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HomeMy WebLinkAboutBP24-107PERMIT #r6/ ,z=) ! `/0 SECTION 135, 6 6 TYPE OF WORK ®'- CONT'RACTOI EST. COSTA ✓CO #� TCO # FOOTING FOUNDATION FRAMING RGH FRAMING INSULATION PLUMBING RGH PLUMBING GAS m SPRINKLER S2 ELECTRIC LOW -VOLT ClALARM 0 AS BUILT CO FINAL i DATE: 5 a 9 a 21 ff� 'g � �.Q•-� Du DATE FEE, c 1 a 9, I LOT � q �00�1 /C2no t/ct7�»�!S 3i(T� goyo p /7 Q/7-3�93 FEE DATE • I NSP plc/C rPo�� �S OTHER APPROVALS OTHER VILLAGE OF RYE BROOK WESTCHESTER CouNTY, NEW YORK NO: 24-130 (Certiftrate of ®ccupaucp This is to certify that �- of, C gv&f) / V having duly filed an application on OCkbf'l- 91 20 requesting a Certificate of Occupancy for the premises known as, /-7 ' Rye Brook, NY, located in a '�Q Zoning District and shown on the most current Tax Map as Section: 13 5. && Block: / Lot: 9 , and having fully complied with the requirements of the Builldiin�g Code and the Zoning Ordinance under Building Permit No. 7 /v-7, issued 200✓`1 , such authority and permission is hereby granted to the property owner to lawfully occupy or use said premises or ilding or part thereof listed under the following New York State Classifications, Use: t° Q �/ Construction: , for the following purposes: Lea S L64L/wm 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 in heig all be m e, nor s all 1 a uildi a moved from one location to another until a permit to accomplish such change has eMin the B it n pector. OCT 2 1 1014 Building Inspector,Village of Rye Brook: Date: h , BUILDING DEPARTMENT For office use�oon��ly, : PERMIT # / dy-/0 7 VILLAGE OF RYE BROOK ISSUEDa S� OCT _ g �A24 ( 938 KING STREET,RYE BROOK,NEW YORK 10573 DATE /O— —� L� (914)939-0668 FEE PAIDV 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 rrwtr►wrrrr�wjwwrr►►►rrrrrtrrwrrt►rtwrwrr►►►►rtr►►r'rr►,w�►►1+rrw►ttrr+►t►rrwrr+rr+rrtwr►r►►►►wrwt+r►►►+r+t►►r►r+rwr►rt►►►r+rr+r►rrr►rr Address ( 1 �� n r ir � y Ey� r IL /,�`t o5j 3 — Occupancy /Use: �4✓UI Parcel) ID #: �3S� �O�- �— �/ Zone Owner: �� � f1J (A+ -(A Address: P.E./R.A. or Contractor: P IN f7 Q 1r)f, 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 y�O.FA NEW �YORK. COUNTY OF WESTCHESTER as: / n 1J being dull sworn.deposes and says that he/she resides at �� ��h n%frr � O'Hilt Aem,:,l \��hli.;u��i Ao .uuf titii�I in 9�l.' ��DO in the County of 1 �5 � M in the State of_N 4 ,that 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: ti ® _ , for the construction or alteration of: fzenoyoJ i onSX, h 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 kno"ledge and belief. the structureAvork 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-I O.A.of the Code of the Village of Rye Brook. Sworn to a re Viis e 1-h Sworn to before me this y o ref 20 ZL day of (D C+UVacr , 20 244 s i giqtwWoiNopp in yyOwner S ureofApplicant Tq--\ *b��`P Print Name of Prop t Oener Print ameofApplicant Notary Public Notary Public MICHAEL A. MCEVOY MICHAEL A. It9CEVOY Notary Public, State Of New York MICHAEL A. ^` 'Y a 12r_021 No.01 MC6054874 Notary Public. St.