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HomeMy WebLinkAboutBP24-176PERMIT 0 , & , - SECTION Z,35 3 TYPE OF WOR ,e 0 Q 10B LOCATION cD OWNER �Q/I/1? %clGl ,EST. COST, / TC* # DATE: BLOCK LOT oils '/n ,Yi",S`�ii2q pis Qi'7 rs C9/2j)974 6a09 FE FEE_ DATE FEE DATE _ • INSrECTI�N RECOlt� I DATE INSP FOOTING FOUNDATION FRAMING _ I(o - ZoL� RGH FRAMING _ 1 b Zoe INSULATION ,_ f 11 - ZoL PLUMBING �[J _ RGH PLUMBING GAS 0 SPRINKLER _/ ELECTRIC co LOW -VOLT O —"---- ALARM 0 6 AS BUILT BUILT Z 8- 2 04L FINAL OTHER APPROVALS ARB BOT PS ZBA OTHER — FINISHED BASEMENT NOT APPROVED FOR USE AS A SEPARATE APARTMENT OR DWELLING UNIT VILLAGE OF RYE BROOK WESTC11ESTER COUNTY, NEW YORK No: 25-020 Certificate of ®ccupaucp This is to certify that _/ je/ h(�zb F Jullc To u d of, -C k I having duly filed an application on 20 0;25 requesting a Certificate of Occupancy for the premises known as, l /O� t� J ��0 �Yl Ve , Rye Brook,NY, located in a /C—15 Zoning District and shown on the most current Tax Map as Section: 1 Block: Lot: and having fully complied with the requirements of the Building Code and the Zoning Ordinance under Building Permit No. -J issued 20� , such authority and permission is hereby granted to the property owner to lawfully occupy or use said premises or building or part thereof listed under the following New York State Classifications, Use: 'J - Construction: fi� AW- for the following purposes: �d Subject to all the privileges, requirements, limitations, and conditions prescribed by law, and subject also to the following: FINISHED BASEMENT NOT APPROVED FOR USE AS A SEPARATE APARTMENT OR DWELLING UNIT 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 facilities shall be made,and no enlargement, whether by extending on any side or by increasing in height shall be made,nor s all the building be moved from one location to another until a permit to accomplish such change e o coed om uilding Inspector. Building Inspector,Village of Rye Brook: Date: �� � M BUILD :BROOKY� ENT For office use only: IECIED VIL K ISSUED:PERMIT# u-/�(,o JAN 2 4 2025 8 KING STRE PORK 10573 DATE: J -a y a,�FEE: 1 S PAIDv VILLAGE OF RYE BROOK BUILD ERTIFICATE 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 i#iitititti#i#####tf#irtrt4trt#i####rtkrtkkt#i#i#krtk#ft#fti#iiif itftif fi if tiff if if tf##iffittitle##f#tit rtrt#rtrtrttrtrtrt#k####k#trtiki##### Address: i a Rc� RVol Df,�-(_ 0K 4Y f d J 73 nn Occupancy/Use: CZ/YI Parcel ID#: /_�j'j, 3- 5 /l Zone: I't �l �Gb� Address:Owner: � P.E./R.A.or Contractor: ��+t B�*+k s r r Address: Person in responsible charge: Address: Application is hereby made and submitted to the Building Inspector of the Village of Rye Brook for the issuance of a Certificate of Occupancy/Certificate of Compliance for the structure/construction/alteration herein mentioned in accordance with law: STATE OF NEW tYORK,COUNTY OF WESTCHESTER as: being duly swom,deposes and says that he/she resides at (Print Name of Applicant) (No.and Street) in !71 6'-' ,in the County of ���`l`� in the State of AY ,that (City/Town/Village) 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 � L f 06 , QO for the construction or alteration of: L'[n cv-3m 6Ut2 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 CQ- 11 Sworn to before me this day of f, , 20 a S: day of ,20 Signature of Property Owner Signature of Applicant 71LAI��� perty O Print Name of Applicant No blic SHARI MEULLO Notary Public Notary Public,State of New y(ok No.01ME6160M Qualified In Westchester County 6/1/2o2a Commission Expires Juttuary 2g,20 2— QyE BR(�k. 1932 BUILDING DEPARTMENT ❑BUILDING INSPECTOR _2'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 :1;� 1� es fC Oy �2 1 V4? DATE: Z ; z u2 S PERMIT# p 1 2 q - ISSUED: SECT: ;' BLOCK: / LOT: S LOCATION: OCCUPANCY: ❑ VIOLATION NOTED THE WORK IS... Er ACCEPTED ❑ REJECTED/ 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 €.! C'! 1� _p N cLAUV ' Q'FINAL PLUMBING ❑ CROSS CONNECTION ❑ FINAL ❑ OTHER �E BR(��. O�` tim 19112 BUILDING DEPARTMENT ❑BBUILDING INSPECTOR e 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.or¢ - - - - - - - - - - - - - - - - - - - - INSPECTION REPORT - - - - - - - - - - - - - - - - - - -- ADDRESS :-I -�_ RE � -.D(- ) VG DATE: ( - Z V - 2 U L� PERMIT#� �� ISSUED: Z�� SECT: /�J! 7� BLOCK: LOT: .S /r LOCATION: ?C'✓� OCCUPANCY: ❑ VIOLATION NOTED THE WORK IS... ,D ACCEPTED ❑ REJECTED/ REINSPECTION ❑ SITE INSPECTION REQUIRED ❑ FOOTING ❑ FOOTING DRAINAGE ❑ FOUNDATION ❑ UNDERGROUND PLUMBING NOTES ON INSPECTION: ❑ ROUGH PLUMBING ❑ ROUGH FRAMING ❑ INSULATION ❑ NATURAL GAS J ❑ L.P. GAS ❑ FUEL TANK ❑ FIRE SPRINKLER ❑ FINAL PLUMBING ❑ CROSS CONNECTION FINAL J ) C_JAA 1 ❑ OTHER r �yE BRCv�. 