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HomeMy WebLinkAboutSP24-003PERMIT r SaPJ Y/ Db 3 TYPE OF WORK JOB LOCATION (QiY)937- 3Go FST. COST w OO _ V/CO A TCO M DATE INSP FOOTING FOUNDATION FRAMING �— FRAMING �— RGH FRAMING INSULATION PLUMBING E RGH PLUMBING GAS Ej SPRINKLER i �- ELECTRIC�- LOW-VOLT M ALARM AS BUILT FINAL OTHER APPROVALS ARB �/kile �8 c�C��i BOT PB ZBA OTHER QyC DRC�,�A 190 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 July 31,2024 Win Ridge Realty LLC c/o Alena Hakanjin 24 Rye Ridge Plaza Rye Brook,New York 10573 Re: 200 South Ridge Street, Rye Brook,New York 10573 Parcel ID#: 141.35-2-36 Sign Permit#24-003 issued on 3/6/2024 for Legalize New Facade Sign This certifies that the new facade sign;"Yogafreak",installed under the above captioned permit has been satisfactorily completed. Sincerely, Steven E. Fews Building& Fire Inspector /to D C��✓IE � JUL - 2 2024 BUILD -_ R _TMENT For office use oah: _ PERMrr VILLAGE OF RYE BROOK VIL OF RYE *q0K ISSUED:7� : y BUILDING DEPARTMENT 938 KING STRE I YE BROOK W YORK 10573 DATE: 9 - FEE: — PAIDA �s "I.xfor 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 ............................................................................................................................. Address: � via e S� Occupancy/Use: Parcel ID# I n Zone: n_ Owner: �n f'i L j 4-4 I Ll p P,' ,- Address:�),� ,lr K l r(4,L �4!DrG� P.E./R.A. or Contractor:`7� L S *�C/�t.�n�r,~ Address:1�6� (f)i( A 4,� Person in responsible charge . (.r p 2x—' Address:404 w.,I Cfw"'><e r, 3��069-3 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 asp �,e, }1 t1 a nZ'_-A_- being duly swom,deposes and says that he/she resides at 4 4 id t(jt4( A"I/2 Pn Name of Applicant) � (Ne ai.d Strccil in �( r p p4 Lly� �L ,in the County of (A 1�JtC T Tom- in the State of that (Cit)'rr0%Vn,'Village) "`--iff--- he/she has supervised the work at the location indicated above,and that the actual total cost of the work,including all site improvements, labor,materials,scaffolding,fixed equipment,professional fees,and including the monetary value of any materials and labor which may have been donated gratis was:S -' for the construction or alteration of: �►� Deponent further states that he/she has examined the approved plans of the structure/wort 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 goveming building construction.Deponent further understands that it shall be unlawful for an owner to use or permit the use of any building or premises or part thereof hereafter created,erected,changed,converted or enlarged,wholly or partly,in its use or structure until a Certificate of Occupancy or Certificate of Compliance shall have been duly issued by the Building Inspector as per§250-IO.A.of the Code of the Village of Rye Brook. Sworn to before me this 4 -1:2 Sworn to before me this / i l day of l (�/ ,20 day of 92 n of Propc ctjyw lute of�Ap t CCU t Print Naorp of Property / ✓ Print of Applicant No Public 'Notary Public ALENAHAKANJIN LOIS NIETO + 122021 NOTARY PUBLIC,STATE Of NEW YORK Registration No.OIMAGO13645 NOTARY PUBLIC, STATE OF NEW YORK Qualified In Westchester County My Commission Expires 911912027 NO. O 1 N14899825 QUALIFIED IN WESTCHESTER COUNTY COMMISSION EXPIRES DECEMBER 3, 2026 QyE BR(uk. O 2 Q,/ �Or '• �9a� `� BUILDING DEPARTMENT BUILDING INSPECTOR f` ❑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 - - - - - - - - - - - - - - - - - - - - \�C DATE: \ ADDRESS :— ' PERMIT# �CcC \` > ISSUED: 1` SECT: !