- . `1+ -w York Notary Public,State O i New York Qualified In Westchester County No.01011- .)r t. No.01 MC6054874 Term Expires February 12,20,Z Qualified In tN Qualified In Westchester County Term Expires f ;ry County_ Tes m Expires February 12,20 z S- - p ''20 21 QyE BR(�jk /�• 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 - - - - - - - - - - - - - - - - - - - - iADDRESS : DATE: PERMIT# ISSUED: SECT: 1 BLOCK: LOT: LOCATION: t Q 1 r "� u � 1� j�1R )C�� OCCUPANCY: ❑ Violation Noted THE WORK IS... [J 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 [Q FINAL ❑ OTHER QyE DRC��, c 1982 •��O BUILDING DEPARTMENT ❑BBUILDING INSPECTOR 9"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 :— ' Sew J -L Lox, � DATE:- - L ' 1 oL PERMIT#QzJr - �l7 / ISSUED: -Z �-i ` ECT: /3S 4L 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 0_ ROUGH FRAMING ❑ INSULATION ❑ NATURAL GAS c+ ❑ L.P. GAS ❑ FUEL TANK ❑ FIRE SPRINKLER /s4 ❑ FINAL PLUMBING ❑ CROSS CONNECTION AA� ❑ FINAL I cot, S/ CtJG� ❑ OTHER !1 E BROO, O Zm a,/� •Fb 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 ..-E} SITE INSPECTION REQUIRED ❑ FOOTING ❑ FOOTING DRAINAGE ❑ FOUNDATION ❑ UNDERGROUND PLUMBING NOTES ON INSPECTION: ❑ ROUGH PLUMBING ' ❑ ROUGH FRAMING ❑ INSULATION ❑ NATURAL GAS �2 ❑ L.P. GAS ❑ FUEL TANK ❑ FIRE SPRINKLER ❑ FINAL PLUMBING ❑ CROSS CONNECTION ❑ FINAL ❑ OTHER a , a : L N N e \CV � W C ca M1, ° � _ Cn p4 4 a s+ a p O p z � � a � M > �" z0 CA PoCU a w �i O Gti.� der t1) a w W a Lgi w v C a tj [z] O �...� O � Q F 3 U o a •• W 44 114 p W Wci ° ariaQ", a ti a � W � „ o �, �W a W �b" � A H o � cILn Q a . = w F W M W °a+zo " von R� W 20 W 0 ri 00 W [� p p ^a v v V z O �j W v Q n cn W V z v o 0 U2CN W s CR r va = ° eQS a �Ia �j z z � a�° � U rR vi w ,'� I, 00 O V. o p o o o o W e y 1FJJ ll fi, E-4 w O v v v V W H z O F+ a s u'� z z 2 z w oQ � (� z V O U y, O Va � �' ►'� W V 2 wI � .o Z O m m ' ° c, o o �- z w C) �i W x CA cu BUILDING DEPARTMENT _D VILLAGE OF RYE BROOK - 938 KING STREET RYE BROOK,NY 10573 MAY 14 2024 1 DD (914)939-0668 «ivw xvebrook.orgy VILLAGE OF RYE BROOK BUILDING DEPARTMENT INTERIOR BUILDING PERMIT APPLICATION FOR OFFICE USE ONLY: �f n ]'� Approval Date: MAY Z 1 20$ m i ��7 �U Application Fee:$ '�!". \ S� Approval Signature: Permit Fees: $ � vo'0 X 3 m Disapproved: Other: L �x `� U Application dated: ,) —1 iW 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. 1. Job Address: 17JENNIFER LANE SBL: 135,66-1-9 Zone: R-10 2. Proposed Improvement. (Describe in detail): RENOVATIONS TO EXISTING KITCHEN AND EXISTING BATHROOM AT FIRST FLOOR DUE TO WATER DAMAGE 3. Does the,�proposed improvement involve a Home-Occupation as per§250-38 of the Code of the Village of Rye Brook? No: V Yes: If yes, indicate: TIER 1: TIER II: TIER III: 4. WiII the proposed project require the installation of a new,or an extension/modification to an existin automatic fire suppression system (Fire Sprinkler,ANSL System, FM-200 System,Type I Hood,etc...) :No: 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: 1 FAM After Construction: 1 FAM 6. N.Y State Construction Classification:VB N.Y. State Use Classification: R-3 7. Property Owner: SEAN DUTRA Address: 17 JENNIFER LANE Phone# Cell#914-318-8090 email: SDutra@freepoint.com 8. Applicant:SAME AS ABOVE Address: Phone# Cell# email: 9. Architect: Address: Phone# Cell # email: 10. Engineer: MANG WONG, P.E. Address: 16 TURNER LANE, MT KISCO Phone# ran/ 914/-441-4834 email. laldesign77@gmail.com it. General Contractor:'/1�gb,i7C�7`S Address: QO N /__gcylae.4�, Phone#91* 3 7)- /8 /a Cell#_, 91 7"ol/ 7_W 9Z _email:/t1��{'I 12. Estimated cost of construction $ D , C)6) D JO`7r1 141�el' i (NOTE:The estimated cost shall include all labor.material,scaffolding.fixed equipment,professional tees,and material and labor%which may be donated gratis.) 13. Job Timetable: Start:Z'eQCtJ I y Y �Finish: _T�A Y (I) 6/I/2Q23 BUILDING DEPARTMENT d QV IE t VILLAGE OF RYE BROOK 938 KING STREET RYE BROOK,NY 10573 MAY 2024 (914)939-0668 ..