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HomeMy WebLinkAboutBP24-166PERMIT # O�i �' ' � (� C� �; o7S �� gip; SECTION �� TYPE OF WORK JOB LOCATION �T. COST.��j �/ CO #___ _�,� TCO # LOT � 4C' e X/s7�ir� C I�PPrI Lv4 / �u�ay C�/vse ,�L �9/ ;- �►- :-. � U00 � FEE �f FEEs� �S® �%DAl FEE DATE JNSPECTION RECORD � DATE INSP FOOTING FOUNDATION FRAMING RGH FRAMING INSULA710N PLUMBING 0 RGH PLUMSiNG GAS L� SPRINKLER ELECTRIC O LiW-VOLT CI ALARM O --F�ir74t- � •� 4\ �ar�� �C�'Q�O � ��/� 8%�iP 'z//J7� OTHER APPROVALS ARB BOT PB ZBA OTHER �� VILLAGE OV-I�YE BROOK WESTCHES COU Y, NEW YORK ��'� �% NO: 24-138 ����Oa Certificate of (Occupancy Shis is to certify that Weer) Gt L4 oldl�e L�f of, PvJ� &OOk, A) having duly filed an application on Don Y �U, 20 requesting a Certificate of Occupancy for the premises known as, -7S Rrifer) wQ (A C/c) .� , Rye Brook, NY, located in a U�� Zoning District and shown on the most current Tax Map as Section: /, / 0 VBlock: CP Lot: C07 , and having fully compli//ed,/with the requirements of the Building Code and the Zoning Ordinance under Building Permit No. (lJ UJ, issued 20 c241, such authority and permission is hereby granted to the property owner to lawfully occupy or use said premises 7aMi/e-/—Construction:—'-y--R ilding or part thereof listed under the following New York State Classifications, Use: , for the following purposes: IV, tP X(' 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 hei hall be made, or all the building be moved from one location to another until a permit to accomplish such change has ee ob 'ne fro ,' a ilding Inspector. Building Inspector,Village of Rye Brook: Date: OCT 3 1 2024 D E C IE � V E BUILDING DEPARTMENT For office ug onl : / PERMIT# —/�Q OCT 2 8 2024 3D VILLAGE OF RYE BROOK ISSUED:`]—�J —a 4/ 938 KING STREET,RYE BROOK,NEW YORK 10573 DATE: VILLAGE OF RYE BROOK (914)939-0668 FEE:V PAIDW BUILDING DEPARTMENT WWW.ryebrookny.Pov 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 *ss**s*ss*****s******ssstts*s***t***tsasassss*aa*t*asaa*ssssst*sssss*ssssssss**sat*assass*sss*aaassassaassssa**ssstatsssssss* Address: e � 8 7Occupan /Us Zone: 6�.L Owner: Address: P.E./R.A. or Contractor: CIA �� �n�-�'��� Address: �� I � y e �"1 / ('(� Person in responsible char g �,�� � �( fUddress: �'�( ��lo©� 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: v ing duly sworn,deposes and says that he/she resides at �O ��T(J(J � "R�� C�Q� Prmt ame of Applica ) (No.and Street) in A VR 7 �— ,in the County of WeSk7d c S44.'Z in the State of (�,that (Ci own/Village) 66 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 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 d Sworn to before me this day of 0 CAV , 20 ` day of , 20 1 lab'l - 'bl� A I S of Property Owner Signature of Applicant UN -Q rint Name of Property Owne Print Name of Applicant No19YJ? bllc,State of New York Notary Public Nu,01NIE6160063 Qualified in Westchester Count� 6;l;2023 Ccrnrrii--sion Exnires lanui ry 2J,20 QyE BRC��• 2m • 1982 BUILDING DEPARTMENT ❑�L7ILDING 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 : O l-r f ee J uj C,LOSQ DATE: PERMIT# ���_�_ ! ISSUED: -l I SECT: �Z 9 S7 BLOCK: LOT: LOCATION: ��W v T (..�!a �� (.Jn OCCUPANCY: ❑ VIOLATION NOTED THE WORK IS... fJ ACCEPTED ❑ REJECTED/ REINSPECTION ❑ SITE INSPECTION REQUIRED ❑ FOOTING ❑ FOOTING DRAINAGE ❑ FOUNDATION ❑ UNDERGROUND PLUMBING NOTES ON INSPECTION: ❑ ROUGH PLUMBING ❑ ROUGH FRAMING ❑ INSULATION ❑ NATURAL GAS ` =1- ❑ L.P. GAS ❑ FUEL TANK ❑ FIRE SPRINKLER ❑ FINAL PLUMBING ❑ CROSS CONNECTION FINAL ❑ OTHER W NL�- r . � • ISN _ vC e \ k w cd N N N N cr Q cuEl -� _ cn z w x � a z 3© cn a. � 4 00 Ho 00 pdp � ° o c Cr a 0r0p o� U = \7J W7 1 4A ,,I4 e O � [~ o � U � �i 0 0 -b qu z �T � ^ 2 ^ - V z v D �» o = w �I C� h+==I M .