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HomeMy WebLinkAboutPP24-048 QR, j CI�0w yG y�y, JJ,LC'V4�V O`C VILLAGE OF RYE BROOK MAYOR 938 King Street, Rye Brook,N.Y. 10573 ADMINISTRATOR Jason A. Klein (914) 939-0668 Christopher J. Bradbury www.ryebrookny.gov TRUSTEES BUILDING& FIRE INSPECTOR Susan R. Epstein Steven E. Fews Stephanie J. Fischer David M. Heiser Salvatore W. Morhno CERTIFICATE OF COMPLIANCE March 17,2025 Win Ridge Realty LLC c/o Alena Hakanjin 24 Rye Ridge Plaza Rye Brook,New York 10573 Re: 15D Rye Ridge Plaza, Rye Brook,New York 10573 Parcel ID#: 141.27-1-6 This document certifies that the work done under Plumbing Permit #24-048 issued on 4/9/2024 for the installation of a new electric water heater has been satisfactorily completed. Sincerely, Steven E. Fews Building&Fire Inspector /to QyE BRC�k '982 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 : DATE: PERMIT# ISSUED: SECT: BLOCK: LOT: LOCATION: OCCUPANCY: ❑ VIOLATION NOTED THE WORK IS... ❑ ACCEPTED ❑ REJECTED/ REINSPECTION ❑ SITE INSPECTION REQUIRED ❑ FOOTING ❑ FOOTING DRAINAGE ❑ FOUNDATION ❑ UNDERGROUND PLUMBING NOTES ON INSPECTION: ❑ ROUGH PLUMBING ❑ ROUGH FRAMING ❑ INSULATION ❑ NATURAL GAS ❑ L.P. GAS ❑ FUEL TANK ❑ FIRE SPRINKLER ❑ FINAL PLUMBING ❑ CROSS CONNECTION ❑ FINAL ❑ OTHER QyE BRC��. 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: DATE:�_C� PERMIT# ISSUED: SECT: 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 ❑ Natural Gas �- ! ❑ L.P. Gas ❑ FUEL TANK ❑ FIRE SPRINKLER ❑ FINAL PLUMBING ❑ CROSS CONNECTION ❑ FINAL ❑ OTHER QyE BRC��, cu � 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: 1 `�" ��' DATE' j(.j 2 1 PERMIT# $SUED: SECT: LOCK: LOT: LOCATION: k, , y ' } J� 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 ❑ Natural Gas ❑ L.P. Gas ❑ FUEL TANK ❑ FIRE SPRINKLER ❑ FINAL PLUMBING ❑ CROSS CONNECTION ❑ FINAL ❑ OTHER \ _ 00 - - W I _ = N � ago w �-+ 4-4 enz u Cl) _ cj W �j F-� E"� � O z � w w o H Q- Q w � �'—+ � w 0 w z u w w © A a o A Z H U U � Q = ° � A w as s W a3 A � ool a w , Z 0 H A H V zo ILn W o z : BUILI G DEPARTMENT 1 AIR - 9 2024 r VEL OF RYE BROOK938 KINLL ET RYE Bgoox,NY 10573 -.a ____. VILLAGE OF RYE BROOK � 8 BUILDING DEPARTMENT www oot.org — --� PLUMBING PERMIT APPLICATION FOR OFFICE USE ONLY BP#: PP#: go Approval Date: i Permit Fee: $- 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, 7— 7 is hereby made to the Building Inspector of the Village of Rye Brook NY, for the issuance of a Permit to install and/or remove Plumbing as per detailed statement described below.The applicant&property owner,by signing this document agree that said plumbing work will be in conformance with all applicable Federal, State,County and Local Codes. I.Address: nl) QAC eidoc lwn SBL: /yJ, 7— CP Zone[ 2.Proposed Work: F-CYY)'a1 c ,6 EW QCC vo woAc( IgC'wce 3.Property Owner: /. •%� Address: Phone#: Cell#: 4.Master Plumber: Address: 1, � OCmI(1 w}[, 2)� Lic. #: 1101 Phone#: ` Cell#: 4 ` goo mail: ��tt Company Name: bi nQ tc 06WACC Address: 0Lf Tom 1 � �Ci CCr� INDICATE FIXTURES& LINES TO BE INSTALLED AS PER THE Fill 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 1 st Floor 2nd Floor 31d Floor 401 Floor 51h Floor Exterior 5.*List Other Equipment/Provide Details: bO} WOLM [ t M 9—CMQ :Qf t �EQM (Notarized Signatures Required Next 2 Pages) -I- 3/3/2023 STATE D OF NEW YOM COUNTY OA} F WESTCHESTER ) as: I V 04PT" � r' t being duly sworn,deposes and states that he/she is the applicant above named, (print name of individual signing as the applicant) and further states that(s)he is the 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 3 Sworn to before me this day of I' ,20 day of t L— 12014 t' zZa -L" Lure of Propeky 0WMr/ Signature of Applicant bA-re' Pr' N e of Prop Oar Print Name of Applicant 1 ENA HA biota AoT/1*Pu9x.STATE of NEM ym Notary Public Rsppistration No.01 HAO013645 GusIHIed in Wostchsstsr Count] SCOTT W.CRAIG 11 Coamlesion Espies W19/2021 