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HomeMy WebLinkAboutBP24-024PERMIT # d - DATE;J�140c� SECTION 4 9. _ BLOCK c TYPE OF WORK / o i/ JOB LOCATI OWNER LI SI.�I% 4�% Ia t) CONTR IST. COST sm V CO # C'i `• w TCO # FEE DATE INSPECTION RECOR,R I DATE INSP FOOTING FOUNDATION FRAMING - RGH FRAMING INSULATION _ PLUMBING 12-4- Zot`4e F, RGH PLUMBING GAS CI SPRINKLER W -VOLT C� 7ALARM O AS BUILT FINAL OTHER APPROVALS ARB BOT PS ZBA OCHER VILLAGE OF RYE BROOK WESTCHESTER COUNTY, NEW YORK No: 24-159 Certificate of ®ccupaucp This is to certify thatPL,01 Wlac of, having duly filed an application on OCkLOef- Zo , 20 requesting a Certificate of Occupancy for the premises known as, QO �-O�lf _, Rye Brook,NY, located in a Pub Zoning District and shown on the most current Tax Map as Section: IX-U Block: j--;2 Lot: and having fully complied with the requirements of the Building Code and the Zoning Ordinance under Building Permit No. 4- , issued 20-,such authority and permission is hereby granted to the property owner to lawfully occupy or use said premises or bu' ing or part thereof listed under the following New York State Classifications, Use: 16ne- Construction: 1 73 for the following purposes: j� ` �� /` _ ��? �� 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 i e' ht shall be made,nor shall the building be moved from one location to another until a permit to accomplish such change has een obta' fro th Building Inspector. Building Inspector,Village of Rye Brook: Date: DEC 1 2 2024 D DBUILD R NT For office use only: \ � C PERMIT# 1 —0dJV OCT 3 0 2024 VIL OF RYE OK ISSUED:C—/ —c: 38 KING STRE YE BROOK,l W YORK 10573 DATE:/ VILLAGE OF RYE BROOK (91�4)9 -06 u FEE:4 f j(�� PAID.S BUILDING DEPARTMENT w'WW ov APPLICATION FOR CERTIFICATE OF OCCUPANCY9 CERTIFICATE OF COMPLIANCES AND CERTIFICATION OF FINAL COSTS TO BE SUBMITTED ONLY UPON COMPLETION OF ALL WORK, AND PRIOR TO THE FINAL INSPECTION Address: Q O &re_P_;,lyA y L¢n e Occupanc`y//Use: � �� Parcel ID#: �c� /. 8�— �—7 /p Zone: Owner: o,h M i c' 0 Address: Q C Gym eA wa y LP kl e P.E./R.A. or Contractor: Address: 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: '(am Al 'a'o being duly swom,deposes and says that he/she resides at 24 QF J n' y, P . (Print Name of Applicant) (No.and Street) in h P R T-C-0k_ ,in the County of �l-��� 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:S R'J , for the construction or alteration of �� � (� ✓`2 6 Y 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 3 Sworn to before me this day of C� , 20 a� day of , 20 41__ SignatiYe of Property Owner Signature of Applicant Ya, m�0.0 Pript Name of Property Owner Print Name of Applicant -, Notary PublicSHARI MELILLO Notary Public Notary Public,State of New York No.01M E6160063 6/I/202a Qualified In Westchester County Commission Expires January 29,20_ QyE BRC>v� O�` tim 1932 BUILDING DEPARTMENT ❑B.bILDING INSPECTOR D'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 : l_1 G f C c ki ICJ DATE: PERMIT# ISSUED: SECT: BLOCK:—_.LOT: LOCATION: L-X,— 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 BRC�v�s o �m 1932 BUILDING DEPARTMENT ❑BUILDING INSPECTOR -0 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 : q o ` DATE: - Z CU L PERMIT# 17\ 2 �'1 V ISSUED: :. SECT: BLOCK: LOT:�� LOCATION: F-I`G I Y` 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 tip �yE BR(�j�• O� 2m 1932 BUILDING DEPARTMENT ❑BvILDING 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 : 1 0 (f7 rF ? yJ A y L A ti DATE: 1�7 PERMIT# ` 2- 1-1 - 0 7 ISSUED: SECT: BLOCK: LOT: LOCATION: l< 1 c J 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 i ❑ L.P. GAS ❑ FUEL TANK ❑ FIRE SPRINKLER n/F F T 1 ❑ FINAL PLUMBING ❑ CROSS CONNECTION❑ FINAL r D /-r /L E ❑ OTHER Ll_ c10Ne . _ N N w N N 4 v rT � l�E 44 W a a o. w CEO VX �-I N z 00 o � v � x © `r W Oa ° o ° w � _ ? , C O W z O z w 8 y _ o p o 00 a� , Q Z W G4 o o ° "'a ►r+ � � o v v OR q v u V} � w c c z �aO �o W � C.) z � q U v _ o p U � z i..i K . � ° w .