� --7 01 rrnn:_:Jon Expires J;gat.. y 29,20/ / �Qy_E BRC��• o �m 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.or - - - - - - - - - - - - - - - - - - - - INSPECTION REPORT - - - - - - - - - - - - - - - - - - - - ADDRESS : �a 7c `` Poc C� DATE: L JZ PERMIT# ISSUED: - - Z y SECT: _ � LOCK: LOT: LOCATION: M L15 A N 2 Q J 4 �A �- � OCCUPANCY: i ❑ 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 Q ❑ NATURAL GAS ❑ L.P. GAS ❑ FUEL TANK ; ❑ FIRE SPRINKLER ❑ FINAL PLUMBING ❑ CROSS CONNECTION ❑ FINAL V V �;,_- M ❑ OTHER ` S UtA C,, ' C QyE BRC�v� 1932 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 :_( I r V ►J y ._,- i V 00 DATE: ` PERMIT# 1 ' J ISSUED: SECT: J /✓ LOCK: LOT: LOCATION: Qj �lJ� r,_� => �L1 OCCUPANCY: ❑ VIOLATION NOTED THE WORK IS... ❑ ACCEPTED ❑ REJECTED/ REINSPECTION ❑ SITE INSPECTION REQUIRED ❑ FOOTING ❑ FOOTING DRAINAGE ❑ FOUNDATION ❑ UNDERGROUND PLUMBING NOTES ON INSPECTION: ❑ ROUGH PLUMBING ❑ ROUGH FRAMING ❑ INSULATION ❑ NATURAL GAS L ❑ L.P. GAS ❑ FUEL TANK ❑ FIRE SPRINKLER ❑ FINAL PLUMBING ❑ CROSS CONNECTION ❑ FINAL ❑ OTHER �yE BRC��. Zm 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 - - - - - - - - - - - - - - - - - - - - INSPECTIONREPORT - - - - - - - - - - - - - - - - - - - - ADDRESS : ' 1Q L DATE: PERMIT# R Z 1- DJ ,o ISSUED:.' SECT: BLOCK: LOT: LOCATION: OCCUPANCY: ❑ VIOLATION NOTED THE WORK IS... ❑ 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 1- ❑ FINAL PLUMBING ❑ CROSS CONNECTION ❑ FINAL ❑ OTHER yE BRC�uk 1932 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 : (.0 DATE: PERMIT# 1 Ll �:2 ISSUED: v SECT: BLOCK: LOT: LOCATION: - lJl 1 I '7 ) '"� OCCUPANCY: ❑ VIOLATION NOTED THE WORK IS... ❑ 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 ❑ FINAL ❑ OTHER s s . N N _ CA � o RW.a CAW a ICI n � d• cn ca� ,,4 � � . A o B w H M z o n o w 0 en O F-I O \ fYi o w ° o �+ s3 v a'' O W , CIS H N w Cs 4-4 cz cn J �4-4 r l W o N .--i p a ro- CD CIS O co Z5 x a h �o . © w W x O 0 L o o -a v v w o, 0�4 CO . o z z o0ov U V U CA O a V1:4 CL W = �► A waN � O o z � o oaf off " ■ [n U o abti v lu Zo U V p 8 ``. .55 N � x r V Az 0 o *� '"'' ' am y a0 C7 p g • os� N A124 V w a rpD 04 a � BUILDING DEPARTMENT D 4rS'�` ��/J ' VILLAGE OF RYE OOK ��N - 5 2OZ�+ 938 KING STRiEET RYE BRo ,NY 10573 (914)9397' -ggu- VILLAGE OF l 'rc 43ROUK ���v�r.tleli 1 BUILDING DEFAi•ti�lvlENT INTERIOR BUILDING PERMIT APPLICATION FOR OFFICE USE ONLY: Approval Date: en it#: • Application Fee:$ /Q 2� Approval Signature: Permit Fees:$- l e?o— b UE Disapproved: _ Other: Application dated: —��d 7 is hereby made to the Building Inspector of the Village of Rye Brook,NY,for the issuance of a Permit for the interior alteration of an existing building,or for a change in use,as per detailed statement described below. 1. Job Address:61 g d SBL:/3.6-,3 7 Zone:e/-S— 2. Proposed Improvement.(Des ibe in detail). f ,m- - 0-Yl _ r 3. Does the proposed improvement involve a Home-Occupation as per§250-38 of the Code of the Village of Rye Brook? No: Yes: If yes,indicate: TIER I: TIER 11: TIER III: 4. Will the proposed project require the installation of a new,or an extension/modification to an exis 'ng automatic fire suppression system (Fire Sprinkler,ANSL System,FM-200 System,Type I Hood,etc...) :No: Yes: (If�CS, Pleasc submit a separate Automatic Fire Suppression System Permit application& ' sets of detailed�cn=ineered plans) 5. Occupancy;(1 fam.,2 fam.,comm.,etc...)Prior to Construction: After Construction: I�1C l YrS� 6. N.Y State Construction Classification: N.Y,State Use Classification: 7. Property Owner: 1C l tG Address: CO3 Phtme# fly 3� (A4 Cel # 1 L4 2-(& Z(P email: n'1 $. Applicant: NYlO OI-/)-*7 - Address: Phone# Cell# email: 9. Architect: _ Address: Phone# Cell# email: 10. Engineer: PV Address: Phone# Cell# email: 11. General Contractor: �'© 'Ad ss CorP 293 2r)tJ OJ�lr1�,Vy,1v, yl Me"" - _Cell# - email: beiOkciz Zot9 O m 12. Estimated cost of construction $:Al© o0c.On (NO I L. I he e,umated cost shall include all lalwr,n alerial,scalluldmc.imcd equipment.professional fees.and material and labor%%hich may be donated gratis. 