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HomeMy WebLinkAboutRP24-095PERMIT N 00 ^\ DATE: ' /3 a� W SECTION . do 4 BLOCK LOT TYPE OF WORK pLI? OWNER S Q� bbQr/l 0 4PIi' KQ ri' 4 ,F CONTRACTOR, Ve0/0/949 EST. COST 2 — FEE Co # FEEWSQ PL) DATE TCO # FEE DATE - INSAECTION RECORD I DATE INSP FOOTING FOUNDATION FRAMING RGH FRAMING INSULATION PLUMBING RGH PLUMBING GAS SPRINKLER ELECTRIC LOW -VOLT [] ALARM AS BUILT C> FINAL Z7 ZO L� S.B �oVQ (3y7)933�3 777 �5 OTHER APPROVALS ARB BOT PB ZBA OTHER DR . 19 VILLAGE OF RYE BROOK MAYOR 938 King Street, Rye Brook,N.Y. 10573 ADMINISTRATOR Jason A. Klein (914) 939-0668 Christopher J. Bradbury www�ebrooknvgov TRUSTEES BUILDING& FIRE INSPECTOR Susan R. Epstein Steven E. Fews David M. Heiser Donald T. Krom,Jr. Salvatore W. Morlino CERTIFICATE OF COMPLIANCE June 30,2025 Askar Djabbarkhodjaev&Karina Babakulova 7 Winding Wood Road Rye Brook,New York 10573 Re: 7 Winding Wood Road, Rye Brook,New York 10573 Parcel ID#: 129.82-1-8 Roof Permit#24-095 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 ,;LAC BR0 >� �O BUILDING DEPARTMENT ❑..,BUILDING INSPECTOR JQASSISTANT 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 : 72 1 V 161 1 9-3 Cy WOOZ) L S7 N1 DATE: b 2-7�zQLS- PERMIT# I` 2 / o /V/ ISSUED: -/ -Z ECT: /2-7 • QZ-BLOCK:_ LOT: V LOCATION: /` W OCCUPANCY: ❑ VIOLATION NOTED THE WORK IS... ErACCEPTED ❑ REJECTED/ REINSPECTION ❑ SITE INSPECTION REQUIRED ❑ FOOTING ❑ FOOTING DRAINAGE ❑ FOUNDATION ❑ UNDERGROUND PLUMBING NOTES ON INSPECTION: ❑ ROUGH PLUMBING ❑ ROUGH FRAMING ❑ INSULATION �\ ❑ NATURAL GAS /" ,00 Q� J V / ` � + ❑ L.P. GAS ❑ FUEL TANK ❑ FIRE SPRINKLER ❑ FINAL PLUMBING ❑ CROSS CONNECTION FINAL Q' OTHER ■ a CN c N $o. a \ 00 a 00 O �y ■ ■ "' W � I1 � «� � � Ar F� s w CA w w 4L 00 roen oz en u j M u S O W Q ^ n E. a ^ C ~ � O ■ d o a °ate a o Qb ° a � 00 a �N O ■ d ,or M oo E . �` p w ■ O W 00 z !t Q O A V CS 4. WW v ° �; ■ cn a z Ei , o � o z w z � EOC pq w H ■ y, cf 4,t N - a V v O l f 2 FH Ln 11 N 7 M z 0 u mar o a a i, Ow FO C v v ■ FBI � � � � Q E-1 z w O O H p O o Z V b W W O7• .� r� a a" W W a O LA n ■ 4414141414141444 QQ- 4ii LCL ��fI � BUILDING DEPAt MENT DD] VI 'AGE OF RY OK AUG 12 2024 938 KING ET RYE BR NY 10573 -0 VILLAGE OF RYE. BROOK Uv BUILDING DEPART MENT FOR OFFICE USE NLY: �y L5110 ) Approval Date: v Pe \# Application# Approval Signature: ARCHITECTURAL REVIEW BOARD: Disapproved: Date: BOT Approval Date: Case# Chairman: PB Approval Date: Case# Secretary: ZBA Approval Date: Case# Other: /� nn Application Fee. — U Permit Fees%&c) ROOF PERMIT APPLICATION Application dated: 8/12/24 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. 1. Job Address: 7 Windingwood Road North SBL:fC)91 ej _/_ 0Q Zone:,e—.(_1 Property Owner: Askar Djabbarkhodjaev Address: 7 Windingwood Road North Phone#: Cell#: (347) 933-3777 email: Askar.djab@gmail.eom 2. Applicant: Perry Verrone Address: 12 Center St, Pleasantville Phone#: 914-747-7663 Cell#: email: maria(cD-perryverroneroofing.com 3. Roofing Contractor: Perry Verrone, LLC Address: 12 Center St, Pleasantville, NY Phone#: 914-747-7663 Cell#: email: maria@perryverroneroofinA.com 4. Job Description,list all Methods&Materials: Roof removal and replacement- 30 sq 5. Estimated Cost of Job: $ 15,900.00 (NOTE:The estimated cost shall include all site improvements,labor,material,scaffolding,fixed equipment,professional fees,and material and labor which may be donated gratis.) 