Notary Public of New York REG NO. 01CR6390567 COMMISSION EXPIRES 04/15/2027 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- 10/30/2023 r_ DD BUIL+ A MENT I= V1L1:A E OF RYE OOK l 938 KMG ET RYE BR ,NY 10573 APR - 9 2Q24 "(9�t4 -066$� L -� VILLA _'JE OF RYE BROOK B1 P! 01IN 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: p� 31, t)t--Jia N S , residing at, oc 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; 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. (A.,Uogre of Proper( Owrtoa s)) (Print Name of Property Ow rerr-,I1 Sworn to before me this g I�' , 20 Z4- I WlarvPubatic) J ALENA HAKANJIN NOTARY PtiaM,STATE OF NEW YORK Registration No.DIHAO013645 Qualified in Westchester County My Commission Expires 9119'2r2- 8/12/2021 a a N W _ (QV N N \ \ i wLn , N w O 0 n ■ rr M "y 5 W �60 s ow» o � � W (AL - x r-4 H Z � x W o �o V H As W • �i W �' ° Z CA � ,o w O Cn ~ � z w u ►� o 4 x • a W o C7 E O u z °�° `� A w o � O A o a0.-0 w o W ►..� cn W U U � 00 w z a � MM U w U w 00 of "' q. M1 F+ I a � Q AA;� o O z Z W W � w z oo � n zw w S� c zs� x 3 a w = LnrTJ z N z wG� HI w az w Volx � ' t r r t r t �r r a r . ■ r r G BUILDING DEPARTMENT VILLAGE OF RYE BROOK [APR 10 2024 938 KING STREET RYE BROOK,NY 10573 VILLAGE OF RYE BROOK (914)939-0668 I BUILDING DEPARTMENT �vw�v.lyebruok.or� ELECTRICAL PERMIT APPLICATION Westchester County Master Electricians License Required I FOR OFFICE USE ONLY —i3.I-#- 1 / EP#: 0`1' — 0 Approval Date: Permit Fee: S Approval Signature: Other: ************************************************************************************************** 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 S750.00 Application dated, 4/5/24 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 electrical equipment,wiring,fixtures,or to perform other high or low voltage electrical work as per the detailed statement described below. By signing this document, the applicant & property owner agree that all electrical work performed will be in conformance with all applicable Federal,State,County and Local Codes. 1.Address:) Rye Ridge Plaza SBL: ���� 7 �— Zone: _� 2.Property Owner:AV I Al ► W5 ft/ /_Address: Phone#: ( 1- 4cmJ Cell#: email `R t 3.Master Electrician/Licensed Installer: Roy Duckworth Address:87 Greenleaf Dr,Stamford,CT 06902 Lic.#: 1769 Phone#: 914-313-8448 Cell#: email: 9 ndviewoffice2l @gmail.com Company Name: Grandview Electric Address: 87 Greenleaf Dr,Stamford, CT 06902 4.Proposed Electrical Work/Fixture Count: Disconnect electric for hot water heater 5.31d Party Electrical Inspection Agency: SWIS **.*.*�«*.**«.*rrtr+r.,t*�***«.*�*,r****«*�*,►**f*****«***�*s�*•****.�*tt***r*«.r.**•*.t*f�**,t+r,rt**.r*,t,t**.**,� STATE OF IN.EW YORK,COUNTY OF WESTCHESTER ) as: KO V TD V C.kN017—+k ,being duly sworn.deposes and states that he/she is the applicant above named,and does further (print na ne ol'indicidual signing as the applicant) state that(s)he is the for the legal owner and is duly authorized to make and file this application. (Master I?lectrician'Licensed Installer) The undersigned further states 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 al I other applicable laws,ordinance-,and regulations. Sworn to before me this Sworn to be ore me this day of 20 _ day of 2 6 f1ii, MoAre of P operty Omer SZOZ 'OE A0N sajldx3 u ?l plicant *� �. L_ in3piau +JA007 C 311gndti¢70 ' lD ( 4U.J O� Pri o Pr Hiao ana lion r o pplicant CAL Notl y u IRLENA IAKANJIN blic WTMy FUBIJC,STATE OF NEW YORK 10/30R023 RO�istration No.01 HA00136a 5 Qualified in Westchester,-, My Commission Expires c STATE WIDE INSPECTION SERVICES, INC. 0•• • • swis . : APPLICATION tel 845.202.7224 1 fax 914.219.1062 •A • Office Use Elect. Permit# Date Bldg Permit# - Sq Ft Plumbing Permit# Final Certificate# City/VillageRq Ir ?re Zip i �`)�7 Eild:ing::Dept. County Address is R v i,> r; P nhGk Cross Street Section Block Lot Owner Name/Address(1f different than above) f 1!