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HomeMy WebLinkAboutBP24-046PERMIT SECTION TYPE OF JOB LOCI - YL DATE: y q S y y DATE uSPECTION RECORD DATE INSP FOOTING FOUNDATION FRAMING RGH FRAMING INSULATION PLUMBING RGH PLUMBING GAS O SPRINKLER ELECTRIC LOW -VOLT O C ALARM C� \ AS BUILT O FINAL OTHER APPROVALS ARB BOT PB zeA OTHER VILLAGE OF RYE BROOK WESTCHESTER COUNTY, NEW YORK No: 24-088 Certtf irate of (9ccupo.ucp This is to certify that of, c8jzDet having duly filed an application on t 20� requesting a Certificate of Occupancy for the premises known as, J 14 1 / Rye Brook,NY, located in a)Q ' Zoning District and shown on the most current Tax Map as Section: S5•(4P7 Block: / Lot: 4 , and having fully complied with the requirements of the Building Code and the Zoning Ordinance under Building Permit No. `� , issued 1 20 , 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 New York State Classifications,Use: I,,-J Construction: for the following purposes: ' 1� � 1T O� �� —�Gd Y Dad/-f16 4 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 gLit faci ities shall be made,and no enlargement, whether by extending on any side or by increasing in h ' t shal nor 1 the building be moved from one location to another until a permit to accomplish such change h be o tained f m uilding Inspector. JUL 1 2 2024 Building Inspector, Village of Rye Brook: Date: Dl� ll R For office use onI ----� BUILD MENT PERMIT# —O�(O Y2 1 2024 VIL OF RYE OK ISSUED:3—/9-�FmA I 38 KING SIRE YE BROOKS V YORK 10573 DATE: S= c1/—c71'� VILLAGE OF RYE BROOK 9 -06 FEE: ��01 PAID BUILDING DEPARTMENT APPLICATION FOR CERTIFICATE OF OCCUPANCY,CERTIFICATE OF COMPLIANCE, AND CERTIFICATION OF FINAL COSTS TO BE SUBMITTED ONLY UPON COMPLETION OF ALL WORK, AND PRIOR TO THE FINAL INSPECTION +ttN•.?R4iti............i■•itltittiiRii3lit#kY*t#F*F*M......kf*##«...........►......il Kt...........t•iii4.......... .....t#s• Address: �1 ''ILrrS¢ tFvCritl� e.., A,Y /t>Sj-9 Occupancy/Use: Parcel ID#: Zone: IeQ p Owner: Address: `bl I��CJrS� /Q.,t•->'�C P.E./R.A. or Contractor: p2//0 ok0CV/n Address: 9 Cda� 4 .Skee/— C<yWaMV,4,*r!0 Person in responsible charge: eo O�'Tt7 � 2 0 /O Address: 1 y 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: Ell-e4l being duly swom,deposes and says that he/she resides at (Prini Name of Applicant) ll (No.and Street) in Q)-t &f p c k ,in the County of 2k-racr in the State of— Aj N/ ,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:$ �j ,%fl0• 11 0 for the construction or alteration of. Se«- eJ -Asm 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 Ca� Sworn to before me this day of A 7 , 2 r� { day of , 20 Z_f211 Signa o roperty Owner Signature of Applicant sr. 0 PriaNNarniVof roperty Owner Print Name of Applicant r Notary Public Notary Public SHARI MELILLO Notary Public,State of New York 8/12/2021 No.OIME6160063 Qualified In Westchester County— Commission Expires January 29,20_� QyE BR(�k. O� Zm BUILDING DEPARTMENT �[J BUILDING INSPECTOR f ❑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 1 I '� � DATE: I PERMIT# 2 J �C ISSUED: ` SECT: t�� BLOCK: LOT: �1 J, 1 2 LOCATION: , " "S f�a�� OCCUPANCY: 9 ❑ Violation Noted