___1 4 iN-w,%.n,ebrook.org I VILLAGE OF RYE BROOK 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: I, S {�CII �(1 �l ll( .,residing residing at. Tt' `1 r' �_N l rtX)k I' i Print name) f Address�Nlierc\uu Ike) 3 being duly sworn, deposes and states that(s)he is the applicant above named, and further states that(s)he is the legal owner of the property to which this Affidavit of Compliance pertains at; 1 Ten -c �� �� r 1� , Rye Brook, NY. Llob 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. (tiignatur ol ' Peru U�tinc .11 r (Print ame of Property Owner(s)) Sworn to before me this r ' day of "y . 202-q _ I�otan I'uhlic► R41CHAEL A. MCEVOY Notary Public, State Of New York No.01 MC6054874 Q) Ouefifted In Westchester County 'term Expires February 12,20_ 8/12/2021 This form must be properly completed&notarized by the Design Professional of record and the Property Owner. Failure to provide this completed f nt" �V l permit application will delay the permitting proce -----L� ***** * * * **** **** ****** ** MAY 14 2024 9 Notice of Utilization of Truss Type, Pre-Engineered o LAGE OF RYE BROOK BUILDING DEPARTMENT or Timber Frame Construction. (Title 19 Part 1264& 1265 N To:The Building Inspector of the Village of Rye Brook. From: SEAN DUTRA SubjectPropegy: 17 JENNIFER LANE SBL. 135.66-1-9 Zone: R-10 Please take notice that the subject; ❑One or Two Family;❑ Commercial, ❑ New Structure ❑ Addition to an Existing Structure WRehabilitation to an Existing Structure to be constructed or performed at the subject property will utilize; ❑ russ Type Construction(TT) YPre-Engineered Wood Construction(PW) ❑ Timber Construction(TC) in the following location(s); ❑floor Framing, including Girders&Beams(F) (Roof Framing(R) ❑ Floor Framing and Roof Framing(FR) Please note that prior to the issuance of the Certificate of Occupancy, the subject dwelling or building utilizing truss type, pre-engineered wood, or timber construction must be posted with a Truss Identification Sian, installed in conformance with NYCRR§1264 for Commercial Buildings, and NYCRR§1265 for One&Two Family Dwellings. Sworn to bef.4re me this I ' Sworn to bef nie this 15 da of ' 1 "y 1202 day of ,20 ZZ I ature of operty Owner Signature of Design P ssional fan ' c Print NWW o op�' Oer Print Name �Pe al Notary Public Notary P Ir ,,.`o�yV G 0 S MICHAELA. MCEVOY ;'��`•' g"iATF Notary Public, State Of New York No. 01 M06054874 (3) �pTARY PUF3l IC = Qualified In Westchester County = Qua1 Teim Expires February 12,202�Z_ p', '&'ichestorCouay% o 'Ll 1"7_.•' C' iSSJON EXQ\�`�,: 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: �'& OL , being duly sworn, deposes and states that he/she is the applicant above named, (print name of individual signing as the applicant) and further state that (s) e,�s the legal owner of the property to which this application pertains, or that (s)he is the L S)rT r CA t7 r for the legal owner and is duly authorized to make and file this application. (indicate architect,contractor,agent,attorney,eta) 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 I_-) Sworn to before me this dav of MA 20 2-` day of , 20 _Z- _ �_. Signature of Propert J� Sign ofApplic t QQ� !nJrW_J_1T Print Name of Property Owner Print Name of Applicant Notary Public Notary Public MICHAEL A. MCEVOY Notary Public, State Of New York MICHAEL A. MCEVOY No. 01 MC6054874 Notary Public, State Of New York Qualified In Westchester County No.01 MC6054874 Tesm Expires February 12,2on— Qualified In Westchester Coun Term Expires February 12,20 , (4) 8/12/2021 r a M � a AN.