1982 BUILDING DEPARTMENT ❑BU"ING 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 :TZ \` C u „ oo-- �e ve- DATE: 7. z Q Z c f PERMIT# 1 !? Z I L 71 ISSUED: SECT: BLOCK: LOT: LOCATION: 22me iY"n v j OCCUPANCY: ❑ VIOLATION NOTED THE WORK IS... ❑ ACCEPTED ❑ REJECTED/ REINSPECTION ❑ SITE INSPECTION REQUIRED ❑ FOOTING ❑ FOOTING DRAINAGE ❑ FOUNDATION ❑ UNDERGROUND PLUMBING NOTES ON INSPECTION: d ROUGH PLUMBING ❑ ROUGH FRAMING ❑ INSULATION ❑ NATURAL GAS ❑ L.P. GAS U ❑ FUEL TANK ❑ FIRE SPRINKLER ❑ FINAL PLUMBING ❑ CROSS CONNECTION ❑ FINAL E}~OTHER QyE DRQ), Fo BUILDING DEPARTMENT ❑BUILDING INSPECTOR El-A' SSISTANT 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: Q e 2 6'- C> D , ✓-k DATE: z j '? `/ PERMIT# y` 2 '7 b ISSUED: 'l 1 SECT: BLOCK: LOT: j' LOCATION: 'J �' ' r ti�. 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 (�. ' '' ✓c ,- ❑ L.P. GAS L SJ ❑ FUEL TANK ❑ FIRE SPRINKLER ❑ FINAL PLUMBING ❑ CROSS CONNECTION JC Nfc� /Se, / '`/ C �.I ❑ FINAL LAP /N S,1 ( f /J ❑ OTHER QyE 4R(bk cu � 0� 1932. BUILDING DEPARTMENT ❑3UILDING 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 : 1 Z ICE►> 7CA 1, ­z)2 , ✓ DATE:--?- /�e - ? 0Z '/ PERMIT# ?� Z Z 8 ISSUED: SECT: I3-5� '&` BLOCK: / LOT: 5 �� LOCATION: Sr ✓rl(�y OCCUPANCY: ❑ VIOLATION NOTED THE WORK IS... CY ACCEPTED ❑ REJECTED/ REINSPECTION ❑ SITE INSPECTION elzit)'C-k REQUIRED ❑ FOOTING ❑ FOOTING DRAINAGE ❑ FOUNDATION ❑ UNDERGROUND PLUMBING NOTES ON INSPECTION: ll 'RoUGH PLUMBING ❑ ROUGH FRAMING ❑ INSULATION / ❑ NATURAL GAS ❑ L.P. GAS ❑ FUEL TANK❑ FIRE SPRINKLER //�h �.> p+ ` ,+, iIQy4 ❑ FINAL PLUMBING ❑ CROSS CONNECTION ❑ FINAL ❑ OTHER = 6 _ • s � _ w � 4 N \ W � C • s �N..� \ 0000 .� .. 0. • N O ■ O0 Q cn DOE W a LAI { 7 FY+ a 0 0 f O a cn F A u = W •• � a� v .. a Ln a� bA s +u � �, 0/ p = p W ovi - • a W O W c/� asae ° � rf • W z a $ � �,� voC O • Z Z Z p M A F� �+ a o r7 i • ° F�--I w c""i� ° o H a � zb o �Lc; O� .� c; o w W v • � A • c � v � 0 O Z � zw M A, • ^ _Z _ W O O o, U c, z o 0 UZ W 0 \ w I Q V • � 5 ° 9cz Qw W j, _ 00 v H m �-4 O p� �--� o ,n Z z w ^ , va � o W rT Hi00 pap A O U A Q O U v o N v M j O H Q z �s � O LL� aZ m ca aW. o z ; A O _j w v v- • � a ,n 0 � � � � b • • J BUILDING DEPARTMENT E C E Q v VILLAGE OF RYE BROOK AUG - 5 2024 938 KING STREET RYE BROOK,NV 10573 (914)939-0668 VILLAGE OF RYE BROOK www.rvehlrookul.tsov BUILDING DEPARTMENT INTERIOR BUILDING PERMIT APPLICATION FOR OFFICE U" AUG - 8 2024:approval Date. ?&Application Fee: $ zoo ,approval Signature- Permit Fees:Disapproved- Other: **hd*ddhkdddddddddddddddd�*.d/dhdkkdd*Rhddkkkkkkkkkk*kd*dk*kdkk Rkkdkddkk*d**kk*dk!***kkdkkkkdk*dkkddd d*R*d*ftkk Application dated: �fS / is hereby made to the Building Inspector of the Village of Rye Crook,NY,for the issuance of a Permit for die interior alteration of an existing bull ' or for a ch ge in use,as per detailed statement described below. 1. Job Address: 0 SBL: 3`-311 —�- S Zone: 2. Pr posed Improve t_ {.)c Ica i I i[Idemi l): W S N LV4re'0+1 4/ V AV i� OAJ4 A&Ld ' ,2 CL A et,1J ;w Sr w' `417< 3. Does the pro ed improvement involve a Home-Occupation as per§250-38 of the Code of the Village of Rye Brook? No: Yes: If yes,indicate: TIER I: TIER II: TIER III: 4. Will the proposed project require the installation of a new,or an extension/modification to an existing automatic fire suppression system t,irt: 1`0-20n ti. t�s:. '('`; I I food, u1c ) :No-, Yes: 5. Occupancy-,(I fam..2 fam..comm.,etc...)Prior to Construction: I After Construction4W AII/ 6. N.Y State Construc on Class fit pion: N.'/State Vie Classification: 7. Property O, /I0��/G�1/4. ___ _Address: 2 b,- Phone# Cell# email. ✓ m rYf S. Applicant: 44 asim LLL A]ddress: 'Y /f ccj -1 4 &t/�S K�1 C l Phone# w Cell# y1 ,? drQ email: 4C-1A pqj -i /1^rLir t. a, wn 9. Architect: —Address.- Phone# Cell# email: 10. Engineer: rl' Address: Phone# C email: 11. Gen C ntractor: Q �1G idress: klz 1 1 e' 1 Phone# DGJ Cell# email: r • 4:2ry& 12. Estimated cost of constructions f.7 O© (J V-f 13. Job Timetable: Start: Finish. (1) 6/11202a BUILDING DEPARTMENT D V L`� VILLAGE OF RYE BROOK 938 KING STREET RYE BROOK,NY 10573 AUG - 5 20211 3 (914)939-0668 H�ww.rvcbrUokn}.uo% VILLAGE OF RYE BROOK BUILDING DEPARTMENT AFFIDAVIT OF COMPLIANCE `TILLAGE CODE §216 • STORM SEWERS AND SANITARY SEWERS THIS AFFIDAVIT MUST BEAR THE NOTARIZED SIGNATURE OF THE LEGAL. PROPERTY OWNER AND BE SUBMITTED ALONG WITH ANY BUILDING OR PLUMBING PERMIT APPLICATION . ANY BUILDING OR PLUMBING PERMIT APPLICATION SUBMITTED WITHOUT THIS COMPLETED AND NOTARIZED FORM WILL BE RETURNED TO THE APPLICANT . STATE OF NEW YORK,COUNTY OF WESTCHESTER ) as: p p �1 A��G1 ,4u6 l Aa R ©li,.c 6 t �� /Z� ��S 7� I, , residing at, '� 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; L 2 A o A""( br',N` Rye Brook, NY. 