THE WORK IS... ;Q PASSED ❑ FAILED 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 �E BR(�k• O� 2m 1982 BUILDING DEPARTMENT ❑BUILDING INSPECTOR ❑ASSISTANT BUILDING INSPECTOR VILLAGE OF RYE BROOK ❑CODE ENFORCEMENT OFFICER 938 King Street• Rye Brook,NY 10573 (914) 939-0668 FAx (914) 939-5801 www ryebrook.org - - - - - - - - - - - - - - - - - - - - INSPECTION REPORT - - - - - - - - - - - - - - - - - - - - ADDRESS:_ - � �� V l DATE: c �-2-s PERMIT# ISSUED: 3 1 r ECT: BLOCK: LOT: LOCATION: D` �� OCCUPANCY: P� ❑ 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 0 Natural Gas ❑ FUEL TANK ❑ FIRE SPRINKLER ❑ FINAL PLUMBING ,CROSS CONNECTION FINAL ❑ OTHER _ S N Lin cCA a M M • % 0 L C 14 PLi b oo v `ncn en v g O �Z Q >� � � O 01, o a a. x _ ° A n rA v = � c/ ' O a 00 rYS z co P O ~ Z v a o I►� O O Q � � C� ^ +� z U z w � .� 'v a � � 0*4 h10 ~ C (� '"� z w W x 00 Q ti N V F� _ 1--4 V a o N qg AU d P4 U o a ej x W p V 0oc ,o � _ V © V z i 14 o A W z A' � O W W a Q. 24 a-o BUILD MENT E C E N E VIL E OF R7 r OOK MAR -5 2024 938 KING ET RvE BR NY 10573 4 -0 -� .� VILLAGE GI" RYE BROOK BUILDING DEPARTMENT INTERIOR BUILDING PERMIT APPLICATION FOR OFFICE USE ONLY: Approval Date: MAR 1 202 it Application Fee:$ / I )OCL Approval Signature: Permit Fees:$ CD Disapproved: Other: Application dated: �w 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. f� e 1. Job Address: in F�`��1 t res' ✓e Q.,t e eo%r i'�% SBL:/ J 7r✓ — — Zone: 2. Proposed Improvement.(Describe in detail): for-cn„-C Of n-S t C V y ZA.1/5 e,_ 11 " ) +� !/'� f ,r� A a-J .7 t c r�'� !f'0://ii► -, ckrtr. Fa! ,�I'u1i� (IV�J�.if d r l GS t��X` 4�as-wr� Au Li�� l.'—S �f •�J /r��i fT �jAle � (S��'a."'e� =...nl boa-5f 3. Does the proposed improvement involve a Home-Occupation as per§250-38 of the Code of the Village of Rye Brook? No: �c Yes: If yes,indicate: TIER I: TIER II: TIER III: 4. 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,FW200 System,Type 1 Hood,etc...):No: *)or- Yes: (If yes,please submit a separate Automatic Fire Suppression System Permit application&2 sets of detailed engineered plans) 5. Occupancy;(1 fam.,2 fam.,comm.,etc...)Prior to Construction: Fa"i l7 _After Construction: ..` s. 6. N.Y State Construction Classification: N.Y.State Use Classification: 7. Property Owner: Address: `31 4.I1 el d J A.—' R-rr d r ilo l- _Ny Phone# j Cell# 9/'{ 3gY 2305' _email: 6rPJ.�„ . cyIQekr- a NQL00 - Le—t 8. Applicant: ml�'�el�� ����d Address: $f idtrce 'r-t 4—, �r7� �7r CCA-, Phone# Cell# `f r`( 3 9 `1 L_1 A $" email: "or e�� ., a1 C' a Qp, c6 ✓A 9. Architect: I—O d T�e!t n C g"I Address: I V S S wi ;i„ A,,,C M 1 � ,u sf t, A,y I d j y y Phone# Mwf. SI4,6 Cell# email: L-IOU gAg"e 's;QLVC- .i-6J.1• co,.^ 10. Engineer: Address: Phone# Cell# email: It. General Contractor: _ 7 c I.;. Address: 9:dW-,J S Phone# 91`1 - "3-Wt,90 Cell# email: 12. Estimated cost of construction $ i 1 ,900 • r (NOTE:'The estimated cost shall include all labor,mate al,scaffolding,fixed equipment,professional fees,and material and labor which may be donated gratis.) 