`(� RI�Q-to ks-.1 I Le Contact Number ❑Basement Q'lst Ff. ❑2nd Fl. ❑3rd FI. ❑More Than 3 A. ❑Garage ❑Attic ❑Outside ❑Residential ❑Commercial Receptacles Special Recept GFCI AFCI Switches Dimmers Smoke Alarms C/O Detector Hood Trash Compact Amt Amps Range(s) Cooktop(s) Oven(s) Dishwashers Refrigerator Disposal Microwave Luminaires Generator Transfer Switch SERVICE Amperage #Panels 1P 3P # Meters # Disconnect ❑Underground ❑ New ❑ Reconnect ❑ Repair ❑Overhead ❑ Upgrade ❑ Disconnect Utility ID# ❑Con Ed ❑ NYSEG ❑Central Hudson ❑ Orange/Rockland PHOTOVOLTAIC SYSTEM PV Modules Inverters AC Disconnect Junction Box Combiner Box Load Center PV Monitor Energy Storage System DC Disconnect ❑Legalization ❑ Safety Inspection ❑Consultation rr rG�i�r�r� i APR 10 2024 VILLAGE Or— RYE BROOK BUILDING DEPARTMENT This application is valid for one(1)year from the date received by SWIS.This application is intended to cover the above listed items to be inspected,if at any time of inspection additional items have been installed,you are authorized to make the inspection and adjust the fee for the additional items inspected.The applicant declares that there is no open applications for the above address with any other inspection company.The applicant, owner or authorized agent agrees to all the above terms and conditions as set forth for the application. Email Address -J/ r v at Name Ill License# t 11 G � Date Signature G� Address t`Z' C.ftz.Q7tY4 t:W Or City/State '—���6�2ar el Zip Code Company � J V �,f r� Phone# --y State Wide Inspection Services C-AD11 1080 Main Street Fishkill, NY 12524 TOSVOKUS 845 202-7224 Phone 914-219-1062 Fax STATE WIDE INSPECTION SERVICES Email: office@swisny.com Website: www.swisny.com Service With Integrity BY THIS CERTIFICATE OF COMPLIANCE STATE WIDE INSPECTION SERVICES CERTIFIES THAT: Upon the application of: Upon Premises Owned by: Grandview Electric, LLC Win Ridge Realty LLC Roy Duckworth IV 15D Rye Ridge Plaza 87 Greenleaf Drive Rye Brook, NY 10573 Stamford,CT 06902 Located at: 15D Rye Ridge Plaza, Rye Brook, NY 10573 Section: Block: Lot: Electrical Permit Number: EP 24-076 141.27 1 Certificate Number: 2024-6821 Building Permit Number: BP 24-048 A visual inspection of the electrical system was conducted at the Commercial occupancy described below.The electrical system consisting of electrical devices and wiring is located in/on the premises at: 15D Rye Ridge Plaza, Rye Brook, NY 10573 The First Floor: Rear Utility Room was inspected in accordance with the NYS and NFPA 70-2017 and the detail of the installation, as set forth below,was found to be in compliance on the 301h day of September 2024. Name Quantity Rating Circuit Type Electric Water Heater 01 VW i Officer: Frank J. Farina This certificate may not be altered in any way and is validated only by the presence of a seal at the location indicated.This certificate is valid for work performed on the date of inspection only. GRANGER Electric Water Heaters with Tank / RHEEM-RUUD Electric Water Heater 480V... RHEEM-RUUD Electric Water Heater: 480V AC, 85 Web Price - $7,030.00/each gal, 36,000 W, Single/Three This item requires special shipping, Phase, 57.7 in Ht additional charges may apply. Qty Item 21 XP20 Mfr. Model ES85-36-G 1 • .. to Cart O Ship Picku P Expected to arrive Wed. Apr 10, Compare Ship to 10956 1 Change Product Details Catalog Page 2595 Shipping Weight 337 Ibs Ship Availability Terms Brand RHEEM-RUUD Sub-brand Commercial Water Heater Add to List Manufacturer Part Number ES85-36-G Standards AHRI Compliant;ASME;CSA Certified; LWH; UL EPH Listed; UL Listed Compliance & Restrictions Market Commercial This product has been certified by a third party to be compliant with the Operating Voltage 480V AC "Safe Drinking Water Act" Manufacturer Warranty Length 1 yr Limited Parts;3 yr Limited Tank requirements for low lead in potable (human consumption-drinking and Maximum Delivered Temperature 190 °F cooking) and