HomeMy WebLinkAboutBP24-065PERMIT �4�O 6 5� DATE: Q•3 � W , c)3 o7J�
SECTION BLO K T i� // /-
TYPE OF WORK / ICye�c'e I / h OA/te I///1,,yl)q e � 6ak s
JOB LOCATI Q,��
OWNER '�// J`�y'�-'�®en
CONTRACTOR %ISSCPAC e sylqll j6 PSi j�) LLC-
EST. COST (' o FEE IJ
✓CO # FEES` J, lO iob DATE c
TCO # FEE DATE
INSPECTION RECORD
DATE
FOOTI N G
FOUNDATION
FRAMING
RGH FRAMING
INSULATION
PLUMBING 0
RGH PLUMBING
GAS
SPRINKLER
ELECTRIC
LOW -VOLT O
ALARM �0{
AS BUILT LJ
FINAL
INSP
OTHER A ROYALS
ARB r' O
BOT
OTHER
3-SU1LTlFINAL SURVEY
REQUIRED PRIOR TO
FINAL INSPECTION
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VILLAGE OF RYE BROOK
MAYOR 938 King Street,Rye Brook,N.Y. 10573 ADMINISTRATOR
Jason A. Klein (914)939-0668 Christopher J.Bradbury
www.iyebrookny.gov
TRUSTEES BUILDING& FIRE INSPECTOR
Susan R. Epstein Steven E. Fews
David M. Heiser
Donald T. Krom,Jr.
Salvatore W.Morlino
CERTIFICATE OF COMPLIANCE
April 28,2025
Alex Szigety&Kaylin Searles
2 Jennifer Lane
Rye Brook,New York 10573
Re: 2 Jennifer Lane,Rye Brook,New York 10573
Parcel ID#: 135.57-1-13
Building Permit#24-065 issued on 4/23/2024 for a New Fence
This certifies that the new five foot high welded wire fence&four foot high white vinyl fence and gates,
installed under the above captioned permit have been satisfactorily completed.
Sincerely,
Steven E. Fews
Building&Fire Inspector
/to
p [E C E N E BUILDING 16tPARTMENT For office use onl
3D PERMFr# a -OILS
VILLAGE OF RYE BROOK ISSUED:
APR - 4 2025 1138 KING STREET,RYE BROOK,NEw YORK 10573 DATE: y-c3-
(914)939-0668 FEE: 0/'5-0—PAID 9-
VILLAGE OF RYE BROOK www xyebrook-.ora
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
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Address: 2 (Jkow ky- ww', �9AP �V A Its
Occupancy/Use: Parcel ID#: Zone: IQ�
Owner: ocuy Address: LAB
P.E./R.A. or Contractor: �2V'(A Address: W +k V OWAd t (N
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:
11N V l .(J� �1-�c�l aging duly sworn,deposes and says that he/she resides at�� S/�
Print Name of Ap h-an') �� 1 (N'o.and Street)
in th-UX Y2Vf)6— in the County of in the State of W -4— that
(Cite'Ftm n 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
for the construction or alteration of: IWolln W444�fA � U t U ki,C
Zvi LAM), �► d��-.e
Deponent fIrther states that he/she h 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-IO.A. of the Code of the Village of Rye Brook.
Sworn to before me this Sworn to before me this
day of 20 day of , 20�
Y "(IA.
Signature of Prop rty(hone —� Signature of Ap icant
S `
ame of1property Owner I Plant.Name of pplicant
J
Notary Public SHARI MEULLO MWPIAEULL0
Notary Public,State of New York Notary Public,State of New York
No.01ME6160063 No.MIVIM60063
Qua!ified In Westchester county Qualified in Westchester County s 1' '� 1
Commission Expires January Commission Expires Janilary 29,20Z
a
�yE BRcb
O�` tim
cu �
BUILDING DEPARTMENT
0 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 : I'll '�� " AQ� Lc-C-Vr-7!) DATE: I-Z3 1
// Lc O VS—
PERMIT# E� ISSUED: SECT: BLOCK: LOT:
LOCATION: A Vf r 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
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[E 3D
BUILDING DEPARTMENT F C r � v
VILLAGE OF RYE BROOK H APR - 2 2024
938 KING STUEET RYE BRoox,NY 10573
(9._14 9-0658 VILLAGE OF RYE BROOK
BUILDING DEPARTMENT
FOR OFFICE USE ONLY:
��Approval Date:APR 2 2 2U Pe m Application# pa2q "(1_" 0�/�
Approval Signature: ARCHITECTURAL REVIEW
BOARD:
Disapproved; Date:
BOT Approval Date: Case# : Chairman:
PB Approval Date: Case# Secretary:
ZBA Approval Date: Case#
Other 1 r
Application Fee: Q Permit Fees: �/c)�o �UC
FENCE I WALL / GATE PERMIT APPLICATION
Application dated: _ZQ is hereby made to the Building Inspector of the Village of Rye Brook,NY,for the issuance of a Permit
for the installation,construction,repair o replacement of a Fence.Wall or Gate,in accordance with Section 250-6 B.(1)(g),of the Code of the Village of
Rye Brook,as per detailed statement described below. Swimming,pool fences must conform to the State Code.
