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HomeMy WebLinkAboutRP24-096 �yE I3R L LUC +�v tt� 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 October 9,2024 Scott Chasanoff&Ellen Chasanoff 5 Old Oak Road Rye Brook,New York 10573 Re: 5 Old Oak Road, Rye Brook,New York 10573 Parcel I D#: 135.51-1-20 Roof Permit#24-096 issued on 8/13/2024 to Re-Roof Existing Building This certifies that the new roof,installed under the above captioned permit has been satisfactorily completed. Sincerely, Steven E. Fews Building&Fire Inspector /to Rif I I BUILDING DEPARTMENT For ufllctr use mri ': OCT - 3 2024 VILLAGE OF RYE BROOK MNIIt k _ 96 ISSI;t:n: I 93810m; STREET,RYE BROOK,NEW VORK 10573 DATE: /O 3-3y VILLAGE OF RYE BROOK (914)939-0668 1 Fr.E:y, _PAtLM BUILDING DEPAR i MENT stw ��brool�v.eu� APPLICATION FOR CERTIFICATE OF OCCUPANCY,CERTIFICATE OF COMPLIANCE, AND CERTIFICATION OF FINAL Cons TO BE SUBMITTED ONLY UPON COMPLETION OF ALL woRK, AND PRIOR TO THE FINAI. INSPECTION •1�,•�•q.•• 90A.•40*0sN*HDuwoN•.*00..*we*.4�,N•sH�•••Nu•••���• •��•••��1u•N��•����••••�►•�•���••�N•�• Address; S dAd Occupancy/Use: 77 /q Panel ID#: 13 51 5/ —/— oZ(D Zone: —/4 - y Owner:__Dlen Ch0SnAek / Address: �j�1.)oak kead P.E-/R,A. or Contractor: QLrr,COc 40'k Q_Address: Person in responsible charge:X--a lz k'-2 O OS Address: Application is Hereby made and submitted to the Building Inspector of the Villagc of Rye Brook for the issuance of a Certificate of Occupancy/Certificate of Compliance for the structurefconstructioniaIteration herein mentioned'ut accordance with lain: S7-ATE OF NEW YORK,COt!N'IY OF WESTC:HESTER as: Ultn7hft'r� LL L being duly sworn,deposes and says that he.'she resides at_ 33 0Ut rvra tV V a v+ I Tint\p9t;.:i1 ,4rplr`antl 1'�l and\Iron, in ti'S _ ,in the County of in die State of_ ,that It i1 IcMT V11111pr, lie 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.3— -31 6(e() - 0 0 for the crostruction or aheration of: keo k0 — - _-- -- Deponent further states that helshc has examined the approved plans of the stiwture;work herein referred to for which a Certificate of Occupancy r Compliance is sought,and that to the best of hivbcr knowledge and belief,the souctuMNvurk has boon erectod1complewd in accordance with the approved plans and any amendments thereto except in so far as variations therefore have been legally authorized.,and as erected/compicted complies with the laws governing building construction.Deponent further understands that it shall be unlawful for an owner to use or pram it the use of any building or prem ices or part thereof hereafter created,crecmd,changed,converted or enlarged,wholly or partly,in its use of structure until a Certificate of Occupancy or Certificate of Compliance shall have been duly issued by the Building Inspector as per$250.10.A.of the Code of the Village of Rye[crook Swim to before me this 0-h'i Swore to before me this lY' day of .20 � day of sixnatute of Prnpert)t"hmcr Sigsstsae of Applicant ivy Print\a ne of P rty C)%net Pant t.rmt eC,'Ip 'ant i Nuury Fit VENESS Nut8tyMI1r SA VITIELLO OTARY PUBLIC-STATE OF NEW YORK NOTARY PUBLIC-STATE OF NEW YORK No.01 V16412798 No.01 VI6412798 Qualified in Westchester County Qualified in Westchester County MyCommission Expires 01-11-2025 My Commission Expires 01-t 1-2025 BUILD RMENT For office�onlDVIL)' OF RYE OK PERMIT �1(c� ISSUED: OCT - 3 2024D H KING STREI T�' YE BROOK, W YORK 10573 DATE: I