non-potable water applications (non-human Maximum Recovery Flow Rate 372 gph @ 40°F consumption) Number of Elements 6 O This item is restricted for international sale. Tank Capacity 85 gal Oj WARNING: Cancer and Maximum Water Pressure 150 psi Reproductive Harm- www.P65Warnings.ca.gov Overall Width 28.3 in Overall Depth 34 in Documents Overall Height 57.7 in rFM Rheem Rudd AP11146 8 Included Valves Temperature and Pressure Relief InstructionManual rA Rheem Ruud AP11828 3 Power Consumption 36,000 W Warranty Water Connection Location Side;Top Rheem I hat with Fin Agent XI;—, Current 75 A p nncci nuuu icavy Uuiy QJJV%, , Sheet Phase Single;Three Recovery Rate @ Rise 106 gph @ 140°F; 115 gph @ 130°F; 124 gph @ 120°F; 135 gph @ 110°F; 149 gph @ 100°F; 165 gph @ 90°F; 186 gph @ 80°F;213 gph @ 70°F;248 gph @ 60`F;298 gph @ 50°F Thermal Efficiency 98% Tank Diameter 28.25 in Tank Lining Material Vitreous Glass Equivalent BtuH 122,839 BtuH Element Material Stainless Steel Cold Inlet Size 1-1/2 in Hot Outlet Size 1-1/2 in Automatic Thermostat Yes Thermostat Mounting Surface Includes Brass Drain Valve; Factory-Installed T&P Valve Minimum Delivered Temperature 90 °F Height to Hot Outlet 57.7 in Height to Cold Inlet 4.8 in Tank Insulation Material Polyurethane Height to T and P Valve 49.5 in Cold Inlet Type NPT Hot Outlet Type NPT UNSPSC 40101826 Country of Origin USA (subject to change) Product Description Fast-recovery commercial electric water heaters rapidly heat water and recover stored volume quickly following peak use times for applications with continuous high demand for hot water. Replacement Parts C1101 wiai an Agent DATE(MWDD/Y/Y/) . CCORV llla. � ® CERTIFICATE OF LIABILITY INSURANCE 4Bi2024 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 Peter Cuomo NTilkUT NAME: Valhalla Agency,Inc. aC,No.Ext: (914)449 4000 FAX (A/C,No): P.O.Box 185 ADDRESS: Peter(a ValhallaAgencylnc.com INSURERS)AFFORDING COVERAGE NAIC 0 Baldwin Place NY 10505 INSURER A: UTICA FIRST INS CO 15326 INSURED INSURER B Dynamic Maintenance and Restoration,Inc. INSURER C: 134 TOMAHAWK ST INSURER D. INSURER E YORKTOWN HEIGHTS NY 10598-6313 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. LTR TYPE OF INSURANCE INSD VWD POLICY NUMBER (MMIDD/YYYY) (MM/DDIYYYY) LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 ltu CLAIMS-MADE ❑ PREMISES OCCUR (Ea occurrence) $ 5,000 MED EXP(Any one person) $ 5,000 A Y ART3001000950 10 I9/2023 10/192024 PERSONAL&ADV INJURY $ 1.000.000 POTHER. L AGGREGATE LIMIT APPLIES PER. GENERAL AGGREGATE $ 2,000,000 POLICY ❑JE T ❑LOC PRODUCTS-COMP/OP AGG S 2,000,000 S AUTOMOBILE LIABILITY (Ea accident) S ANY AUTO BODILY INJURY(Per person) S OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS HIRED NON-OWNED PRUAMAUL $ AUTOS ONLY AUTOS ONLY (Per ac 71.,1) S UMBRELLA LIAR OCCUR EACH OCCURRENCE $ EXCESS LIAS HCLAIMS-MADE AGGREGATE $ DEC I I RETENTIONS S ORKERS COMPENSATION ND EMPLOYERS'LIABILITY YIN STATUTE ER NY PROPRIETOR/PARTNER/EXECUTIVE❑ E.L.EACH ACCIDENT $ FFICERIMEMBER EXCLUDED? N/A Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ yes,describe under ESCRIPTION OF OPERATIONS beiow E.L.DISEASE-POLICY LIMIT S DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more apace is required) Plumbing&Heating CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN Building Department Village of Rye Brook ACCORDANCE WITH THE POLICY PROVISIONS. 938 King Street AUTHORIZED REPRESENTATIVE Rye Brook NY 10573 �eZ— /_ ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD (JN Y aK Workers' Certificate of Attestation of Exemption STATE Compensation p from New York State Workers' Compensation and/or Board Disability and Paid Family Leave Benefits Insurance Coverage **This form cannot be used to waive the workers'compensation rights or obligations of any party.