+ 00 00 o z In, n F b W z A � x W M � O rill Z O W o � w w F 00 a U w w o cn • W w PC 0 M4t w z ` A W .., oo a �; z W a a � u00 z can Z Z \ M a a < O '-a V0.0 00 en , Q w w z q CY .. c w A r V OW F � " z z W C4 a d w N 0 04 r I--� p U 4 a Ue W z H o F 11. 0 z N W ui o Hs W W v W o 0. V °` x a w A a 02 BR BUIL MENT ��(.`� Et L7, Lr VIL E OF RYE; OK 1 0 938 KIN •> -r RYl?B ,NY 10573 FJUN' 2 7 2024 w � VILLAGE OF RYE BROOK �ELECTRICAL PERMIT APPLICATIO BUILDING DEPARTMENT Westchester County Master Electricians License Required FOR OFFICE USE ONLY BP#: Qq— l O 7 EP#: ^��— .... . ...-- Approval Date: 2 I �- Permit Fee: $ Approval Signature: Other: DO NOT START WORK or CONSTRUCTION UNTI1, 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 dateZ-Q7—3—// 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. 17 Jennifer Lane // —/o 1.Address: SBL:�3J�.to�—�—� Zone: 2.Property Owner: Sean & Lori Dutra Address: 17 Jennifer Lane Rye Brook NY Phone#: 914-318-8090 Cell#: email: 3.Master Electrician/Licensed Installer: Carmine Mazzuoccolo Address: 3231 Ampere Ave Bronx Ny 1046` Lic.#: 1767 Phone#: 6466624226 Cell#: email: empireelectricnyc@gmail.com Company Name: Empire Electric NYC Address: 4.Proposed Electrical Work/Fixture Count: Legalize Interior Kitchen and Bathroom Renovations 5.3rd Party Electrical Inspection Agency: Swis ******ie ie******ix*ix ie*ie*ic ie**ie ix*ie**ix*ie*ix i*c****ie ix ix is is ie is is it it it icx is**iz*iz*ie it ie**ie ie**ie is*ir is is*i is is**ie*ix***ir ie***ir***ix**r.*i: STATE,OF NEW YORK.COUNTY OF WESTCHESTER ) as: 5 e I �u-�-rw- .being duly swom,deposes and states that he/she is the applicant above named,and does further (print name of individual,,-ning as the applicant) state that(s)he is the for the legal owner and is duly authorized to make and file this application. (Master Electrician I 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 all other applicable laws,ordinances,and regulations. SwojMj_ojiefbre in this C12C Sworn t fore me this day + _ ,20 day of U^-- - ,20 Sr�pa$tre o etnei ture of Ap nt Pr" e of Property Owner At#*TTE MORLINO ame of Applicant • Nuaaay liubk,!State of New York �_ _� �.01 M0601 1261 Nota ELiI Notary Public Otrx: WettCfw►edK C ounty a 0063 ,(Ptwe" ai>n Expires august, 3, Qualified in Westchester County 6/1/2024 Cornmission Expires January 29,202� STATE WIDE INSPECTION SERVICES, INC. ••0 • SWIS JOB APPLICATION tel 845.202.7224 1 fax 0. Office Use Elect. Permit# — Z/ /3 Date Bldg Permit# tp �t� _ G Sq Ft Plumbing Permit# Final Certificate# City/Village f Zip 1. Building Dept. County � Address Cross Street Section Block Lot Owner Name/Address(If different than above) ,n v L< v Contact Number �-(� CI t -"'r o U ❑Basement ❑ 1st FI. ❑ 2nd FI. ❑3rd FI. ❑More Than 3 FI. ❑Garage ❑Attic ❑Outside `❑Residential ❑Commercial Receptacles Special Recept GFCI AFCI Switches Dimmers Smoke Alarms C/0 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 D ICCCWr JUN 2 7 2024 VILLAGE OF 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 e�^ �� ;`N `���, Name Ck V W ec-L L U c c License# ` 7 Date — _�� Signature Address 7) � e City/State ���,,� A)-,( Zip Code G(A Company 1� Phone# `C )L — q State Wide Inspection Services 1080 Main Street OCT 1 1 2024 Fishkill, NY 12524 845 202-7224 Phone 914-219-1062 Fax STATE WIDE INSPECTION SERVICES Email: office(a)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: Empire Electric NYC, LLC Sean & Lori Dutra Carmine Mazzuoccolo 17 Jennifer Lane 3231 Ampere Avenue