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 al l State, County and Village Codes. x t � starfe of ' n/e w 'yq, r t ant af ' New7 ► &ori�to before met� Gis c SUZAMday of��j 4 _ , 20 2 f WNY i n e-ew:'�i+.�.at "M roc.otuwi� oaf eqft (2) 61U2024 This application must be properly completed in its entirety and must include the notarized signature(s) of the legal owner(s) of the subject property, and the applicant of record in the spaces provided. Any application not properly completed in its entirety and/or not properly signed shall be deemed null and void and will be returned to the applicant. Please note that application fees are non-refundable. STATE OF NEW YORK,COUNTY OF WESTCHESTER ) as: ,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 (0 Ail Sworn to before me this day of y q US'r , 20�'t day of It 20 Signature of Property Owner l�a4;P_I lam,b �- ?47� TnfiTName of Property Owner Pf t Name oikAphl icant It/lfi�- tary Public Notary Public NILZA P TEIXEIRA NOTARY PUBLIC,STATE OF NEW YORK ECOmmission BETH BUkGrJs r NO.01TE6137774 C,STATE of NEB% roar, LIUAL{>IEO IN WESTCHESTER COUNTY N0 01gUpp 17453 MY COMMISSION EXPIRES DECEMBER 5,20, in King County res aecember 2nd,2027 (4) b/1/2024 O� N � � W U �•" W �1 � � � pn end' �S W � a ' ONO OWWI a+ , p CIA M u � � H M W \ z U A ' o w ! o 8 � ' M z � 0 p Q a cv 0..4 kn �i -0- 00 I-- " Q z W CD N U w 0 (n W �+ 00 �4 w U u N w00 Z O z Uz . W Z M z Mw < p , z �. w a V A z � w W�yx W . a w N a cn Cl) z w o W o z F a u Za 0 $ W z U W z a6-t x w � H N z w z A oP. H ] gz U z ] w 0 � ' �I as a i as w z BR BUIL Et. ov NTLi ) , .�� VIL E OF RYEK U 938 KIN c;� , ET RYE BY 10573 i�^ 16 2G2�i \ v�l VILLAGE OF RYE BROOK BUILDING DEPARTMENT ELECTRICAL PERMIT APPLICATIO __-- --�— Westchester County Master Electricians License Required FOR OFFICE USE ONLY P#: y' 6 EP#: Approval Date: Permit Fee: $ Approval Signature: Other: DO NOT START WORK or CONSTRUC ION UNTIL A PERMIT HAS BEEN ISSUED BY THE BUILDING INSPECTOR. THE ADMINISTRATIVE FEE FOR WORK PROGRESSED OR COMPLETED WITHOUT A PERMIT IS 12%OF THE TOTAL COST OF CONSTRUCTION WITH A MINIMUM FEE OF$750.00 Application dated,,f-16--00 is hereby made to the Building Inspector of the Village of Rye Brook NY, for the issuance of a Permit to install and/or remove electrical equipment,wiring, fixtures, or to perform other high or low voltage electrical work as per the detailed statement described below. By signing this document, the applicant & property owner agree that all electrical work performed will be in conformance with all applicable Federal, State,County and Local Codes. 12 Raj � �IU e SBL: �s. .1.Address: Zone: 2.Property Owner: YVeI �►V10 Address: A� R.y4 06/G Phone#: 114 C6 l Cell#: email: sl ,,n 3.Master Electrician/Licensed Installer: cC ✓ t U i Cu VLG Address: as ed e✓ria''n L1,411 Lic.#:Phone#: T1jftV 63 Cell#: email: �,f Company Name: Lw y 1 L70=c 1 iC Address: W '�— fL11AQI WN 4 t! 9j tJ y 4.Proposed Electrical Work/Fixture Count: (W rmtm ' '�r m 4A� Qu•L_e 1.4 ct,x n1e h i�xi�-hrae�inn fQ4W'f ,�.b✓1 I q F-1 . ZE 5.31 Party Electrical Inspection Agency: '5Uit 3 *�*xxxxxx*************xxxxxxxxxxxxxxx**xxxxxxxxxxxx**xxxxxxxxxxxxxx„xx, xx�xxxxxxxxxxxxxxxxxxxxxxxxxxxxxx, STATE OF NEW YORK,COUNTY OF WESTCHESTER ) as: Cesar M U i w OA —being duly swom,deposes and states that he/she is the applicant above named,and does further (print name of individual signing as the applicant)state that(s)he is the eA9.7 ele4n kk&^^ for the legal owner and is duly authorized to make and file this application. (Master Electrician/Licensed Installer) The undersigned further states that all statements contained herein are true to the best of his/her knowledge and belief,and that any work performed,or use conducted at the above captioned property will be in conformance with the details as set forth and contained in this application and in any accompanying approved plans and specifications,as well as in accordance with the New York State Uniform Fire Prevention&Building Code,the Code of the Village of Rye Brook and all other applicable laws,ordinances,and regulations. Sworn to before me this Sworn to efore this day of 20 day of a ,20 Signature of Property Owner Signature of Applicant Print Name of Property Owner Priqljarne of Applicant