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HomeMy WebLinkAboutBP24-021P+'ERMR N /�-�/ ' aa'I W1TE• � 1� �� 0cP• �S SECTION ` BLO LOT TYPE OF WORK � Q roe LocanoN 4 o CLIJ e h C9, 7�79�_'��s9 OWNER O // C �� �/ /� P �- /BSc - - o�K/in �or�z�i�a�aD3�`�9"/9810 CONTRACTOR // CIS � S / EST. COST � J - FEES �CO N FEES ��O r�� DATE TCO Y Fly DATE DATE FOOTING FOUNDATION FRAMIN(D RGH FRAMING INSULATION PLUM81Nd 0 RGH PLUMBING GAs � SPRINKLER ELECTRIC 0 LOW -VOLT O ALARM O AS BUIIT � Z, 1 FINAL INSP OTHER APPROVALS ARB _ BOT PB ZBA OTHER 2y�DRC�'�". O�LL1�11J la"j Oct" JJ V G�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.tyebrook.org TRUSTEES BUILDING & FIRE INSPECTOR Susan R. Epstein Steven E. Fews Stephanie J. Fischer David M. Heiser Salvatore W.Morlino CERTIFICATE OF COMPLIANCE March 26,2024 Scott Hirsch&Christine Staeger-Hirsch 1 Beacon Lane Rye Brook,New York 10573 Re: 1 Beacon Lane, Rye Brook,New York 10573 Parcel ID#: 135.58-1-11 Building Permit#24-021 issued on 2/6/2024 for a New Front Entry Door This certifies that the new front entry door,installed under the above captioned permit has been satisfactorily completed. Sincerely, Steven E. Fews Building&Fire Inspector /to BUILDING DEPARTMENT PERMIT FEB — 7 224 VILLAGE OF RYE BROOK tSSUEU: — -a i 938 KING STREET,11YE BROOK,NEw YORK 10573 DATE: Q—7 d (914)939-0668 FEE: ,t I In— PAIDJR www.rvehrook.or<g APPLICATION FOR CERTIFICATE OF OCCUPANCY,CERTIFICATE OF COMPLIANCE, AND CERTIFICATION OF FINAL COSTS TO BE SUBRITTED ONLY UPON CUIPL) TION Or F;LL WORK, IIJID PRIOR TO THE FINAL I1•IC-PECTION ....•..........................................................................................•....•................4....... Address: 1 Beacon Ln . Rye Brook, NY 10573 8P ag—Qaz'l Occupancy/Use: 1-Fam Parcel ID#: 135.58-1-11 Zone: O zo Owner: Christine &Scott Hirsh Address. 1 Beacon Ln Rye Brook, NY 10573 P.E./R.A.or Contractor: FairChester Custom Windows Address: 2041 West Main Street Stamford CT 06902 Person in responsible charge: Franklin Barahona Address: 2041 West Main Street Stamford CT 06902 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: Christine & Scott Hirsh being duly sworn,deposes and says that he/she resides at 1 Beacon Ln (Print Name of Applicant) (No.and Street) in .Rye Brook ,in the County of Westchester in the State of NY ,that (Citvlrown!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:S 6,895 for the construction or alteration of: Installation of Replacement Entry Door into Existing Openings with No Structural Alterations. Deponent further states that he/she has examined the approved plans of the structure/work herein refer ed 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/complctcd 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 y250-I O.A.of the Code of the Village of Rye Brook. Sworn to before me this tP M Sworn to before me this day of rY 20 P q day of �Mrva-ry 201 J-11--- SignatWc PropartyOwncr SILII:nUIC cant Christine & Scott Hirsh Franklin Barahona Print Name of Property Owncr Print Name of A,plica t BRIAN MACDONALD NOTARYPUULc Stub of Connecticut Notary Pu lie MY COMMISSION EXPIRES Oct 312026 Notary Public 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 : / e.O,-,, �,C