13. Job Timetable: Start: °� I if/ Finish: (1) 6/1/2023 BUILD MENT GEE 5 2�24 VIL E OF R OOK 938 Ki NG ET RYE BR ,NY 10573 VILLAGI=pF RYE BROOK 4 4 -� 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: residing at, (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; ,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. y//V (Signature of Property Owner(s)) 6,,e f 1. (Print Naive of Property Owe s)) Sworn to before me this day _ nod 11 20 04 OL 0� ,Oq � ,- fiye'o (Notary P 11 GREGORY K RtVERA Notary Public,State of New York No.01 R16441398 Qualified In Westchester County (�� (2) Commission Expires September 26,20 8/12/2021 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 YOM 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�ithis Sworn to before me this day of ► I + l..t ' , 24� fi day of , 24 /l Signaturc of roopeay Owner Signature of Applicant Print Name of Prop ty O n r Print Name of Applicant Notary Public Notary Public GREGORY K RIVERA Notary Public,State of New York No.01 R16441398 Qualified In Westchester County Commission Expires September 26,202( (4) 8/12/2021 COELLOLICENSED & FULL INSURED CONTRACTING • 843 4750 COSTUMER: CONTRACTOR: BREDDY ALFARO 9 EDWARD ST. CORDLANDT MANOR LIC. WC- 36400- H23 81 HILLCREST AVE. RYE BROOK NY. MARCH, 05/2024 - Remove existing walls on secound floor follow the Architects drawing - build new partition interior walls for new closets 2x4 framing walls. - Bedroom 3 closet. - Bedroom 2 closet. - Hallway walking closet and 2'x2" small closet. - M. bedroom walking closet. - Install 1/2" drywall on the new closets and wall partition. -Taiping and sanded get it ready to paint. - Install new doors, basbords and trim. - Install new doors hardwer. TOTAL PRICE: $ 8,800 THIS PRICE INCLUDE: -All construction materials. - New doors. - New basboards and trim. - Remove construction debris from the house. THIS PRICE NOT INCLUDED: -Closet organizer or doors hardwer. - New floor or floor installation - Painting. - Plumbing or electrical work. .Building Petnut Check List&Zoning Anal is Address: \ C SBL• Zone: se: Const.Type: J Other: Submittal Date: L�4 Revisions Submittal Dates: Applicant: Nature of Work: \-4;?St2�1t� c - Reviews:ZBA: MAR 11 2024 PB: BOT: Other. NEED OK FEES.Filing. \��P: � C/O: Flood Plane: on: APP: Dated: /—Notarized: — SBL ��russ I.D. Cross Connection: H.O.A.: ( ) ( ) Scenic Roads: Steep Slopes: Wetlands: Stony 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 7S3#: Dated: N/A: HIGH-VOLTAGE ELECTRICAL:Plans: Permit: N/A: Other. ( ) ( ) LOW-VOLTAGE ELECTRICAL:Plans: Permin 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: Permiu N/A: Other. ( ) ( ) FUEL TANK Plans: Pennin 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 Area: Date! Circle: Fie Front: Front: Sides: Rear. Main Cov: Accs.Cov: Ft.H Sb: Sd.H Sb: GFA: Tot.imp: Ft.In' PP HHei,ht/Stories notes: 0 '1'1'+ �'�} 1,'+'+,I'. -..�11•1'+, ; lSYvIAt "I, �yy 111 1111 A vIN ,It % 1�11 ,: 4' .►►Lis111�11 ZA s y a N (. .J 0-4 40 Q .AMA •• ;n =f v z m o c •— w section ' c� V w o Q� ELU O a aLU v �� ♦r W V !lw a o , (. ., 7E! a Ale a, a ri o O 6 zCD CV G v 4! r a. 11, { 1 'afzz a •♦ +,,,her{ 4/1 1 y s:111 11,Ss 4 .7p Z."