� BLOCK: LOT: LOCATION: — 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 ❑ Natural Gas ❑ L.P. Gas ❑ FUEL TANK ❑ FIRE SPRINKLER ❑ FINAL PLUMBING ❑ CROSS CONNECTION FINAL ❑ OTHER = M N v v - O 1 N \ (V CV v W\ v o o �-) iC � _ z -W 41 01 W O G. ° _ V A 0 vd' E y v O +� 4�0.0 1+ a o v b PL( _ Mci v r- z O `O aCi 0. u a O C7 6 w c�� ;? v i--�- ° A U z � 0 c�jj - Oi vi G� enun v ° " F-+ M > w N V w `O ° aV w �T� 00 o z rahh w z Q W A z n - f-� x U o4; W °� p r p v o V v �-, 4.4 , O © C7 O A z C7 M � � o o lu � � _ 2 V F I BUILD,61A' AI`MENT VIL E OF RY ,kOOK I MAY 8 2024 938 KING L ET RYE BRSi W,NY 10573 L----- VILLAGE OF RYE BROOK BUILDING DEPAR,M-ENT FOR OFFICE USE,ONLY: : Approval Date: Application# Approval Signature: ARCHITECTURAL REVIEW BOARD: Disapproved: : Date: r BOT Approval Date: Case# : Chairman: PB Approval Date: Case# Secretary: ZBA Approval Date: Case# : Other: f Application Fee. 6 Permit Fees: IY Q7J ��y- � : SIGN PERMIT APPLICATION Application dated: 6 is hereby made to the Building Inspector of the Village of Rye Brook,NY,for the issuance of a Permit for the construction/installation of a fign in accordance with Village Code§250-35 as per detailed statement described below. 1. Address: Ze— SBL: �[� Zone: 2. Property Use or Business Name: r 3. Proposed Sign(s)(Describe in detail including number of signs,types,sins,exact location(s),and illumination method(s) if applicable.) ,A separate Electrical Permit will be required for any associated electrical work / !/ 1 ,// , IIL PVC 1CcS 4. Height from grade to highest point of sign: p sign: ,(�1 ,~f ,to lowest Dint of 5. Property Owner: 1�,h elAe, Y Address• Phone#qI" - O i ` Oaf< Cell# email:Q}�1 r� ��1 't I G,�^r 6. Applicant: t�[tL/_ [-)C',i Address: �S � Cell# email:�v )d rjL4- 613bES14 7. Architect/Engineer: Address: Phone# J` GCell# email: 8. Sign Contractor: ial��ez5 t �� -(l- AW Address: ► 6^C (,tJ;IIC 1ai�, ye 0�ty-164-1-f u Phone# ��� Cell email: �5(4 ) �s1eqo'�h -1- 8/l2/2021 9. Will the proposed sign require a Site Plan Review by the Village Planning Board as per§209 of Village Code? Yes: No. (lfves.You must submit a Site Plan Application,&provide detailed drawings) 10. Does the proposed sign involve a Home-Occupation as per§250-38 of Village Code? Yes:—No: If yes, indicate: TIER I:_TIER IT:_TIER III:_ (If yes,a Home Occupation Permit Application is required) 11. If building is located on a corner lot,which street does it front on: 12. Property frontage: 13, Property size:Sq.Ft.: Acres: 14. What is the total estimated cost of construction: S 6 roll. 0 (The estimated cost shall include all site improvements,labor,material,scaffolding,fixed equipment,professional fees,including any material and labor which may be donated gratis-) 15. Estimated date of completion: This application 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: c' , 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. Swom to before me this Sworn to before me this day of_J t , 20 ZA day of , 20 i e of Prolfrty()earrer ^WVT ature of licant f(W t'o-n Z n- Pri a of Prop own cr - Print— Name�f Notary Public Notary Public ALENA 14AKANJON Nodrmy ,STA'rE aNanYM LOIS NIETO Registrnttan No.OINAGO13645 NOTARY PUSLiC, STATE OF NEW YORK G c EMhM y VIV"27 NO. 01 N14899825 QUALIFIED IN WESTCHESTER COUNTY CC V,IAISSiON EXPIRES DECEMBER 3, 2026 .1. 