13. Job Timetable: Start: I).C. DO, z(Jv�s Finish: i Z, 2-U2- ' (I) 6/II2023 BUILD; DEPARTMENT VILLAGE OF RYE 1*OOK 938 Knvc STET RvE BRoci,NY 10573 JAN -5 2024 iD (914)939-066tV VILLAGE OF RYE BROOK BUILDING DEPARTMENT AFFIDAVIT OF COMPLIANCE VILLAGE CODE §216 • STORM SEWERS AND SANITARY SEWERS THIS AFFIDAVIT MUST BEAR THE NOTARIZED SIGNATURE OF THE LEGAL PROPERTY OWNER AND BE SUBMITTED ALONG WITH ANY BUILDING OR PLUMBING PERMIT APPLICATION. ANY BUILDING OR PLUMBING PERMIT APPLICATION SUBMITTED WITHOUT THIS COMPLETED AND NOTARIZED FORM WILL BE RETURNED TO THE APPLICANT . STATE OF NEW YORK, COUNTY OF WESTCHESTER ) as: 1, ntbej It c L�c residing at, Q�3 i:k rr being duly sworn,deposes and states that(s)he is the applicant above named, and further states that(s)he is the legal owner of the property to which this Affidavit of Compliance pertains at; <n K , Rye Brook,NY. f oh A dressI Further that all statements contained herein are true,and that to the best of his/her knowledge and belief, that there are no known illegal cross-connections concerning either the storm sewer or sanitary sewer, and further that there are no roof drains, sump pumps, or other prohibited stormwater or groundwater connections or sources of inflow or infiltration of any kind into the sanitary sewer from the subject property in accordance with all State, County and Village Codes. (tii�n��lurc�i1'E'rup�rt} 1?��ncr .11 Irlh d le- S+a (Nrint Name of Property t)n riff el Sworn to before me this day of 7Gnuc, r�) , 20 _ GREGORY M.RIVERA hl'"Public,State of New York No.Q1 R1644 t 398 t Qualified in Westchester County Commission Expires September 26,2 8/122021 This application must be properly completed in its entirety and 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. 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. By signing this application,the property owner further declares that he/she has inspected the subject property, and that to the best of his/her knowledge there are no roof drains, sump pumps or other prohibited stormwater or groundwater connections or sources of infiltration into the sanitary sewer system on or from the subject property. Sworn to before me this Sworn to before me this day of � , 20 day of 20 Signature of Property Owne Signature of Applicant 1 Print Name of Property Owner Print Name of Applicant Notary PW.F Notary Public GREGORY M.RIVERA Netts Public,State of New York No.01RI6441398 Qualified In Westchester County Commission Expires September 26,201 (41 8/12/2021 BUILD MENT3D VILI; E OF RY OOK MAR 1 1 2024 938 Knvc ET RYI BIt NY 1057 VILLAGE OF RYE BROOK BUILDING DEPARTMENT FOR OFFICE USE ONLY: MAR 1 Z 2 Approval Date: mit = Application# Approval Signature: ARCHITECTURAL REVIEW BOARD: Disapproved: : Date: BOT Approval Date: Case Chairman: PB Approval Date: Case# Secretary: ZBA Approval Date: Case# �� Other: /n1 Amendment Fee: `/ �— Permit Fee: APPLICATION TO AMEND APPROVED PLANS Application dated:3 lit I 9L4 is hereby made to the Building Inspector of the Village of Rye Brook,NY,to amend the approved plans associated with an exiltink open pemut,and/or from any prior approvals granted by the approval authority as per detailed statement described below. 