6. If corner property,indicate street frontage: 7. Construction Type: NYS Construction Class: 8. Number of stories: Height: 9. Is garage being re-roofed:No:( )•Yes:( )Attached No:W•Yes:( )Number of Cars: 10. Is roof peaked,hip,mansard,flat,etc: peaked 11. Estimated date of completion: Mid August -t- 6/1/2024 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. STATE OF NEW YOM COUNTY OF WESTCHESTER ) as: Perry Verrone ,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 contractor 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. ^,� Sworn to before me this (( Sworn to before me this day of Awv ,20 4 day of , 20 Signature of Property Owner L'`1P!!!,' tature of Applicant L`11 i 1 1 r can r r rint Name of P e Oxv b c `� l i '+ R Fete, p = OTgRY RK t = n e of A plic t = ! = r. LBII� i BIILIZy = Y i`4.•�r`49'p Rk�� AA Notary Public Notary Public ,j:�. ,, '•o,`��!�, l�/1 f 19 11111 i,'!I F•YP1kES 1�V�L�\\ !!lf 11111111111 -2- 611/2024 2ECENE ID BUILDING DEP'AR.TMENT JAN 31 2025 For office us ont VILLAGE OF RYE BROOK PERMIT# 938 KING STREET,RYE BROOK,NEw YORK 10573 ISSUED: VILLAGE OF RYE BROOK DATE: BUILDING DEPART�^;ENT_ (914)939-0668 FEE: q ���._�rAID jA wwwmitr0-01-m nv APPLICATION FOR CERTIFICATE OF OCCUPANCY,CERTIFICATE OF COMP AND CERTIFICATION OF FINAL COSTS LICE, TO BE SUBMITTED ONLY UPON COMPLETION OF ALL WORK, AND PRIOR TO THE FINAL INSPECTION N Address: 7 Windingwood Road North Occupancy/Use: Single family P y Resident;a, Parcel ID#: /c��, yam} Owner: Askar Djabbarkhodjaev —f- Zone: / P•E./R.A. or Contractor: Perry Verrone, LLC Address: 7 Windingwood Road North Address: 12 Center r St, Pleasantville, NY 10570 Person in responsible charge: Perry Verrone t. Application is hereby made and submitted to the Building Inspector sof he Vella esof Rye Pleasantville, NY 10570 Certificate of Occupancy/Certificate of Compliance for the structure/construction/algterationherefn mentioned in accordance STATE OF NEW yOW COUNTY OF WESTCHESTER as: Perry Verrone being duly sworn,deposes and says that he/she resides at 12 Center Street (Print Name of Applicant) in Pleasantville (No.and Street) (('ib•/Town/Village) in the County of Westchester he/she has supervised the work at the location indicated above,and that the actual total cost of the work,includingSalle of NY _ that labor,materials,scaffolding,fixed equipment,professional fees,and including the monetary value of any materials and labor improvements, have been donated gratis was:s 15,900.00 may for the construction or alteration of: Roof removal and replacement Deponent further states that he/she has examined the approved plans of the structure/work herein referred to for which a Certificate Occupancy/Compliance is sought,and that to the best of his/her knowledge and belief,the structure/work has been erected/completed accordance with the approved plans and any amendments thereto except in so far as variations therefore have been legally authorized, f as erected/completed complies with the laws governing building construction.Deponent ,a in owner to use or permit the use of any building or premises or part thereof hereafter created,erected,changed,converted or enlarged,wholly d or partly,in its use or structure until a Certificate of Occupancy or Certificate of Compliancshall have been that it shall be unlawful for an Inspector as per§250-IO.A.of the Code of the Village of Rye Brook. been duly issued by the Building Sworn to before me this a dayof �' Sworn to before me this N = ,20 Sighature of Pro perty Owne: � IC >{!?