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HomeMy WebLinkAboutBP24-151PERMIT # SECTION 1 TYPE OF WO 10B LOCATJ,C OWNER $0-15/ DATE: J O a1/ W: ) 0 BLOCK LOT 0�o , I a i _ %EST. FEE VCO # FEES % DATE TCO # FEE DATE INSPECTION RE�QRD I DATE I NSP FOOTING FOUNDATION FRAMING RGH FRAMING INSULATION PLUMBING C.] RGH PLUMBING GAS C7 SPRINKLER ELECTRIC C� LOW -VOLT ALARM AS BUILT FINAL 60zoel,4 C9iy)aYao- 30390 -T //ate o Alelieses �9/4q) 50 - 791/!0 OTHER APPROVALS ARB BOT PS ZBA OTHER E Q � It . 19 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. Morlino CERTIFICATE OF COMPLIANCE November 7,2024 Ronald Greenbaum&Veronica Wolf Greenbaum 243 Tree Top Crescent Rye Brook,New York 10573 Re: 243 Tree Top Crescent,Rye Brook,New York 10573 Parcel ID#: 129.76-1-78 Building Permit#24-151 issued on 7/10/2024 for Replacement Window& Door This certifies that the new master bedroom window and new sliding door,installed under the above captioned permit has been satisfactorily completed. Sincerely, Steven E. Fews Building&Fire Inspector /to R ECIEMC -- 3DBUILD DEPARTMENT For office use only: PERMIT#�F� =! 51 OCT 2 9 2024 VIL OF RYE OK ISSUED: 7—/O-a4/ 938 KING STRE YE BROOK,; YORK 10573 DATE: VILLAGE OF RYE BROOK 9 -06 FEE: O/S-O—PAID _BUILDING DEPARTMENT ov 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 Z�I p a Address: �'f'� � \/V'�' S C�'L.� Occupancy/Use: Parcel ID#:/ol 9, 7 74 Zone: Owner: T, Address: 2 �re e�/► S C L. 1, P.E./R.A.or Contractor: V'l IZ3 A VO I[4/,f,4 Address: Person in responsible charged 111,I4 de"e 17 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: S ATE OF NEW YORK, COUNTY OF WESTCHESTER as: ��� 11, E �� being duly sworn,deposes and says that he/she resides at 29 3 Itr? (Print Na`�e of App icant) 1 / I (No.a Street) in �1�� ,in the County of ,S"C`(�O S 1� G✓ in the State of that (Cityrrown/Village) he/she has supervised the work at the location indicated above,and that the actual total cost of the work,including all site imprq4ents, labor,materials,scaffolding,fixed equipment,professional fees,and including the monetary value of any materials and labor which may have been donated gratis was: _2, D for the construction or alteration of: S 11 6 1, (2 0 VAA1 '4— c .0 Deponent further states that he/she has examined the approved plans of the structure/work herein referred to for which a Certificate of Occupancy/Compliance is sought,and that to the best of his/her knowledge and belief,the structure/work has been erected/completed in accordance with the approved plans and any amendments thereto except in so far as variations therefore have been legally authorized,and as erected/completed complies with the laws governing building construction.Deponent further understands that it shall be unlawful for an owner to use or permit the use of any building or premises or part thereof hereafter created,erected,changed,converted or enlarged,wholly or partly,in its use or structure until a Certificate of Occupancy or Certificate of Compliance shall have been duly issued by the Building Inspector as per§250-10.A.of the Code of the Village of Rye Brook. Sworn to before me this 9 C� Sworn to before me this day of w--06 e , 20 C"n') "k day of , 20 Signatur of Property Owner C Signature of Applicant nt a of Property Owner Print Name of Applicant M7 Notary PubNARI MELILLO Notary Public Notary Public,State of New York No.01M E6160063 6/I/2o2a Qualified In Westchester County Commission Expires January 29,20Z� �yE BRC�k. O� 2� BUILDING DEPARTMENT ❑BvILDING INSPECTOR ETASSISTANT 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 :- 2 Ll R ' Q G,,. DATE: PERMIT# bq 2q f5 ISSUED: "/0"Zj SECT: /2-9j(o BLOCK: LOT: LOCATION: T 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 _; J Li ❑ L.P. GAS ❑ FUEL TANK \ ❑ FIRE SPRINKLER ❑ FINAL PLUMBING ❑ CROSS CONNECTION 0 FINAL ❑ OTHER Opyt)� N O a �-1 w acn _ a `n `° 1� � � � 0 � cn a O O. V o w x v w O OS G0-4 � ro m ai .