j7 e, DATE: - ---�,W- o?OoZ PERMIT# -b 1�C/- 0 CQ t ISSUED:Z SECT: S -S BLOCK: / LOT: LOCATION: f /\O j �O L . OCCUPANCY: / A) ❑ Violation Noted THE WORK IS... 0 PASSED ❑ FAILED REINSPECTION ❑ SITE INSPECTION REQUIRED ❑ FOOTING ❑ FOOTING DRAINAGE ❑ FOUNDATION ❑ UNDERGROUND PLUMBING NOTES ON INSPECTION: ❑ ROUGH PLUMBING ❑ ROUGH FRAMING ❑ INSULATION r [INatural Gas ��'P C ❑ L.P. Gas ❑ FUEL TANK ❑ FIRE SPRINKLER ❑ FINAL PLUMBING ❑ CROSS CONNECTION El"PINAL ❑ OTHER - a 0 N - P �- \ N N .E �� o ff ■ F G1 + if ■ .- CL 'N v a ?C 001 e ICI cr V `j�`" 1� v� v FFes�!! a I--1 ° (� dptn Fes! a in tenlLO cs H C Q a C O'C00 a .� rn 1 te ■ � w ^ . o 00 co w o a0E, Cr W Q N n A O Q b V V _ O PTO O W N Rr z W z n" v P-t ■ [� (••� v� G1 �I !—I M z p Q W C7 CA Sao $ IVI C!) l ■ oo CM Z W F �"� v' a� u 3 0 a 1� ►� �' P.( z a v c a u� V I �j z E� LZ' aeon Q floe ° 0-4 A z U= d'o C VolT7 y a U W v 1��1 Q W Ei z z z �" `� W o p8 'w � � � CA U U ° z x H �. W ° 5 a 4;a 4 4;4 4;49.0 4;41.4 a a a Q 46 46 46 46 Q 4 4 a 4 a 41414 49 a 4;4;aa4;41414;aaaa4. BUILDING DEPARTMENT R VILLAGE OF RYE BROOK FEB — 2 2024 938 KING STREET RYE BROOK,NY 10573 (914)939-0668 VILLAGE OF RYE BROOK r1 t+,ryebt•ook.or�, BUILDING DEPARTNIENT ADMINISTRATIVE EXTERIOR BUILDING PERMIT APPLICATION FOR Ex'rER10R WORK WHICH DOES No'r REQUIRE VILI ALGE ARCHITha"I'110j,Ri-xit,'w BOARD APPRoy.m, FOR OFFICE USE Oil LY: DrL� APPROVAL DATE: L `''� PE #: 11-041 APPLICATION FEE: A6 APPROVAL SIGNATURE: PERMIT FEES:'s / 86` 6 H.O.A.APPROVAL: DATE.:) f DISAPPROVED: OTHER: Application dated:February 1, 2024 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: 1 Beacon Ln 2. Parcel ID#: 135.58-1-11 Zone: 3. Proposed Improvement(Describe in detail): Installation of( 1 ) Front Entry Patio Door into Existing opening with no structural alterations. 4. Property Owner: Christine Hirsh Address: 1 Beacon Ln Phone#(917) 796-4659 Cell#(914) 937-2484 a-mail hirschgirls@yahoo.com List All Other Properties Owned in Rye Brook: Applicant: �1a\T- woo() Address:421 West Avenue, Stamford CT 06902 Phone# 203.406.0545 Cell# 203.249.1986 e-mail Permits@RBAWestchester.com Architect: Address: Phone# Cell# e-mail Engineer: Address: Phone# Cell# e-mail General Contractor: Fairchester Custom Windows dba Renewal by Andersen Westchester Address:421 West Avenue, Stamford CT 06902 Phone# 203.406.0545 Cell# 203,249.1986 a-mail Permits@RBAWestchester.com {t) 6/l/2023 5. Occupancy;(1-Fam.,2-Fam.,Commercial.,etc...)Pre-construction: 1-FAM Post-construction: 1 FAM 6. Area of lot: Square feet:n!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 comer lot,which street does it front on: 9. Area of proposed building in square feet: Basement: 11,fl: 2nd fl: 31d fl: 10. Total Square Footage of the proposed new construction: 11. For additions,total square footage added:Basement: 11 fl: 2nd fl: 31 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:O Typical Western Lumber Frame;()Timber Frame[TC];()Wood Truss[TT]; ()Pre-engineered wood[PW];Located;O Floor Framing[F];O Roof Framing[R];O Floor&Roof Framing[FR];Other: 15. Number of stories:3 Overall Height: 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: Roofing material: 19. What system of heating: 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"tension/modification to an existing automatic fire suppression system?