Rye Brook, NY 10573 Bronx, NY 10465 Located at: 17 Jennifer Lane, Rye Brook, NY 10573 Section: Block: Lot: Electrical Permit Number: EP24-136 135.66 1 9 — - - J Certificate Number:2024-6308 Building Permit Number: BP24-107 A visual inspection of the electrical system was conducted at the Residential occupancy described below.The electrical system consisting of electrical devices and wiring is located in/on the premises at: 17 Jennifer Lane, Rye Brook, NY 10573 The First Floor Bathroom& Kitchen were 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 loth day of September 2024. Name Quantity Rating Circuit Type Island GFCI 02 Counter GFCI 04 Stove 01 Refrigerator 01 Dishwasher 01 Recessed Luminaires 12 Switches 03 A Visual Inspection of existing conditions was performed on September 101h, 2024 of the First Floor bathroom & Kithhen and Conforms to NFPA 70-2017 NEC. No Defects Were Noted. 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. i � N N � i \ M Ln N r W a a a o H O � � M� i ON ASC W bo • O '� O O z o W a0 0w A �i Z Z p w ~' Q o can = 00 w Fa O ' A W OP oo W O W O U C7 w 's H xcs A 00 o w z CN ►-� C� A > V , a 3 '--4 A x pp G1 o W _ Zj i--r O fn w Z � M `. Ood5g 1-4 z8 a .. 101, O z o , Z 1 a Vg � , W v a a. 6o , x z w z A c � ., w A o w a w � BUILDING DEPARTMENT I VILLAGE OF RYE BROOK MAY 3 0 2024 938 KING STREET RYE BROOK,NY 10573 VILLAGE OF RYE BROOK (914) 939-0668 BUILDING DEPARTMENT ,,N w-xv.ryebrook.org PLUMBING PERMIT APPLICATION l/ �/ FOR OFFICE USE ONLY BP#: �� 0� PP#: �'7 —O / t _ Approval Date: 3?2� Permit Fee: $ Approval Signature: ed 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$750.00 Application dated,- 30—c2$L/ 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. 1.Address: 1 7Z :Tc)adjAe L one SBL: 135,64 Zone: 1 2.Proposed Work: \ C S � �� 1�e 3.Property Owner: Sect h �164 Cv Address: 1-7SC rod K v IOS`T_? Phone#u/0 Cell #(M —go /D email: 4.MasterPlumber:"D.J Address:;'o ��. oW ne w_ n 105fy Lic. #: Phone 44W Cell #��/�`� 755A7y.5 email: ee r p Company Name:Vq A',e O V+IT �,� Address: 'a I 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 Ist Floor 7 2nd Floor 3`1 Floor 411 Floor 5"Floor Exterior 5.* List Other Equipment/Provide Details: 1��, r l��ry fc S '��l n p!w 6 Li.r j' Se coo ts°- FL 8�i'1, — -TZLl (Notarized Signatures Required Next 2 Pages) -I- 3/3/2023 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 be^ ^ met 's � Sworn to before me this day of I v 1 120 Z L- day of ,20 -1010, St re o perty O r Ignature of Applicant on Print Name of Property Owner Print Name of Applicant Notary Public MICHAEL A. MCEVOY Vi I'�State of New York Notary Public, State Of New York No.01ME6160063 No.01 MC6054674 Qualified In Westchester County Qualified In Westchester County Commission Expires January 29,20Z-7 Term Expires February 12,20_.?_2 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 BUILDING DEPARTMENT D E C EN E I VILLAGE OF RYE BROOK MAY 3 0 202.4 U 938 KING STREET RYE BROOK,NY 10573 (914)939-0668 VILLAGE OF RYE BROOK ��w«.r�ebrook.ora BUILDING DEPARTMENT xzi:iirzzr.iric*icicicrcic�cxcr. czzicxxxxxxxxxxxxFiticicxxicxirxkzic*zzieir:FicicxicKiez�xicczccezici:xKk:Fx:Fieiei:�eF*ieFkie:kkirkisit*Ficis**x 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 YYORK, COUNTY OF WESTCHESTER ) as: 3, S �`�� 1JUl '— , residing at, 1-7 12on1 ►—N (Print name) (Address N\here\ou li\e) 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; i6roo ie M 1 11-11 :_� , Rye Brook,NY. (Joh :Addres,) 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 