-ad Q chi p oOC � = vU V U �, u u a o 1 7 .w o .01 .� o O ON 0 E.v u V I-1 A z u qr. w o v � v ° F a,� .� .� d o w o O 00 ,5 2 w .0 _ .. ,.a w a a, °' x � � _ BUIL "MENT VIL E OF RY OOK lAN 3 Q 2024 ID 938 KING ET RYE BR ,NY 10573 VILLAGE OF RYE BROOK BUILDING DEPARTMENT INTERIOR BUILDING PERMIT APPLICATION FOR OFFICE USE ONLY: ^^!!�� Approval Date: F E s Permit#: /Application Fee:$ / � Approval Signature: Permit Fees:$ 14QVV—)WE Disapproved: Other: Application dated:/-3CT'a is hereby made to the Building Inspectorof the Village of Rye Brook,NY,for the issuance of Permit for the interior alteration of an existing building,or for a change in use,as per detailed statement described below. , 1. Job Address: ,C GMetlWOL Lktle e �rW�, IW • SBL:���� d '1're�' -7 y Zone:JdU6 2. Proposed Improvement.(Describe in detail): 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 1: TIER It: TIER III: 4. Will the proposed project require the installation of a new,or an extension/modification to an existi g automatic fire suppression system(Fire Sprinkler,ANSL System,FM-200 System,Type I Hood,etc...) :No: Y Yes: (If yes,please submit a separate Automatic Fire Suppression System Permit application&2 sets of detailed engineered plans) 5. Occupancy;(I fam.,2 fam.,comm.,etc...)Prior to Construction: After Construction: 6. N.Y State Construction Classification: N.Y.State Use Classification: 7. Property Owner: 1 m, M'e, tAddress: 24- Pe o 4lio—% " , l C 6 rva v- (c�7 Phone# 0t4) bS°�115d Cell# (`�"�) �' 1 It�4 • email: M iWya►� Ity� 1��+ �• Caw, 8. Applicant: ~Address: S104 e Phone# Cell# 0'6) 01. It 1ax email: &"'t) 9. Architect: Address: Phone# Cell# email: 10. Engineer: Address: Phone# Cell# email: it. General Contractor:\,Veo.. 2--kt'vt Address: 7 ! 1 )�i 4- J I � ) _ email: Phone# '�1 � "� '� Cell# (�+ 12. Estimated cost of construction (NOTE:The estimated cost shall include all labor,material,scaffolding,fixed equipment,professional fees,and material and labor which may be donated gratis.) 13. Job Timetable:Start: { ►' , ZO L Finish: Her 3 1 (I) 6!1/2023 T�) BUIqET lv>�1vT D �� �� VIA :RYE Y OOK FAN 0 2024 938 KING BR ,NY 10573 VILLAGE OF RYE BROOK o k.or 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: Ul a ,residing at, -24 RE L 0 i , (Print name) (Address where 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; Cl 0 Lahk , lv,`r �',�wk , V f , i0513 ,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. (Sig a re of Property Owner(s)) Ylk%% 'e 0 (Print Name of Property Orvncr(s)) Sworn to before me this 1/501 day of K 20 (Notary Pu ir1 r GREGORY M.RIVERA Me"Public,State of New York (2) No.OI Rt644139a Qualified In Westchester County Conm*slon Expires September 26,20 8112a021 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 70 `l {J , 24 14 day of,20 L=_1� Signal eof Property Owner Signature ofApplicant Y4y\ W i0,0 Print a of Pro r ' /perty Owner Print Name of Applicant Notary Publi Notary Public GREGORY M.RIVERA Notary public,State of New York No.01 RI6441198 QuaNfled to Westchester County Cotnnasston Expires September 26,20 (4) 8/12/2021 tl t. N o z -> i N o H ti 00 g < 0 ON 1-1 as U a p' U �o V O � o � = �' t z1 � W ►-y J' t ck �--+ 3 O A z `r > V •• a ~ x Z A Q CA a N C La 4 t, ►^^.�'' � z z } � o aj 0-4� W z z F W Lie) V � $ o z A z a oe G1 ~ w ~ o � �) � 04 a �;) w 0 < BUILDING DE MENT U DEC - 2 2024 VILLAGE OF RYE OK j 938 KIN REST RYE B NY 10573 V;Li (914)939 .1 vebrW nv.gLov PLUMBING PERMIT APPLICATION FOR OFFICE USE ONLY BP#: — PP#: Approval Date: 2 2 ZO 2. Permit Fee: ININ Approval Signature: Disapproved: (fees are non-refundable) ************************************************************************************************** DO NOT START WORK or CONSTRUCTION UNTIL A PERMIT HAS BEEN ISSUED BY 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)Q—3—Q�/ 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. I` 1.Address: D reel,WD'`� SBL: A)9i L/ 3-7 Q/ /Zone:�uU 2.Proposed Work: ���tc e ?14 3.Property Owner: Y�' MQ"`d Address: Rev^'e y. 1�d _ ►—`l e R►�' Phone#: �� �) 68`�'1 1 a` Cell#: —email:"";",,,, '09►'4'4.. ss i 4.Master Plumber: Address: 'yt//o 40;7- IV Lic.