I (91449-V-066O�' FEE: PAID 17VILLAGE OF RYE BROOK o ov _ BUILDING DEPARTMENT APPLICATION FOR CERTIFICATE OF OCCUPANCY, CERTIFICATE OF COMPLIANCE, AND CERTIFICATION OF FINAL COSTS TO BE SUBMITTED ONLY UPON COMPLETION OF ALL WORK, AND PRIOR TO THE FINAL INSPECTION Address: J aK.K. Occupancy/,Use: Parcel ID#: Zone: Owner: 'Eller) rhaS V16 Address: 6 aw QQY- aa- d P.E./R.A. or Contractor: Address: Person in responsible charge: Address: Application is hereby made and submitted to the Building Inspector of the Village of Rye Brook for the issuance of a Certificate of Occupancy/Certificate of Compliance for the structure/construction/alteration herein mentioned in accordance with law: STATE OF NEW YORK, COUNTY OF WESTCHESTER as: f it\11t r'-Mfrr5 _tom L&W 1L00>Q1 LL(- being duly sworn,deposes and says that he/she resides at 33 Q v 1 V 1-J-0(v D a V`e (Print Name of Applicant) i (No.and Street) in�(1 "� S{-�f ,in the County of Is/Lhf S in the State of µ' ,that (Cityrrown/Village) he/she has supervised the work at the location indicated above,and that the actual total cost of the work,including all site improvements, labor,materials,scaffolding,fixed equipment,professional fees,and including the monetary value of any materials and labor which may have been donated gratis was:$ 23 15(OQ' 00 for the construction or alteration of: Mew Q&I'j t a.0 09 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. rL Sworn to before me this Sworn to before me this J day of , 20 day of AV6 V 5 r- . 20 Signature of Property Owner Signature of Applicant fYa►1�CI►h 1 ra rPS Print Name of Property Owner Print Name of Applicant r Notary Public Notar P blic ►v1ARGARET ORSINO Notary Public,State of Cofrnecti Ut My Commission Expires 10-31-2027 QyE BRC�v� 1982 BUILDING DEPARTMENT ❑BUILDING INSPECTOR [}ASSISTANT BUILDING INSPECTOR VILLAGE OF RYE BROOK ❑CODE ENFORCEMENT OFFICER 938 KING STREET • RYE BROOK,NY 10573 (914) 939-0668 FAx (914) 939-5801 www.ryebrook.org - - - - - - - - - - - - - - - - - - - - INSPECTION REPORT - - - - - - - - - - - - - - - - - - - - ADDRESS : E L "-)r y, 9'l l (� DATE: Z 0 Z PERMIT# , `` 1 `e ISSUED: -/3 -Z SECT: 13 S l BLOCK: LOT: 20 LOCATION: `` T OCCUPANCY: ❑ VIOLATION NOTED THE WORK IS... ACCEPTED ❑ REJECTED/ REINSPECTION ❑ SITE INSPECTION REQUIRED ❑ FOOTING ❑ FOOTING DRAINAGE ❑ FOUNDATION ❑ UNDERGROUND PLUMBING NOTES ON INSPECTION: ❑ ROUGH PLUMBING ❑ ROUGH FRAMING ❑ INSULATION ❑ NATURAL GAS ❑ L.P. GAS ❑ FUEL TANK /✓ ❑ FIRE SPRINKLER ❑ FINAL PLUMBING ❑ CROSS CONNECTION FINAL ❑ OTHER R�� x 1-I a.i 'V N w = O CIS N (U 6 1 n1 \ LH ` 4 v 00 1 '1 00 M m N a w " a s. � Cl) W R. U o yyaCC.., L ^ CA W a a y q 0 A a L19 -C j--1 M en zLir) f--I \ Q�'r OHM O O n w ^ ��TT� F u C .--1 M F-�--1 0 O Q 14 0000 ��,, -a ¢ O x PLO `�4 � 'b A 0 � o v v Cl) 0 ,5 00 eq en 20 OV W 00 t��--�� z x t �'� A Q u m ° j Z WW1 \ z `�-� P-4 z u z - v Q � Cn W a M W O a va 1�1 FBI V '7� a Z cn p d o 0 A, Q�r � z z � ti •� s 00 CN z c °a a. v t Q 0 V 0 V HS 'o M u § •N x A Z O a � � z cn BUILDING DEPARTMENT VII1�, OE OF RYE BROOK 13 2024 938 KING STREET RYE BROOK,NY 10573 _j (914)939-0668 VILLAGE OF RYE BROOK �ti"vwi: )oknv.