Villag odes. (Sid Prope ner(s)) 'Se CLC\ 1 (Print Name of Property Owner(s)) 1 _ Sworn to before me this w' day of �� , 20 2-J (Notar\ PUhliC) MICHAEL A. MCEVOY MICHAEL A. tL6:'I`-VOY Notary F . ^''' Of New York Notary Public, State Ot h.ew York No 1874 No. 01 MC6054874 Qualified Ir, `'r (7mfi" Qualified In Westchester County Term Expires 7 Term Expires February 12,20 8/12/2021 .Building Pernut Check List&Zoning Analysis Address: �\yN 1 ��C 2RG SBL• Zone: use: COM Type: Other. Submittal Date 1��S 1 1 Revisions Submittal Dates: Applicant: ,,/ 1 Nature of Work `-'e t �� '�-�1 < < �� u� tQ� o 1 C C., 1 QG'bS ` -)�C V(a i cY S Reviews:ZBA: MAY 9 0 2 n 9 n PB: BOT: Other. W.OX3 F � � � �D - 1 (7'C,YFEES.Filing: '� BP: C/o. Flood Plane Legalization: P ( ) ( YAPP: Dated G Notarized:_�SBL_,1Trtm I.D. Cross Connection: H.O.A.: Jam, l U� ( ) ( ) Scenic Roads: Steep Slopes: Wetlands: Storm Water Review: Street Opening- ) EIWIRO: Long,. Short Fees: N/A: ( ) ( ) SITE PLAN:Topo: Site Protection: S/W Mgmu Tree Plan: Other. ( ) ( ) SURVEY:Dated. Current Archival:- Sealed: Unacceptable: j( ) (,� LANS:Date Stamped `Seale¢ / Copies: Electronic Other. ( Llcense: ✓ Workers Comp: ✓ L,ab hty: 1/ Other. :-\ -QII S L t Q04-sSdT5 Cat c,cie ( ) ( ) 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.:_Batter)r_Ocher. (y( ) 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 Places PeM3it 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. ( ) ( ) Ocher: ( }ARB mug.due: approval:- notes: ( )ZBA mtg.due: approval.• notes: ( )PB mtg.date: approval notes: a Q1QAn\/1213 REOUMED EXISTING PROPOSED NOTES Ara: Date: MAY 2 1 2024 Circle Frm�ta G Front Front Sides: Rear. Main Cov. a+1PTt Accs.Cov ;r + Ft.H Sb: Sd.H Sb: GFA ` Tom: Ft.imp: Hei&/Stories notes: �E BRC��, O�` tim .`i�O-c 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 :— ' �P0� i .__� DATE: J j `�L7 PERMIT# S t �e y i S J ISSUED: SECT: BLOCK: LOT: LOCATION: 5 i � V(tA S -w. O , OCCUPANCY: ❑ Violation Noted THE WORK IS... ❑ PASSED FAILED / REINSPECTION E'-SITE INSPECTION REQUIRED ❑ FOOTING ❑ FOOTING DRAINAGE ❑ FOUNDATION ❑ UNDERGROUND PLUMBING NOTES ON INSPECTION: ❑ ROUGH PLUMBING ❑ ROUGH FRAMING ❑ INSULATION C / k SP❑ Natural Gas T J IP -L I C c> .> i S( L ❑ L.P. Gas W011c [wo 1� ❑ FUEL TANK I- ' � S D ( ❑ FIRE SPRINKLER �� WALL S C u 1 S L-P `K) h � V ❑ FINAL PLUMBING ❑ CROSS CONNECTION ❑ FINAL V a, 1� ❑ OTHER E BR(8 FO 1932 BUILDING DEPARTMENT ❑BBUILDING 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 : ` ;7 1 Q/ DATE: 2i 7iGZY" PERMIT# ;5TD P A10 ei K. U2C�aSSUED: SECT: �3S L� BLOCK: I LOT: C� LOCATION:`2>0 I11I rJ2�G /'V �10A%e 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 --�- p ❑ Natural Gas JL-A_ ❑ L.P. Gas❑ FUEL TANK w �dim _ ❑ FIRE SPRINKLER IVG . ❑ FINAL PLUMBING ❑ CROSS CONNECTION ❑ FINAL /240'/ A / 500 P /,6 ❑ OTHER p N. _ Q o 1 QLLJ 6q N L ' O V !� G. 1 O O 1 uj i Q O m � V n _ �- w a O W w CL CC z Q) uj �-- ? a W r �' co A y CC LL ` r m o �. = r LL UJ W .. � i < ` MM 1 r'• Ij�1 1 1 L Z � ? t _ / \ 1 — CJ U y m Q _ ul O, Va 1 Lu 1 w 1 >\ LU 1 - col d 1 1 1 Q � o tiZ 1 1 L11 _ o;O W i c lic 1 1 O1 m' 1 � o W CLQ)l 0;'S�z V a 1 ry O O N Q), `/ 1 1 1 L ld V Ci - C Q Z cc � n; 21J .r /, QI=41m .000 w O till m :z � _M � w Q � r Cl LLuj ✓ �/ °I Q 1 x w $� cI W 1 _ ... u,Z. 1 V >I�i H 1 of�} ul I od UJ n (� r' ca i 0 o 8-1 o - � Of 3 .E o W 1 ,o x CL Ix a \ Wail y o Z ? .. ' N W i. 2Y U O S = c!C7 W x0 Co i x o >=�m = M \ W N, Q a.� Q' ; Z Q ~ = ! wn 0 O� to Z E(" W Z. " • ...I i _ f LL. � t Ic IC w 3: Z _ +■'�i 31 r' W ce _ _, U_ O J o �� o!QI e — c i � .