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HomeMy WebLinkAboutBP24-098PERMIT # A6109 L/-O 9 DATE: �a aP; as a5 SECTION ISO, lv 9 BLOCK LOT TYPE OF WORK Q //>/ Q Q /� �` S J06 LOCATION o7 /S O,D O 000 C�7�Ly/ -e' 17e 7 LV/ Tio _ �C� ST • I• �♦ • # FEE�DATE INSPECTION RECORD I DATE I NSP FOOTI N G FOUNDATION FRAMING RGH FRAMING INSULATION PLUMBING 0 RGH PLUMBING GAS SPRINKLER ELECTRIC 0 LOW -VOLT C7 ALARM AS NBUILT O �&Z -•�-- T-��- 1j u�Ue Cql q 59r 73/8 OTHER APPROVALS ARB BOT PB ZBA OTHER - LL�yEO VILLAGE OF RYE BROOK MAYOR 938 King Street, Rye Brook,N.Y. 10573 ADMINISTRATOR Jason A. Klein (914) 939-0668 Christopher J. Bradbury www.ryebrooknyg_ov TRUSTEES BUILDING & FIRE INSPECTOR Susan R. Epstein Steven E. Fews Stephanie J. Fischer David M. Heiser Salvatore W. Morlino CERTIFICATE OF COMPLIANCE September 26,2024 Anthony Bueti&Anne Bueti 26 Bishop Drive North Rye Brook,New York 10573 Re: 26 Bishop Drive North, Rye Brook,New York 10573 Parcel ID#: 130.69-1-10 Building Permit#24-098 issued on 5/22/2024 for Retaining Wall Repair&Three Steps This certifies that the retaining wall and three steps,repaired under the above captioned permit has been satisfactorily completed. Sincerely, Steven E. Fews Building&Fire Inspector /to D v 1 PERMIT# , , )y_D 9d' BUILDING DEPARTMENT VILLAGE OF RYE BROOK ISSUED:5—��j SEP 2 3 2024LU 938 KING STREET,RYE BROOK,NEW YORK 10573 DATE: — Z (914)939-0668 FEE: j''��Q-- PAIDs� VILLAGE OF RYE BROOK BUILDING DEPARTMENT APPLICATION FOR CERTIFICATE OF OCCUPANCY, CERTIFICATE OF COMPLIANCE, AND CERTIFICATION OF FINAL COSTS �##/ D##-#{#-#ifi#ii#####ii#►iiii######ii##i##i###t####iii Address: < D C t e jy c)J_- ` H Occupancy/Use: Parcel ID#: j /3 O_ �� - ! /U Zone: Owner: 4*'yyty —A-n y\— Address: Q2 L�W Q P I ✓-- y D/L P.E./R.A. or Contractor: P V 4 oe_ Lis}R�G�-icn� Address: L l c ��... &''5/.v /Y y Person in responsible charge: d22,E2 �s 1 c, P� Address: (, P DR l ye-- AV o1ftl-, / 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: dyU j -—fi-n A'e—l���bimg duly sworn,deposes and says that he/she resides atj 6 fop D Q 1 J� ��+lt in k v.e /��' 8 ,in the County of lU•e S f r N-,eS f in the State of 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: for the construction or alteration of: f Deponent further states that he/she has examined the approved plans of the structure/work herein referred to for which a Certificate of Occupancy/Compliance is sought,and that to the best of his/her knowledge and belief,the structure/work has been erected/completed in accordance with the approved plans and any amendments thereto except in so far as variations therefore have been legally authorized,and as erected/completed complies with the laws governing building construction.Deponent further understands that it shall be unlawful for an owner to use or permit the use of any building or premises or part thereof hereafter created,erected,changed,converted or enlarged,wholly or partly,in its use or structure until a Certificate of Occupancy or Certificate of Compliance shall have been duly issued by the Building Inspector as per§250-10.A.of the Code of the Village of Rye Brook. Swom