—. c ►n `° o 0 ° V w o "' as A u n ;54 3 C a 6. O W O O Q F"" M fx O O ° 'd s >--' bA F' d O x c o o ^ cn �4 .n vow0 a 0 O gz4 �� a � � - PLI Q o (mil ° x y `�avpvwo �j W O Q A 0 1 , � -p a�i � a� U z M SO 1 I� oO U u w 3 o Q _ PL4 O Wyk O ' z o °a a n u lot UV o on �I GQ � a W ✓ � � o C s BUILDING DEPARTMENT L� �' VILLAGE OF RYE:BROOKDD ' 938 KING STRET RYE BROOK,NY 10573 ��N �� (9)4)939-0668 www.ryebrookny.gov VILLAGE OF RYE BROOK BUILDING DEPARTMENT ADMINISTRATIVE EXTERIOR BUILDING PERMIT APPLICATION FOR EXTERIOR WORK WHICH DOES NOT REOUIRE VILLAGE ARCHITECTURAL REVIEW BOARD APPROVAL FOR OFFICE USE ON �-1 APPROVAL DATE: 1 � RM � ApptwATION FEE: APPROVAL SIGNATURE: PERMIT FEES: C)0'q— DU H.O.A.APPROVAL: DATE: DISAPPROVED: OTHER: Application dated: g 7— Z is hereby made to the Building,Inspectorof the Village of Rye Brook,NY,for the issuance of a Permit for the construction of buildings,structures,additions,alterations or for a change in use,as per detailed statement described below. 1. Job Address: '2- (r^G e t.'z G r e SCG Qs•? -rtv- &G 6 Q F-s 2. Parcel ID#: :7 to Zone: 3. Proposed Improvement(Describe in detail): G e-K! oVt/ IS(;Our" f f`O d.O v- ah C, ' i Say 4. Property Owner. 6( 6-4-C . Address: Z.�tA 'Tr.-f Phone Ij3!t'-cj ! ?6 Cell# q /�y - tZU e-mail ju�g0gty- VeW"Z,0.7 het List All Other Properties Owned in Rye Brook: Applicant: I°4 R E r J N' Address:—Z- 7 r C to p C.ntS e_, Phone# `i 1`t'O13`A ' S1 '76 Cell# otl �i - �f �o g� `%_O_ e-mai1P`lsLn4e_4✓f ( _Vtrr:,z,?,%.j4e Architect: AJi(A Address: Phone# Cell# e-mat Engineer: Address: Phone# Cell# I� e-mat General Contractor. N or" t e" L L C-• Address: \eyi, JO -� Phone# q l`I -`tsa '-7 S Cell# e-mail u(I' 4'7 a ( _ a aN • Lah (l) 6?1/2024 5. Occupancy;(1-Fain.,2-Fam.,Commercial.,etc...)Pre-construction: I 'Fpwost-construction: �r+. 6. Area of lot: Square feet: 1 -7 !± -Z. Acres: Od C q 7. Dimensions from proposed building or structure to lot li es: front yard: A/1,4 rear yard: right side yard: Nl left side yard: 646& other: All 14 8. If building is located on a corner lot,which street does it front on: /JIA 9. Area of proposed building in square feet: Basement: Al1A11 fl: 4ZI& 21 fl: AJIA 31d fl:_ 10. Total Square Footage of the proposed new construction: i`+1 O NI e- ll. For additions,total square footage added:Basement: N/!&. 1"fl: VA fl: Nth 3`d fl: N/A 12. Total Square Footage of the proposed renovation to the existing structure:__ t4/t 13. N.Y.State Construction Classification: V-" Q N.Y.State Use Classification: 2. [ O 14. Construction Type&Location. Typical Western Lumber Frame;()Timber Frame[TC];()Wood Truss[TT]; ()Pre-engineered wood[PW];Located;( )Floor Framing[F];()Roof Framing[R];()Floor&Roof Framing[FR];Other: i 15. Number of stories: �• Z Overall Height: Median Height: 16. Basement to be full,or partial: IQ o h e finished or unfinished: &J,1 17. What material is the exterior finish: C. t d,o 0. � t o r, k- S i k"--to p 18. Roof style:peaked,hip,mansard,shed,etc: 1 ecl kj4d Rooting material: A 1 19. What system of heating: d s F%+ M]� E"�D•{• 4"�'''fi` 20. If private sewag�spo al is necessary,approval by the Westchester County Health Department must be submitted with this application. / 21. Will the proposed project require the installation of a new,or an extension/modification to an existing autornati tyre suppression system?