1. Job Address: �� _ Existing Permit#: ►J/- "r�e4 "o 2. Parcel ID#: 13 3`� —) Zone: , IS_Original Approval Date: I ° l 7 3. Proposed Amendment(Describe in detail): enm� r-)n' kith yya m• Z� (bg "y,06 in m 4t/ r hec -i- - e. 4. Property Owner: S / Address: o L `t Phone# Cell# gig Sa (o G Q40 e-mail fm45-6_YV'I oo�� r^, Applicant:� ` Address: Phone# Cell# e-mail Architect/Engineer: Address: Phone# Cell# e-mail 5. Occupancy;(-Fam.,�� -Fam.,Comm.,etc...)Prior to construction: 1� After construction: V1'\ 6. Will the ro os r mendment require the installation of a new,or an extension/modifrcation to an existing automatic fire P P q g suppression system?(Fire Sprinkler,ANSL System,FM-200 System,Type I Hood,etc...)Yes:_No: (if yes,you must submit a separate Automatic Fire Suppression System Permit application&2 sets of detailed engineere plans) 7. Will the proposed amendment disturb 400 sq.ft.or more of land,or create 400 sq.ft.or m re of impervious coverage requiring a Storm water Management Control Permit as per§217 of Village Code'?Yes:_No:TArea: l 8/12/2021 8. Will the proposed endment 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) 9. Will the proposed amendment require a Steep Slopes Permit as per§213 of Village Code Yes: —No: (if yes,you must submit a Site Plan Application,&provide a detailed topographical survey) 10. Is the lot located within]00 ft of a Wetland as per§245 of Village Code? Yes: No: (if yes,the area of wetland and the wetland buffer zone must be properly depicted on the survey&site plan) 11. Is the Lot or any portion thereof located in a Flood Plane as per the FIRM Map dated 9/28/07? Yes: No: (if yes,the area and elevations of the flood plane must be properly depicted on the survey&site plan) 12. Will the proposed amendment require a Tree Removal Permit as per§235 of Village Code?Yes: - No:_K(ifyes,you must submit a Tree Removal Permit Application) 13. Does the proposed amendment involve a Home-Occupation as per§250-38 of Village Code? Yes: No:-If yes,indicate: TIER I: TIER II: TIER III: (if yes,a Home Occupation Permit Application is required) 14. Will the proposed amen en t result in additional square footage to the building or subject structure,and if so,provide such additional footage here. (Please submit additional Bulk Regulation Application Pages for review) 15. What is the total added cost of the work associated with the amendment: $ 1(), eon (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.) 16. N.Y.State Construction Classif ion: N. tate Use Classification: 17. Estimated date of completion: This application must be properly completed in its entirety by a N.Y. State Registered Architect or N.Y. State Licensed Professional Engineer&signed by those professionals where indicated.It must also 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. STATE OF NEW YORIL COUNTY OF WESTCHESTER ) as: C�\Q `�t �� , 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.By signing this application,the property owner further declares that he/she has inspected the subject property,and that to the best of his/her knowledge there are no roof drains,sump pumps or other prohibited stormwater or groundwater connections or sources of infiltration into the sanitary sewer system on or from the subject property. Sworn to before me this Sworn to before me this day of Y-C ,20,W day of ,20 r � � i Signature of Property OXmer Signature of Applicant IellC' 5+u-r N me of Property Owner Print Name of Applicant No Public Notary Public 2 SHAPI MELILLO Notary Public,State of New York No.OIME6160063 Qualified In Westchester County 7—] Commission Expires January 29,20 v ' 8/12/2021 a s s s N O W , O � N N \ PC W M O W CL.rA a (la U k a z / LL. ,� x a Z M U Z o a s M a ai �, � w C7 �"" °D O ■ x O a 00 �, T w N i� 00 W ci o .