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HomeMy WebLinkAboutBP24-0056�� 4— CX�S DATE: `a PERMIT # SECTION BLOCK TYPE OF WORK JOB LOCATION OWNER WQ� CONTRACTORn== . COST 41 j 7 0 VCO # CIO TCO # FOOTING FOUNDATION FRAMING RGH FRAMING INSULATION 0 PLUMBING RGH PLUMBING GAS SPRINKLER O ELECTRIC LOW -VOLT 0 ALARM AS BUILT 0 FINAL n FEE DATE Iw�cv� F(�RECORQ DATE INSP �z �� *iQ 7 P4"& 0 / 3 OT}{ER APPROVALS ARB _ BOT _ IZBA 1 OTHER DRY 19 l7 L� C � G ••uu u Yy G VILLAGE OF RYE BROOK MAYOR 938 King Street, Rye Brook,N.Y. 10573 ADMINISTRATOR Jason A. Klein (914) 939-0668 Christopher J.Bradbury www.tyebrook.org TRUSTEES BUILDING & FIRE INSPECTOR Susan R.Epstein Steven E. Fews Stephanie J.Fischer David M. Heiser Salvatore W. Morlino CERTIFICATE OF COMPLIANCE April 23,2024 Edward Horan 46 Woodland Avenue Rye Brook,New York 10573 Re: 46 Woodland Avenue,Rye Brook,New York 10573 Parcel ID#: 135.75-1-61 Building Permit#24-005 issued on 1/11/2024 for Replacement Windows This certifies that the twenty two new windows,installed under the above captioned permit have been satisfactorily completed. Sincerely, %,-- 4 Steven E. Fews Building&Fire Inspector /to DE C O " R For office use oniv. BUILD ENT PERMIT# - S APR 10 2024 VIL OF RYE K ISSUED: 9 8 KING STRE YE BROOK, YORK 10573 DATE: VILLAGE OF RYE BROOK 9 -06 FEE: j�'j�j PAID BUILDING DEPARTMENT POOrff � _�— 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 ss►r►►r►ss/�ssrsssrs�ss,�►ss►ss►►ssssrr►►s r«ssrs►ss►►ssrrs►rs►s\►^«ssrsa►r«ssrrrsss►►srss►rsrrs«rsrsssrr►►►r►srss«ssrs:►sas►r Address: " V �� y �• Occupancy/Use: m Parcel ID#: /,2j�j. 75 -- r/- �a / Zone: /�[-F Owner: �V WA R D H 0 RAN Address: //& �000'/-orJ c ///4V P/7l(� P.E./R.A. or Contractor:4t4,4 ,4�&IArD�/%al,- ddress: 6 C�J)/k&Le CT. ,��z keA)ooj �— Person in responsible charge:A 0 Stie'&/-to&)/-/Z Address: /1 / I 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: 6RD � /tiei" ng duly swom,deposes and says that he/she resides at (Print Name of Applicant) ,, �, (No.and Street) in f 46AO X ,in the County of we s�C 4, 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:$ 2-T, Coo for the construction or alteration of W W S 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. 1 Sworn to before me this Sworn to before me this l day of (� , 2mV .. day of Signature of Property Owner Si r o pplicant ame of Property Owner P ame of Applicant V-\-t�- M, — "', Q �. Notary Public No ublic SHARI MELILLO Notary Public,State of New York SHARI MELILLO No.01ME6160063 Notary Public,State of New York Qualified In Westchester Countyn--j No.OIME6160063 s;12!,021 Commission Expires January 29,20 v Qualified in Westchester County Commission Expires January 29,20 QyE BR(b 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 : / �/V �� V�V Y F DATE: / - JAY- Z UL PERMIT# T:)I:> ISSUED:f L SECT: AJJ+ 7J" BLOCK: / LOT: LOCATION: OCCUPANCY: ❑ Violation Noted THE WORK IS... PASSED ❑ FAILED REINSPECTION ❑ SITE INSPECTION REQUIRED ❑ FOOTING ❑ FOOTING DRAINAGE ❑ FOUNDATION ❑ UNDERGROUND PLUMBING NOTES ON INSPECTION: ❑ ROUGH PLUMBING ❑ ROUGH FRAMING ❑ INSULATION n ❑ Natural Gas I-1 l A, ❑ L.P. Gas ❑ FUEL TANK ❑ FIRE SPRINKLER ❑ FINAL PLUMBING ❑ CROSS CONNECTION ❑ FINAL -D'OTHER : e LO y s N � v cn a CA 3 Izt Q W a Z a g - .. w � W N M s � v Lrn— \ a Q o O N 2 0 a o o 0 u � v , c1 ob A W u� $ �.� qo0 _ V d' O p Q 4-4 �/ ~ O 4 b Q v,•, M 64 5- � "- co c,, 0 o M °�° A 0 0 ob v � u 9. U ° o o o o V Q z \�o z UZ W 0-4 F` c� �I ` M 0 W � J, ESQ ]M w Q� O t� N ., A 4 � °o•:, . 0-4 oo ( a pa �F A � \ H �V Q .�ro v ° z CD4 uoroU' W o oo _ A z O 1-4 p b o +r U � N g p v ON z "o.