to before me this 56kfe"'%iI5ffA Sworn to before me this of 2 0 day of S f YfE M 6 F,,� , 20—i-* day of SEbfEM 6 at , 20 _ Signature of Property ner SiV mature ol-Applicant t'LD►,14 6 U e'l I y1 t Jvt y 13 o off+-I &Vy Print Name of Property Owner Print Name of Applicant Notary Pub Notary Pu ALEJANDRO A GARCIA MONTHS Notary Public-State of New York ( ALEJANDRO A GARCIA MONTHS NO.01GA6383865 Notary Public.State of New York • Qualified in Bronx County NO.01GA6383865 My Commission Expires Nov 26,2026 Qualified in Bronx County My C ommission Expires Nov 26, 2026 �E BRC�v� • 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 : Z (p %J �- 0 �4 Q. t ✓2 fjo L I1 DATE: ! - 2 a ?7 l _ G PERMIT# �_ � �� � ISSUED: r Z Z Z` SECT: BLOCK: LOT: �G 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 rr ❑ NATURAL GAS 4- { i ❑ L.P. GAS ❑ FUEL TANK ❑ FIRE SPRINKLER ❑ FINAL PLUMBING ❑ CROSS CONNECTION FINAL OTHER = i i = a _ NLO N W Q O i 1 N N � ma s N p = L a eq � wv y ■ ki' of � E W = VI0-4 � v ° cn A snow = . p4 H 6 41 t O V) ■ 1�1 � '� i� �7 .� � � y� i 4d r., 1 � M � Apt•' � ,� � C y � _ W 4 u i = O HLr) o 0 © W O u a cd ob $ a w o LZ Ir i• 0 ,1] � w � 1 Q A� �a v O �~y U�� � ram i Ln G1 IU cozO� `PLO " Z ZV -© i = � ■ R �"1 0-4 c) a0 �' w+� CNwin R _, w a o zz � o � _ 0-0 � v V U r� v' o w ao H8 �° ,� „ a u av ■ R e BUILDINGIDEPARTMENT VILLA, OF R ,kF BROOK MAY 1 3 2024 938 KINOf�'l F.ET RYF;BROOK,NY 10573 VILLAGE OF RYE BROOD b$� DD ,_�, BUILDING DEPARTMENTwww:r rooks FOR OFFICE USE ONLY: Approval Date MAY 2 4 permit Application# Approval Signature: 6 ARCHITECTURAL REVIEW BOARD' Disapproved: Date: BOT Approval Date: Case# Chairman: PB Approval Date: Case# Secretary: ZBA Approval Date: Case# Other: CO—A-)Fees6/CO—r Permit Fees. 7 — FEN,Cy E / WALL / GATE PERMIT APPLICATION Application dated: > z. ] 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 or 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 1. Job Address: U' I�r � f� Q '"r eS 1 j pv 2. Occupancy/Use: /� S.B.L.#:. 130 ,i &O / "f—)u Zone: — 3. Proposed FZ&G to(describe in detail): 11 k Alas- 4. Property Owner: Address: Ir1 l 'Q Phonc t,q lq G,S�1 1`{�5 Cell# q/`f 6s' email: AT13 62r+AoJxv� 9 e M1-40 Applicant: Yt Address: / f� N Phone# � Cell# ! kL!; mail: Architect/Engineer: Address: Phone# Cell#+ _ email: Contractor: <lL�S tY uc L/ --,n� WC/l5� — v Address&Phone: �� Tt/`� l ,`-� 1�� 5. If building is located on a corner lot,which street does it front on: 6. What is the estimated cost of construction 06,'� (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: --7 1 512,y,� 1 t 61112023 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. • ***wwww**wwwww*,r***,�:r,r�,�,r*,r*xww,r*wwwwww�ewwwwww*ww*w**ww,rw,t#,twwwwwawwww**,�w**w*wwwwwwwww,�ww*www**�r*:rr+��w�� ST TE NEW YORK,COU TY•OF WESTCHESTER ) as; ,being duly sworn,deposes and states that he/she is the applicant above named, (print name of in ivi al SiAtkg as the applicant) and further states that (s)he is the legal owner of the property to which this application pertains, or that (s)he is the for the legal owner and is duly authorized to make and file this application. (indicate