(Fire Sprinkler,ANSL System,FM-200 System,Type I Hood,etc...)Yes: No: (fyes,applicant must submit a separate Automatic Fire Suppression System Permit application&2 sets of detailed engineeredplans) 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 proje require a Site Plan Review by the Village Planning Board as per§209 of Village Code? Yes: No: (rf yes,applicant must submit a Site Plan Application,&provide detailed drawings) 24, WiIl 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: ✓ (if yes, the area and elevations of the flood 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 1I: TIER III: (if yes,a Home Occupation Permit Application is required) 29. What is the total estimated cost of construction: $ (0 �� Note:estimated cost shall include all site improvements, labor,material,scaffolding,fixed equipment,professional fees, including any material and labor which may be donated gratis.If the final cost exceeds the estimated cost,an additional fee will be required prior to issuance of the CIO. 30. Estimated date of completion: Estimated February 2024 (2) 6/1/2023 J) E BUILDING DEPARTMENT FEB - 2 2024 VILLAGE OF RYE BROOK 938 KING STREET RYE BROOK,NY 10573 VILLAGE OF RYE BROOK (914)939-0668 BUILDING ®LPARTMENT rv�rr�r.r�e[n-aolc.cu-y 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, Hirsch, Scott and Christine , residing at, l Beacon Lane (Print uinc) :here you live) 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; 1 Beacon Lane ,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. i� (tiiennun• roparl� Oiner(sJ) Hirsch, Scott and Christine (Print Naar_-t)f Property Mnel Swum to before rae this— '� FRAikru E, day of� 20 Notary Public Stat@ ui ut y Commisslp�,gl , �.� Dec 37,..�0 7 (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: Koa �-' � , 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 Contractor 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 lye 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 .2, Sworn to before me this 2 day of bqk1 . 20 014 day of �i1X-tl� , 20 2 &Fdfure of Property Owner S' afore o Hirsch, Scott and Christine V)t Ytiat%meoI PropertyOwncr Print Name of Applicant _ X". `Notary Pts c Notary P FRANKLIN E. BARAHONA Notary Public, State of Connecticut FRANKLIN E, BARAHONA My Commission Expires Dec 31, 2027 Notary Public, State of Connecticut My Commission Expires Dec 31, 2027 (a) 6ni2o23 P 7� I e g v, -JA oko 1 i! µ • !� F. "Y � ems•`^4. �• r . .'� t`'L� '•�_ r n! :7. 1�. T r t l' f / '". •}�4�. ��✓ +ram �} V ,+ r.+; t t.b r �' �Y1R �� '! '� �;���.� P. •7`' r '`^,�, �yN!��s..�r ,* � ���. r fit, t �- e i 3 - r i i } '4 Y r w r 1I r GYM" 7 ✓T � �� � {/ ��� � •`� _ _ ��•• _ � �� '^sew„, _ :J {v . i dry' 1 r N 'VJN°..y 11 p FIIY� '�►1'.(ld� �!. �.G,l` �•i7 •1�f' l '11'�iSr•�rS,�, 'M ,�rx�)Yl . '-err. �r''"''J�'N d"1J��i+•°Ji'frr• jp�.'4r�1 i��j'�L t� ,.i3,�. 1 r1,��r► R �f. •� +Ny•.wl,ql�j,irl .�l°b �{+�� �� ' + ►F" ~'S 'riff �i�iA +, p °u; q: ,t1,Y)i Yi i� 1 � AlAp r,I rA47, t AM J: rY4�Jr�Sb',1°'i •ic �l� vr�`7� a�r�� �Jr 1\,�!!tt+_J eyJt� p+ •E •'(M�'�rn Ip .. �.y.-; y Ewa a Iiy� y� ql !lA•d?