< o BUILDING DEPARTMENT FOR OFFICE USE ONLY: C� Approval Date: \, mit —09,6 Application # Approval Signature: ARCHITECTURAL REVIEW BOARD: Disapproved: Date: BOT Approval Date: Case# Chairman: PB Approval Date: Case# Secretary: ZBA Approval Date: Case# Other: b Application Fee:4 00 46 Permit Fees: p] ROOF PERMIT APPLICATION Application dated: 4 r5 2-L1 is hereby made to the Building Inspector of the Village of Rye Brook,NY,for the issuance of a Permit to Re-Roof an Existing Building,as per detailed statement described below. /I. Job Address: 5 OW p k( d SBL:�3SiS/�! —�� Zone: k—/4 Property Owner: Olen C h a m o 7 Address: 0 W QQ k /24 Q 4 Phone#:_9/�#,.—� ,5, —39S5' Cell#: _` �� T(d-d pp email: 2. Applicant: 1Gi Rook-, LI,C. -1,,rr'Y�,r►1kJ)17 kss: 33 Quirn and 6v--- Phone#: q I N- 3­7 3- QZOT Cell#: q I Lf- 3-7 3` 0 2 ott email: �Qy L 0(a,# r(L)O Pe - ZZ.@ 3. Roofing Contractor: OW 10(cO [Zoo&- LLL Address: 3 3 Quinlarda! YDrrCh�s Phone#: 4)4.3-1 3. 0 L0 8' Cell#: R 1N• -j~?,7j- OZOB' email: VOt'r j0f&P f0oPe1 Zz 4DC4 s-taAR. 4. Job Description,list all Methods& Materials: C Replace >,hoa; rod 6n aliej 5. Estimated Cost of Job: $ 19, 500 (NOTE: The estimated cost shall include all site improvements. labor.material.scaffolding. fixed equipment.professional 1'ecs. and material and labor which may be donated gratis.) 6. If corner property,indicate street frontage: 7. Construction Type: Res i a ctlad NYS Construction Class: 8. Number of stories: Height: 9. Is garage being re-roofed:No:( )•Yes:()Attached No: ( )•Yes:ffi Number of Cars: 10. Is roof peaked,hip,mansard,flat,etc: 11. Estimated date of completion: -t- 6/112024 Please note that this application must Include the notarized signature(s) of the legal owner(s) of the above-mentioned property, in the space provided below. Any application not bearing the legal property owner's notarized signature(s) Shall be deemed null and void, and will be returned to the applicant. rr' *yr++rAaa*#►A#A A*altar*%****,b* rrrrrAkyaRR,►r.+hew A&rrr S t'ATE OF TJ6W Yf}ltlC,Cowry or wEsTCtiEs'rm ) as: being duly sworn,deposes and suites that helshe is the applicant above named, (print name of io3ivuauwt 3iSAing a,jhe r�+hcanr} and further states that (qha is the legal owner of the property to which this application pertains, or that (s)he is the fordw legal ow nor and k duly audiorimd to make and the this application. (indi pre atiltiltx�tx+nlcocxN, ,att�wtip,etc) That all statements mntained herein arr true to the best of hiAer 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 Wntained in this application and in any ac company ing approved plans and specifications,as well as in accordance with the New York State Uniform Fire Prevention&Buikling Code,the Curie ofthe Village of Rye Brook and all other applicable laws,ordinances and regulations. Sworn to before me this Pt Swam to bet'are me this -7 t day,of�4, � , ,2t1 day of L , 20_2:�y L , Signature at Pro tarry Owne Signature of Applicant I Print Name of Prciperty Uw r Print Not a ofApplicant Notary Public LISA M. LAGROTTA Notary Public Notary Public, State Of New York No. 01 LA5067483 Oualified in Orange County Commission Expires October 15,20� ` cntlnAr l Please note that this application must include the notarized signature(s) of the legal owner(s) of the above-mentioned property, in the space provided below. Any application not bearing the legal property owner's notarized signature(s) shall be deemed null and void, and will be returned to the applicant. **,�**�Nx�x���x***,��***,�*���xxxxxxxxxx*xx�xxxr���x���x�x��xx���xxx��KxxxxxxxMxxK�x��F�FFFxF�x�x��RxRx�xxx�� ST,6.TE OF NEW YORK,COUNTY OF WESTCHESTER ) as: ran kit n 'Torre S , being duly sworn, deposes and states that hekAw 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 (a)he is the ri1 YI 1,ni eny— 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 ofthe Village of Rye Brook and all other applicable laws,ordinances and regulations.