�-� A .�-i W `f' cwj va 5 -o Ca a " (� ` A M 1-1 O a � W 2 U p P-� q a _ _ a a „ U 00 ICI 1�1 w �w V o "q W p4 A " � �U; ' � � � � ° w z 00 v � o A v V = HOJOL B - MM Z p v� U V U w z = o = Lu W z 00 z W W -g-5 � az •• A G4 W W '� a� _ a � _ BUILDING DEPARTMENT VIL� E OF RYE OOK 938 KING STRI�ET RYE BR� ,NY 10573 (914)939-0648 JUL 19 2024 www.ryehrookny.Qov VILLAGE OF RYE BROOK BUILDING DEPARTMENT FOR OFFICE USE ONLY: ,Q Q l�,/ //�/ Approval Date:JUL 4 Application# Approval Signature: ARCHITECTURAL REVI OARD: Disapproved: : Date: BOT Approval Date: Case# Chairman: PB Approval Date: Case# Secretary: ZBA Approval Date: Case# ; Other: Application Fee: D Permit Fees:' � EXTERIOR BUILDING PERMIT APPLICATION //Application dated: /9_ y is hereby made to the Building Inspec orof the Village of Rye Brook,.NY,for the issuance ofa Permit forthe construction of buildings,structures,additions,alterations or for a change in use,as per detailed statement described below. 1. JobAddress: v� 2. Parcel1D#: �9. 9 — 07—eo I Zone: "0'06 3. Proposed Improvement(Describe in detail): In S 4. Property Owner: Address: Phone# Cell# q � Q' - A91E e-mail List All Other Properties Owned in Rye Brook Applicant: Address: Phone# Cell# e-mail Architect: Address: Phone# Cell# e-mail Engineer: + Address: Phone# Cell# e-mail General Contractor: ONadox,-, \[ac r Dxd -- o//rn ,� IP ,�, Address:�� ��hnwbo� �. 11t111. t E��1�73 r\, F�-Y. �{�(.10`f' Phone# Qq- g l� - ( -�' Cell#��q- aAt.to � e-mail � �9 L. Con cl� 6/1 i2o2a 5. Occupancy;(I-Fam.,2-Farn.,Commercial.,etc...)Pre-construction: Post-construction: 6. Area of lot: Square feet: Acres: 7. Dimensions from proposed building or structure to lot lines: front yard: rear yard: right side yard: left side yard: other: 8. If building is located on a corner lot,which street does it front on: 9. Area of proposed building in square feet: Basement: I`fl: 2°d fl: 3rd fl: 10. Total Square Footage of the proposed new construction: 11. For additions,total square footage added: Basement: 15,fl: 2"d fl: 31 fl: 12. Total Square Footage of the proposed renovation to the existing structure: 13. N.Y.State Construction Classification: N.Y.State Use Classification: 14. Number of stories: Overall Height: Median Height: 15. Basement to be full,or partial: finished or unfinished: 16. What material is the exterior finish: 17. Roof style;peaked,hip,mansard,shed,etc: Roofing material: 18. What system of heating: 19. If private sewage disposal is necessary,approval by the Westchester County Health Department must be submitted with this application. 20. Will the proposed project require the installation of a new,or an extension/modification to an existing automatic fire suppression system?(Fire Sprinkler,ANSL System,FM-200 System,Type I Hood,etc...) Yes: No: (fyes,applicant must submit a separate Automatic Fire Suppression System Permit application&2 sets of detailed engineered plans) 21. Will the proposed project disturb 400 sq.ft.or more of land,or create 400 sq.ft.or more of impervious coverage requiring a Stotmwater Management Control Permit as per§217 of Village Code? Yes: No: Area: 22. Will the proposed project require a Site Plan Review by the Village Planning Board as per§209 of Village Code? Yes: No: (if yes,applicant must submit a Site Plan Application,&provide detailed drawings) 