1. Job Address: Z, J4.,eM -Gy L4 N, V-j"k?Yd c G I 1 N) t osa 3
2. Occupancy/Use: S.B.L.#: l Zone: r,
3. Proposed Fence/Wall/Gate(describe in detail):
E 1v, l�l c.at
4. Prope Owner: _ pp
Address: I- -4v VA vwz Irp
Phone# Cell# �, L4 0W email: II'1,S G 1. bo 4M
Applicant: 1,M�
Address:
Phone# Cell# email:
Architect/Engineer:
Address:
Phone# Cell# email:
Contractor: IDAU IY (M <9lV Lk 1YKMtA Uub
Address&Phone: -4 VULkit4 ILA) �A- (� - R)- -
5. If building is located on a corner lot,which street does it front on: �diV1V111 �A VU_
6. What is the estimated cost of construction Lt,V
(NOTE:The estimated cost shall include all site improvements,labor,material,scaffolding,fixed equipment•professional fees.and
material and labor which may be donated gratis.)
7. Estimated date of completion: 18Sr1 Mow
Please note that this application must include the notarized signature(s) of the legal owner(s)
of the above-mentioned property, in the space provided below. Any application not bearing
the legal property owner's notarized signature(s) shall be deemed null and void, and will be
returned to the applicant.
STATE OF NEW YORK, COUNTY OF WESTC14ESTER
being duly sworn,deposes and states that he/she is the applicant above named,
(print n of individual si ng as l;applicant)
and t er states that (s)he is the legal owner of the property to which this application pertains, or that (s)he is the
A {m L )1( 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 Rve Brook and all other applicable laws,ordinances and regulations.
Sworn to before me this 9 Sworn to before me this
day of (1\ , 20 day of k , 24
4 . � �Q
Signature ol Property 4 r Signs re of plicant
t ame of operty Mrier j P7trej)f Applicant
Nota blic Notary Public
SHARI MELILLO SHARI MELILLO
Notary Public,state of New York Notary Public,State of New York
No.OIME6160063 No,OIME6160063
Qualified In Westchester County. Qualified in Westchester County
Commission Expires January 29,201� Commission Fxplres January 29,20��
2
.Building Permit Check List&Zoning Analysis
01 �NN �
Address. 1" \ l-- l SBL: � L
Zone: Us �—�� Cont.Type: v Other:
Submittal Date: �- Z Revisions Submittal Dates:
Applicant: 2 1
Nature of WorkAPR 0
1-4
Reviews:ZBA: $ 024 P&_ ,,. Other.
NEED OK kj
(a- r44i FS:Filing: \� BP: \2 C/O: Flood Plane: Legalization:
( ) (L�-XPP: Dated: Notarized: SBL: Truss I.D. Cross Connection: H.O.A.:
Scenic Roads: Steep Slopes: Wetlands: Storm Water Review: Street Opening.
( ) ( ) ENVIRO.Long Short Fees: N/A:
( ) (a SITE PLAN:Topo: Site Protection: S/W Mgmt.: Tree Plan: Other.
( ) ( � SURVEY:Dated Current Archival:- Sealed: Unacceptable:
( ) ( PLANS:DayStamped. Sealer Copies: Electronic Other.
( (c/ ease Workers Co %/ Liabilit Comp.Waiver. Other.
(� ODE 753#: J — / J Dated —a — N/A:
( ) ( ) HIGH-VOLTAGE ELECTRICAL:Plans: Permit N/A: Other.