** The applicant may use this Certificate of Attestation of Exemption ONLY to show a government entity that New York State specific workers'compensation and/or disability and paid family leave benefits insurance is not required. The applicant may NOT use this form to show another business or that business's insurance carrier that such insurance is not required. Please provide this form to the government entity from which you are requesting a permit,license or contract. This Certificate will not be accepted by government officials one year after the date printed on the form. In the Application of Business Applying For: (Legal Entity Name and Address): Plumbing Permit dynamic maintenance&restoration inc 134 Tomahawk St From:VILLAGE OF RYE BROOK Yorktown Heights,NY 10598-6313 PHONE:914-439-9655 FEIN:XXXXX7600 The location of where work will be performed is 938 KING STREET,RYE BROOK,NY 10573. Estimated dates necessary to complete work associated with the building permit are from April 9,2024 to October 9,2024. The estimated dollar amount of project is $0-$10,000 Workers'Compensation Exemption Statement- The above named business is certifying that it is NOT REQUIRED TO OBTAIN NEW YORK STATE SPECIFIC WORKERS'COMPENSATION INSURANCE COVERAGE for the following reason: The business is a one person owned corporation,with that individual owning all of the stock and holding all offices of the corporation. Other than the corporate owner,there are no employees,day labor,leased employees,borrowed employees,part-time employees,other stockholders,unpaid volunteers(including family members)or subcontractors. Disability and Paid Familv Leave Benefits Exemution Statement: The above named business is certifying that it is NOT REQUIRED TO OBTAIN NEW YORK STATE STATUTORY DISABILITY AND PAID FAMILY LEAVE BENEFITS INSURANCE COVERAGE for the following reason: The business MUST be either: 1) owned by one individual; OR 2) is a partnership(including LLC,LLP,PLLP,RLLP,or LP)under the laws of New York State and is not a corporation; OR 3) is a one or two person owned corporation,with those individuals owning all of the stock and holding all offices of the corporation(in a two person owned corporation each individual must be an officer and own at least one share of stock); OR 4) is a business with no NYS location. In addition,the business does not require disability and paid family leave benefits coverage at this time since it has not employed one or more individuals on at least 30 days in any calendar year in New York State. (Independent contractors are not considered to be employees under the Disability and Paid Family Leave Benefits Law.) I,mohamad k.salameh,am the President with the above-named legal entity. I affirm that due to my position with the above-named business I have the knowledge,information and authority to make this Certificate of Attestation of Exemption. I hereby affirm that the statements made herein are true,that I have not made any materially false statements and I make this Certificate of Attestation of Exemption under the penalties of perjury. I further affirm that I understand that any false statement,representation or concealment will subject me to felony criminal prosecution,including jail and civil liability in accordance with the Workers'Compensation Law and all other New York State laws. By submitting this Certificate of Attestation of Exemption to the government entity listed above I also hereby affirm that if circumstances change so that workers'compensation insurance and/or disability and paid family leave benefits coverage is required,the above-named legal entity will immediately acquire appropriate New York State specific workers' compensation insurance and/or disability and paid family leave benefits coverage and also immediately furnish proof of that coverage on forms approved by the Chair of the Workers' mp ns ioa$oard to the government entity listed above. HERE Signature:Fq�� Date: Exemption Certificate Number Received 2024-026134 April 9, 2024 NYS Workers'Compensation Board CE-200 01/2018