#:I62' Phone#: Cell#:aJ//�8�'� Zf'' /i/email: Company Name: �✓l.�H�Lo Address: 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 Service Service Sewer LP Gas Basement I st Floor 2nd Floor 3rd Floor 4'Floor 5'Floor Exterior 5.*List Other Equipment/Provide Details: (Notarized Signatures Required Next 2 Pages) -1- 6/1/2024 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 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 day of(< =tGl t (" °�- C/,20 — A Signs re of Property Owner Signature of Appli t Yo, 1\ /XX Print Name of Property Owner Pri a of Applicant r N ���ffir.,5ttte of New York NN p� No.O�fliv160063 TVoo ar Pu ic,State of New York Qualified in Westchester County No.GilN EU60063 Qualifier)In Westchester County Commission Expires J�-u' 'Y 29, C^mmission Expires J,11L'.y 29,20 27 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. 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- 6/1/2024 E-H BUILDk DEPAR MENT T Q "� VILLAGE OF RYE OK _ �JI' W DEC 2 2024 938 KnvG Q ET RYE BIRO ,NY 10573 -066 4 Qo� 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: "c'o , residing at, '2- �e 0 0," 0 , e I�rw�� . !U I (Print name) (Address where 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; Lek I La \t �1 z t�► L, , Rye Brook,NY. (.lob 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. (Signat &e of Property Owner(s)) yam M-I c ,o . (Print Name of Property Owner(s)) Sworn to before me this o 'e M 20 (Nola ub ic) SHARI MELILLO Notary Public,State of New York No.01ME6160063 Qualified In Westchester County Comrnission Expires Jett.' y 29, ?j -3- 6/1/2024 S 4 Y r r r t 7. ni r, J 4 P{- A, _ t,, t r ��� 4 ..) �_, .. 3 �. � #? t - R � t � h Xi '1101 tt �J .�, ow PPP"' a .Building Permit Check List&Zoning Analysis Address: ` SBL• Zone: `/ se: C Const.Type: Other. Submittal Date b _ 2�3 evisions Submittal Dates: Applicant: Nature of Work: J�1 �LJ—b U Reviews•ZBA: F E B 0 b -u 2 4 PB: BOT• Other. K 9-- �, � .� �(�FEES:Filing: BP: C/O: Flood Plane: Legalization: ( ) (✓"P: Dated. Notarized: SBL: Truss I.D. Cross Connection: H.O.A.: ( ) ( ) Scenic Roads: Steep Slopes: Wetlands: Stone Water Review: Street Opening ( ) ( ) ENVIRO: Long. Short: Fees: N/A: ( ) ( ) SITE PLAN:Topo: Site Protection: S/W Mgmt.: Tree Plan: Other. ( ) ( ) SURVEY:Dated: Current: Archival• Sealed Unacceptable: ( ) ( ) S:Date Stamped: Sealed Copies: Electronic Other. ( ) ( License: Workers Comp: Liability: Comp.Waiver. - Other. ( ) CODE 753#: Dated: N/A: ( ) � ) 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: REQUIRED EXISTING PROPOSED NOTES Arm: Cirde: Fr n e Front: Front Sides: R,Ar. Main Cov Accs.Cov Ft.H Sb: S .H S Tot,Imp Fr.I�nP Pkin4 H_gight/Stories: notes: L f f�1..f ��Q� \ 1 �'L? 6�_ �i 1 �S fp+CUIC �S sauac+afM-1 ru••y nGIrCYY/1L VGn 11rIVA • '. ':= :'•ii'aisiii': ii'::''"'iii''"'"''':'`':''i""iii'iiis?ii's€ i iiiiiiiiiii`.iiiiE i iiiiiiii'=_i'•iiiiiii€ii;i ii:=:"°; PO Box 2356 1MB F1:::::::::::::::: �;1;.... oomington 61702-2356 Rental Dwelling Pol-Special Form MAR 01 2024 to MAR 01 2025 AT1 H 28 12A8 FBOD R F 000656 0001 TO BE PAID BY MORTGAGEE MIAO, YAN & SUN, YU 24 REUNION RD Coverages and Limits RYE BROOK NY 10573-1085 Section I A Dwelling $314,900 Dwelling Extension 31,490 1111111 Jill 11111 �I�'I"�I�I�ll��l'll'I'll"1��1111�1��11111�1� B Personal Property 15 745 s C Loss of Rents Actual Loss 0 0 Deductibles-Section I Basic 2.00% 6,298 Hurricane 2.00% 6,298 Location: 90 GREENWAY LN RYE BROOK NY 1 0573-1 51 3 Section 11 L Business Liab (per occurrence) $300,000 (annual aggregate) 600,000 M Medical Payments to Others 10,000 Mortgagee: TD BANK NA (each person) ITS SUCC &/OR ASSIGNS ATIMA Loan No: 5003267277 Forms, Options, and Endorsements Special Form 3 FP-8103.3 Amendatory Endorsement FE-8232.2 Debris Removal Endorsement FE-7540 Annual Premium $1,299.00 Lead Poisoning Exclusion FE-8499 Arson Reward Delete FE-5307 Real Property Endorsement FE-5401 premium Reductions Notice in Event of Liab Claim FE-1319 Mandatory Reportng Endorsement FE-5801 Home Alert Discount 25.00 Losses Not Insured Amendatory FE-8777 Sprinkler Discount 25.00 Rental Dwelling Endorsement FE-5610 Actual Cash Value Endorsement FE-3650 Extra Replacement Cost Cov FE-8702 Continued on back of page Inflation Coverage Index: 439.0 NOTICE: Information concerning changes in your policy language is included. Please call your agent if you have any questions. U s Subzone: 10 Zone: 12 Construction: Frame Please help us update the data used to determine your premium. Contact your agent with the year each of your home's utilities (heating/cooling, plumbing, or electrical) and roof were last updated. D D 7 b n �_•_ Moving?See your State Farm agent. I � �- See reverse for important information. 1571 401E I Agent MIKE DIMARCO INS AGCY INC Prepared v * G,JR3 Telephone (914) 612-4000 RE_B JAN 09 2024 Affidavit of Exemption to Show Specific Proof of Workers' Compensation Insurance Coverage for a 1, 2, 3 or 4 Family, Owner-occupied Residence **Thu form cannot be used to waive the workers'compensation rights or obligations of any parry.** Under penalty of perjury, I certify that I am the owner of the 1, 2, 3 or 4 family, owner-occupied residence (including condominiums) listed on the building permit that I am applying for, and I am not required to show specific proof of workers' compensation insurance coverage for such residence because (please check the appropriate box): ❑ I am performing all the work for which the building permit was issued. ❑ I am not hiring,paying or compensating in any way,the individual(s)that is(are)performing all the work for which the building permit was issued or helping me perform such work. I have a homeowners insurance policy that is currently in effect and covers the property listed on the attached building permit AND am hiring or paying individuals a total of less than 40 hours per week (aggregate hours for all paid individuals on the jobsite) for which the building permit was issued. I also agree to either: ♦ acquire appropriate workers' compensation coverage and provide appropriate proof of that coverage on forms approved by the Chair of the NYS Workers' Compensation Board to the government entity issuing the building permit if I need to hire or pay individuals a total of 40 hours or more per week(aggregate hours for all paid individuals on the jobsite)for work indicated on the building permit,or if appropriate,file a CE- 200 exemption form; OR ♦ have the general contractor, performing the work on the 1, 2, 3 or 4 family, owner-occupied residence (including condominiums)listed on the building permit that I am applying for,provide appropriate proof of workers'compensation coverage or proof of exemption from that coverage on forms approved by the Chair of the NYS Workers' Compensation Board to the government entity issuing the building permit if the project takes a total of 40 hours or more per week(aggregate hours for all paid individuals on the jobsite)for wo indicated on the building permit. 2/2G� ( ignature of Homeowner) (Date Signed) i l c� Ln Home Telephone Number (CP 4 ,6 2 1 . I I t a (Homeowner's Name Printed) —T o • • Swor to before me this day of Property Address that requires the building permit: >��G r (� L ( ount Cler or Notary ublic) GREGORY K RIVERA No Public,State of New York No.01 R16"098 Qualified In Westchester County Commission Expires September 26, Once notarized,this BP-1 form serves as an exemption for both workers'compensation and disability benefits insurance coverage. BP-1 (12/08) NY-WCB