� N ti I` uz I `f >ui W wo coo CL �., 0, Q J1 _ a � 1 r. _ 1 ^ ��,•_�.°f5' ^ �: w!yS 1� '..� n({1j1� /y'�•ppal�"r• .>'*� /'• ^.�.,� �N17^A' ,7s•� �^ ,c \ f� (ir.. `f•,� �' �f •,•mos f// ����f. �Y•,rrl Y ,���/N " Y rir�'7 '� l ,, R? ��R� t1���j{� � ` tN tt t y •�, {� r.C(Os- •• �� 4 ) ` (11�i..\ i:,. �j r ....�1,1(,''�/,' � v^ '.e-1�1�'�1111�`��•�'{ ',��11 .���)/l�yi ,1;,1,;1�,'ir`��;^�IfiC" 11�/'I�II �i'�lt.���,, ,1�,�;���41�"�1/)�'_,,I�,I;I,I,TjIS�'�(' �:.\Ill�lll+t;`:�-. 111�111 '+St!�/ V.'+,'`''l l,�lll�;'�... t;. 11l,�lll•'',r�••:_r •t `111.`IIIi�Tt•l..y.:='s"�111 111 °?`�_i' �'"� 'll�l,l'�+• d'^+.� �'t �t s. fv > �.. 0. N LO U Ucr "• � .4.0 / O �' Y CD _ � = LU fn au ci ca 94 ci • 4:•ram`,,,' U Vl I" •'� ��. 10' � yw 11�t�:!�1��'` 3tr�jw �rF �l:)�I��:f� t1�j��i�� ''�'��`y�1���,�►`t��t� 1�i�i "9 1,iill '�t!' � ���'�i • ' �l.J ' .�. t.•J.r.t., A• li ����� r'-� `A 'r a�"W��J+t:?\1•` • -),. �: v ��b A :,� 3`.�7a+�'a�'_ '4•.. 'Y�0�+1 �`^ "�`�' (Nv� ��{` ,� u' �1/v~�•„+�•'� ��.l,?N"Y` A`�10,.�� i"—`ssN YOURWAY-01 GNEAL .40cOR0 CERTIFICATE OF LIABILITY INSURANCE F��51231' /Yyyy)(MMDD `—'"'� 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 Gary Neal NAME: LambrOS Insurance SefVICeS Inc PHONE FAX 4 West Red Oak Lane (roc.No,Eaq:(914)686-0100 �,No):�914)686-0544 White Plains,NY 10604 AIL ADDRESS,9n@lambros-insurance.com INSURERS AFFORDING COVERAGE NAIL tl INSURER A:Twin City Fire Insurance Co 29459 INSURED INSURER B:PrO ressive Casualty Insurance Co 24260 Your Way Custom Cabinets,Inc. INSURER C:CenturySurety Company 36951 dba N. Ma Cabinets Pro and Casual Insurance Company of Hartford 20 N. MacQuesten Pkwy INSURERD:Property Casualty Pa Y 34690 Mount Vernon, NY 10550 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE rj DDL BIIBR POLICY NUMBER POLICY EFF POLICY EXPLTR LIMITS A X COMMERCIAL GENERAL LIABILITY 2,000,000 EACH OCCURRENCE CWMS-MADE 'OCCUR X 16SBAAC0748 12/31/2023 1213112024 DAMAGE TO RENTED 1,000,000 X Contractual Liab 10,000 MED EXP An one person) PERSONAL d ADV INJURY 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE 4,000,000 POLICY�jp� LOC PRODUCTS-COMPIOP AGG 4,000,000 OTHER: B AUTOMOBILE LIABILITY COMBINED(Ea ident)SINGLE LIMIT s 1,000,000 JxANY AUTO 06280029-4 10/20/2023 10/20/2024 BODILY INJURY Perperson) OWNED Ix SCHEDULED AUTOS ONLY AUTOS SSWryEp BODILY INJURY Per accident AUTOS ONLY AUTOS ONLY PPa�e citlen DAMAGE C UMBRELLA LIAB X OCCUR L $EACH OCCURRENCE 5,000,000 X EXCESS LIAB CLAIMS-MADE CCP1194527 12/31/2023 1213112024 AGGREGATE 5,000,000 DED I X I RETENTIONS D WORKERS COMPENSATION X I PER OTH- AND EMPLOYERS'LIABILITY A LITE Y/N ANY PROPRIETORPARTNER/EXECUTIVE 16WECABI000 12/31/2023 12/3112024 1,000,000 OFFICER/MEMggEER EXCLUDED? N/A E L EACH ACCIDENT (Mandatory In NM) E.L.DISEASE-EA EMPLOYEE S 1,000,000 If yes,describe under 1,000,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT A Miscellaneous Rented 16SBAAC0748 12/31/2023 12/31/2024 Equipment 100,000 DESCRIPTION OF OPERATIONS/LOCATIONS!VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Proof of Liability insurance 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 g y ACCORDANCE WITH THE POLICY PROVISIONS. Building Department 938 King Street Rye Brook,NY 10573 AUTHORIZED REPRESENTATIVE ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD ,—I vYORK Workers' CERTIFICATE OF STATE Compensation Board NYS WORKERS' COMPENSATION INSURANCE COVERAGE Ia.Legal Name&Address of Insured(use street address only) 1b.Business