( ) ( ) LOW-VOLTAGE ELECTRICAL:Plans: Permit. N/A: Other.
( ) ( ) FIRE ALARM/SMOKE DETECTORS:Plans: Permit nw.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:
O O Other.
(�yPCRB mtg.date: `I- 17— Zy approval:- y -17- Z,4 notes 0 -
( )ZBA mtg.date: approval:- notes:
( )PB mtg.date: approval:- notes: APPPPR r)V
REQUIRED EXQSITNG PROPOSED NOTES APR ,t!2 2 "'
Area: Dates• A
Circle:
Fronta¢�
Front:
Front--
Sides:
Rear.
Main Cov.
Accs.Cov:
Ft H Sb:
Sd.H Sb:
GFA:
Tot•Im :
Ft Im :
P�
Height/Stories 1_
notes: u 1 mf SZ i Vl f
CowC.
-
d
r BUILDING DEPARTMENT
VILLAGE OF RYE BROOK APR - 2 2024
l
938 KING STREET RYE BROOK,NY 10573 _
(9 4 �9 "C- VILLAGE OF RYE BROOK
; BUILDING DEPARTMENT
ARCHITECTURAL REVIEW BOARD CHECK LIST FOR APPLICANTS
This form must be completed and signed by the applicant of record and a copy shall be
submitted to the Building Department prior to attending the ARB meeting. Applicants
failing to submit a copy of this check list will be removed from the ARB agenda.
Job Address: 2- 4yNw�o r' uA/4 .(, Date of Submission:
Parcel ID#: � b�.�+_— �—k� Zone:
Proposed Improvement(Describe in detail):
APPLICANT CHECK LIST:
MUST BE COMPLETED BY THE APPLICANT
�- � The following items must be submitted to the Building
Department by the applicant-no exceptions.
Property Own v � 1. Completed Application
2. ( )Two(2) sets of sealed plans. (one full size f maximum
Address: 2- VU, `Z61/ �k allo-v%able plan size=36"x 42") and one 11"x17")
Phone# ft- S 14 - 1- t 3. (4Two(2)copies of the property survey.
4. ( ) Two(2)copies of the proposed site plan.
Applicant appearing before the Board: 5. (>�One electronic/disc copy of the complete
application materials.
6. (Vf Filing Fee.
Address: 7. ( )Any supporting documentation.
Phone# �1.,( s�-1• l� 8. ( ) HOA approval letter. tifapplicable)
9. (\4 Photographs.
Architect/Engineer: V>d ut C S�k 10.( ) Samples of fmishes/color chart. la sample board or
model may be presented the night of the meeting)
Phone# Ns— 30H- W?2�
By signature below, the owner/applicant acknowledges that he/she has read the complete Building Permit
Instructions&Procedures, and that their application is complete in all respects. The Board of Review reserves
the right to refuse to hear any application not meeting the requirements contained herein.
Sworn to before me this I? Sworn to before me this
day of 20 a -� day of \ 20�y
Si ature of ro erty(honer Signature o A Iiicant p /
u V1 11 mil/
ame of P operty Owner 'nt 1 ame ppli�ant
Not Public Notary Public
SHARI MELILLO
Notary Public,State of New York SHARI MELILLO
No.01ME6160063 Notary Public,State of New York
^ --lifled in Westchester county No.OIME6160063
o t Qualified in Westchester county
=x^Tres January 29,201
00mmis.sion Expires January 29,202
• �yE �• Village of Rye Brook ML MR
OttAgend FB SE
Architectural Review Board Meeting AC 1�D
W Wednesday,April 17,2024 at 7:30 PM
Village Hall,938 King Street JM SF
1. ITEMS:
1.1. ARB24-028 (Consent Agenda)
Daniel Albano&Felicia Albano
57 Tamarack Road
Rooftop solar array.
1.2. ARB24-029 (Consent Agenda)
Danielle Freeman
78 Woodland Avenue
C high wood fence.
1.3. ARB24-030(Consent Agenda)
Alex Szigety&Kaylin Searles
2 Jennifer Lane
5'high welded wire fence and 4'high white vinyl fence and gates.
1.4. ARB24-031 (Consent Agenda)
Grant Kurti&Antigona Balidemaj
4 Westview Avenue
Rooftop solar array.
1.5. ARB24-032 (Consent Agenda)
Robert Weisz
22 Elm Hill Drive
Replace patio,repair front stairs and foundation.