¢ Sworn to before me this Sworn to before me this 0 day of , 20 day of us — , 20 Signature of Property Owner Signature of Applicant f-ran Kflki ipo-r5 Print Name of Property Owner Print Name of Applicant Notary Public N tary Publ' MARGARET ORSINO Notary Public,State of Connectiart My Commission Expires 10-31-2027 calf 6/112024 YOUR LOCAL ROOFER www.yourlocalroofer.us PO. BOX 4751 01M /1h o jet noM LIC #. CT-0638304 GREENWICH CT 06831 LIC #. WC-30388-H18 PHONE#. 1-800-308-9527 CUSTOMER: Lu- Pmen s es 5 OLD OAK ROAD RYE. BROOK,NY Tr3 m PAWeHad (V ba"00. ctryn Proposal for new roof. 1. Cover the exterior walls, windows, gardens, before removing existing roof. 2. Remove the existing asphalt shingles. 3. Inspect the plywood and replace where is necessary (on this proposal include one sheets of plywood any extra will be additional charge.) 4. Customize and install new copper drip edge. 5. Install new ice water shield 6ft. from the gut-L- .ne, and where is necessary to prevent the ice damage. 6. Install new synthetic underlayment on the entire roof. 7. Install and provide new tiSphalY- 8. Install new ridge vent follow by ridge caps. 9. Customize and install new copper flashing around the chimneys. 10.Permit fees will be billed out separately. 11.Clean work area. COST OF THE ROOF. $19,500.00 Repoint the chimney: $2900.00 will provide labor materials dumpster equipment and other items to complete this project. We will provide a 5-year warranty on the workman ship after the completion date. Shingles have a lifetime warranty. - i.. Why \ .11Ipy}�t to 'y4i ' '��A'�J�, •>>A� 1• ��,^r- �SATj / "low r ' - 11ARM1►111,1 = IlNlljl ��111,111Vi 11fj1 «o» ,,,,, ' 1 v = �,i„If 11�:r=:==vim=:IN11i h-F:- ,-��:hl 11 . -� ����,.I llu � �_.-,. 1/► ,1 �. / � � .t ti '•� t Z a, C L' yco h Ecu •� o «f ed � M X' � �� Cd O b C 'O Z '� n mqi �i•, � O ° • r a .p" U) IX Z w j o O �, p j a ° to�ection LU ,-4 O O O Z w y O 4-o ~ N p irl Z } O ° :t4 , �, ate • �r � � a. X oo , �♦ O W Cd Qj z 00 I.] O Oj O Fi co \ U y \ � 1 i� IIII (si A • a A ,. IIY A w. w N A �i11 ( (� IIII/IIIIII p� I I)I/�III I j I II I I II I� y y F g� �� A 1 � r l�^�i' , •• F�'^�! •"• t�!s�^�I�I ,� I�I�I��/' �rAi'4+a �' "��i�v+r` � •, ry.f }wr.t,1 vihV��bi� tiiV�y' - _vo � v O � I ���� . , ice -_ �v ,, •• _•�r y\ S.•A�I.._ FAIRCOU-02 CDOLCE A�OR� CERTIFICATE OF LIABILITY INSURANCE FDAT 8/2/2 D/YYYY) 8/2/2024 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER NAMEACT Kevin Kelley Levitt-Fuirst Associates, LTD PHONE FAX 520 White Plains Road (A/C,No,Ext):(914)457-4230 A/C,No):(914)457-4230 2nd Floor ao RIL ,kkelley@levittfuirst.com Tarrytown,NY 10591 INSURERS AFFORDING COVERAGE NAIC# INSURER A:Admiral Insurance Company 24856 INSURED Fairfield County Roofing&Construction LLC INSURER B:New York State Insurance Fund 36102 Fairfield County Roofing&Construction LLC dba INSURERC: Your Local Roofer INSURER D: 33 Quintard Drive 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. INSR TYPE OF INSURANCE ADDL SUBR POLICY NUMBER POLICY EFF POLICY EXP LIMITS LTR I /YYYY MM/ A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE FX] OCCUR CA000033936-06 3/26/2024 3/26/2025 DAMAGE TO RENTED n $ 300,000 