23. Will the proposed project require a Steep Slopes Permit as per§213 of Village Code Yes: No: (if yes,you must submit a Site Plan Application,&provide a detailed topographical survey) 24. Is the lot located within 100 ft.of a Wetland as per§245 of Village Code? Yes: No: (if yes,the area of wetland and the wetland buffer zone must be properly depicted on the survey&site plan) 25. Is the lot or any portion thereof located in a Flood Plane as per the FIRM Map dated 9/28/07? Yes: No: (if yes,the area and elevations of the,flood plane must be properly depicted on the survey&site plan) 26. 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) 27. Does the proposed project involve a Home-Occupation as per§250-38 of Village Code? Yes: No: Indicate: TIER 1: TIER 11: TIER III: (ifyes,a Home Occupation Permit Application is required) 28. List all zoning variances granted or denied for the subject property: w 29. What is the total estimated cost of construction: S kad— Note:77te estimated cost shall include all site improvements,labor,material,scaffo'ding,fixed equipment,professional fees,including any material and labor which may be donated gratis.If the final cost exceeds the estimated cost,an additional fee will be requiredprior to issuance of the CIO. 30. Estimated date of completion: (2) 6/1/2024 Li BUILDING DE E4R MENT V1 AJf(;E OF RY OK J U L 19 2024 938 KING 7REI:T RYE BR 1 10573 (914)939-06157� VILLAGE OF RYE BROOK www.rvebrookn„ry. ov BUILDING DEPARTMENT AFFIDAVIT OF COMPLIANCE VILLAGE CODE §21 6 • STORM SEWERS AND SANITARY SEWERS THIS AFFIDAVIT MUST HEAR THE NOTARIZED SIGNATURE OF THE LEGAL PROPERTY OWNER AND HE 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 Y((ORK, COUNTY OF WESTCHESTER ) as: fit, �ln_� D , residing at, (Print name) I (Address whey- ou live) being duly sworn, deposes and states that(s)he is the applicant above named, and further states that(s)he is the legal owner of the property to which this Affidavit of Compliance pertains at; O (O=je- , Rye Brook,NY. (Job Address) Further that all statements contained herein are true, and that to the best of his/her knowledge and belief,that there are no known illegal cross-connections concerning either the storm sewer or sanitary sewer, and further that there are no roof drains, sump pumps, or other prohibited stormwater or groundwater connections or sources of inflow or infiltration of any kind into the sanitary sewer from the subject property in accordance with all State, County and Village Codes. (Si,urturc of oper (kkner(s)) a'n'�h"_ '� yN (Print Namc of Property 0%%nk i ,i i Sworn to before me this dVof ,�3� , 20 (Notary Public) SHARI MELILLO Notary Public,state of New York No.01ME6160063 Qualified in westchester Countyr7 (b) Commission Expires January 29,2 6/1/2024 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. 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 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. 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 z day of 120 kL "'Ili nature of roperty owner Signature of Applicant Print Kame of Property UwnerT Print Name of Applicant "Lo, No ry Public Notary Public SHARI MELILLO Notary Public,State of New York No.OIME6160063 Qualified in Westchester County mmission Expires January 29,20ZI (S) 6/l12024 BuddLpg Permit Check Luc&Zoning Analysis At O SBL• I '2 Zone: l Use:�'\ y Corot T Other: Subnumal Date- \\SS L Revisions Submittal Dar Applicant oOROS Name of Work: (!,C\.C k(— , tJl_1C� Reviews:ZBA: BOT: Other. i NEWK FEES: /0 ( ( ) ES:Fling BP: \ C/O Flood