Telephone Number of Insured (914)371-1870 Your Way Custom Cabinets Inc. dba Fina Cabinets 1c.NYS Unemployment Insurance Employer Registration Number of 20 N MacQuesten Pkwy Mount Vernon,NY 10550 Insured Work Location of Insured(Only required if coverage is specifically limited to 1d.Federal Employer Identification Number of Insured or Social Security certain locations in New York State,i.e.,a Wrap-Up Policy) Number 13-3737111 2.Name and Address of Entity Requesting Proof of Coverage 3a.Name of Insurance Carrier (Entity Being Listed as the Certificate Holder) Twin City Fire Insurance Co Village of Rye Brook 3b.Policy Number of Entity Listed in Box"ta" Building Department 16WECAVICCC 938 King Street Rye Brook,NY 10573 3c.Policy effective period 12/3112023 to 1 2/3 112 024 3d.The Proprietor,Partners or Executive Officers are �X included.(Only check box if all partners/officers included) all excluded or certain partners/officers excluded. This certifies that the insurance carrier indicated above in box"3"insures the business referenced above in box"1a"for workers' compensation under the New York State Workers'Compensation Law. (To use this form,New York(NY)must be listed under Item 3A on the INFORMATION PAGE of the workers'compensation insurance policy). The Insurance Carrier or its licensed agent will send this Certificate of Insurance to the entity listed above as the certificate holder in box"2". The insurance carrier must notify the above certificate holder and the Workers'Compensation Board within 10 days IF a policy is canceled due to nonpayment of premiums or within 30 days IF there are reasons other than nonpayment of premiums that cancel the policy or eliminate the insured from the coverage indicated on this Certificate. (These notices may be sent by regular mail.)Otherwise,this Certificate Is valid for one year after this form Is approved by the insurance carrier or its licensed agent,or until the policy expiration date listed in box"3c",whichever is earlier. This certificate is issued as a matter of information only and confers no rights upon the certificate holder. This certificate does not amend, extend or alter the coverage afforded by the policy listed, nor does it confer any rights or responsibilities beyond those contained in the referenced policy. This certificate may be used as evidence of a Workers'Compensation contract of insurance only while the underlying policy is in effect. Please Note: Upon cancellation of the workers'compensation policy indicated on this form,if the business continues to be named on a permit,license or contract issued by a certificate holder,the business must provide that certificate holder with a new Certificate of Workers'Compensation Coverage or other authorized proof that the business is complying with the mandatory coverage requirements of the New York State Workers'Compensation Law. Under penalty of perjury, I certify that I am an authorized representative or licensed agent of the insurance carrier referenced above and that the named insured has the coverage as depicted on this form. Approved by: Roseann P.Lambros (Print name of authorized representative or licensed agent of insurance tamer) Approved by: lli)/��ra— H Z3)21 (Signature) (Date) Title: President Telephone Number of authorized representative or licensed agent of insurance carrier: Please Note: Only insurance carriers and their licensed agents are authorized to issue Form C-105.2.Insurance brokers are NQT authorized to issue it. C-105.2(9-17) www.wcb.ny.gov