� � � U W o z 4 Au o O ° " +o U gw .0o CA I C7 O A Z O acne i z 0 •4 w Cn u �i O �i 1 � Q � i V x Q a .. � z W w 0 � a7. � 2 _ a w x �.Q- = a TMENT BUILD VIL F OF Ry OOK 938 KING I-,i R),v B imf), NY 10573 LJAN 5 202411 J!4)939-066 -E OF RYE BROOK 793-_2� VILLAG !nl ADMINISTRATIVE EXTERIOR BUILDING PERMIT APPLICATION FOR EXTERIOR WORK WHj(.,ji Doi,"s NOT Rt.S2tJlRE VILLAGE Agoll-l-EICTOI.W., Ri�vivw BOARD APPROVAI, FOR ()Fl;I('I" 11 S F ONLY:_Y: APPROVAL DATE: 1- 18- 2oaq PERMIT #: did �`- APPLICATION FEE:'4j 00—P6 APPROVAL SIGNATURE: d PERMIT FEES: H.O.A.APPROVAL: DATE: DISAPPROVED: OTHER: Application dated: is hereby made to the Building Inspector of the Village of Rye Brook,NY,for the issuance of a Permit for the construction of buildings,structures,additions,alterations or for a change in use,as per detailed statement described below. 1. Job Address: fA 2. Parcel ID4:- Zone: 3. Proposed Improvement(Describe in detail): Vqdoiv korLv�kt- In ki 4. Property Owner: _W , Address: -3-0? AL-AD Iq Ve t 70 Phone# cell# e-mail List All Other Properties Owned in Rye Brook: Applicant: Address: Phone 4 Cell# e-mail Architect: Address: Phone# Cell 4 e-mail Engineer: Address: Phone# Cell# e-mail General Contractor: Address: �A� L-4e"- 06-0&!S t". Phone# -ceii4 e-mail 61112023 5. Occupanc {1-Fain., -Fam.,Commercial.,etc...)Pre-construction: Post-construction: 6. Area of lot: Square feet: /V A Acres: 7. Dimensions from proposed building or structure to lot lines: front yard: rear yard: right side yard: left side yard: other: 8. If building is located on a corner lot,which street does it front on: 9. Area of proposed building in square feet: Basement: 1"fl: 2hd fl: 3rd fl: 10. Total Square Footage of the proposed new construction: 11. For additions,total square footage added:Basement: 1 S`fl: 2"d fl: 3rd fl: 12. Total Square Footage of the proposed renovation to the existing structure: 13. N.Y.State Construction Classification: N.Y.State Use Classification: 14. Construction Type&Location:()Typical Western Lumber Frame;()Timber Frame ITC];()Wood Truss[TT]; O Pre-engineered wood[PW];Located;O Floor Framing[F];O Roof Framing[R];O Floor&Roof Framing[FRI;Other: 15. Number of stories: �_' Overall I]eight: 20 Median Height: 16. Basement to be full,or partial: finished or unfinished: 17. What material is the exterior finish: 18. Roof style:peaked,hip,mansard,shed,etc: Roofiwg material: 19. What system of heating: 61,4 20. If private sewage disposal is necessary,approval by the Westchester County Health Department must be submitted with this application. 21. Will the proposed project require the installation of a new,or an extension/modification to an existing automatic fire suppression system?(Fire Sprinkler,ANSL System,FM-200 System,Type I Hood,etc...)Yes: No: (f yes,applicant must submit a separate Automatic Fire Suppression System Permit application&2 sets of detailed engineered plans) 22. Will the proposed project disturb 400 sq. ft.or more of land,or create 400 sq.ft.or more of impervious coverage requiring a Stormwater Management Control Permit as per§217 of Village Code? Yes: No: / Area: 23. Will the proposed project require a Site Plan Review by the Village Planning Board as per§209 of Village Code? Yes: No: (if yes, applicant must submit a Site Plan Application, &provide detailed drawings) 24. Will the proposed project 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) 25. Is the lot located within 100 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) 26. Is the lot or any portion thereof located in a Flood Plane as per the FIRM Map dated 9/28/07? Yes: No: (tf yes,the area and elevations of the,/lood plane must be properly depicted on the survey&site plan) 27. Will the proposed project require a Tree Removal Permit as per§235 of Village Code?Yes: No: (if yes,applicant must submit a Tree Removal Permit Application) 28. Does the proposed project involve a Home-Occupation as per§250-38 of Village Code? Yes: No: Indicate:TIER I: TIER II: TIER IIl: (if yes,a Home Occupation Permit Application is required) 29. What is the total estimated cost of construction; S 23, A Note:estimated cost shall include all site improvements,labor, material, scaffolding,fixed equipment,professional