Plana Legalinnon ( ) (%�C P: Dated- Notaaze&-- SBL• — Truss I.D. Cross Connection: `��H.O.A.: ( ) ( ) Scenic Roads: Steep Slopes: Wetlands: Storm Water Review Street Opemng. ( } ( ) fNVIRO: Long Short: Fees: N/A: ( ) ( ) SITE PLAN:Topo: Site Protection: S/W Mgmt.: Tree Plan Other: ( ) ( ) SURVEY: Dated: Current Archival Sealed Unacceptable ( ( ) PLANS Dare Stumped Scaled Copies: Electronic Other. (� ( License Workers Comp: Liability Comp.Waiver. Other. (�( ) CODE 753#: Dated N/A: ( ( ) HIGH-VOLTAGE ELECTRICAL-Plans: Permit N/A: Other. ( ) ( ) LOW-VOLTAGE ELECTRICAL•Plans: Pernut N/A: Ocher. ( } ( ) FIRE ALARM/SMOKE DETECTORS Plans: Permit H W.I.0:_Baacry._Other. ( ) ( ) PLUMBING:Plans Permit Nu.GIs: LP Gas: N/A/: Other. ( ) ( ) FIRE SUPPRESSION:Plans: Permit N/A: Other. ( ) ( ) H.V.A.C. Plans: Pemuc N/A Other. ( ) ( ) FUEL TANK Plans: Pa u: Fuel Type. Other. ( ( ) 2020 NY Sure ECCC: N/A Other. (� ( ) Final Survey Final Topo: RA/PE Sign-off Letter. As-Built Plans: Other: ( ) BP DENTIAL LE-I`I'ER: C/O DD41AL U:FITR Other. ( ) ( ) Other. ( )ARB ttrtg.due: approvaL• notes: ( )ZRAA mcg.dui approval:- notes: ( )PB nrtg.data approval• notes: REQUIRED EXMING PROPOSED 'NOTI_ti A 5 10144 curl _ F-m-g� Riau: rmnt Sides: ELCIT Main COr. Accs.Cc Ft.H/Sb: Sd.H/�' - — — QBti Ta—ice: Few: — P Hsht/Stones notes: The Arbors Homeowners' Association 173 V2 Ivy Hill Crescent Rye Brook, NY 10573 D I Eju 19 2024 ID July 18, 2024 __ VILLAGE OF RYE BROOK Liz Tippens BUILDING DEPARTMENT �-- ---------- 78 Greenway Close Rye Brook, NY 10573 Re: Replace Existing Walkway Dear Liz, The Architecture and Grounds Committee (A&G) and the Board has reviewed your application for the above-named work. This project requires a permit from The Village of Rye Brook. You are approved to get a permit from the Village of Rye Brook. You are directed to submit this letter to the Village along with your permit application. Once the permit is obtained, a copy must be provided to A&G. If any changes are made to the original plans submitted to A&G, due to input from the Village or arising during construction, the Committee must be notified in writing. Work cannot proceed until you receive written approval for those changes. Since walkways are the HOA responsibility you must contact me before you make the final payment. We allow homeowners to do work but we want to make sure this work does not impact the HOA> Failure to comply with these procedures will result in fines and/or work stoppage. If you have any questions, please contact me. Sincerely, Nicholas Salzarulo Property Manager 44 • a t- -v # �• 1!6 S L �- 11 ------------- AM f4 r 4VW :Cf � Al I 7 1 \ J P c, 1 fjiJ 7Jfpn 4T 61W �e3 k"M _Tv ,771:�s NO, 17— � � �, r.._�,�-•' i �f�r ,.��' ";4 r' " '�J<�a "e��� 1n \ a� .ate �.. f q -' r N,�l"+•� ,/� dam"` �-'ys''y �yy k a r r uname vaccaro Mpg NAMI Ttppens Rolling Stone Masonry Ltd. 78 Cmenway lose 15 Elmwood Avenue,West Harrison,NY 10604 Rye Brook, 914-874-4278 License:WC-17004-1-105 SCOPE OF WORK: PROPOSED UNIT SUBTOTAL DESCRIPTION INTY(sq.ft.) COST Front of the Residence:Masonry Dena&removal of existing bring walkway&prep for new trick paver walkway 1 600 600 Supply&install Cambridge brick pavers over 5"of Item 4,1"stonedust level bed w.polymeric sand joints 1 3,400 3,400 Extend Cambridge brick pavers under the window w.5"of Item 4,1"stonedust level bed w.polymeric sand will be 6'x T:$1200 0 Price to Complete Above Project Scope of Work 4,000 Issued April 19,2024 Valid for 60 days(prices subject to change) All materials and work performed