8/12/2021 Building Permit Che List&Zoning Anal is Address: vo S SBL• Zones Us • Conic Type: Ocher Submittal Date: 7- Revisions Submittal Dates: q Applies - 1�-�'Ci 1�- Nuure of Work:_ �-e l C C S1 S Reviews:ZBA: RU 1 3 2024 P BOT: Other: NEM OK GEES Fm P: C/O Flood Plant Legalization: ( ) ( ) APP: Dated Notarized: SBL: Truss I.D. Cross Connection: H.O.A.: ( ) ( ) Scemic Roads: Steep Slopes: Wetlands: Storm Water Review: Sheet Opening. ( ) ( ) ENVIRO: Long. Shorn Fees: N/A: ( ) ( ) SITE PLAN:Topo: Site Protection S/W Mgmt.: Tree Plan: Other. ( ) ( ) SURVEY:Dated Current Archival Sealed Unacceptable: ( ) ( ) PLANS:Date Stamped: Sealed: 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: Permit N/A: Other: ( ) ( ) FIRE ALARM/SMOKE DETECTORS:Plans: Permit H.W.I.C.:_Battery:_Other. ( ) ( ) PLUMBINGs Plans: Permit Nat.Gas: LP Gas: N/A/: Other. ( ) ( ) FIRE SUPPRESSION:Places Permit N/A Other: ( ) ( ) H.V.A.C.: Plans: Permit N/A: Other. ( ) ( ) FUEL TANK Plans: Permit Fuel Type: Other. ( ) ( ) 2020 NY State ECCC N/A Other. ( ) ( ) Final Survey Final Topo: RA/PE Sign-off Lair: As-Built Plans Other. ( ) ( ) BP DENIAL L.E ITER C/O DENIAL I.ETI-ER Other. ( ) ( ) Other. GARB mrg.date: -1,,t,� approvaL• (p-Jig-t y notes: ( )ZBA mtg.date: approvaL• notes: ( )PB mtg.date: approval• notes: APPROVED REQUIRED EXLSTING PROPOSED I`OTFS Am: oats: ;SUN 2 6 2014 gkdv Front Front Sides: Rear. Main Cov. Aces.Cor.. Ft.H Sb: Sd.H Sb: QFA: Tot. Ft.imp: Height/Stories notes: BUILD �lRTMENT VILL� OF RYL'BROOK ( MAY - 8 202- 938 KING STWEET RYE BROOK,NY 10573 4 9 9�0b6>�'� VILLAGE OF RY'= BROOK r g BUILDING DEPARTMENT #ikiiii##i##ff#f######if##tkk##iii4###kki#i#ifftt#ti###f#ti#t#iki####it#ik#ikkikii##if#f#ftk#k########tik## ARCHITECTURAL REVIEW BOARD CHECK LIST FOR APPLICANTS This form must be completed and signed by the applicant of record and a copy shall be submitted to the Building Department prior to attending the ARB meeting. Applicants failing to submit a copy of this check list will be removed from the ARB agenda. Job Address: yo S. //� '3+ ' Date of Submission: S� Parcel ID#: /y�,A 7 -/- Zone: 7 7/:-� Proposed Improvement(Describe in detail): � 1 lb P��l_ SLLt y'1 APPLICANT CHECK LIST: V MUST BE COMPLETED BY THE APPLICANT tl�I YYla r\ r'Taih t::5 The following items must be submitted to the Building a:J�-e�� _ Department by the applicant -no exceptions. Property�—Towner: in Ir,(Ae- 0""a i��. LLC- 1. (,, Completed Application n n p 2. (/ Two(2)sets of sealed plans. (one full size (maximum Address:a� !ejd e f r"G allowable plan size=36"x 42") and one I 1"x17") 3. ( )Two(2)copies of the property survey. Phone# Uf/�- 7 % �� 4. ( )Two(2) copies of the proposed site plan. Applicant appearing before the Board: 5. ( )One electronic/disc copy of the complete C �� n I application materials. 