��4',ptl`V' 11Y yJ.' wr: N `Y 1' 1�rR �. H1. Y 0• yfy 1 ,p. � IN ��m ^:•r � �N�.l��°�i1"'Oy���Ya►"� �,w9�e'W.oi'•'Y �r Vie r,'�'��\�+ t. �,�•k)}j�agr9��1�t,7��;.M�,�,�ro�•yy ,� �� - •j I , I I � J 11 yyy"y�ry •- 40 i 3� __,._,1_--------- _-z -� __ , ------T-. -,----�. � - -- _ , _ --_ - _- -- z--._ -, -- _ _ _ _ .. _ �.. �� �_ �� _ - �-r--.ti - -� ,_ - '----- _ i . . . .. ,� ,� � 4 .� i .. -- i I ' I ;' � �. _ � s i A. _� y •_�_'_.�". - � �� i F ���s ���.�. ���P. -- � � { .! I� I i f Ll low] - 1 �. t 25r, s-F ?- � Agreement Document and Payment Terms DBA:RENEWAL BY ANDERSEN OF WESTCHESTER AND FAIRFIELD COUNTY Christine Hirsh Legal Name:Fairchester Custom Windows LLC 1 Beacon Ln. RENEWAL CT HIC#.0667292,WC-35743-1-122,Putnam#51220 Rye Brook,NY 10573 byANDER$EN 2041 West Main Street I Stamford,CT 06902 H:9177964659 v�vmn moc.wa nrt�rn Phone:203-406-0545 1 Fax:203-406-0828 1 sales@rbawestchester.com C:(917)796-4659 Christine Hirsh 12/30/23 BUYER(S)NAME CONTRACT DATE 1 Beacon Ln., Rye Brook ,NY 10573 9177964659 (917)796-4659 BUYER(S)STREET ADDRESS PRIMARY NUMBER SECONDARY NUMBER hirshgirls@yahoo.com PRIMARY EMAIL SECONDARY EMAIL NOTES: Buyer(s)hereby jointly and severally agrees to purchase the products and/or services of Fairchester Custom Windows LLC d/b/a Renewal By Andersen of Westchester and Fairfield County("Contractor"),in accordance with the terms and conditions described in this Agreement Document and Payment Terms, any documents listed in the Table of Contents,and any other document attached to this Agreement Document,the terms of which are all agreed to by the parties and incorporated herein by reference(collectively,this"Agreement"). Buyer(s)hereby agrees to sign a completion certificate after Contractor has completed all work under this Agreement. TOTAL JOB AMOUNT: $6,895 By signing this Agreement,you acknowledge that the Balance Due,and the Amount Financed must be made by personal check,bank check,credit card,or cash. DEPOSIT RECEIVED: $1,329 BALANCE DUE: $5,566 We schedule installations based on..the date of the signed contract and secondarily on the date in which we complete the technical measurements.The installation date that we are providing at AMOUNT FINANCED: $0 this time is only an estimate.We will communicate an official date and time at a later date.Rain and extreme weather are the most common causes for delay. METHOD OF PAYMENT: Credit Card NOTES: Buyer(s)agrees and understands that this Agreement constitutes the entire understandings between the parties and that there are no verbal understandings changing or modifying any of the terms of this Agreement.No alterations to or deviations from this Agreement will be valid without the signed,written consent of both the Buyer(s)and Contractor.Buyer(s)hereby acknowledges that Buyer(s)1)has read this Agreement,understands the terms of this Agreement,and has received a completed,signed,and dated copy of this Agreement,including the two attached Notices of Cancellation,on the date first written above and 2)was orally Informed of Buyer's right to cancel this Agreement. NOTICE TO BUYER: Do not sign this contract if blank.You are entitled to a copy of the contract at the time you sign. YOU, THE BUYER, MAY CANCEL THIS TRANSACTION AT ANY TIME NOT