�►�",-i- a J /111 nlil� ,11 ,aco CERTIFICATE OF LIABILITY INSURANCE 7DATE(MM/DD/YYYY) /28/2024 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 NAME: JALEN WILSON wAlbert Palancia Agency, Inc. PHONE.. EX : (914)698-1373 No; (914)698-0125 116 Mamaroneck Avenue E-MAIL ADDRESS: Jaien@palanciainsurance.Com Mamaroneck, NY 10543 INSURERS AFFORDING COVERAGE NAIC III INSURER A: Evanston Ins Co INSURED INSURER B COELLO CONTRACTING INC INSURERC: 9 EDWARDS ST INSURERD: CORTLANDT MANOR, NY 10567 INSURERE: INSURER F: COVERAGES CERTIFICATE NUMBER: 10011751-94542 REVISION NUMBER: 11 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 POLICY EFF POLICY EXP LTR TYPE OF INSURANCE ADDL SUBR POLICY NUMBER MMIDD YYYY MM DDYYYY LIMITS A X COMMERCIAL GENERAL LIABILITY 3FH3419 04/05/2023 04/05/2024 EACH OCCURRENCE $ 1,000,000 CLAIMS MADE I � OCCUR PREMISES Ea occurrence) $ 100,000 MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 1 000 000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 _ X POLICY❑PEC LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY Per accident L $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED I ! RETENTION$ $ WORKERS COMPENSATION I PER OTH- AND EMPLOYERS'LIABILITY Y/N STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ OFFICER/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 $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) 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 St RYE BROOK, NY 10573 AUTHORIZED REPRESENTATIVE (J.W) 1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD Printed by J.W on 02/28/2024 at 10:15AM NYSIF Nava.�.s,.t ^n.�•.rrv:a i Inc PO Box ON99.AM"- NY 122% 1 nyBIf.60II1 CERTIFICATE OF WORKERS' COMPENSATION INSURANCE kotak " 923108096 CABALLERO INSURANCE AGENCY Ilk 505 WHITE PLAINS RO STE 216 TARRYTOWN NY ID591 SCAN TO VALIDATE AND SUBSCRIBE POLICYHOLDER CERTIFICATE HOLDER COELLO CONTRACTING INC VILLAGE OF RYE BROOK 9 EDWARDS ST.APT 98 938 KING ST CORTLANDT MANOR NY 10567 RYE BROOK NY 10673 POLICY NUMBER CERTIFICATE NUMBER POLICY PERIOD DATE W2588144-2 402035 04KI6,2023 TO 04,KO2024 2�2&'2024 THIS IS TO CERTIFY THAT THE POLICYHOLDER NAMED ABOVE IS INSURED WITH THE NEW YORK STATE INSURANCE FUND UNDER POLICY NO. 2598144.2, COVERING THE ENTIRE OBLIGATION OF THIS POLICYHOLDER FOR WORKERS' COMPENSATION UNDER THE NEW YORK WORKERS• COMPENSATION LAW WITH RESPECT TO ALL OPERATIONS IN THE STATE OF NEW YORK EXCEPT AS INDICATED BELOW. AND. WITH RESPECT TO OPERATIONS OUTSIDE OF NEW YORK, TO THE POLICYHOLDER'S REGULAR NEW YORK STATE EMPLOYEES ONLY IF YOU WISH TO RECEWE NOTIFICATIONS REGARDING SAID POLICY,INCLUDING ANY NOTIFICATION OF CANCELLATIONS, OR TO VALIDATE THIS CERTIFICATE.VISJT OUR WESSITE AT HTTPSJIWWW.NYSW-CONK19tT(CERTVAL.ASP-THE NEW YORK STATE INSURANCE FUND IS NOT LIAILE N THE EVENT OF FAILURE TO GIVE SUCH NOTEICATIONS_ THIS POLICY DOES NOT COVER CLAIMS OR SUITS THAT ARISE FROM BODILY INJURY SUFFERED BY THE OFFICERS OF THE INSURED CORPORATION. PRESIDENT ROBERTO P COELLO COELLO CONTRACTING INC ONE PERSON CORPORATION THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS NOR INSURANCE COVERAGE UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICY NEW YORK STAT ZCE FUND rr/ DIRECTOR INSURANCE FUND UNDERWRITING VALIDATION NitAOSER: 163163%9 U-26 3