� . r CN 00 W 0 � a Z - r O eq a z Ad u :� w • �'" u. W W H F o o Z � c z z ., � x ✓✓ (� �" A U cn a e-i z 0 �I ~ D IECE0 EE BUILDING DEPARTMENT OCT - 8 2024I Dil VILLAr,E OF RYE BBOOK I 938 KING 9f1jWET RYE BROOK,NY 10573 VILLAGE OF RYE BROOK BUILDING DEPARTMENT WWw,ryetWQ0:nv.aov PLUMBING PjERMIT APPLICATION FOR OFFICE USE ONLY BP#: d /—C,�C) PP#: Approval Date: r�O 9 24 Permit Fee: S Approval Signature: Disapproved: (fees are non-refundable) **********s******s**s*************#*s*****ss***s**s*s*s**ss**s***s#s**s*******************s**s**s* DO NOT START WORK or CONSTRUCTION UNTIL A PERMIT HAS BEEN ISSL`ED Bl'THE BUILDING INSPECTOR.THE ADMINISTRATIVE FEE FOR WORK PROGRESSED OR COMPLETED WITHOUT A PERMIT IS 12%OF THE TOTAL COST OF CONSTRUCTION WITH A MINIMUM FEE OF$750 00 Application dated, /15-' -C�7 is hereby made to the Building Inspector of the Village of Rye Brook NY,for the issuance of a Permit to install and/or remove Plumbing as per detailed statement described below.The applicant&property owner,by signing this document agree that said plumbing work will be in conformance with all applicable Federal,State,County and Local Codes. 1.Address:(p/ W 0tick„�g t✓ad d ie SBL:f::�13'7- -7 Zone: -IS7 2.Proposed Work::�Ar>-fQ 6 �/ �w Ty 13 +-S ,Q(� V �tJY t/ 1�� �4eq- 3.Property Owner: In I vte�,e 7iq{I-2 Address:( Phone#: Cell T<4Z S2-(40r'241 email: d' 4.Master Plumber: "- A- nrp tag Trt Address:_ dam✓Xf,.y Lic. #:�n�.6 Phone#: / Cell#�! 3 O- email: a7- /0twh P eiv Company Name:c/� gL�b� _Address: /9 LA' Tt� /(-(l e, r1A����arr INDICATE FIXTURES& LINES TO BE INSTALLED AS PER THE FOLLOWING SCHEDULE Location Water Urinals Drinking Sinks Showers Bath Laundry Domestic Fire Sanitary Natural/ Other* Total Closets Fountains Tubs Tubs I Service Service Sewer LP Gas Basement 1st Floor 2nd Floor 3.d Floor 411 Floor 5s'Floor Exterior 5.*List Other Equipment/Provide Details: (Notarized Signatures Required Next 2 Pages) 6/l/2024 STATE OF NEW YORK,COUNTY OF WESTCHESTER ) as: (Pent name of individual signing as the applicant) being duly swom,deposes and states that he/she is the applicant above named, and further states that(s)he is the Master Plumber for the legal owner and is duly authorized to make and file this application. 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 of_ CL-1l-(1t1 ,20_2 day of 20 Signature�ofProerty O ner ig ature 4,f Applicant M/ch ,11e '-/Zz✓r 66-M:) CIRcint Name of Property Owner ANoVS Print Name of Applicant Aft � lic,State of New York No blic No.01ME6160063 Qualified In Westchester County. GREGORY M.RIVERA Commission Expires January 29.2a Nftq Public,State of New York No.01 RI644e113398 This application must be properly completed in its entirety and mu � Y`�r�igt}{tty r p embeX Zp of the legal owner(s)of the subject property, and the applicant of record in the spaces provided. Applications not properly completed in its entirety and/or not properly signed shall be deemed null and void and will be returned to the applicant. -2- 6/12024 BUILDING(; DEPARTMENT VILLAGE OF RY1lfROOK 3D 938 KING S OCT - $ 2024 TAFET RYE BROOK,NY 10573 VILLAGE OF RYE BROOK `�w` ,ae_ o°k ov BUILDING DEPARTMENT AFFIDAVIT OF COMPLIANCE VILLAGE CODE 6216 • STORM SEWERS AND SANITARY SEWERS THIS AFFIDAVIT MUST BEAR THE NOTARIZED SIGNATURE OF THE LEGAL PROPERTY OWNER AND BE SUBMITTED ALONG WITH ANY BUILDING OR PLUMBING PERMIT APPLICATION. ANY BUILDING OR PLUMBING PERMIT APPLICATION SUBMITTED WITHOUT THIS COMPLETED AND NOTARIZED FORM WILL BE RETURNED TO THE APPLICANT. STATE OF NEW YORK,COUNTY OF WESTCHESTER ) as: 3, - �M a 6Ie Y-I — , residing at, ©(' UNY 1Pruu name) iAddre.N%%her �uu li,r} 10 being duly sworn,deposes and states that(s)he is the applicant above named,an further states that(s)he is the V legal owner of the property to which this Affidavit of Compliance pertains at; 573 Rye Brook,NY. Further that all statements contained herein are true, and that to the best of his/her knowledge and belief,that there are no known illegal cross-connections concerning either the storm sewer or sanitary sewer, and further that there are no roof drains, sump