fees, including any material and labor which may be donatedgratis.If the final cost exceeds the estimated cost,an additional fee will be requiredprior to issuance of the C/O. 30. Estimated date of completion: F50)6� Q (2) 6/1/2023 BUILD MENT VIL KofftY OOK 938 KING 'T R: R: ,NY 10573 **k****ic*****k kirk*kkkix iskk*k*kkkic**k**ir***kkk*kkitk is*ic is*kn'ric*ix*kk kie***k**x*k*kk*k*k*k*iskk;�xikkkic*k*kit**kkk 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: I, Q41dgl�e j v�ZR ,residing at, _2_?7�3 1�e4rW (Print inatne) (,Addres,-where you fix 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; 16 WeOD4zv,�1 , 11`� ' , P—ye fv,Ll , ��5� 3 , 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. -0144�a 6"n_�__— (Signature of Propert} ()wner(s)) _T_:WW dR. 61 geld h 4 (Print Name of Property Owner(s)) Sworn to before me this SHARI MELILLO d 20 Q'� Notary Public,state of New York No.0IME6160063 Qualified in Westchester county commission Expires January 29,20Z-7 (Notary ublic) (3) 6/1/2023 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 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)hc 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. Swom to before me this Sworn to before me this day of SaC��� 20 2- day of 20 Signature of Property Owner Signature of Applicant Print Name of Property Owner Print Name of Applicant Not blic SHARI MELILLO Notary Public Notary Public,state of New York No.01ME6:L60063 Qualified in Westchester countx. commission Expires January 29,26k�� (4) 6JI/2023 American Craftsman 31.75 in.x 53.25 in. 70 Pro Series Low-E Argon... https://www.homedepot.com/p/American-Craftsman-31-75-in-x-53-25... 31 .75 in. x 53.25 in. 70 Pro Series Low-E Argon Glass Double Hung ... by American Craftsman (16T1) 234 $279 0 Product Details Specifications Questions&Answers Customer Reviews I I L u a+ ` J Y MW v LF a d LL�Q l�J +4 Hover Image to Zoom $27900 Pay $254.00 after$25 OFF your total qualifying purchase upon opening a new card. c Apply for a Home Depot Consumer Card Width (in.) x Height (in.): 31.75 x 53.25 31.75 x 53.25 2 of 12 1/18/2024,3:56 PM American Craftsman 31.75 in.x 53.25 in.70 Pro Series Low-E Argon... https://www.homedepot.com/p/American-Craftsman-31-75-in-x-53-25... 31 .75 in. x 53.25 in. 70 Pro Series Low-E Argon Glass Double Hun by American Craftsman (1671) 234 $279�0 Product Details Specifications Questions &Answers Customer Reviews r-1 - y Uc11vCl y Today Today In stock 15.0 mi away 96 available FREE 4/ t Get it as soon as today. Schedule your delivery a+ in checkout. >_ J f Get Expert Window Installation Y v A local pro will take care of the job for you v ❑ Request a consultation LL What to ap=0 M13 Have Questions? We're Here to Help. Speak to a Virtual Associate about Doors or Windows today. Monday - Friday from 9AM - 11 PM ET & Saturday - Sunday from 9AM - 9PM ET. ❑ Request Appointment What to Exp= Or call 1-833-HD-APRON(1-833-432-7766) 1 + Mai Add to Cart Free & Easy Returns In Store or Online Return this item within 90 days of purchase. Read Return Policy Product Details 3 of 12 1/18/2024,3:56 PM American Craftsman 31.75 in.x 53.25 in.70 Pro Series Low-E Argon... https://www.homedepot.com/p/American-Craftsman-31-75-in-x-53-25.. 31 .75 in. x 53.25 in. 70 Pro Series Low-E Argon Glass Double Hun by American Craftsman (1671) 234 $279�0 Product Details Specifications Questions&Answers Customer Reviews Dimensions Grid Width (in.) None Jamb Depth (in.) 3.25 in Product Depth (in.) 4.5 in r u a+ Product Height (in.) 53.25 in Product Width (in.) 31.75 in Y u �0 Rough Opening Height (in.) 54 in a, a, Rough Opening Width (in.) 32 in �0 Width (in.) x Height (in.) 31.75 x 53.25 Details Exterior Color/Finish White Exterior Color/Finish Family White Features Tilt-In Cleaning Frame Material Vinyl Frame Type Pocket Frame Glass Type Low-E Glass Glazing Type Double-Pane Grid Pattern No Grid 4 of 12 1/18/2024,3:56 PM American Craftsman 31.75 in.x 53.25 in.70 Pro Series Low-E Argon... https://www.homedepot.com/p/American-Craftsman-31-75-in-x-53-25... 