(Fire Sprinkler,ANSL System,FM-200 System,Type I Hood,etc...)Yes: No: (if yes,applicant must suhmtt a separate Automatic Fire Suppression Syslem Permit application&2 sets of detailed engineered plans) 22. Will the proposed project disturb 400 sq.ft.or more of land,or create 400 sq.ft.or more opervious coverage requiring a Stormwater Management Control Permit as per§217 of Village Code? Yes:—No: V Area: 23. Will the proposed project pedbire a Site Plan Review by the Village Planning Board as per§209 of Village Code? Yes: No: (if)vs,applicant nntsr submit a Site Plan Application,&provide detailed drawings) 24. Will the proposed project require a Steep Slopes Permit as per§213 of Village Code Yes: No: Of yes,you must submit a Site Plan Application,&provide a detailed topographical sitrvev) 25, Is the lot located within 100 ft.of a Wetland as per§245 of Village Code? Yes: No:-Ne� (if yes, the area of wetland and the wetland buffer fer zone must be pmperh^depicted an the survey&site plan) ` 26. Is the lot or any portion thereof located in a Flood Plane as per the FIRM Map dated 928/07? Yes: No: V (if yes,the area and elevations of the flood plane must be properly depicted on the survev&site plan) 27. Will the proposed project require a Tree Removal Permit as per§235 of Village Code?Yes: No: (ifyes.applicant must submit a Tree Removal Permit Application) 28. Does the proposed project involve a Home-Occupation as per§250-38 of Village Code? Yes: No: indicate:TIER 1: TIER II: TIER III: (if}rs,a Nome Occupation Permit Application is required) 29. What is the total estimated cost of construction: S I I N O 0 �- Note:estimated cast shall include all site improvements,labor,material,scaffolding,fixed equipr4ent,professional fees,inchtding any material and labor which mm,be. donoted gratis,ff the final cost exceeds the 51iin le I c)st.( cudilitional fee will be required prior to issuance of the CAD. 30, Estimated date of completion:—,� � © /Z C7 61/2024 BUILDING DEPARTMENT RIJUL ECIE � �/ IE VILLAGE OF RYE BROOK _ 5 20?4, t 938 KING STREET RYE BROOK,NY 10573 (914)9 9-0668 VILLAGE OF RYE BROOK ��wdrr e okM.20V BUILDING DEPARTMENT xxxwxwxrxxwwwxxxxxxwxxwxxxxxxxwxxxwwwxxxxxxxxxwxwxxwwxwxxxwwwrxxrxxwxwxwwwxxrwrrwxrrwrrwwwrrwwwfwwwwwww AFFIDAVIT OF COMPLIANCE VILLAGE CODE U16 • 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, &-1 Cet �4wy" ,residing at, _-2- ltl vNes.-top C—'eyc fzy'c 6-". /Jy IPrnua.unrl iadifrc.,� hrrrrutln'cl 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; �- 71-t e. -t4a CrtAc- &ft;(-- Rye Brook, NY. 111h yJdrr111 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. Itit,'nanuu..I I'ny�crn th�ourr.11 I` O+n 1.1 C/ G-r 4- 4 C_ e II'rmt Nallic ,I I'rul',riv()vvnerltit) Sworn to before me this SHARI MELILL0 7 Notary Public,State of New York day OF �`\� ,20 L No.OIME6160063 Qualified in Westchester County —1 Commission Expires January 29,20? 