1.6. ARB24-033 (Consent Agenda)
Paul Tyler&Linda Tyler
16 BelleFair Boulevard
Install egress window,legalize finished basement.
Consent Agenda
Approvals: Motion TM Second P%Q Abstention
Aye; Nay; Adjournment;
Notes TT
Page 1 of 4
• Architectural Review Board
April 17,2024
1.7. ARB24-020
556 Westchester Ave LLC
c/o Anthony Guastella
556 Westchester Avenue
New rear windows.
Approvals: Motion Second Abstention
Aye; Nay; Adjournment;
Notes
1.8. ARB24-034
Michael Chiappini&Joanne Chiappini
10 Paddock Road
Legalize rear deck.
Approvals: Motion Second Abstention
Aye; Nay; Adjournment;
Notes
1.9. ARB24-035
Cerebral Palsy of Westchester
260 Lincoln Avenue
Exterior handicap ramp.
Approvals: Motion Second Abstention
Aye; Nay; Adjournment;
Notes
1.10. ARB24-036
Win Ridge Realty LLC
120 South Ridge Street
New awning and illuminated sign. "SBG Home&Design"
Approvals: Motion Second Abstention
Aye; Nay; Adjournment;
Notes
Page 2 of 4
• Architectural Review Board
April 17,2024
1.11. ARB24-037 (Amendment to Prior Approval)
Peter Glantz&Lynn Glantz
3 Old Orchard Road
Keep railroad tie wall as sitting wall.
Approvals: Motion Second Abstention
Aye; Nay; Adjournment;
Notes
1.12. ARB24-038
713 Westchester Ave LLC
c/o Avinash Khatri
713 Westchester Avenue
Convert garage to living space and interior renovation.
Approvals: Motion Second Abstention
Aye; Nay; Adjournment;
Notes
1.13. ARB24-039
Cameron Sager&Jessica Sager
41 Winding Wood Road
2nd story addition over garage,enclose porch and new front entry.
Approvals: Motion Second Abstention
Aye; Nay; Adjournment;
Notes
1.14. ARB24-040
Jamie Billington&Kara Billington
6 Bonwit Road
2nd story addition,one story rear addition,new deck,portico,siding and windows.
Approvals: Motion Second Abstention
Aye; Nay; Adjournment;
Notes
Page 3 of 4
Architectural Review Board
April 17,2024
1.15. ARB24-041
Shubin Ma&Wen He
10 Boxwood Place
New deck.
Approvals: Motion Second Abstention
Aye; Nay; Adjournment;
Notes
1.16. ARB24-042
Dziugas Reneckis&Cristina Pires
9 Maple Court
New deck.
Approvals: Motion Second Abstention
Aye; Nay; Adjournment;
Notes
NEXT MEETING:
May 15,2024
Page 4 of 4
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Hirsch Fence Install & Desi q APR - � 2o2
747 Route 9W LAGE OF RYE BROO
Valley Cottage, NY 10989 BUILDING DEPARTMEEN
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Cusk-WI Dq.,t.P►Irr No. EvrlYq Ph"No CudwWs Erad Adtbws
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PERM!TANSPECTON INFORMATION
-, -W-1Zoes ❑No to obtain Mmd Installabon proiessiorm,
(srrarron PnIftev na rP&w mPr a pwre belt trrsldsrq 10 obtain pemot
APPROXIMATE LAYOUT
Se'ect,on f
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NULL BE At,..S TE 0 MM ON ACTUAI ErOOTAOE USE D AS SLT r CUgr-LATER US A%D CCNOrMNS,J
AMMONAL COST
ADD TIE PMCM N TMS
COLUMN To rE sEISLIMN
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ANRY OLD FENCE
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FINAL AMOUNT DUE /
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---Ili ..