6 /� 6. ( �Filing Fee. AddresO,164 J �1�� �yp . ��� E p�/ 7j 7. ( )Any supporting documentation. Phone#y(�1 - �; - �!1 8. ( )HOA approval letter. (,fapplicable) 9. Photographs. Architect/Engineer: 10.( )Samples of finishes/color chart. (a sample board or model may he presented the night of the meeting) Phone# By signature below, the owner/applicant acknowledges that he/she has read the complete Building Permit Instructions&Procedures,and that their application is complete in all respects. The Board of Review reserves the right to refuse to hear any application not meeting the requirements contained herein. Sworn to before /me this L)fli Sworn to before me this .� da of / I , 20 day of , 20_s� azure of Pro aw�ter/ � tare of A licant PR;�74_: t Print Name of pplicant 'Rotary Public Notary Public LOTS NIETO ALENA HAKANJIN NOTARY PUBLIC, STATE OF NEW YORK NOTARY PUBLIC,STATE OF NEW YORK NO. O1 N14899825 Registration No.OIHAO013645 NTY Qualified in Westchester County COMMISSION QUALIFIED EXPIRES DECEMBER 3, 2026 1 m My commission Expires 91191,'07' Bi 12/2021 �yE DR k. Village of Rye Brook ML ✓ MR vo- Agenda FB ✓ SE Architectural Review Board Meeting AC AD W Tuesday June 18,2024 at 7:30 PM QVillage Hall,938 King Street JM SF 1. ITEMS: 1.1. ARB24-062(Consent Agenda) Uriel Alejo&Maria Becerra 12 Jean Lane Rooftop solar array. 1.2. ARB24-063 (Consent Agenda) (Amendment to Approved Plans) Eric Steinert&Caryn Steinert 24 Meadowlark Road Install two skylights on rear deck roof. 1.3. ARB24-064(Consent Agenda) Bruno Stephan Veras de Melo&Luciana Traverso de Resende Melo 260 Betsy Brown Road Rooftop solar array. 1.4. ARB24-065 (Consent Agenda) Vipul Ramesh Nayi&Fany Delacruz Nayi 50 Valley Terrace Rooftop solar array. 1.5. ARB24-066 (Consent Agenda) Sooah Park 47 Bonwit Road Replace front steps and walkway. 1.6. ARB24-067 (Consent Agenda) Jie Gao&Lei Deng 10 Lawridge Drive Rooftop solar array. 1.7. ARB24-068(Consent Agenda) Lance Hochhauser&Heather Katz Hochhauser 22 Talcott Road Install egress window,finish basement. 1.8. ARB24-069 (Consent Agenda) Eric Steinert&Caryn Steinert 24 Meadowlark Road 6'high white PVC fence and gate. Page 1 of 4 • ' Architectural Review Board June 18,2024 1.9. ARB24-070 (Consent Agenda) Emily Groglio Irrevocable Trust,Shari Melillo,Trustee 5 Paddock Road Rear window and door changes. 1.10. ARB24-071 (Consent Agenda) Matthew Altman&Alexandra Altman 42 Lawridge Drive Remove one window and reduce size of one window. 1.11. ARB24-072(Consent Agenda) Salvatore Morlino&Annette Morlino 1 Bonwit Road New rear patio&composite stone veneer over existing brick 1.12. ARB24-073 (Consent Agenda) Jose Poza&Rosweny Flores Hidalgo 115 North Ridge Street Legalize 6'high wood fence&remove rear wood deck on grade. 