��� Si rkurtt Askar Djabbarkhodjaev Print ameofProperty/pier Perry Verrone'G'�� / t 1 t ,, t Name of Applic Notary �Public Diary Public Perry Verrone, LLC 12 Center Street Pleasantville, NY 10570 info@Perryverroneroofing.com Office: (914)747-7663 Fax: (914)747-7665 License WC 21701 H09 Askar Djabbarkhodjaev Prepared by Perry 7 Windingwood Road North REVISED 8/12/2024 Rye Brook, NY 10573 REVISED 8/9/2024 (347) 933-3777 8/8/2024 Askar.djab@gmail.com PROPOSAL ROOF REMOVAL AND REPLACEMENT • All existing asphalt roofing removed and carted from job site • All rotted plywood replaced at$90.00 per sheet • GAF Weather Watch Ice and Snow barrier installed on all gutter edges,valleys and around skylights (6 feet up) • GAF TIGER PAW paper installed on the entire field of roof • GAF LIFETIME Timberline Architectural HDZ shingles installed on entire field of roof(SHINGLE COLOR: ) • GAF Cobra Ridge vent installed on all ridges of roof for attic ventilation • GAF TimberTex hip and ridge shingles installed on all ridges • Aluminum vent pipe boots installed over all vent pipes • Aluminum drip edge flashing installed around entire perimeter of roof • GAF Weather Blocker starters installed on all perimeter edges • Copper chimney flashing fabricated and installed • Removal of TV Antenna and Cupola included Page 1 of 5 Initial& Date: • GAF GOLDEN PLEDGE WARRANTY INCLUDED (25 Years Labor and 50 Years Materials) • GAF Lifetime Material Warranty included • Perry's Roofing"10 Year Workmanship Warranty"included The price for the aforementioned work,which includes labor and material (excluding any additional plywood),totals to the sum of: $15,900.00 PRICE EXPIRES 90 DAYS AFTER ESTIMATE DATE ADDITIONAL WORK OPTION Please check appropriate box for desired extra work ❑ Carpentry/handyman work calculated on a time and material basis,said work performed at$120.00 per man hour plus material ❑ GAF LIFETIME Timberline Architectural ULTRA HDZ shingles installed for an additional $612.00 (Courtesy Discount Included) FIXED skylights (45x45) installed for an additional $877.00 each (Courtesy Discount Included) Bathroom fan vents installed for an additional$135.00 each (Courtesy Discount Included) ❑ Dryer vent installed for an additional$135.00 each (Courtesy Discount Included) ❑ Aluminum Seamless Gutters and Leaders fabricated and installed 0 5-inch gutters and 2x3 leaders (white or brown) for an additional 0 6-inch gutters and 3x4 leaders (white or brown) for an additional o Gutter screens installed for an additional ❑ Rye Brook Building Permit for an additional cost TBD (if needed) Payment schedule is as follows: $10,000.00 3 days Prior to Start Remaining Balance Paid over Six Month Period,to be Paid Monthly by Check Payment is accepted via personal checks and certified bank checks (made payable to Perry Verrone LLC or Perry's Roofing),MasterCard,Visa,American Express,and Discover credit Page 2 of 5 Initial& Date: QuickMeasure 7 Windingwood Rd N, Rye Brook, NY 10573 (1) August 5, 2024 Roof Reports in Under an Hour Prepared For: Perry's Roofing A N D Contents Measurements Overview 1 Roof Area 2,957 sq ft Top View 2 Roof Facets 10 Side Views 3 Predominant Pitch 6 / 12 Lengths 4 Ridges/Hips 111 ft Pitches 5 Valleys 34 ft Areas 6 Rakes 125 ft Summary 7 Eaves 175 ft Materials 8 QuickMeasure Top view Roof Reports in Under an Hour pA lb Yyu << r •� 4 w`mil a. . 