are guaranteed to be as specified for 2 full years upon completion of the job only if all material is urc thro Roll Stone J Y p Rolling andscaping Ltd. This does not include any wear&tear of the stone,asphalt,concrete,stucco or cement joints.These areas are covered for 12 months upon day of completion on a limited warranty. All work will be performed in a professional manner in accordance with standard practices. Any deviations or changes from the above specifications involving extra work or removal of work will be executed only upon written order, and will became an extra charge above estimated total. All agreements arc contingent upon including but not limited to strikes,accidents,acts of God,safe working conditions for our employees,or delays beyond our control. Proposal excludes Permits,Architect Plans,Bonds,Plumbing,Sprinkler Connections,Carpentry,Electical,BBQ Applumes,Surveys,&Any Unforeseen Excavation Conditions. Price Includes Dumping Fees&Removal of any Debris Payment Schedule:1/3 beginning deposit,1/3rd middle of the project&1/3rd final payment upon day ofcompletion.No work shall commence until 113rd deposit is received&clears. If you have any disputes or questions regarding your invoice&or work performed,please notify us within 5(five)days.Thereafter the invoice will be darned consented to you&correct. The Scope of the work to be completed to is limited to what is set forth above in the section entitled scope of work. All prior understandings,agreements,representations and warranties,oral or written between Rolling Stone Masonry Ltd. Neither this contract nor any provision thereof may be waived or changed or cancelled except in writing and signed by Rolling Su me Masonry Ltd.,& the authorized signatory is mull and void and of no further force and effect. The start date is subject to change depending an states,accidents,ants of God,safe working conditions for cur employees,or delays beyond our control. ACCEPTANCE OF PROPOSAL The above price and conditions are satisfactory and are hereby accepted.You are authorized to do the work specified. Payment will be made as above. Authorized S Title -/ •.. .• ...: A A -n �.__-�er' Ayr��.,�• "tA �\.. t. '•�S �__--�=�jt .A. r - � r ♦♦ v .t1,• �,t �� ,.. �•� wt,y� tv E,r�i'�•� 5� ;.ir! �I�y, •3 vQ `` � p<�)>�' - s%_Ill�lll.:��r ��•�- If�111.. `- i• I�j+�i 1�iy-� �. �Ij � '� - .�.:9 . .. . . . . . . . . . . .. .. . . . ... .. 7 hri :;\•. h Cd tV , 04 C L LL) O _�• cu i � V V •O � `��� U ca FL2.1 PCtion V 1 T-1 UJ Co W I— H w 4f/ j4, 0 C� J � �•1 C Q -CIS a ��T' a. •� C. �e aet �? tr) , •y L {� •c6 Ri v O �• l" y <(oIf %It PP. s . /•. i%' se:. - �.,1{ =�- ,11 111 '�..,1{�111 - :'=�=111+1 j•-�.s. .,,� ,il,lll`•. '.�v s_ ' l.. d/1 11 1 // 1 �� �r�'"{ ! 1 1-�vim- 1{//t t 1{ 1 t{�}�,►► - WK KA CERTIFICATE OF LIABILITY INSURANCE DATE(IIW D/YYYY) OU22/2024 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(les)must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WANED,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 endorseme s). PRODUCER Scavone Insurance Agcy Ctr LLC REACT Maria Gizzo PHONE 914 428 7764 470 Mamaronck 914-428-7111e Ave Suite 205 White Plains,NY 10605 ADDRESS maria@scavoneins.com INSURE S AFFORDINOCOVERAGE NAICNf INSURER A: AMERICAN FIRE AND CASUALTY COMPANY 24066 INSURED Roping Stone Landscaping Ltd INSURER B: OHIO SECURITY INSURANCE COMPANY 24082 15 Elmwood Ave INSURER C: OHIO CASUALTY INSURANCE CO 24074 West Harrison,NY 10604 INSURER D: 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 I ADDL BR POLICY EFF POLICY EXP