1.13. ARB24-074(Consent Agenda) (Amendment to Approved Plans) 2 Elm Hill LLC 6 Elm Hill Drive Legalize 6'high black cedar fence&porcelain pool patio. Consent Agenda Approvals: Motion Second Abstention Aye; Nay; Adjournment; Notes 1.14. ARB24-020 556 Westchester Ave LLC C/o Anthony Guastella 556 Westchester Avenue New rear windows. Approvals: Motion Second Abstention Aye; Nay; Adjournment; Notes Page 2of4 Architectural Review Board June 18,2024 1.15. ARB24-075 Win Ridge Realty LLC 200 South Ridge Street Legalize facade sign."Yogafreak" Approvals: Motion Second_jC6 Abstention Aye;_ Nay; Adjournment; Notes 1.16. ARB24-076 Jose Herrera 506 West William Street Legalize roof over rear patio. Approvals: Motion Second Abstention Aye; Nay; Adjournment; Notes 1.17. ARB24-077 Victor Paterno&Annemarie Paterno 15 Old Orchard Road Legalize deck expansion and stairs. Renovate entire deck. Approvals: Motion Second Abstention Aye; Nay; Adjournment; Notes 1.18. ARB24-078 G&G Homebuilders Corp 18 Rock Ridge Drive Second story addition,deck and fence. Approvals: Motion Second Abstention Aye; Nay; Adjournment; Notes 1.19. ARB24-079 Sean Kirby&Erika Sanchez 270 North Ridge Street Legalize new rear patio&construct a pergola. Approvals: Motion Second Abstention Aye; Nay; Adjournment; Notes Page 3of4 Architectural Review Board June 18,2024 1.20. ARB24-080 Densy Gonzalez 213 Irenhyl Avenue New rear deck,window and door changes. Approvals: Motion Second Abstention Aye; Nay; Adjournment; Notes 1.21. ARB24-081 Kenneth Gerchick&Amy Bernstein Gerchick 3 Mohegan Lane Second floor dormer addition. Approvals: Motion Second Abstention Aye; Nay; Adjournment; Notes 1.22. ARB24-082 Randy Hamlet&Anne Marie Hamlet 21 Country Ridge Circle New front portico and window changes. Approvals: Motion Second Abstention Aye; Nay; Adjournment; Notes 1.23. ARB24-083 Robert O'Neill&Melissa O'Neill 4 Loch Lane Garage door overhang. Approvals: Motion Second Abstention Aye; Nay; Adjournment; Notes NEXT MEETING: July 17,2024 Page 4of4 AC R® DATE(MM/DDMWI CERTIFICATE OF LIABILITY INSURANCE 06117/2024 THI:':E'-TIFICATE 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 p'olicy(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 Joanne Sinco NAME: Borreili Partners Insurance Agency ,PHONE (g14)939 7900 FAX (g 14)407-5088 LAIC No Ext. —_ _,_I1UC No_):_. 287 Bowman Avenue EMAIL )sirico@borrellipartnerscwm ADDRESS Suite 406 INSURER(S)AFFORDING COVERAGE NAIC N Purchase NY 10577 j INSURER A: Travelers Casualty Ins Co of America 19046 INSURED INSURER B Travelers Indemnity Co 25658 Lanza Corporation dba Sign Design&J C Awning INSURER C: _ 404 Willett Ave INSURER D: INSURER E Port Chester NY 10573 INSURER F COVERAGES CERTIFICATE NUMBER: CL2451305722 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. .-..—- AT}DL LTCR' _-...-_. -_ POLICY EFF POLICY EXP ___... _.. IN R v WVD�_ _ POLICYNUMBER _ iMMIDDrNW) MI MIDD/WV1'1 LIMITS LTR TYPE OF INSURANCE N&D - - - - �COMMERCIALGENERALLIABILITY EACH OCCURRENCE E 1,000,000 1 oA.T ,7_r7,N D 300,000 CLAIMS-MADE a OCCUR PREMISES Ea occurrence, E _ - �__ MED EXP(Any one on) E 5.000 A J _ 8805J175092 06105/2024 06/05l2025 PERSONAL&ADVINJURY E 1,000,000 _GEN'LAGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2.000.000 JECTPOLICY PRO-- LOC PRODUCTS-COMP/OPAGGj E 2,000,000 OTHER: -"-- - -- t MBINED SINGLE LIMIT -- AUTOMOBILE LIABILITY �ECOaaoGtlere la ANY AUTO BODILY INJURY(Per person) E - OWNED SCHEDULED BODILY INJURY(Per accident) E AUTOS ONLY AUTOS - HIRED NON-OWNED PROPERTY DAMAGE is AUTOS ONLY AUTOS ONLY iPar acUdenn __ � __ IS 1 UMBRELLA UAB X OCCUR EACH OCCURRENCE $ 5,000,000 B XI EXCESS UAB CLAIMS-MADE EX5J175240 06/05/2024 06/05/2025 `AGGREGATE s 5,000,000 DED RETENTION s 1 _ E WORKERS COMPENSATION X 5T TUTS ERH AND EMPLOYERS'LIABILITY y/N 1,000,000 ANY PROPRIETOR/PARTNERIEXECUTIVE E.L.EACH ACCIDENT E B OFFICER/MEMBER EXCLUDED? El NIA UB5J175160 06/05/2024 06/05/2025 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000 If yas,describe under 1,000,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT s i DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) BLANKET Al-OWNERS,LESSESS OR CONTRACTORS,AI-MANAGERS OR LESSORS OF PREMISES,A(-STATE OR POLITICAL SUBDIVISIONS PERMITS RELATING TO PREMISES,Al LESSOR OF LEASED EQUIPMENT.PRIMARY&NON-CONTRIBUTORY WORDING,WAIVER OF SUBROGATION-WC POLICY INCLUDES BLANKET WOS 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 Brook NY 10573 l-- _ __ -Z_—__. " _ ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD / Yo Workers' STATE Compensation CERTIFICATE OF Board NYS WORKERS' COMPENSATION INSURANCE COVERAGE la Legal Legal Name&Address of Insured(use street address only) II 1b.Business Telephone Number of Insured Lanza Corporation DBA Sign Design and J C Awning 1 914-937-6360 404 Willett Avenue i 1c.NYS Unemployment Insurance Employer Registration Number of Port Chester, NY 10573 Insured Work Location of Insured(Only required it coverage is specifically limited to certain locations in New York State,i e., a Wrap-Up policy) 1d.Federal Employer Identification Number of Insured or Social Security Number 13-3525268 2.Name and Address of Entity Requesting Proof of Coverage(Entity Being Listed as the Certificate Holder) 13a.Name of Insurance Carrier Travelers Indemnity Company Village of Rye Brook i 3b.Policy Number of Entity Listed in Box"la" 938 King Street Rye Brook, NY 10573 �65J175160 3c.Policy effective period 06/0S/2024 to 06/0025 3d.The Proprietor,Partners or Executive Officers are ® included.(Only check box if all partnersJomcers included) —--- ❑ all excluded or certain partners/officers excluded. — This certifies that the insurance carrier indicated above in box"T'insures the business referenced above in box"la"for workers' on the INFORMATION PAGE of the workers' -- - --- __ _ _ compensation under the New York State Workers'Compensation Law. (To use this form,New York(NY)must be listed under!—em 3A this Certificate of Insurance to the entity listed a pensation insurance policy). The Insurance Carrier or its licensed agent will send b comove as the certificate holder in box"2" (Will the carrier notify t--- he certificate holder within 10 days of a policy being cancelled for non-payment of premium or within 30 days i cancelled for any other reason or if the insured is otherwise eliminated from the coverage indicated on this certificate prior to the end of the policy effective period? YES y f ❑ ®NO 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 P 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: Joanne SIrICO (Print name of authorized representative or licensed agent of insurance Carr er) Approved by: 06/17/2024 (Date) Title: Sf&Ct Mgf --- Telephone Number of authorized representative or licensed agent of insurance carrier 914-939-7900 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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