GREGORY M.RNERA Notary Public Netary Public,State of New Nota ublic No.011116441398 ry Qualified In Westchester County 6/1/2024 Conxntssion Expires September 26, i__ STATE WIDE INSPECTION SERVICES, INC. Service With Integrity 080 • • SWIS JOB APPLICATION0. • Office Use Elect. Permit# /_ 7— /6 17 Date Bldg Permit# ��-�( .. + 6 Sq Ft Plumbing Permit# Final Certificate # City/Village Zip Building Dept. County Address Cross Street Section Block Lot Owner Name/Address(If different than above) I I To r L Contact Number y/-� Shy -) 0- ❑Basement ❑ 1st Fl. ❑2nd Fl. ❑3rd Fl. ❑More Than 3 Fl. ❑Garage ❑Attic ❑Outside ❑Residential ❑Commercial Receptacles Special Recept GFCI AFCI Switches Dimmers Smoke Alarms C/0 Detector Hood Trash Compact Amt Amps LJ Range(s) Cooktop(s) Oven(s) Dishwashers Refrigerator Disposal Microwave Luminaires Generator Transfer Switch SERVICE Amperage #Panels 1P 3P # Meters # Disconnect ❑Underground ❑ New ❑ Reconnect ❑ Repair ❑Overhead ❑ Upgrade ❑ Disconnect Utility ID# ❑Con Ed ❑ NYSEG ❑Central Hudson ❑ Orange/Rockland PHOTOVOLTAIC SYSTEM PV Modules Inverters AC Disconnect Junction Box Combiner Box Load Center PV Monitor Energy Storage System DC Disconnect ❑Legalization ❑ Safety Inspection ❑Consultation p I : AUG 16 2024 VILLAGIZ OF RYE BROOK BUILDING DEPARTMENT This application is valid for one(1)year from the date received by SWIS.This application is intended to cover the above listed items to be inspected,if at anytime of inspection additional items have been installed,you are authorized to make the inspection and adjust the fee for the additional items inspected.The applicant declares that there is no open applications for the above address with any other inspection company.The applicant, owner or authorized agent agrees to all the above terms and conditions as set forth for the application. Email Address I(,A I - ,r 2 `i Name P XA I�f License# S y Date (�%�- l 6 y Signature ' ,l Address `I I �� �)d. City/�5 �< r�� (�� }cf Zip Code iC' Company tl�j 2 L o? 4-1 q E/t( —Q /tV� Phone# C� �' J r I` f�l ' State Wide Inspection Services 080 Main Street CALDFIAkI 2 � 2Q� Fishkill, NY 12524 845 202-7224 Phone VILLAGE OF RYE BROOK 914-219-1062 Fax STATE WIDE INSPECTION SERVICES BUILDING DEPARTMENT Email: officeCa swisny.com Website: www.swisny.com Service With Integrity BY THIS CERTIFICATE OF COMPLIANCE STATE WIDE INSPECTION SERVICES CERTIFIES THAT: Upon the application of: Upon Premises Owned by: IWIRE 24/7 Electric Inc Daniel Taub Cesar M. Vicuna 12 Red Roof Drive 25 White Road Rye Brook, NY 10573 Putnam Valley, NY 10579 Located at: 12 Red Roof Drive, Rye Brook, NY 10573 Section: Block: Lot: Electrical Permit Number: EP-24-169 135.43 1 5.11 Certificate Number: 2025-0353 Building Permit Number: 24-176 A visual inspection of the electrical system was conducted at the Residential occupancy described below.The electrical system consisting of electrical devices and wiring is located in/on the premises at: 12 Red Roof Drive, Rye Brook, NY 10573 The Basement was inspected in accordance with the NYS and NFPA 70-2017 and the detail of the installation,as set forth below,was found to be in compliance on the 161h Day of January 2025. Name Quantity Rating Circuit Type Luminaires 03 Receptacles 02 Switches 04 GFCI 01 Ejector Pump 01 Officer: Frank J. Farina This certificate may not be altered in any way and is validated only by the presence of a seal at the location indicated.This certificate is valid for work performed on the date of inspection only. _ • 00 e� � of 00 N 0 00 W a 00 �. a 't C a o H 00 z v z a � F W �, � � • aW bq lyl O M Lgi Car a a 'v Z n � O � N g V) A pw , cp Ln _ 00 tn w _ oW °�° O F 00R, Z u z v, 1-4 _ 00 x 04 v F cn s ,I. � w 'n r ` V O Rr a fA ° N z w z A o � 0 w a � w a°c � _ • E BUILDING DEPARTMENT �, AUG 2 2 2024 VILLAGE OF RYE PftOOK 938 KfNG\STREET RYE BROOK,NY 10573 (9]',1) 668 wwW&ebrookny.gov PLUMBING PERMIT APPLICATION L FOR OFFICE USE ONLY BP#: Aq— I�!b PP#: Approval Date: ��- Permit Fee: $Z�� Approval Signature: Disapproved: (fees are non-refundable) ************************************************************************************************** DO NOT START WORK or CONSTRUCTION UNTIL A PERMIT HAS BEEN ISSUED BY THE BUILDING INSPECTOR.THE ADMINISTRATIVE FEE FOR WORK PROGRESSED OR COMPLETED WITHOUT A PERMIT IS 12%OF THE TOTAL COST OF CONSTRUCTION WITH A MINIMUM FEE OF$750.00 Application dated, as a is hereby made to the Building Inspector of the Village of Rye Brook NY,for the issuance of a Permit to install and/or remove Plumbing as per detailed statement described below.The applicant&property owner,by signing this document agree that said plumbing work will be in conformance with all applicable Federal,State,County and Local Codes. 