TR TYPE OF INSURANCE Jwn I Ifirwil POLICY NUMBER IUMID fMIM1DnIYYYYiLIIaTS A ✓I COMMERCIAL GENERAL LIABILfTY Y BKA65489884 11/21/2023 1 1/21/2024 EACH OCCURRENCE $ 2,000,000 cuRV,MADE ✓ occLlR PDAMAGE TO KEN I ED REMISES E a a occurrence) $ MUM MED EXP(Any one ) $ 15,000 PERSONAL a ADV INJURY $ 2,000,000 oEtrl AGGREGATE PRO- APPLIES PER GENERAL AGGREGATE $ 4,000,0()0 POLICY ✓ �T LOC PRooticTs-colrPloP AGG s 4,000,000 OTHER: $ B AUTOMOBILE LIABILITY BAS65489884 11/21/2023 11/21/P024 CEaOMBINED SINGLE LIMIT $ 1,000,000 AN AUTO acodenN BODILY INJURY(Per person) $ OWNED �/ SCHEDULED AUTOS ONLY AUTOS BODILY INJURY(Per accident) $ ✓ A�ONLY ✓ AUTO ONLDY PROS SAGE $ s C ✓ 11NBREL1AL1A8 ✓ OCCUR US065489584 1121/2023 11/21PL024 EACH OCCURRENCE s 1,000,000 EXCESS LIAR CIAMASJJADE EXCLUDES AUTO LIABILITY AGGREGATE s 1,000,000 DED ✓ RETENTION s 10000 s C WORKERS COMPENSATION XWO65489884 1121/2023 1121/2024 ✓ — OTH- AND EMPLOYERS'LIABNJTY ANYPROPRIETORIPARTNERIEXECLFnVE YIN ER STATUTE OFFICER/MEMBEREXCLUDED? ❑ MIA EL EACH ACCIDENT s 1,000,000 (Mandatory in NH) V yes,describe under E1 DISEASE-EA EMPLOYEE $ 1,000,000 DESCRIPTION OF OPERATIONS below E.L DISEASE-POLICY LYIT $ 1,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VE}9CLES(ACORD 101,Additional Remarks Schedule,racy be attached if more space is requi.ed) The Village of Rye Brook is included as an Additional Insured with respect to issuing permits. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE VOLL BE DELIVERED IN Village Of Rye Brook ACCORDANCE WITH THE POLICY PROVISIONS. 938 King St Port Chester,NY 10573 AUTHORIZED REPRESENTATIVE 01988-2015 ACORD CORPORATION. All rights reserved. ACORD 26(2016/03) The ACORD name and logo are registered marks of ACORD STATE OF NEW YORK WORKERS' COMPENSATION BOARD CERTIFICATE OF NYS WORKERS' COMPENSATION INSURANCE COVERAGE Ia.Legal Name&Address of Insured(Use Street address only) 1b.Business Telephone Number of Insured 914-874-4278 Rolling Stone Landscaping Ltd la NYS Unemployment Insurance Employer 15 Elmwood Ave Registration Number of Insured West Harrison,NY 10604 Work Location of Insured(Only required if coverage is specifically Id. Federal Employer Identification Number of Insured limited to certain locations in New York State, i e., a Wrap-Up or Social Security Number Policy) 20-3322707 2.Name and Address of the Entity Requesting Proof of 3a. Name of Insurance Carrier Coverage(Entity Being Listed as the Certificate Holder) Liberty Mutual Insurance Group 3b.Policy Number of entity listed in box"la" Village of Rye Brook XWO65489884 938 King Street Port Chester,NY 10573 3c. Policy effective period 11-21-2023to 11-21-2024 3d. The Proprietor,Partners or Executive Officers are F1 included. (Only check box if all partners/officers included) X n 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 "la" 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 will also notijy the above certificate holder within 10 days IF a policy is canceled due to nonpayment ofpremiums 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. Please Note: Upon the 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: Joseph A Scavone (Print name of authorized representative or licensed agent of insurance carrier) Approved by: f awpvk S('.GZvmP/ 1/22/2024 (Signature) (Date) Title: Authorized Representative/Licensed Agent Telephone Number of authorized representative or licensed agent of insurance carrier: 914-428-7111 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. 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