AcoR" CERTIFICATE OF LIABILITY INSURANCE DATE(MM:DDIY`rYY)
llk � 3/28/2024
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: Courtney Potter
McCarthy Insurance PHONE (914)769-0417 FAc(AI No:
378 Elwood Avenue E-MAIL RE ADOSS: courtney@mccarthyinsurance.net
Hawthorne, NY 10532 INSURERS)AFFORDING COVERAGE NAIL N
INSURER A: Preferred Mutual Insurance Company
INSURED INSURER B:
Hirsch Fence Install & Design LLC INSURERC:
747 Rt 9w Cottage #4 INSURER0:
Valley Cottage, NY 10989 INSURERE:
INSURER F:
COVERAGES CERTIFICATE NUMBER: 00002210-0 REVISION NUMBER: 7
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 ADOL SUBR POLICY EFF POLICY EXP
TYPE OF INSURANCE W"DPOLICY NUMBER MMIDDfY MM/DD UMfrS
A X COMMERCIAL GENERAL LIABILITY Y BOP0100721375 11/12/2023 11/12/2024 1 EACH OCCURRENCE s 11000000
CLAIMS-MADE OCCUR AMA N
urD S
MED EXP(Any oneperson) S 10,000
PERSONAL&ADV INJURY S 1,000,000
GEN'L AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE S 2,000,000
POLICY C�7CTC LOC PRODUCTS-COMP/OP AGG S 2,000,000
^'HER.
S
AUTOMOBILE LU186J1Y COMBINED SINGLE LIMIT S
enD
ANY AUTO BODILY INJURY(Per person) S
OWNED SCHEDULED BODILY INJURY(Per accident) S
AUTOS ONLY _AUTOS
HIRED NON-OWNED PROPERTY DAMAGE S
AUTOS ONLY AUTOS ONLY
S
UMBRELLA UAB OCCUR 1 EACH OCCURRENCE S
EXCESS LIAS CLAIMS-NIADE AGGREGATE S
DED RETENTION S
WORKERS COMPENSATION PER OTH-
AND EMPLOYERS'LIABILITY Y I N STA LITE ER
ANY PROPRIETORPARTNEPJEXECUTIVE E.L.EACH ACCIDENT S
OFFICER'MEMBEREXCLUDED' N/A
(Mandatory in NM) E.L DISEASE-EA EMPLOYEE S
If yes.describe under
DESCRIPTION OF OPERATIONS below E.L DISEASE-POLICY LIMIT S
DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES (ACORD 101.Additional Remarks Schedule,maybe attached if more space is required)
Address : -2 Jennifer Lane Rye Brook, New York 10573
Certificate holder listed as Additional Insured
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 NY10573
AUTOO_ D T1uF
CPO
C,1988.2015 ACORD CORPORATION. All rights reserved.
ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD Printed by CPO on 03 282024 at 01 09PM
"EW i Workers' Certificate of Attestation of Exemption
STATE Compensation 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): Building Permit
Hirsch Fence Install do Design LLC
747 Route 9AV#4 From:Village of Rye Brook
valley Cottage,NV 10989-2452
PHONE:845-304-8622 FEIN:\Y—XX►0091 The location of where work will be performed is
2 Jennifer Lane,Rye Brook,NY 10573.
Estimated dates necessary to complete work associated with the building
permit arc from March 28,2024 to March 25.2025.
The estimated dollar amount of project is SO-SI0,000
Workers'Comnensation 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 LLC,LLP,PLLP or a RLLP;OR is a partnership under the laws of New York State and is not a corporation. Other
than the partners or members,there arc no employees,day labor,leased employees,borrowed employees,part-time employees,unpaid
volunteers(including family members)or subcontractors.
Partners/Members: Bruce Hirsch
Disability and Paid Familv Leave Benefits Exento(ion 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: I) 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,Bruce Hirsch,am the Member 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 1
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 a ve-named legal entity will immediately acquire appropriate New York State specific workers'
compensation insurance and/or disability and pa' family leave benefits coverage and also immediately furnish proof of that coverage on forms approved
by the Chair of the Workers'Compensatio B d to the government entity listed above.