pumps, or other prohibited stormwater or groundwater connections or sources of inflow or infiltration of any kind into the sanitary sewer from the subject property in accordance with all State, County and Village Codes. i Si gnatury ul n� ,11 il'rini\anu �t ProPcrt� (h,ncrl�i, Sworn to before me this y, f c i� , 20 21l iNotar% Puhli,l SHARI MELILLO Notary Public,State of New York -3- No.01ME6160063 Qualified In Westchester County. Commission Expires January 29,202-� 6f 1/2024 � C C < _- w ■ ry U V J a cz ►� L a P. v F M en o x z � w O C A 0 � 4 N W W ° W °% Q Z z • w V [: F z a U Q O W � Q � H o o —` � H 0 z u z Wo z � ad O � xtr � O o cz i A o z PLO �✓ z a CZ A a o �- Q T I BU MENT V OF RYE VliOM OCT 2 8 2024 938 KtNd` RYE B NY 10573 DRR VILLAGE OF RYE BROOK Dien or t_ BUILDING DEPARTMENT PLUMBING �P/ERMIT'APPLICATION FOR OFFICE USE ONLY #: r— � PP 4: Approval Date: Permit Fee:S Appro%al Sigature Disapproved: ttiri err aweftro�stle) ♦t 466 ♦46•0MN of"N411"M DO NOT START%'ORt►or COSS I Rt (170N IIVI It. A PCW%lIT H.4_S SEEN ISSUED 8% 'I HE St ILDIM; INSPECTOR THE ADMINIS1'RATML FEE FOR WORK PRMIIES'SED Olt COMPLETLD W ITHOU T A PERMIT IS 12%OF I'HE't'(NrAl.COST OF CONS Rt'(-I'H)V 141'1 H A MININIt'!11 FEE OF$750.00 Applxatwo duel,/n-2) —a4 n bavby ma&b the Buikbug Inspecuw of dw Village o(R)v Ek NY.(or the tssunincx of a Permit to in tall smAar remove Pkrrnbing as per detailed statement dc-ycnbed behave•.The applicant dr pnr}terty owner.by signing this document agree that said phtmbag work w•dl be inconfurmaiwe with all applicable Federal.State.County an Local Coda. I.Address: 1Q_d�/� �--SBL: /35;3y-/-7t,<zo : 9�' 2.Prupmed Work: /4` 7ilA'nV�/" __.G(- nA G�ra=- 0,NA 3.Pruperty Owner: 4�ne�ts: ee ss(�t/>N�/ G(!0 I�r Phooc e. Cell mail: /06 MH*G0N1 4.Masher Plumber: f2� /Jo h'7it>_ W C4 S-rnv— LjL-#:/Q(44 PYaae Cell 0 Company Name--/:4 Adtlrem-rj_i4/''le &I Q�DIJ`�i INDICATE FIXTURILS&LINES TO 11E INSTALLFD AS PER 771E FOLLOWMG SCHEdt!LE: t.orsum 'A nut Urmsk Drinbag Soaks Shower Bob tawdry Damesttc Fire Sanailay mannav Odms* Total ' Closets Fouat<tms Tabs Tabs Se -Sce Senioe Sewer LPGas Basement 1 st Floor /, tad Fbar 3d Floor 41b Floor 5 Floor EtttQior S.'List Ckhrr Equipriwat Provide Details: (Notarised Signatures Raquired next 2 Pages) STATE OF NEW YOM COUNTY OF WESTCHESTER .being duly sworn,deposes and states that he she is the applicant abmc rvmeci tprim acre of udisrt+rt 6""d i e apphesui and fur*m slater that(s)lae a the 1NaMer Plumber for the legal owner and a duly authortzid to make and file this application. That all sratemenis cxsnumcd herein arc true to the best of lus her knuw Icdgc and belief.mid that any wort performed.or we conduLwd at the above captioned pnapem,well be is conformance with the details as set forth and contamed in this applicauat and m any accompanying approved plats►and gwcifxmtwa.%,as weal as in accordarx-e wsth the New York State Uniform Firr Prcive limn& Budding Cody,the Code of the Village of Rye Bruol• and all other applicable laws.ordinances and regulations Sworn to be this \ Sworn to before m the c}e O day (_G c r.20�`1 day of .20 Sigsomm of Rope Owner S moor of Applicant J2),al ells t one of Property Owner Name of Applicant A I E / Nalaryhblid-IARI N ELILLO 6160063 Notary Public,State of New York Qualifies!In Westchester County No.01PAE6160063 Commission Expires January 29,20 Z Qua!lfied In Westchester County Ccmmission Expires January 29,20Z -7 This application must be properly completed in its entirety and must include the notarized signature(s)of the Icgal ownctis)of the subject property,and the applicant of record in the spaces provided. Applications not properly completed in its entirety and or not properly signed shall be deemed null and void and will be returned to the applicant. -z- `"t 