PREMISES(Ea occurrMED EXP(Any oneperson) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GENT AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY�X JE� LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: EMPLOYEE BENEFI $ 2,000,000 AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT ANY AUTO BODILY INJURY Perperson) $ OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY Per accident $ HIRED NON-�WNED PROPERTY DAMAGE AUTOS ONLY AUTO ONLY Per accident $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAR CLAIMS-MADE AGGREGATE $ DIED I RETENTION$ $ B WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY Y/N T ANY PROPRIETOR/PARTNER/EXECUTIVE G2371855-4 6/29/2023 6/29/2025 E.L.EACH ACCIDENT $ 1,000,000 N1Fand R/MEMBER EXCL D?UDE ❑N NIA ry in NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000 If yes,describe under 1,000,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Village of Rye Brook-is included as Additional Insured for covered operations of the named insured CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Village of Rye Brook THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Building Department 938 King st Rye Brook, NY 10573 AUTHORIZED REPRESENTATIVE /" 4!2 ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD NYSI F New York State Insurance Fund PO Box 66699,Albany, NY 12206 1 nysif.com CERTIFICATE OF WORKERS' COMPENSATION INSURANCE ^^^^^^ 464058402 FAIRFIELD COUNTY ROOFING&CONST } LLC DBA YOUR LOCAL ROOFER ❑� • , 33 QUINTARD DRIVE PORT CHESTER NY 10573 SCAN TO VALIDATE AND SUBSCRIBE POLICYHOLDER CERTIFICATE HOLDER FAIRFIELD COUNTY ROOFING &CONST VILLAGE OF RYE BROOK LLC DBA YOUR LOCAL ROOFER BUILDING DEPARTMENT 33 QUINTARD DRIVE 938 KING STREET PORT CHESTER NY 10573 RYE BROOK NY 10573 POLICY NUMBER CERTIFICATE NUMBER POLICY PERIOD DATE G2371855-4 10618 06/29/2024 TO 06/29/2025 8/2/2024 THIS IS TO CERTIFY THAT THE POLICYHOLDER NAMED ABOVE IS INSURED WITH THE NEW YORK STATE INSURANCE FUND UNDER POLICY NO. 2371855-4, COVERING THE ENTIRE OBLIGATION OF THIS POLICYHOLDER FOR WORKERS' COMPENSATION UNDER THE NEW YORK WORKERS' COMPENSATION LAW WITH RESPECT TO ALL OPERATIONS IN THE STATE OF NEW YORK, EXCEPT AS INDICATED BELOW, AND, WITH RESPECT TO OPERATIONS OUTSIDE OF NEW YORK, TO THE POLICYHOLDER'S REGULAR NEW YORK STATE EMPLOYEES ONLY. IF YOU WISH TO RECEIVE NOTIFICATIONS REGARDING SAID POLICY, INCLUDING ANY NOTIFICATION OF CANCELLATIONS, OR TO VALIDATE THIS CERTIFICATE,VISIT OUR WEBSITE AT HTTPS://WWW.NYSIF.COM/CERT/CERTVAL.ASP.THE NEW YORK STATE INSURANCE FUND IS NOT LIABLE IN THE EVENT OF FAILURE TO GIVE SUCH NOTIFICATIONS. THIS POLICY DOES NOT COVER THE SOLE PROPRIETOR, PARTNERS AND/OR MEMBERS OF A LIMITED LIABILITY COMPANY. THE POLICY INCLUDES A WAIVER OF SUBROGATION ENDORSEMENT UNDER WHICH NYSIF AGREES TO WAIVE ITS RIGHT OF SUBROGATION TO BRING AN ACTION AGAINST THE CERTIFICATE HOLDER TO RECOVER AMOUNTS WE PAID IN WORKERS'COMPENSATION AND/OR MEDICAL BENEFITS TO OR ON BEHALF OF AN EMPLOYEE OF OUR INSURED IN THE EVENT THAT, PRIOR TO THE DATE OF THE ACCIDENT, THE CERTIFICATE HOLDER HAS ENTERED INTO A WRITTEN CONTRACT WITH OUR INSURED THAT REQUIRES THAT SUCH RIGHT OF SUBROGATION BE WAIVED. THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS NOR INSURANCE COVERAGE UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICY. NEW YORK STAT SU NCE FUND T4 4/ DIRECTOR,INSURANCE FUND UNDERWRITING VALIDATION NUMBER: 265655622