SIGN HERE Signature: Date:
Exemption Certificate N ber Received
2024-023022 March 28, 2024
NYS Workers' Compensation Board
CE-200 01/2018
Laura Petersen
From: UDig NY Exactix <tickets@exactix.udigny.org>
Sent: Tuesday,April 23, 2024 11:18 AM
To: Steven Fews
Subject: Message from UDig NY
****REGULAR****
DIG REQUEST from UDig NY for: VIL RYE BROOK Taken: 04/23/2024 11:17
To: VIL RYE BROOK PRIMARY Transmitted: 04/23/2024 11:17 00002
Ticket: 04234-001-238-00 Type: Regular Previous Ticket:
------------------------------------------------------------------------------
State: NY County: WESTCHESTER Place: RYE BROOK
Addr: From: 2 To: Name: JENNIFER LN
Cross: From: To: Name:
Offset:
------------------------------------------------------------------------------
Locate: WORKING ON LINCOLN AVE SIDE AND JENNIFER LN SIDE
NearSt: LINCOLN AVE
Means of Excavation: POST HOLE DIGGER Blasting: N
Site marked with white: N
Boring/Directional Drilling: N
Within 25ft of Edge of Road: N
Work Type: INSTALLING FENCE
Estimated Work Complete Date: 04/26/2024 Depth of excavation: 2 FEET Site dimensions:
Length 200 FEET Width 10 INCHES Start Date and Time: 04/26/2024 07:00 Must Start By:
05/10/2024
------------------------------------------------------------------------------
Contact Name: BRUCE HIRSCH
Company: HIRSCH FENCE INSTALL & DESIGN
Addrl: 747 RT 9W Addr2:
City: VALLEY COTTAGE State: NY Zip: 10989
Phone: 845-304-8622 Fax:
Email: bruce@hirschfence.com
Field Contact: BRUCE HIRSCH
Alt Phone: 845-304-8622 Email: bruce@hirschfence.com
Working for: HOMEOWNER
------------------------------------------------------------------------------
Comments: Lookup Type: PARCEL
------------------------------------------------------------------------------
Members: ALTICE USA BELL-VALHALLA/ WSCHSTR
CONED SUEZ WTR WESTCHESTER
VIL RYE BROOK WESTCHESTER CTY SWR
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Lot 2
Survey of Property
F-) re p) a red for
=
n i APR _ Z 2024
.- D e N fir'% k yi" 5 w i iS
Alex Szigety M y1lim Searles
in the Villoge of
Rye Brook
Town of Rye
Westchester County, N. Y.
Scale 1"-20' Aug . 17, 2022
Certifications added Sept. 21, 2022.
The premises being Lot 1 as shown on a mop entitled "Mop of Rye f�i//s "doted Mari IE
rj
V\
,�1, 1950 and fi%d May 17, 1950 as Coun y Clerk Map No. 7064.. D IE
Abstract, LL C `Yestcor L and Tit/e Insurance Company, f
Certified to Cornerstone Land bs ,o y.
First Republic Bonk, /.SAGA, and Alex Szige y & Kay/in Searles k OCT 3 2022.10
L�.- __j
1 VILLAGE OF RYE BROOK
BUILDING DEPARTMENT
L of Area = 10, JM sq. ft or 0. 290 acres
Subsurface structures and their encroachments, if any exist are not shown hereon.
"(Jnaudhor/zed aIterations or additions to a survey map is a violation of section 7209,
sub-div/SYon 2, of the New York State Education Law.
"Only copies of the original survey marked with the land surveyor's inked or embossed
seal shall be considered a true and rro/id copy . "
'Certifications indicated hdr&On signify that this survey was prepared in accordance with the
existing code of ,practice for Land Surveys adopted by the New Yon(r State Association of
Professional Land Surveyors: Said certifications shall run to the person for whom the survey
is prepared only, and on his behalf to the Title Company, governmental agency and /ending
institution listed hereon, and to the assIynees of the lending institution . CER77FIC417ONS
ARE NOT TRANSFERABLE TO A0,0MONAL INST/TUTIONS OR SUBSEQ!/ENT OWNERS . Al
Copyright ('c) 2022 `Yam' Carpenter Engineers, Inc. All Rights Reserved.
� S-BUILT
DOCUMENT
76 Mamaroneck Avenue
White Plains, N. Y. 10601
Job # 56538 File # LDD 52612\dwg\56538.dwg
—Unauthorized additions to or alterations of this
plan is a violation of Section 7209 of the N.Y.S.
Education Law.
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AS -BUILT
DOCUMENT
1 V. O l f � may` �Z /�
Richard A. Spinelli
650 Halstead Avenue
Mamaroneck, N. Y. 10543
(914) 381-2357
N.Y.S. Lic. Land Surveyor
No. 49240
JENNIFER
LANE
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Survey of Lot 1 as shown on
"Map of Rye Hills" in the Village of Rye
Brook, Westchester County, NY.
Filed March 31, 1950 as Map No 7064
Scale 1"=15' July 23, 2020
(Updated)March 26, 2025
E
JEN N'F r_R D L _E
APR - 4 2025
VILLAGE OF RYE BROOK
BUILDING DEPARTMENT