architect,contractor,agent,attorney,etc.) That all statements contained herein are true to the best of his/her knowledge and belief,and that any work performed,or use conducted at the above captioned property will be in conformance with the details as set forth and contained in this application and in any accompanying approved plans and specifications,as well as in accordance with the New York State Uniform Fire Prevention&Building Code,,the Code of the Village of Rye Brook and all other applicable laws,ordinances and regulations. ` Swom to before is !(J 11 Sworn to before me /0A day of , 20 a day of , 20a AP4JTW_ Signature of Property wner Signature of Applicant '-wi L4 &)6 4 0 yi Print Name of Prope Owner Print Name of Ap ant Notary Public Notary Puglic MICHAEL ESQUIVEL Notary Public-State of New York MICHAEL ESQUIVEL NO.01ES6442359 Notary Public-State of New York Qualified in Westchester County NO.OIES6442359 My Commission Expires Oct 11, 2026 Qualified in'Westchester County My Commission Expires Oct 11, 2Q26 2 6/1/2023 rs / v. � E i h 5 Cti . 1 J Duque"s Construction Inc. t r Proposal Lauro Duque 2024 Proposal Duque's Construction Inc. 34 Belleview Avenue Ossining, NY 10562 914.941.0129 or Cell: 914.659.7318 Customer Name: Phone: Date: Anthon Bueti (914)659-1479 05/07/24 Job Address: 26 Bishop Dr. Rye Brook, NY 10573 We hereby propose the following for the job site listed above Masonry Wall & Steps • Repair existing concrete wall. • Repair existing Concrete steps. 1 r Proposal We hereby propose to furnish material and labor,complete in accordance with above specifications,for the sum $6 500.00 lus tax)with payment to be made as follow 40%percent is required as down payment and the rest would be one accor mg to work advance. All material is guaranteed to be specific.All work to be completed in a workmanlike manner according to standard practices.Any alteration or deviation from above specifications involving extra charge costs will be executed only upon written orders,and will become an extra charge over and above the estimate.All agreement contingent upon strike,accidents and delays beyond and control.Owner to cant'fire,tomado and others necessary insurance.Our workers are My covered by Workman's Compensation insurance. Acceptance of Proposal:I/We do hereby agree to the price,specifications and conditions referred to herein,and authorize the contractors named herein to perform the work as specified with payments to be made as outlined above. In Advance We Thank You for Your Business! Authorized Signature: ' Aluww,3 IAZ' Date of acceptance: ( ; l L o 01'{ Note:this proposal may be withdrawn by us if not accepted within30days. 2 Building Permit Check List&Zoning Analysis I Address- Zone:!