31 .75 in. x 53.25 in. 70 Pro Series Low-E Argon Glass Double Hunq.. by American Craftsman (1671) 234 1279 Product Details Specifications Questions &Answers Customer Reviews Included Hardware, Screen Interior Color/Finish Family White Lock Type Cam Action Number of Grids No Grid o r u a Number of Locks 2 J Product Weight (lb.) 40 lb Y v Returnable 90-Day v v a, Solar Heat Gain Coefficient 0.25 " U-Factor 0.29 Window Type Other Window Use Type Replacement Warranty / Certifications Energy Star Qualified Not Qualified Manufacturer Warranty Limited Lifetime Warranty How can we improve our product information? Provide feedback. Questions & Answers v 982 Questions Customer Reviews Frequently Bought Together 5 of 12 1/18/2024,3:56 PM ROXALL SIZE: 32 54 i UNIT DIMENSION 31 3/4" x 53 1/4" Dimension de le unlded c LASS Low— E TYPE Tlpo de vldrlo Argon COLOR WHITE Color Blanco SCREEN INCLUDED Poltldle Incluldo ENERGY STAR cis la"101j1011e5[C-S311,11J1,11S. in Ceniliegenihcado Farf Il infamation,saa 1aba1 on product. Para informaci6n complaa,consulter is atiquata dal producto. 3254786 AC786 s�26922578. 1 . 100 Dimensions Grid Width (in.) None Jamb Depth (in.) 3.25 in Product Depth (in.) 4.5 in Product Height (in.) 45.25 in Product Width (in.) 27.75 in Rough Opening Height (in.) 46 in Rough Opening Width (in.) 28 in Width (in.) x Height (in.) 27.75 x 45.25 Details Exterior Color/ Finish White Exterior Color/Finish Family White Features Tilt-In Cleaning Frame Material Vinyl Frame Type Pocket Frame Glass Type Low-E Glass Glazing Type Double-Pane Grid Pattern No Grid Grille Type No Grille Hardware Color/Finish Family White Included Hardware, Screen Interior Color/Finish Family White Lock Type Cam Action Number of Grids No Grid Number of Locks 2 Product Weight (lb.) 32 lb Returnable 90-Day Solar Heat Gain Coefficient 0.25 U-Factor 0.29 Window Type Other Window Use Type Replacement Warranty / Certifications Energy Star Qualified Not Qualified Manufacturer Warranty Limited Lifetime Warranty m Li E LL N LL N S r 'c LL LL L IA O LA. 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CN •r,1. d O � � 1 •��5 " s vim, v u (�0 VY t<�� .�'.11�I1111��� *jff�J/.'/I�s -�1 1 •-t -r- 1 �I �e :scz :�^'-•" �" r .-^w�--�• r� "��j Y Y. 11 ,a..� r r;� S.4-1 <t0)>J 1 1 / IrINI Ir 1 -%J 1 s 1 1 i'• A �^ 1, / f ;il1 •..` c.'•csti', l�iw�llfr-k c,�,c f� �1 t,l c1 %`� 1 e LEADP-1 OP ID: DS ACORO CERTIFICATE OF LIABILITY INSURANCE DATE( 01/02/2o242/2 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 endorsements . PRODUCER 732-363-8300 COMNTACT E: N Ideal Insurance Agency Inc. PHONE 732-363-8300 FAX 732-363-5656 PO Box 558 (A/C,No,Ertl: (A/C,No): Lakewood,NJ 08701 E-MAIL Alexander Lerner INSURERS AFFORDING COVERAGE NAIC• INSURER A:Beazely USA Services Inc INSUR D Lead professionals Inc DBA INSURER B DBA AAA Lead Professionals INSURERC: 6 White Dove Court Lakewood,NJ 08701 INSURER D INSURER E INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. NSR TYPE OF INSURANCE DDL BIR POLICY NUMBER POLICY EFF POLICY EXPLTR MF "YYY]l LIMITS A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE �OCCUR X ENC0006712-03 06/10/2023 06/10/2024 DAMAGES( RENTEDE.occurrenrel $ 100,000 MED EXP(Any oneperson) $ 25,000 PERSONAL&ADV INJURY $ 1,000'600 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY JECT LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT ANY AUTO BODILY INJURY Perperson) $ OWNED SCHEDULED AUTOS ONLY AUTOS SSyyryEp BODILY INJURY Per accident $ AUTOS ONLY AUOTOS ONLY Perr a dentDAMAGE $ A X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 2,000,000 EXCESS LIAB CLAIMS-MADE ENX 0006713-02 06/10/2023 06/10/2024 AGGREGATE $ 2,000'OOO DED 1 1 RETENTION$ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY Y I N STA LITE ER ANY PROPRIETOR/PARTNER/EXECUTIVE ❑ E.L.EACH ACCIDENT $ ( FICER/MEMBER EXCLUDED? N/A (Mandatory In NH) E.L.DISEASE-EA EMPLOYE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT A Professional Liabi ENC0006712-03 06/10/2023 06/10/2024 Per Claim 1,000,000 A CPL ENC0006712-03 06/10/2023 06/10/2024 Aggregate 2,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Certificate holder is included as additional insured if required by written contract per Blanket Al form. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Village of Rye Brook THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN g Y ACCORDANCE WITH THE POLICY PROVISIONS. 938 King Street Rye Brook, NY 10573 AUTHORIZED REPRESENTATIVE a44't-C-4 ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD PORK Workers' CERTIFICATE OF STATE Compensation NYS WORKERS' COMPENSATION INSURANCE COVERAGE Board 1a.Legal Name&Address of Insured(use street address only) 1b.Business Telephone Number of Insured AAA Lead Professionals (845)547-8009 978 Route 45 1c.NYS Unemployment Insurance Employer Registration Number of Pomona,NY 10970 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 270414886 2. Name and Address of Entity Requesting Proof of Coverage 3a.Name of Insurance Carrier (Entity Being Listed as the Certificate Holder) United Wisconsin Insurance Company Village of Rye Brook 3b.Policy Number of Entity Listed in Box '1 a" 938 King Street Rye Brook,NY 10573 WC588-00050-024-SZ 3c. Policy effective period 1/1/2024 to 1/1/2025 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"T'insures the business referenced above in box 1 a"for workers' compensation under the New York State Workers' Compensation Law. (To use this form, New York(NY)must be listed under Item 3A on the INFORMATION PAGE of the workers'compensation insurance policy). The Insurance Carrier or its licensed agent will send this Certificate of Insurance to the entity listed above as the certificate holder in box"2". The insurance carrier must notify the above certificate holder and the Workers'Compensation Board within 10 days IF a policy is canceled due to nonpayment of premiums or within 30 days IF there are reasons other than nonpayment of premiums that cancel the policy or eliminate the insured from the coverage indicated on this Certificate. (These notices may be sent by regular mail.) Otherwise,this Certificate is valid for one year after this form is approved by the insurance carrier or its licensed agent,or until the policy expiration date listed in box "3c",whichever is earlier. This certificate is issued as a matter of information only and confers no rights upon the certificate holder.This certificate does not amend, extend or alter the coverage afforded by the policy listed, nor does it confer any rights or responsibilities beyond those contained in the referenced policy. This certificate may be used as evidence of a Workers'Compensation contract of insurance only while the underlying policy is in effect. Please Note: Upon cancellation of the workers'compensation policy indicated on this form, if the business continues to be named on a permit, license or contract issued by a certificate holder,the business must provide that certificate holder with a new Certificate of Workers'Compensation Coverage or other authorized proof that the business is complying with the mandatory coverage requirements of the New York State Workers'Compensation Law. Under penalty of perjury, I certify that I am an authorized representative or licensed agent of the insurance carrier referenced above and that the named insured has the coverage as depicted on this form. Approved by: Alicia Christiansen (Print name of authorized representative or licensed agent of insurance carrier)/ Approved by: ,(QED 1/3/1-0Z!T (Signature) (Date) Title. Director of Sales Operations Telephone Number of authorized representative or licensed agent of insurance carrier: 941-306-3077 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