4 t , � l .n IL4 h. WAS6., Prepared For: Perry's Roofing © 7 Windingwood Rd N, Rye Brook, NY 10573 (1) North East ip South West , 1 w l. -.. -. .. 3 ... - •. QuickMeasure Lengths Roof Reports in Under an Hour A Flash Step Drip N 21 1 1 1 31- 1 1 11 I 1 Eave Hip Rake Ridge Valley 175 12 125 99 34 Lengths in feet Prepared For: Perry's Roofing U 7 Windingwood Rd N, Rye Brook, NY 10573 (1) QuickMeasure Pitches Roof Reports in Under an Hour A N Cl a Pitches in inches per foot Prepared For: Perry's Roofing © 7 Windingwood Rd N, Rye Brook, NY 10573 (1) QuickMeasure Areas Roof Reports in Under an Hour A N Cl -18 91,1 Areas in square feet Prepared For: Perry's Roofing 7 Windingwood Rd N, Rye Brook, NY 10573 (1) QuickMeasure Summary Roof Reports in Under an Hour Pitch 3 6 Area 907 2,049 Percent 31% 69% Suggested Waste 0% 6% 9% 11% 13% 16% 21% Area 2,957 3,134 3,223 3,282 3,341 3,430 3,578 Squares 30 32 33 33 34 35 36 Roof Area 2,957 sq ft ARoof Facets 10 N Pitch 6 / 12 Eaves 175 ft Hips 12 ft Rakes 125ft Ridges 99 ft ❑ Valleys 34 ft Flash 21 ft Step 35 ft Drip Edge 300 ft Leak Barrier 401 ft Ridge Cap 111 ft Starter 300 ft Penetrations 2 Pen. Area 29 sq ft Pen. Perimeter 30 ft Notes:1)Measurements are rounded to the nearest whole number.2)Rakes are defined as sloped roof edges.3)Eaves are defined as level roof edges.4)Flashing pertains to level roof edges and excludes valleys.5)Step flashing pertains to sloped root edges and excludes areas around penetrations.b)Drip edge=eaves+rakes.7)Waste table excludes additional materials needed for ridges,hips.valleys,etc.8)Suggested waste factor is based on the roof complexity and is provided for guidance purposes only. you should confirm the appropriate waste factor prior to ordering. Prepared For: Perry's Roofing 7 Windingwood Rd N, Rye Brook, NY 10573 (1) QuickMeasure Roofing Materials Roof Reports in Under an Hour Suggested Waste 0% 6% 1 1% 16% Shingle Products HDZ, UHDZ, Natural Shadow, ASII, bundle 91 96 101 105 Reflector, Royal Sovereign, Cool Series Low-Slope Roofing System Liberty Base/Ply Sheet roll 0 0 0 0 Liberty Cap Sheet roll 0 0 0 0 Liberty Asphalt Primer gallon 0 0 0 0 Liberty Flashing Cement gallon 0 0 0 0 Starter WeatherBlocker bundle 3 4 4 4 Pro-Start bundle 3 3 3 3 Buick-Start roll 10 10 11 11 Roof Deck Protection Deck-Armor, Tiger Paw, FeltBuster 10 sq roll 3 4 4 4 Shingle-Mate roll 8 8 9 9 VersaShield roll 9 9 10 10 Leak Barrier StormGuard, WeatherWatch 2 sq roll 7 7 7 7 WeatherWatch 1.5 sq roll 9 9 9 10 Ridge Cap Seal-A-Ridge, Seal-A-Ridge AS bundle 5 5 5 6 TimberTex bundle 6 6 7 7 Z-Ridge bundle 4 4 4 4 TimberCrest box 6 6 7 7 Nails Cap Nails box 2 2 2 2 Coil Nails 1.25 in box 2 2 2 2 Step Flashing Step Flashing 10 ft piece 4 4 4 5 Step Flashing 8 ft piece 5 5 5 6 Drip Edge Drip Edge 10 ft piece 30 32 34 35 Drip Edge 8 ft piece 38 40 42 44 Notes.1)These approximate quantities are based on estimated