� Use: Const.Type Ocher: Submittal Date: 2 Revis'ons Submittal Dates: Applicant: Nature of Work £ VQ t Cb Reviews:zBA:_MAY 2 0 2024 3g BOT: Other. NEED OK Cj-) Fq- FEES: g Filin . t BP: C/O: Flood Plane Legalization: ( ) (L —APP: 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: ( ) ( ) SITE PLAN:Topo: Site Protection S/W Mgmr.: Tree Plan: Other. ( ) ( ) SURVEY:Dated: Current: Arduval• Sealed Unacceptablc ( ) ( ) PLANS.Dart Stiatped Scaled Copies: Electronic: Other. �( (-' License: 1 Workers Comp:_Lcf" Liability: mp.Waiver. Other. CODE 753#: Dated: N/A: ( ) ( ) HIGH-VOLTAGE ELECTRICAL-Plans: Permit N/A: Other. ( ) ( ) LOW-VOLTAGE ELECTRICAL Plans: Permit: N/A: Ocher: ( ) ( ) FIRE ALARM/SMOKE DETECTORS:Plans: Permit: H.W.I.C.:_Battery_Other. ( ) ( ) PLUMBING:Plans: Permit: Nat.Gat: LP Gas: N/A/: Other. ( ) ( ) FIRE SUPPRESSION:Plans: Permit: N/A Ocher: ( ) ( ) 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 Leger As-Built Plans: Other. ( ) ( ) BP DENIAL LETT-ER. C/O DENIAL LETTER. Other. ( ) ( ) Ocher: ( )ARB mtg.date: approval;- notes: ( )ZBA mtg.date: approval• notes: ( )PB mtg.date: approval;- notes: REQUIRED EXLSTQJG PROPOSED NOTES Date&Y 2 n g n 2 n Area: Code: FF Front: Front: Sides: Rear. Main Cov: Accs.Cov. Ft.H Sb: Sd.H Sb: GFA: Tor-imp: Ft. : Height/Stories notes: Residential Building Permit Fee Work Sheet Permit A Date Issued: SBL: Zone: Address: Property Owner&Contact Info: Job Description: For all new dwellings and for additions measuring 800 sq. ft. or more made to existing dwellings, the following fee schedule shall apply: (plus any alteration fees) Total Sq. Ft. (excluding basements) x $300.00 x $I8.00/$1,000.00 Basement Sq. Ft. x $65.00 x $I 8.00/$I,000.00 New Construction Sq.Ft: • New Construction Cost • Building Permit Fee Basement = sq. ft. x $65.00 = $ x $I8.00/$I,000.00= $ Attached Garage= sq. ft. x $300.00= $ x$I8.00/$I,000.00= $ I" Fl. = sq. ft.x $300.00= $ x$I8.00/$1,000.00= $ 2"1 Fl. = sq. ft. x $300.00 = $ x $I 8.00/$I,000.00= $ P FI. = sq. ft.x $300.00= $ x $I8.00/$I,000.00= $ 4,h Fl. = sq. ft.x $300.00= $ x$18.00/$I,000.00= $ Total Sq.Ft. _ sq. ft. Total Cost = $ Taal B.P.Fee= $ ! Total Amount Paid = $ Total Amount Due = $ Date: Signori: C .ter �> t:aore.I.anmi Jam'a Ma„ann J -� er,nn..m,c�,m.l,,,mna �O1111t.V tNraYmcc,,.,mnrrrmHr.n �; Department of Consumer Protection Home Improvement License C_ � DUQUE'S CONSTRUCTION INC. i 34 BELLEVIEW AVENUE € C�a OSSINING,NY-10562 �� f !3� Thn laxnae r,r>,w<a w,..,,ta..<.,m Anrak xvI or rn�w�>t�neat�,wooly con>�rm�rrw«non ewk,na�,.aii�„nI,op<m t pexn.e oftne oR.ul,S.yorlmrnt u.l.PmofofaunnshrP or immigrannn smmsrs nut rcgwred for i­cc o(tni,nccroc NOT FOR FEDERAL PURPOSES s. r i t a Ltcrnx Xumb,r mF Y Date of ExP'w n WC75030-HO4 c q 03I1812026 3 .; f�`neVer CO _ ,, - •-+r,r ate- —xr--++r' J�, DATE(MWDDYYYY) ACQR�c� CERTIFICATE OF LIABILITY INSURANCE 05/07/2024 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 Michael J.Donnelly NAME: Donnelly Insurance Center Agency Inc PHONE (914)347-6500 FAx (g14)347-6303 A/C No Ezt: AIC,No 6 North Lawn Ave. EMAIL INFO@DONNELLYAGENCY.COM ADDRESS: P O.BOX 880 INSURERS)AFFORDING COVERAGE NAIC# Elmsford NY 10523-0880 INSURERA: American European Insurance Company 233337 INSURED INSURER B: PROGRESSIVE CASUALTY INS CO 24260 Duques Construction, Inc. INSURER C: TRAVELERS CASUALTY&SURETY 19038 34 Belleview Ave INSURER D: INSURER E: Ossining NY 10562-4325 INSURER F: COVERAGES CERTIFICATE NUMBER: CL2431934485 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. I NICY EFF POLICY