2a34 BUILDING DEPARTMENT p V VIL E OF RYE OOK 938 KING ET RYE BRO ,NY 10573 OCT 2 8 2024 (914)939-0668� w `" ov VILLAGE OF RYE BROOK BUILDING DEPARTMENT AFFIDAVIT OF COMPLIANCE VILLAGE CODE �216 • STORM SEWERS AND SANITARY SEWERS THIS AFFIDAVIT MUST BEAR THE NOTARIZED SIGNATURE OF THE LEGAL PROPERTY OWNER AND BE SUBMITTED ALONG WITH ANY BUILDING OR PLUMBING PERMIT APPLICATION. ANY BUILDING OR PLUMBING PERMIT APPLICATION SUBMITTED WITHOUT THIS COMPLETED AND NOTARIZED FORM WILL BE RETURNED TO THE APPLICANT. STATE OF NEW YORK,COUNTY OF WESTCHESTER ) as: Af !S / -, residing at, I d (Print name) (Av ss where you live) 3 being duly sworn, deposes and states that(s)he is the applicant above named, and further states that(s)he is the legal owner of the property to which this Affidavit of Compliance pertains at; (0l W In di oC4 jbnc d !_�v LA Qyr yd c N� a57 � , Rye Brook,NY. (Job Address) Further that all statements contained herein are true, and that to the best of his/her knowledge and belief,that there are no known illegal cross-connections concerning either the storm sewer or sanitary sewer, and further that there are no roof drains, sump pumps, or other prohibited stormwater or groundwater connections or sources of inflow or infiltration of any kind into the sanitary sewer from the subject property in accordance with all State, County and Village Codes. 4/�'d'I&,J 1�'- � (Signature of Property Owner s)) M/c hel% 'S ►�' (Print Name of Property Owner(s)) Sworn to before e this d f Dc -�� , 20 7 (Notary lic) SHARI MELILLO NO' Public,State of New York No.01ME6160063 Qu:lllfied In Westchester County -3- Commission Expires January 29,20 Z_7 6/l/2024 �- o = Qi ull) � F- --� O o 00 I Q Y N m z 0 I � W 0 (, W I I Z O o o = W O _j d M (D N o Z ' GC I— o . 4. 0� I.. a. t W O - CY CY U) W , . .� Z fin✓ 3 � m w O 0 L UJ = ' i � W O ..� qU - m � a } " mQ z W O .-� _ F- , Ox00 �J " 4 � - ct_A CO w W a � Q fui { \ x C! o z m v) a o v) o A W 0 W a c Z `^7 c� o v W 00 o U r••i C7 �o W 1� o ch ooa W J N � w _. Z �' 3 U, W a . 0 1 1 J U 0 F— d o rn F� N w O 0 R o i W f -0 0 cu cv LLJ N W Cts :E ca v, T� 0FA J W 04 N � Q 'O ` LL cc o O z m � �E BRC��, • 1982• BUILDING DEPARTMENT ❑BUILDING INSPECTOR 91WISTANT 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: (0 1 AJCJ V v J O 1\�. _ DATE: 16 G uZ / PERMIT# G QQ•b ISSUED: 2 SECT: I:. BLOCK: LOT: LOCATION: C r^J U C .J�� �J I' U 2 OCCUPANCY: 2/y ❑ Violation Noted THE WORK IS... ❑ PASSED ❑ FAILED / REINSPECTION Z SITE INSPECTION REQUIRED ❑ FOOTING ❑ FOOTING DRAINAGE ❑ FOUNDATION ❑ UNDERGROUND PLUMBING NOTES ON INSPECTION: ❑ ROUGH PLUMBING ❑ ROUGH FRAMING ❑ INSULATION / I / ❑ Natural Gas J� L vet 4 C4 ?-eA-"v) i Q y V C' C ❑ L.P. Gas �� C) • C� l C i P vN C /cc. ❑ FUEL TANK n ❑ FIRE SPRINKLER e P 7 P v f �„ ❑ FINAL PLUMBING ❑ CROSS CONNECTION ❑ FINAL ❑ OTHER �yE [lR(�uk CERTIFIED MAIL Vf BUILDING DEPARTMENT HAND DELIVERED VILLAGE OF RYE BROOK 1987 938 KING STREET RYE BROOK, NY 10573 (914) 939-0668 FAX (914) 939-5801 NOTICE OF VIOLATION AND ORDER TO REMEDY SAME OWNER: G �-t rc VIOLATION# 2014 / .J i LAI '� Qd NOTICE:# / Q*g hri-kuk PJ � 10-:E 2 3 SECTION: /.3J - 2 BLOCK: LOT: THE FOLLOWING VIOLATIONS OF THE NEW YORK STATE UNIFORM FIRE PREVENTION AND BUILDING CODE AND/OR,THE CODE OF THE VILLAGE OF RYE BROOK WERE FOUND TO EXIST AT..... Lis ✓J�ud v,� = 1U ` ci S , LOCATED IN AN / ZONE, IN THE COUNTY OF WESTCHESTER,VILLAGE OF RYE BROOK,NY ON, J- 20 i . CODE SECTION TITLE/DESCRIPTION -------------------------L--2P��� --------------------------Az'-1-y-a4--�o- ------------------- -------------------- ------------------------s�qL� 6e '2 v0 -- -------------------------- i7------- ----- ZfQ�-' —— �—�vN � /Q�_J�/t ago,J^� -----------------0--------(nn''„ TT/��i__•�1//�1 _�J ��dL_ _/Qt.,�. .