measurements and are for guidance purposes only. You should always confirm quantities prior to ordering and ensure you are following local building code requirements.2)For Timberline.3 bundles=0.984 squares.3)Starter=eaves+rakes.4)Leak barrier=bends+eaves+flashing+hips+rakes+step+valleys 5)Ridge cap=hips+ridges.6)Low-slope products applied to 1/12 pitch areas.7)Timberline products applied to 2/12 pitch areas and above.8)Installed coverage will be less and depend on quantity and width of side and end lops.9)Liberty low slope rooting system should be installed as a system.For more information,see gal.com/liberty. Prepared For: Perry's Roofing U 7 Windingwood Rd N, Rye Brook, NY 10573 (1) QuickMeasure Attic Vents Roof Reports in Under an Hour Static Quantity Units Cobra@ Rigid Vent 31m, SnowCountryw & SnowCountrym Advanced 40 ft Cobra@ Exhaust Vent Roll - Nail Gunnable 51 ft Cobra@ Exhaust Vent Roll-Hand Nailable 42 ft Cobra@ RidgeRunner'R 57 ft Cobra@ Hip Vent 79 ft Master Flow@ SSB960 Metal Super Slant-Back Roof Vents 12 vent Master Flow@ RV50/R50 Square-Top Roof Vents 15 vent Master Flow@ IR65 Plastic Slant-Back Roof Vents 11 vent Master Flow@ High-Capacity Dome Vents 5 vent Master Flow® 10' Aluminum Ridge Vent 34 ft Cobra IntakePro@ Rooftop Intake Vent 79 ft Master Flow@ Undereave Intake Vents- 16" x 8" 15 vent Powered - Roof Mount Exhaust Cobra Master Flow 16x8 (vent) IntakePro (ft) Intake (vent) Master Flow@ ERV4 Power Attic Vents 2 107 20 Master Flow@ ERV5 Power& Wi-Fi Attic Vents 2 134 24 Master Flow@ ERV6 Power Attic Vents 2 160 29 Master Flow EZ Coollm Plug-in Power Attic Vents 2 112 21 Master Flow@ GreenMachineTm Solar/Dual-Powered Vents 4 112 21 Master Flow@ GreenMachinelm High-Power Solar/Dual-Powered Vents 3 120 22 Master Flow@ 12"Wind Turbines 5 132 24 Master Flow@ 14" Wind Turbines 3 112 21 Note,The estimated quantify of attic ventilation products in this report is based solely on the total exterior square footage of all roof planes and is meant for estimating purposes only. It is the responsibility of the installer to verity the correct quantity and type of attic ventilation products prior to commencement of work. Installer must always review job-specific attic ventilation needs such as local code requirements,attic floor square footage.roof design,and conditioned spaces under the root. GAF recommends a minimum of 1 square foot of attic ventilation(evenly split between intake and exhaust)for every 300 square feet of attic floor space.The amount of exhaust ventilation at or near the ridge must never exceed the amount of intake ventilation at or near the soffit See gaf.com/ventcalculator for details. Prepared For: Perry's Roofing 7 Windingwood Rd N, Rye Brook, NY 10573 (1) a LO dj Cl / J1\ .► +. O �O 0 OLLIt .cas)> • : ^ y w z w� > o = oo.o�ection W V/ L__ L L O } � W z Co 3 s w a w o : U. � e Cd ' y 4 = 4- H N w = \ tu l- c " • -F' A . j. .' f; dd' h ;► ' At ; y PERRVER-01 CDOLCE A�ORL7 CERTIFICATE OF LIABILITY INSURANCE DATD/VYYV) 61271227/2024 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). MTACT Kevin Kelley PRODUCER NAO Levitt-Fuirst Associates, LTD PHONE 520 White Plains Road (A/C.No,EXq:(914)457-4200 (Ax (A c,No):(914)457-4200 2nd Floor AD E-MAIDREL info@levittfuirst.com Tarrytown,NY 10591 INSURERS AFFORDING COVERAGE