LATER THAN MIDNIGHT OF 01/04/2024 OR THE THIRD BUSINESS DAY AFTER THE DATE OF THIS TRANSACTION, WHICHEVER DATE IS LATER. SEE THE ATTACHED NOTICE OF CANCELLATION FORM FOR AN EXPLANATION OF THIS RIGHT. SIGNATURE OF SALES PERSON SIGNATURE SIGNATURE Richard Vaccaro Christine Hirsh PRINT NAME OF SALES PERSON PRINT NAME PRINT NAME 12/30/23 Page 2/ 30 4NE Itemized Order Receipt DBA:RENEWAL BY ANDERSEN OF WESTCHESTER AND FAIRFIELD COUNTY Christine Hirsh Legal Name:Fairchester Custom Windows LLC 1 Beacon Ln. R E WA L CT HIC#.0667292,WC-35743-H22,Putnam#51220 Rye Brook,NY 10573 byANDERSEN 2041 West Main Street 1 Stamford,CT 06902 H:9177964659 u it.xl t.Dw t OOOt LLIIYNIfill Phone:203-406-0545 1 Fax:203-406-0828 1 sales@rbawestchester.com C:(917)796-4659 • • DETAILS: 0 W Misc Misc, Permit Fees, Town of Rye Brook- Estimated Permit 0 H Fees, Quantity 1, Renewal by Andersen will faciliate the application of the building permit to the Town of Rye Brook. Homeowner is responsible for any outstanding permit applications or code violations that may prevent Renewal by Andersen from procuring permit. Renewal by Andersen is not responsible for any historical or architectural review applications and approvals that may be required as pre- requisite for a building permit. 101 Front Door 0 W Misc Misc, Miscellaneous Job Items, Pro-Via Door, Quantity 0 H 1, Details of ProVia door specifications to be provided on supplemental agreement. WINDOWS: 0 PATIO DOORS: 0 ENTRY DOORS: 0 SPECIALTY: 0 MISC: 2 TOTAL $6,895 Renewal by Andersen is committed to our customers'safety by complying with the rules and lead-safe work practices specified by the EPA. 12/30/23 Page 3/ 30 Tax Parcel Maps Address: 1 Beacon Ln Print Key: 135.58-1-11 SBL: 13505800010110000000 i'RAV FURL)PARK SS RYE HILL`. PARK r' t` BELL FL m'e Disclaimer: This tax parcel map is provided as a public service to Westchester County residents for general information and planning purposes only,and should not be relied upon as a sole informational source.The County of Westchester hereby disclaims any liability from the use of this GIS mapping system by any person or entity.Tax parcel boundaries represent approximate property line location and should NOT be interpreted as or used in lieu of a survey or property boundary description.Property descriptions must be obtained from surveys or deeds.For more information please contact the assessor's office of the municipality. 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'r<*',?::;�"'a' --'�•rr — �d(�nu1))' .,re pA qdi1�'£'�r't1t4Y�•r y�`6'gtrtr-:�Q(tttt.}rr �.� bsY; .��It4}ttttr #x?a,-t'sj; `it�l'4'i'tlt It -'�� 7: f .ii111tittt'i)• iePai: a s}<;�I jt 1#�'�r.'.i}�y :'•Ij11#+fFl i-r �''`' "`'•' R 1fs4tt r1 a d`'4 -E}t11tr! B�" :3 � n � r• f aj Y r n .� �.1 n it ....f � 3 ��' ���� 1.a•.di� r � �"t✓+tl��'ti �3 � � +yv�'ti.. �� �a � vx � 4Y r `' Cv Y�°f �ti�nt QI t�/ ��,;: � �'' "1'�, �e.,�. �"s4�'k}(w�'{ rl��-�J�' Sjs•.• "�3'y7`.�,-V { 's� 6.-�V� st �, r V y ,; n V +i�z ar,N;�4: v� d,�yr ryt'r�V s K�r`y,t 'k a:^is � r'}ar•+ :r":• '�.vv .% YJ9,.