EXP TRR TYPE OF INSURANCE INSD WVD POLICY NUMBER MMLDDYYYY MMIDD YYYY LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE TO CLAIMS-MADE FX OCCUR PREMISES Ea occTu ante $ 100,000 MED EXP(Any one person) $ 5,000 A Y SKP 5005788 10 03/09/2024 03/09/2025 PERSONAL&ADV INJURY $ 1,000,000 GEN'LAGGREGATE LIMIT APPLIES PER. GENERAL AGGREGATE $ 2,000,000 X POLICY PRO LOC PRODUCTS-COMP/OP AGG $ 2,000,000 PRO- OTHER $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT S 500,000 Ea accident ANYAUTO BODILY INJURY(Per person) $ B OWNED r SCHEDULED 07864468 07/10/2023 07/10/2024 BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY Per accident $ UMBRELLA LIAR OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED I I RETENTION$ r $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY STAT YIN UTE ER C ANY PROPRIETOR/PARTNER/EXECUTIVE N/A U67X414518 02/11/2024 02/11/2025 E.L.EACH ACCIDENT $ 100,000 OFFICER/MEMBMBER EXCLUDED? (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 100,000 If yes,describe under 500,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) DRIVEWAY,PARKING AREA,YARD OR SIDEWALK-NO COMMERCIAL SIDEWALK OR STREET OR ROAD WORK CERTIFICATE IS SUBJECT TO TERMS,CONDITIONS AND EXCLUSIONS OF THE ACTUAL POLICY AT THE TIME OF ISSUANCE CERTIFICATE HOLDER NAMED AS ADDITIONAL INSURED AS PER WRITTEN CONTRACT. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN Village of Rye Brook ACCORDANCE WITH THE POLICY PROVISIONS. 938 King Street AUTHORIZED REPRESENTATIVE Rye NY 10573 ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD NW Workers' SYORK TATE Compensation CERTIFICATE OF Board NYS WORKERS COMPENSATION INSURANCE COVERAGE la. Legal Name&Address of Insured(use street address only) 1 b. Business Telephone Number of Insured DUQUES CONSTRUCTION, INC 914-318-3012 34 BELLEVIEW AVENUE 1c. NYS Unemployment Insurance Employer Registration Number of OSSINING, NY 10562 Insured Work Location of Insured(Only required if coverage is specifically limited to 1 d. Federal Employer Identification Number of Insured or Social Security certain locations in New York State,i.e., a Wrap-Up Policy) Number 274820367 2. Name and Address of Entity Requesting Proof of Coverage 3a. Name of Insurance Carrier (Entity Being Listed as the Certificate Holder) Old Dominion Insurance Company Village of Rye Brook 3b. Policy Number of Entity Listed in Box '1a" 938 King Street Rye, NY 10573 UB7X414518 3c. Policy effective period 02/11/2024 to 02/11/2025 3d. The Proprietor, Partners or Executive Officers are ❑ included. (Only check box if all partners/officers included) X� 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 1 a"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: MICHAEL J.DONNELLY (Print name of authorized representative or licensed agent of insurance carrier) Approved by: �d D D 1 D 7 (Sig ure) (Date) Title: AGENT/BROKER Telephone Number of authorized representative or licensed agent of insurance carrier: 914-347-6500 Please Note: Only insurance carriers and their licensed agents are authorized to issue Form C-105.2. Insurance brokers are NOT authorized to issue it. C-105.2 (9-17) www.wcb.ny.gov