--- -ezL1G)L------Z 12d------ ------------------------zae 44-za .1pcf NOTES: Wi le k a ti41 2 P.v a ✓a ��� 1J . You are hereby directed to contact this department, obtain all necessary permits & commence to correct the above captioned violation(s) immediately.Violations of the NYSUFP&BC must be remedied by, 20 ,which is thirty(30) days after the date of this notice and are returnable at the rate of$1,000,00/day for each day of continued violation, or imprisonment not exceeding one year, or both. A re-inspection of the premises is required by law to confirm compliance with this notice&all applicable codes. FAILURE TO COMPLY WITH THIS NOTICE IS A CRIME PUNISHABLE Y FINE, IMPRISONMENT OR BOTH. ❑ BUILDING INSPECTOR ASSISTANT BUILDING INSPECTOR ❑ VILLAGE ENGINEER �w � ,� f /'.. 4, ' T�'Y,Rh r `� .� r i + i• / s �� �� r: i � � � i . �< l � �,,, .. --- _. , f i USG DUROCKaro-1-4 C nt Board N^tr.EcgeGu. ww- a N QLL d 3 • "F0LL � �1 m Lm m Q 2 C �7 lL M G a Q ? 2 U V r r o 4 $ U) E 2 m a ti § m m 4 m �c�OO�❑ a o m '0 U fn w a .s H a A �U OTCC T70T rrnn l ncom ❑Tni �yE DRCuk CERTIFIED MAIL V BUILDING DEPARTMENT HAND DELIVERED VILLAGE OF RYE BROOK 1982 938 KING STREET RYE BROOK, NY 10573 (914) 939-0668 FAX (914) 939-5801 NOTICE OF VIOLATION AND ORDER TO REMEDY SAME OWNER: 6 rc' VIOLATION# 2014 i Q4 NOTICE:# I �t]n nJ•�/ lox23 SECTION: /36-- 2Y BLOCK: LOT: 7 THE FOLLOWING VIOLATIONS OF THE NEW YORK STATE UNIFORM FIRE PREVENTION AND BUILDING CODE AND/OR,THE CODE OF THE VILLAGE OF RYE BROOK WERE FOUND TO EXIST AT..... WIZA I V-C Woo 4 2 d —C , LOCATED IN AN 9 /S ZONE, IN THE COUNTY OF WESTCHESTER, VILLAGE OF RYE BROOK,NY ON, 414lu. S- 20 .2 Y' . CODE SECTION TITLE/DESCRIPTION ✓i ----------CO= y =------��— o. Sow _s�aLc G ------------------------- 'r -------------------------� �Q--- =P m�y 1 1��,_-------�� �--------�`a_pz: iiA�G -------- y1 -- -------- --- ✓tda L$4=Z-3------- 1tQ_�0_�sG --------------------------^r/'-^,'; TpQI� �-�/�-- -�--I°Q�'="-''-�•--- �1t�a-�-------1�'l°'¢ �------ - �1�stc_-� NOTES• tYQ ✓ �� Z /2-e N O ✓a, /o"J You are hereby directed to contact this department, obtain all necessary permits & commence to correct the above captioned violation(s) immediately.Violations of the NYSUFP&BC must be remedied by, , 20 ,which is thirty(30)days after the date of this notice and are returnable at the rate of$1,000,00/day for each day of continued violation, or imprisonment not exceeding one year, or both. A re-inspection of the premises is required by law to confirm compliance with this notice&all applicable codes. FAILURE TO COMPLY WITH THIS NOTICE IS A CRIME PUNISHABLE iY FINI,, IMPRISO NMENT OR BOTH. IAI ❑{ BUILDING INSPECTOR CJ ASSISTANT BUILDING INSPECTOR ❑ VILLAGE ENGINEER M O 3 M o LO N k'� ? O 0 W O C) a o Lz 1 a I D a � l � O Qi U' d�o o ai O o ,� Lo U a. v0 t,1 O�<'7 O IL 7 O NOO M `I NOO ..- -M-0, h a •y M-.. r #'• r a••f v/1, 1 s �• m —Q Ln ru co _._-- C3 0 3 � mED — � k,,b � � M �Yj n Y o Y o ® Z ® Z cc CD pp SEW YOR W Y a6W YO W �i O 0 oC y0 39d11 V d y0 39d1�\ W v Q HtA V v c Y � Y M M O� p� r .Building Permit Check List&Zoning Anal sis �( Address: I SBL: S7 1 1 Zone: AS U co Type: � Other: Submittal Date: 2 Revisions Submittal Dates: Applicant: IV C— Nature of Work: nn^r. Reviews:ZBA PB: Other. NEED OK Gj y FEES Filing BP: ` C Flood Plane: Legalization: 1 ( ) ( ) APP: Dated: Notarized: SBL: Truss I.D. Cross Connection: H.O.A.: ( ) ( ) Scenic Roads: Steep Slopes: Wetlands: Storm Water Review Street Opening. ( ) ( ) ENVIRO:Long Shore 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 Comp.Waiver. Other. CODE 753#: Dated: N/A: (v) ( ) 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: N/A/: Other. ( ) ( ) FIRE SUPPRESSION:Plans: Permit: N/A Other: ( ) ( ) H.V.A.C.: Plans: Permit: N/A: Other. ( ) ( ) FUEL TANK Plans: Permit: Fuel Type: Other. ( ) ( ) 