1.Address: j a, Red �OD��l t � SBL: � �. ��—��„ tf � Zone:��� 2.Proposed Work: pQ144.d �_1,_ AV 7� V.Property Owner: p14.1JI$�►'taul3 �v.1.1e'tr�wb Address: la Red ROG'!r teewe Phone#: Cell#:q1) -SW•-.570(a mail: 4.Master Plumber: AjLLVS Yftl Aga9 &:Address:jiftsiAmt tee AA kJA0419,r t.f yu 1" T Lic.#: 1gyS Phone Cell#{q5- 41ffA'`37 email: /Lg14 CZ t.u"ibiwl Company Name: pj {.t,o/VhAj4�c2 P+u l4)G Address: 3 mAd IA&w e lag W owin eic f.l VV If;'" INDICATE FIXTURES&LINES TO BE INSTALLED AS PER THE FOLLOWING SCHEDULE: Location Water Urinals Drinking Sinks Showers Bath Laundry Domestic Fire Sanitary Natural/ Other* Total Closets Fountains Tubs Tubs Service Service Sewer LP Gas Basement I 1 st Floor t r 2nd Floor 3rd Floor 4'Floor 51 Floor Exterior 5.* List Other Equipment/Provide Details: (Notarized Signatures Required Next 2 Pages) I- 6/l/2024 STATE OF NEW YORK,COUNTY OF WESTCHESTER ) as: being duly sworn,deposes and states that he/she is the applicant above named, (print name of individual signing as the applicant) and further states that(s)he is the Master Plumber for the legal owner and is duly authorized to make and file this application. That all statements contained herein are true to the best of his/her knowledge and belief,and that any work performed,or use conducted at the above captioned property will be in conformance with the details as set forth and contained in this application and in any accompanying approved plans and specifications,as well as in accordance with the New York State Uniform Fire Prevention&Building Code,the Code of the Village of Rye Brook and all other applicable laws,ordinances and regulations. X Sworn to before me this I 1-r h d Sworn to before me this 22 day of P Vq Q-S+- ,20 Z 1 day of )' ,20 2L\ l Signature of Property Owner Si ature of Ap cant Print Name of Property Owner Print N e of pplicant c Wotary Public Notary Public This application must be properly completed in its entirety and must include the notarized signature(s) of the legal owner(s) of the subject property, and the applicant of record in the spaces provided. Applications not properly completed in its entirety and/or not properly signed shall be deemed null and void and will be returned to the applicant. PATRICIA B NEFF NOTARY PUBLIC,STATE OF NEW YOW nA i HLEEN ELIIABETH BURGOS MA, Registration No.01 NE6434642 NOTARY PUBLIC,STATE OF NEW'r!_-i Qualified In Westchester County Registration No.01B00017453 Qualified in King County MY Commisslon Expires June 13,2028 Commission Expires December 2nd.20271 nlI/?IC1 BUILDtNCDEPARTMENT D .� VILjb OF RYE OOK AllG 2 2 2Q?_�t938 MNcT RYE�A BR ,NY 10573 ot><� ov BUILP.i '! AFFIDAVIT OF COMPLIANCE VILLAGE CODE §216 • STORM SEWERS AND SANITARY SEWERS THIS AFFIDAVIT MUST BEAR THE NOTARIZED SIGNATURE OF THE LEGAL PROPERTY OWNER AND BE SUBMITTED ALONG WITH ANY BUILDING OR PLUMBING PERMIT APPLICATION. ANY BUILDING OR PLUMBING PERMIT APPLICATION SUBMITTED WITHOUT THIS COMPLETED AND NOTARIZED FORM WILL BE RETURNED TO THE APPLICANT. STATE OF NEW YORK,COUNTY OF WESTCHESTER ) as: ri)OL I—OWL residing at, JX Xt� Aool 04ve, Ay- &J N Hof73 (Prins mml1c) (Address%Nhereyou Ii\c) 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; 2 Re Rtso� Qnvt6iaok AY lof 7—? , Rye Brook,NY. (.lob 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. ignature of Property Owncr(s)) (Pant Name ol'Property Owicr(s)) Sworn to before me this day of aV 9 U6+ 20Jy ( otary Public) KAIHLEEN ELIZABETH BURGOS MAh NOTARY PUBLIC,STATE OF NEW YORK Registration No.01B00017453 Qualified in King County Commission Expires December 2nd.2027 6/1/2024 Date: 28/07/2024 Client: DANIEL TAUB JOB LOCATION: 12 RED ROOF DR—RYE BROOK- 10573 Email: dptaub@gmail.com Contract:#171 Estimator: Antonio C. La Pasta DETAILED PROJECT SPECIFICATION Re: Basement renovations and repairs Regarding the above referenced property, LA PASTA PAINTERS LLC will provide the necessary labor and materials to prepare, and finish project. • Complete supervise and be on job site every day until job is completed. • Job site safety,cleaning, and organization. • Communications and scheduling of contractors. • Provide all site plans and permits, and insurance on site. • All town requirements for inspections and codes. • Work and manage sub-contractors on property site. • Coordinate all site meetings at owner's request. • Lead and take full responsibility for property and owner's requests. • Responsible