� .Ca6` �t�"�,.k. r .. , FAIRCUS-01 TBRAND ACORO CERTIFICATE OF LIABILITY INSURANCE FDATEIMMIDDNYYY) 9/29/2023 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT Theresa Brandon NAME: MBI Company Group LLC. PHONE,E<t):(203)288-3401 jAc,No):(203)281-0414 280 State Street North Haven,CT 06473 E-MAIL-ADDRESS:theresa.brandon@mbi-ins.com INSURERS AFFORDING COVERAGE NAIC 0 INSURER A:Selective Insurance Company of America 12572 INSURED INSURER B: Fairchester Custom Windows LLC dba: Renewal by Andersen INSURERC: Fairchester 2041 West Main Street INSURER D: _ Stamford,CT 06902 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. INSR TYPE OF INSURANCE ADDL SUBR POLICY NUMBER POLICY EFF POLICY EXPLTR LIMITS A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE a OCCUR X S 2516791 8/12/2023 8/12/2024 DAMAGE TO RENTEDREMISES 1E, $ 500,000 MED EXP(Any oneperson) $ 15,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 3,000,000 POLICY[XJ jEeT Fx]LOC PRODUCTS-COMP/OPAGG $ 3,000,000 OTHER: $ A AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000 (Ea accident)ANY AUTO S 2516791 8/12/2023 8/12/2024 BODILY INJURY Per n $ OWNED AUTOS ONLY X AUTOSyU�L.�EDp BODILY INJURY Per accident $ X AUTOS ONLY X AUOTO_S ONLY PPeOr acEclRde^t AMAGE $ xiComp Ded$500 X Collision Ded$500 A X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 4,000,000 EXCESS LIAB CLAIMS-MADE X S 2516791 8/12/2023 6112/2024 AGGREGATE $ 4,000,000 DED TXTRETENTION$ 0 A WORKERS AND EMPLO ERS'L ABI OTM X PER X FIR ANY PROPRIETOR/PARTNER/EXECUTIVE YIN C 9099063 8/12/2023 8/12/2024 500,000 OFFICERIMEMBER EXCLUDED? �N N/A E.L.EACH ACCIDENT $ (Mandatory In IfE and E.L.DISEASE-EA EMPLOYE $ 500,000 D es,describe under SCRIPTION OF OPERATIONS bel E.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Village of Rye Brook is Additional Insured as required by written contract per the endorsements included with this certificate. 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 938 King Street ACCORDANCE WITH THE POLICY PROVISIONS. Rye Brook, NY 10573 AUTHORIZED REPRESENTATIVE 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 Board NYS WORKERS' COMPENSATION INSURANCE COVERAGE 1 a.Legal Name&Address of Insured(use street address only) 1 b.Business Telephone Number of Insured Fairchester Custom Windows LLC. 203-406-0545 dba204 Renewal by Andersen Fairchester 1c.NYS Unemployment Insurance Employer Re Registration Number of 2041 West Main Street9� Stamford,CT 06902 Insured 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 88-2855660 2.Name and Address of Entity Requesting Proof of Coverage 3a.Name of Insurance Carrier (Entity Being Listed as the Certificate Holder) Selective Insurance Company Village of Rye Brook 3b.Policy Number of Entity Listed in Box"l a" 938 King Street Y Y Rye Brook,NY 10573 WC9099063 3c.Policy effective period 08/12/2023 to 08/12/2024 3d.The Proprietor,Partners or Executive Officers are �X 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"3"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,1 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: Theresa Brandon (Print name of authorized representative or licensed agent of insurance carrier) Approved by: U?�f .�� 09/29/2023 (Signature) (Date) Title: Agent Telephone Number of authorized representative or licensed agent of insurance carrier: 203-288-3401 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