1 INutury Public) 1�1 h 1 2t114 This application must be properly completed in its entirety by a N.Y. State Registered Architect or N.Y. State Licensed Professional Engineer& signed by those professionals where indicated. It must also 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, wwwrwwwwwwwwwwwwwxxxxxxwwwwwwwxxxxxxxwwwwwwwwwwwewwwwwwwwwwwwwwwwwwwwwxwwwwwwwwwwwwwwwwwwwwwwwwwwxwwwww+ww STATE OF NEW YOM COUNTY OF WESTCHESTER ) as: ,being duly sworn,deposes and states that he/she is the applicant above named, (print name of individual signing as the appticant) 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 anal 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 Sworn to before me this day of ��` �, ,20 '`� day of �� ` 20� Si nature of Property Owners Signature of Applicant o ( kv.', s(K G'r-e t. N bq!&t%A Print Name of Property Owner] SHARI MELILLO Print Narne of Applicant Notary Public,State of New York No.01ME6160063 �4C Qualified In Westchester County Notary Public -- Commission Expires January 29,20 Notary Public lal a/lno2a The Arbors Homeowners' Association 173 1/2 Ivy Hill Crescent Rye Brook, NY 10573 J June 191h , 2024 Ron and Veronica Greenbaum 243 Treetop Crescent Rye Brook, NY 10573 Re: Painting and Replacing Siding Rear 2nd Floor Dear Ron and Veronica, This letter serves as confirmation that the Architecture & Grounds (A&G) Committee has reviewed and accepted your application for the above-named work. This approval is valid for six (6) months from today's date. If any changes need to be made to the original plans submitted to A&G either before or during construction, the Committee must be notified in writing and your application must be amended. Work must stop and cannot proceed until you receive written approval for those changes. You are required to inform the Property Manager when work begins. When the project is complete, the Property Manager must again be notified so that an inspection may take place. Please include a photograph of the work as well. Failure to comply with these procedures will result in fines and/or work stoppage. If you have any questions, contact me at manager@arbors-ryebrook.com. Sincerely, Nicholas Salzarulo Property Manager The Arbors Homeowners' Association 173 '/2 Ivy Hill Crescent Rye Brook, NY 10573 i June 26, 2024 Ronald and Veronica Greenbaum 243 Treetop Crescent Rye Brook, NY 10573 Re: Glass Sliding Door and Master Bedroom Window Replacement Dear Ron and Veronica, This letter serves as confirmation that the Architecture & Grounds (A&G) Committee has reviewed and accepted your application for the above-named work. This approval is valid for six (6) months from today's date. If any changes need to be made to the original plans submitted to A&G either before or during construction, the Committee must be notified in writing and your application must be amended. Work must stop and cannot proceed until you receive written approval for those changes. A permit from the Village of Rye Brook must be presented to the property manager before work begins. You are also required to inform the Property Manager when work begins. When the project is complete, the Property Manager must again be notified so that an inspection may take place. Please include a photograph of the work as well. Failure to comply with these procedures will result in fines and/or work stoppage. If you have any questions, contact me at: Property Manager. Nicholas Salzarulo Property Manager ft / ill 1 J From: Ronald Greenbaum ronald.greenbaum@icloud.com (:f Subject: 3 photos Date: June 6,2024 at 10:26AM To: Ronald Greenbaum pushgears@verizon.net v - � I �1 5 �( WQ0r I •r�' 1 f r 1 S l �• � 1 OMS Ver.0004.08.01(Current) Greenbaum-243 Treetop Cries Rye Brook Product availability and pricing subject to change. Essential Glider/Elevate Glider&Slider Quote Number:CTFNNPI Line#5 Mark Unit:Glider Net Price: 1,417.91 Qty: 1 Ext, Net Price: USD 1,417.91 MARV