for all subcontractors' workflow and contractual obligations. • Responsible for All subcontractor's insurances, works compensation and liability. • Received payments from owners and made payments to all subcontractors as contract terms and payments schedule. Demolition/Removal of debris: • Complete removal of exterior perimeter drywall, sheetrock. Notes: Partition walls to stay. Framing: • All moldings, base molding,to be removed. • Remove carpet and laundry room ceramic tiles. • Complete demolition of full bathroom, remove all fixtures. • Frame new exterior walls (all basement). Pressure treated lumber studs as plates and 2x4 regular walls studs. • Frame around existing windows, ceiling, boiler room, and patrician walls layout as basement to remain. • Frame Laundry room exterior walls, and closet walls. • Frame new walls in bathroom, new shower areas for new shower pan. (Frame new shower walls, and niche). Electrical: • Complete new roughing electrical wiring for new Exterior walls and bathroom all new Frame areas. (all other basement partitions rooms electrical to stay). • Ceilings lights remain,wiring and fixtures. (unless customer request for new recessed lighting and basement lighting layout). • Complete new roughing electrical wiring for new laundry and bathroom, new dedicated lines for washer and dryer/and GCFI'S addition on both laundry and bathroom. • New (3) Home runs to new water ejection pumps. (GFI outlets) 15 AMPS breakers. • Provided and installed all additional rooms, outlets and switches. (exterior walls). • Provide and install new exhaust fan and proper venting outside. (bathroom) • Install all customer provided light fixtures. Plumbing: • Remove all old supply water valves and drains, (Bathroom, laundry) install new water valves and new drains for a for bathroom toilets and sinks. • Remove radiant heat, (baseboard heating zone temporary). • Provide and install new radiant heat, connect to existing heating system. • Install all new bathroom fixtures, and shower fixtures. • Install rough valves for new shower fixtures,all bathroom and rough box for new washer and washer drain) • All new venting lines and penetration to roof. (existing connections) • Install toilets, vanity faucets, shower finish fixtures. • Install washer and dryer. • All new water lines, new venting, all drain to be connected to house exiting sewer lines, all roughing lines will be use plex and pvc piping. All according to code and plans. (bathroom) Interior insulation and drywall: • Provide and install fiber glass insulations to all new framed walls. • Provide and install Green moister proof 1/2"sheets of sheetrock on all new walls. • Provide and apply drywall taping and plastering, 3 coats of taping Tiles installations: • Prepare all bathroom and laundry floors, mud job leveling for new floor tiles installations. • Prepare mud for new bathtubs/shower and proper pitch for drainage. • Prepare and install mosaic shower walls, niche • Prepare and install mosaic wall designs according to decorators' designs. • Seal and grout all tiles. Notes: All sub-floors to be sealed completely with waterproof. (laticrete roll on sealer 3 coats). (Waterproofing Shower area only) Interior Finish Trim work: • Provide and install new trim casings to windows and doors. • Provide and install all base moldings. • Install new bathroom vanity, and medicine cabinet. Basement painting preparation and finishes: • Prepare Room (Drop Cloths, Masking, and Furniture Protection). • Ceiling- Minor Prep. (Spot Spackling/Repair). • Walls- Extensive Prep. (Spot Spackling/Repair). • Additional Preparation Ceilings and Walls. (Cracks Repairs) • Ceiling—Flat Latex-2 coats. • Walls—Mate finish Latex- 2 coats. • Baseboard - Prep. Existing (Scuff Sanding). • Baseboard (Standard) -). Satin Finish- latex Paint - 2 coats. • Flat Panel Door& Frame—Satin Finish latex Paint - 2 coats. • Windows-Panels&Trims-Casings and seal-Latex-2 coats. : Customer to choose up to 3 paint samples per room. (Customer provides color of choice and we provide the samples) Items Not included: • Shower glass doors. • Any customized walk-in closets or build-ins organizers. • Appliances, Cabinets pull, knobs or hardware. • Mirrors, medicine cabinets, or vanity lighting. • Extra bathroom cabinets. • Shower rods. • Bathroom vanity. • Tubs. • Toilets. • Tiles, stone slab work, countertop,grout. • Vanity faucets, shower and tub diverter and shower body. Items included: • Installation of all light fixtures. • All building materials. • Paints and stain • Installations of washer and dryer • Installation of fixtures. • Removal of debris All the above work to be completed in a workmanlike manner for the sum of: $87,500.00 Construction Agreement: This Construction Agreement is made and entered into as of 07/25/2024 by and between: DANIEL TAU, referred to as the homeowners and LA PASTA PAINTERS LLC, hereinafter referred to as the builder/contractor. NOW THEREFORE, the parties bind and agree to the following terms below: I. PROJECT 1.The location of the CLIENT'S property will be properly endorsed to the CONTRACTOR, including the necessary technical details of the lot parcel/building. 