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. ( )ARB mtg.date: approval:- notes: ( )ZBA mtg.date: approval• notes: ( )PB mtg.date: approvaL• notes: G aPROVEQ REQUIRED EXISTING PROPOSED NOTES Date: JAN 1 7 284 Area: Circle: Frote Front: Front: Sides: Rear. Main Cor. Accs.Cov: Ft.H Sb: Sd.H Sb: GFA: Tot : FtEt.II71U: pg�kjw. Hei& Stories: notes: 7lqZlg5 C I O-A , SEP 2 5 2024 ID VILLAGE OF RYE BROOK BUILDING DEPARTMENT Laura Petersen From: michelle Starr <mgstarr100@gmail.com> Sent: Monday, September 30, 2024 10:38 PM To: Laura Petersen Subject: Starr - contractor license Attachments: IMG_1695.jpeg Laura- Regarding the bathroom renovation at 61 Winding Wood Road, please see attached the home improvement license of our contractor. His name and phone number are: - Manuel Hernandez - 914 525 4040 1 believe these are the final pieces of information required for us to move forward. Please let me know what we are approved to begin work and if there is anything else that we need to do. Thank you again for all of your help. Michelle Starr i o 1 WINM 1 .r0 vj : \ .�� > 1: M. N 04 °+ E O N t- 03 vl U U c� w o y r j ice, v U _ �' cn = g section +� A Q t� . '(�j p w Lu � p w o �iuedaCl Z p O �-a j 4. O idyi� • <(rs) u u fl � u�q -70 u w u N . e � E _ Z CA CL ad mrwn%iI, NOR,' 1M''`A �.� 1l�^,��. r 1'`•' 1 vyfiir 11 `.+.+�rl.��1 .• ��1/ ~M S } \ o v '.171�wr�1* �O1jnn �f�•. AC"R" CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) `� 09/23/2024 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 Deniece Carter-Hall NAME: RSC Insurance Brokerage,Inc. PHONE FAx A/C No Ext: AC No): 2288 State Route 208 E-MAIL deniece.carter@risk-strategies.com ADDRESS: INSURERS)AFFORDING COVERAGE NAIC A Montgomery NY 12549 INSURERA: Utica First Mutual 15326 INSURED INSURER B MJH Home Improvement Services,LLC INSURER C: 330 N Fulton Ave INSURER D: INSURER E: Mount Vernon NY 10552 INSURER F: COVERAGES CERTIFICATE NUMBER: CL2492391072 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 CONTRACTOR 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 INSURANCEADDLSUBR 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 ❑X OCCUR DAMAGEN PREMISES Ea occurrence $ MED EXP(Any one person) $ 5,000 A ART3000892380 04/03/2024 04/03/2025 PERSONAL&ADV INJURY S 1,000,000 GEN'LAGGREGATE LIMITAPPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY PRO- JECT LOC PRODUCTS-COMP/OPAGG $ 2,000,000 OTHER: Blanket Additional $ AUTOMOBILE LIABILITY Ot3MBMdED SINGLE LIMIT nt $ Ea accide ANYAUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per accident) S AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY Per accident $ UMBRELLA LIAB OCCUR EACH OCCURRENCE S _ EXCESS LAB CLAIMS-MADE AGGREGATE $ DED I I RETENTION $ $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY Y/N STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE ❑ NIA A E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE S If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) In regard to work performed by the named 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 ©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 ^^^^^^ 365005820 ' MJH HOME IMPROVEMENT SERVICES LLC I*�;t'fiY' 330 N FULTON AVE MOUNT VERNON NY 10552 SCAN TO VALIDATE AND SUBSCRIBE POLICYHOLDER CERTIFICATE HOLDER MJH HOME IMPROVEMENT SERVICES LLC VILLAGE OF RYE BROOK 330 N FULTON AVE 938 KING STREET MOUNT VERNON NY 10552 RYE BROOK NY 10573 POLICY NUMBER CERTIFICATE NUMBER POLICY PERIOD DATE W2586 741-7 213679 03/14/2024 TO 03/14/2025 9/23/2024 THIS IS TO CERTIFY THAT THE POLICYHOLDER NAMED ABOVE IS INSURED WITH THE NEW YORK STATE INSURANCE FUND UNDER POLICY NO. 2586 741-7, 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 STATESUR NCE FUND 4 I// DIRECTOR.INSURANCE FUND UNDERWRITING VALIDATION NUMBER: 502851473 U-26.3