I N Bronze Exterior Bronze Interior Essential Glider Triple Sash- Glass Add For All Sash— Left Sash D IG-1 Lite Low E3/ERS w/Argon Stainless Perimeter Bar Center Sash As Viewed From The Exterior IG-1 Lite 1 Z Egress Information Low E3/ERS w/Argon Width:20 3/4" Height:41 1/8" Stainless Perimeter Bar Net Clear Opening:5.93 SgFt Right Sash Ultrex Fiberglass: AAMA 624-10 IG-1 Lite Low E3/ERS w/Argon Stainless Perimeter Bar 2 Oil Rubbed Bronze Sash Lock Exterior Aluminum Half Screen Bronze Surround Bright View Mesh 2"Jambs Nailing Fin ***Note:Essential rough openings are 112"greater than overall frame size width and 112"greater than frame size height.Please take note of this when ordering Essential custom sized units. ""Note: Unit Availability and Price is Subject to Change Project Subtotal Net Price: USD 5,972.59 8.375%Sales Tax: USD 500.20 Project Total Net Price: USD 6,472.79 CMS Ver.0004.08.01(Current) Processed on:6/5/2024 3:44:18 PIA Page 6 of 8 For product warranty information please visit,www.marviii.com/support/warranty. OMS Ver.0004.08.01(Current) Greenbaum-243 Treetop Cres Rye Brook Product availability and pricing subject to change. Essential Glider/Elevate Glider&Slider Quote Number:CTFNNP1 Line#4 Mark Unit:Patio Slider Net Price: 2,839.52 Qty: 1 Ext. Net Price: USD 2,839.52 MARV�N Bronze Exterior White Interior _ Elevate Sliding Patio Door OX Left Panel Bronze Exterior White Interior IG-1 Lite Tempered Low E2 w/Argon d Stainless Perimeter Bar Right Panel Bronze Exterior ✓ go White Interior !� IG-1 Lite Tempered Low E2 w/Argon Stainless Perimeter Bar White Interior Weather Strip Package Slat Active Northfield Handle Oil Rubbed Bronze PVD Exterior Primary Handle Set As Viewed From The Exterior Northfield Handle White Interior Primary Handle Set Non Keyed Egress Information Exterior Sliding Screen Width:4117/64" Height:77 1S/64" Bronze Surround Net Clear Opening:22.13 SgFt Bright View Mesh Ultrex Fiberglass: AAMA 624 ***Screen/Combo Ship Loose Bronze Ultrex Sill/Black Weather Strip 4 9/16"Jambs Nailing Fin ***Note: Unit Availability and Price is Subject to Change OMS Ver.0004.08.01(Current) Processed on:6/5/2024 3:44:18 PM Page 5 of 8 For product warranty information please visit,www.marvin.com/support/warranty. a � G u (� � i. N 1 � � 6. i d N r L ' o y v C E ar •.. co m N >. N.Iso �.r Z w e r_ c r section ^""• ri � p L .0 � J .� _y mod. �. CLcn U a 10 r O u L Z 3 r. `«• a Q M I N 0 Lp aQ 3 " 54, J :J f. co to I- 1 AC" DATE(MMADD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 06/13/2024 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 NAME CT CLIENT CONTACT CENTER FEDERATED MUTUAL INSURANCE COMPANY PHONE FAX HOME OFFICE: P.O.BOX 328 LAIC,No,Ezt):888-333 4949 (AlC,No):507-446 4664 OWATONNA, MN 55060 ADMDRESS:CLIENTCONTACTCENTER FEDINS.COM INSURERS AFFORDING COVERAGE NAIC f/ INSURER A:FEDERATED MUTUAL INSURANCE COMPANY 13935 INSURED 183-631-1 INSURER B: HORIZON PAINTING AND RENOVATION LLC INSURER C: 33 TEMPLE ST HARRISON, NY 10528-2706 INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:39 REVISION NUMBER:0 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 ADDL SUBR POLICY NUMBER POLICY EFF POLICY EXP LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $1.000,000 CLAIMS-MADE L�OCCUR AMPLE T rreO ELATED PREMISES $100,000 X BUSINESS OWNER'S LIABILITY MED EXP(Any one person) A N N 6123192 05/21/2024 05/21/2025 PERSONAL a ADV INJURY $1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $2,000,000 X POLICY ❑Loc PRODUCTS&COMP/OP AGO $2,000,000 