1.The CLIENT agrees to pay the CONTRACTOR an initial$52,500.00-60%of the estimated contract cost, upon the finalization of the estimated project cost and signing of this contract and deposit. 2.The CLIENT will pay an additional $21,875.00-25%of progress work performed. (prior to tilling walls close and rough inspections completed) 3. The CLIENT will pay an additional $13,125.00- 15% as the finalization's details. 4. Full payment of the project balances or extras will be due on completion and satisfactions of client. 5. Payments should be made to the CONTRACTOR in Checks and will be given an Official Receipt or Acknowledgement Receipt for every check received and validated. 6. THE PAYMENTS FOR ALL PERMITS FEE ON BUIDING DEPARTMENT IS THE RESPONSIBILITY OF THE CUSTOMER. Ill.CONSTRUCTION MATERIALS: 1. All materials listed in the materials specification list will be reviewed and agreed by the CLIENT before the actual construction commence. 2. Changes in materials will be reflected in the estimated project cost and will be reviewed by the CONTRACTOR and CLIENT. Any increase of materials cost will be discussed and added if agreed. 3. Modifications in the list of materials will be subject to approval of the CONTRACTOR and CLIENT. 4.The CONTRACTOR warrants the Work against defects in workmanship and materials for a period of 12 months after full completion and turnover of the building. 5.The warranty does not take effect if the CLIENT is in default of this Agreement or the effects of normal damages brought by wear and tear, caused by the faulty maintenance of the CLIENT. 6. Should the CLIENT provide the CONTRACTOR with a notice of a warranty claim under the 12- month period stated in this Agreement, the CONTRACTOR should respond within thirty(30) business days to the said warranty. Signed by: / J, DATED: 07/29/2024 DANIEL TAUB DATED: 07/29/2024 LA PASTA PAYNTERS LLC .Bui 1 Permit Check List&Zonin Anal `is Address: ' SBL• 135 o '1 Zone: ('�-t Use Const.Type: VC Other: Submittal Date 2 2 1Revisions Submittal Dates: Applicant: Gt Nature of Work `°` ��/U l �� \ ��'N e SQ A- a V---�- 1-0 SIMI ti \A oa Reviews:ZBA: AU - 8 2924 PB• BOT. Other. NEED K �� ( FEES.Filing: _BP. \� Flood Plane: Legalization: ( ) ( "P: Dated: L—Notarized.— SBL Truss I.D. Cross Connection: H.O.A.: ( ) ( ) Scenic Roads: Steep Slopes: Wetlands: Storm Water Review: Street 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. (�( ,�iLicense:_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: ( ( ) PLUMBING:Plans: Permit Nat.Gas: LP Gas: N/A/: Other. ( ) ( ) FIRE SUPPRESSION:Plans: Permit N/A: Other: H.V.A.C» Plans: Permit N/A: Other. ( ) ( ) FUEL TANK:Plans Permit Fuel Type: Other: ( ) ( ) 2020 NY State ECCC: N/A: Other. ( ) ( ) Final Survey Final Topo: RA/PE Sign-off Letter: As-Built Plans: Other. ( ) ( ) BP DENIAL LETTER C/O DENIAL LETTER Other. ( ) ( ) Other: ( )ARB mtg.date: approval:- notes: ( )ZBA mtg.date: approval• notes: ( )PB mtg.date: approval• notes: REQUIRED EXISTING PROPOSED NOTES APPROVLU Ate: Date: aUG 0 a 2024 Circle: Fie Front Front Sides Rear. Main Cov. Accs.Cov: Ft H Sb: Sd.H Sb: GFA: Tot.imp: Ft.imp: P� Hewht/Stories: notes: X HAS)► � 0 .J. C .. � w .!Z O v cp u U G� L � w J OO e� � boo 0 rA V y Lo con 17 4) w y c • -- L cn U cu �4 e as ' ► ' -'.i MCI a k o z O Q i t EZ a 3 C i y � z N v ci 4 ON i 1 1 ;ry DATE(MM/DWYYYY) ACORO CERTIFICATE OF LIABILITY INSURANCE 11i 07/31/2024 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 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 NELLA CARRICO TOP INSURANCE AGENCY,INC PHONE 914-690-1440 FAX 914-690-2875 (A/C.No.U4, -- (A/C,No): E-MAIL TOPINSNYQGMAIL.COM 18 PUTNAM AVE ADDRESS;__ PORT CHESTER.NY 10573 INSURER(S)AFFORDINGCOVERAC_aE NAIL# INSURER A: UTICA FIRST MUTUAL INS INSURED LA PASTA PAINTERS LLC INSURpec: 14 WILLOW ST INSURER0: — PORT CHESTER,NY 10573 -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. _ - YYY1 LIi1fT8 --- ILTR P ADDL SUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE POLICY NUMBER .MlDD/YYYY MM/DDltf GENERAL LIABILITY EACH OCCURRENCE S 1,000,000 X DAMAGE TO RENTED;COMMERCIAL GENERAL LIABILITY�/ � �PREMISES occurrenp $ 000 50 _ CLAIMS-MADE /_ OCCUR _M_ED EXP(Arty one person) S 5,000 A I ART 3000299620 06/24/2024�06J24/2025 PERsoNAL a ADv IruuRY $ 1,000,000 GENERAL AGGREGATE S —---2,000,000 GEWL AGGREGATE LIMIT APPLIES PER: i PRODUCTS-COMPlOP AGG I s 2,000,000 - -- i— -- POLICY PRO- LOC '------------ is JECT AUTOMOBILE LIABILITY I IN IN LE LIMIT I i � accident) ANY AUTO BODILY INJURY(Per person) s ALL OWNED SCHEDULED BODILY INJURY(Per accident)�s AUTOS AUTOS NON-OWNED !- PROPERTY DAMAGE S HIRED AUTOS AUTOS S UMBRELLA LIAB OCCUR EACH OCCURRENCE S EXCESS LIAB CLAIMS-MADE AGGREGATE S DED RETENTIONS S WORKERS COMPENSATION WC STATU- OTH- AND EMPLOYERS'LIABILITY Y/N _. -TORYLIM ANY PROPRIETOR)PARTNERIEXECUTIVE E.L.EACH ACCIDENT �$ OFFICER/MEMBER EXCLUDED? N 1 A (Mandatory In NH) E.L.DISEASE-EA EMPLOYE $ If yes.describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space is required) PAINTING AND CARPENTRY CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE BUILDING DEPARTMENT THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN VILLAGE OF RYE BROOK ACCORDANCE WITH THE POLICY PROVISIONS. RYE BROOK,NY 10573 AUTHORIZED REPRE ENT(1TIVE i l �- ACORD 25(2010/05) ©1 8-2010 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD YOR Workers' CERTIFICATE OF STATE Compensation NYS WORKERS' COMPENSATION INSURANCE COVERAGE Board 1a.Legal Name&Address of Insured(use street address only) 1 b.Business Telephone Number of Insured La Pasta Painters's LLC 914-979-0009 14 Willow Street 1c.NYS Unemployment Insurance Employer Registration Number of Insured Port Chester, NY 10573 N/A 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 62-2880978 2.Name and Address of Entity Requesting Proof of Coverage 3a.Name of Insurance Carrier (Entity Being Listed as the Certificate Holder) National Liability &Fire Insurance Company VILLAGE OF RYE BROOK 3b.Policy Number of Entity Listed in Box"1a" 938 KING STREET N9WC227212 Rye Brook, NY 10573 3c.Policy effective period 07/20/2024 to 07/20/2025 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"1a"for workers' compensation under the New York State Workers'Compensation Law. (To use this form, New York(NY)must be listed under Item 3A on the INFORMATION PAGE of the workers'compensation insurance policy). The Insurance Carrier or its licensed agent will send this Certificate of Insurance to the entity listed above as the certificate holder in box"2". The insurance carrier must notify the above certificate holder and the Workers'Compensation Board within 10 days IF a policy is canceled due to nonpayment of premiums or within 30 days IF there are reasons other than nonpayment of premiums that cancel the policy or eliminate the insured from the coverage indicated on this Certificate. (These notices may be sent by regular mail.)Otherwise,this Certificate is valid for one year after this form is approved by the insurance carrier or its licensed agent,or until the policy expiration date listed in box"3c",whichever is earlier. This certificate is issued as a matter of information only and confers no rights upon the certificate holder. This certificate does not amend, extend or alter the coverage afforded by the policy listed, nor does it confer any rights or responsibilities beyond those contained in the referenced policy. This certificate may be used as evidence of a Workers'Compensation contract of insurance only while the underlying policy is in effect. Please Note: Upon cancellation of the workers'compensation policy indicated on this form, if the business continues to be named on a permit, license or contract issued by a certificate holder,the business must provide that certificate holder with a new Certificate of Workers'Compensation Coverage or other authorized proof that the business is complying with the mandatory coverage requirements of the New York State Workers' Compensation Law. Under penalty of perjury, I certify that I am an authorized representative or licensed agent of the insurance carrier referenced above and that the named insured has the coverage as depicted on this form. Approved by: Rakesh Gupta (Print name of authorized representative or licensed agent of insurance carrier) Approved by: _ ,I f �t�,,�—� _ 07/31/2024 (Date) Title: Chief Operations Officer Telephone Number of authorized representative or licensed agent of insurance carrier: 844-472-0967 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