OTHER' AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $1,000,000 Ea accidenf�_ ANY AUTO BODILY INJURY)Per Person) A OWNED AUTOS ONLY N N 6123193 05/21/2024 05/21/2025 BODILY INJURY(Per Accident)XAUTOS HIRED AUTOS ONLY ]SCHEDULED NON-OWNED PROPERTY DAMAGE AUTOS ONLY cidentli X UMBRELLA LIAR X OCCUR EACH OCCURRENCE $2,000,000 A EXCESS LIAR CLAIMS-MADE N N 6123194 05/21/2024 05/21/2025 AGGREGATE $2,000,000 DED X RETENTION$10,000 WORKERS COMPENSATION X PER STATUTE I DTHER AND EMPLOYERS'LIABILITY YIN ANY PROPRIETORIPARTNERI EXECUTIVE E.I.EACH ACCIDENT $500.0()0 A OFFICERIMEMBEREXCLUDED? N/A N 1851764 05)21/2024 05/21/2025 IMandatory in NH) E.L DISEASE EA EMPLOYEE $500,000 It yes,describe under DESCRIPTION OF OPERATIONS below E.L DISEASE-POLICY LIMIT $500,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached it mare space is required) CERTIFICATE HOLDER CANCELLATION 183-631-1 39 0 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED VILLAGE OF RYE BROOK 938 KING ST BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN RYE BROOK,NY 10573-1226 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE Dc 1988-2015 ACORD CORPORATION.All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD • r Workers' 1 -; PORK Compensation �l�� CERTIFICATE OF '*4— Board NYS WORKERS COMPENSATION INSURANCE COVERAGE Ia.Legal Name&Adcress of Insured(use street address only) 1b.Business Telephone Number of Insured (914)450-7946 Horizon Paining And Rerovation LLC 33 Temple St Harrison,NY 50528-2;06 1c NYS unemployment Insurance Employer Registration'dumber of IInsured i Work Local of Insured(Qnly repuued if coverage is spx4ficady G'mited to I td.Federal Empoyer edent�cation Number of Insures or Social Security certain locations in NBA,York State,i,e.,a Wrap-Up Policy,; I Number 81--5277680 2.Name and Address of Entity Requestng Proof of Coverage 1 3a.Name of Insurance Carver ---- — --------- (Entiiy Being Listed as he Certificate Helder) i Federated Reserve Insurance,-omparry Village of Rye Brook 938 King St 13b.Policy Number of Ent:r y_sfed in Box'ta' Rye Brook,NY 10573-1225 185175a I 13c.Policy 4-cctve period 05;2112024 to 051212025 I 3d.The Proprietor,Partners or Executive Officers are included.(Grli, e�c box A TK all psrtne-&oers icdjdedj QX all exciuded or certain partnersloffcers excluded. This certifies that the insurance r arrier indicated above in box'3"insures the business refererxxad above in box'l a"^x workers compensation under'he 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 certlicate 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 prem ums that cancel the policy or el,minate the insured from the coverage,ndicated on this Certficate.(These roboes 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 certifcate 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 e0clence of a Workers'Compensation contract of insurance only while the underlying poiicy 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 folder,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,1 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: Tyler Bush (?trM r�m�Maurhorized rep:eser rs!ir;e cr merserl agent ni ineu�e�ce carrier; - Approved by: ( r Qi ,' ' 1 07/0Vf2024 (Sigrwlcro) iDate) Title:Authorized Representative Telephone Number of authorized representative or licensed agent of insurance carrier:888-333-4949 Please Note:Only insurance carriers and their licensed agents are authorized to issue Form C-1051-Insurance brokers are NOT authorized to issue it- C-105.2(9-17) www.wc�b.r.y.gov