NAIC M INSURER A:Admiral Insurance Company 24856 INSURED INSURER B:Accident Fund Insurance Company of America 10166 Perry Verrone LLC INSURER C:ShelterPoint 81434 12 Center Street INSURER D Pleasantville,NY 10570 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 7ypE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP TR N WVD POLICY NUMBER MM/D /YYYY MIDD/YYYY LIMITS A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE S 1,000,000 CLAIMS-MADE OCCUR CA000045827-03 7/1/2024 7/1/2025 DDRAMAGEM ETORENTEDn $ 300,000 MED EXP(Any oneperson) $ 5,000 PERSONAL&ADV INJURY S 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER 2,000,000 POLICY EK PRO- ❑ GENERAL AGGREGATE $ JECT Loc 2,000,000 PRODUCTS-COMP/OP AGG S OTHER S AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT accident) S ANY AUTO BODILY INJURY Per personj S OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY Per accident $ HIRED NON,pWNED PROPERTY DAMAGE AUTOS ONLY AUTOS ONLY Per accident $ S B UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 5,000,000 X EXCESS LIAB CLAIMS-MADE GXL000147003 7/1/2024 7/1/2025 AGGREGATE s 5,000,000 DED I X I RETENTIONS 10,000 5 WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY Y/N STATUTI ER ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICERWEMBER EXCLUDED? ❑ N I A E.L.EACH ACCIDENT $ (Mandatory In NH) If yes,describe under E.L.DISEASE-EA EMPLOYEE $ DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ C NYS Disability 6BL358637 5/10/2022 5/10/2025 Limit-Statutory DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101.Additional Remarks Schedule.maybe 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 938 King St ACCORDANCE WITH THE POLICY PROVISIONS. Rye Brook, NY 10573 AUTHORIZED REPRESENTATIVE ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD NEW Workers' YORK CERTIFICATE OF STATE Compensation Board NYS WORKERS' COMPENSATION INSURANCE COVERAGE la.Legal Name&Address of Insured(use street address only) 1b. Business Telephone Number of Insured 914-867-1747 Perry Verrone LLC DBA Perry's Roofing 1 c. NYS Unemployment Insurance Employer Registration Number of 12 Center Street Pleasantville,NY 10570 Insured 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 26-2754386 2.Name and Address of Entity Requesting Proof of Coverage 3a.Name of Insurance Carrier (Entity Being Listed as the Certificate Holder) Continental Indemnity Village of Rye Brook 3b.Policy Number of Entity Listed in Box"l a" 938 King Street 46-8841910120 Rye Brook,NY 10573 3c.Policy effective period 03/01/2024 to 03/01/2025 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 1 a' 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: Steven Diamond(President) (Print name of authorized representative or licensed aqent of insurance carrier) Approved by ��[!i� �GCLl4ld 02/26/2024 (Signature) (Date) Title: Licensed Insurance Broker Telephone Number of authorized representative or licensed agent of insurance carrier: 516-488-3040 Please Note: Only insurance carriers and their licensed agents are authorized to issue Form C-105.2. Insurance brokers are Q authorized to issue it. C-105.2 (9-17) www.wcb.ny.gov Workers' Compensation Law Section 57. Restriction on issue of permits and the entering into contracts unless compensation is secured. 1. The head of a state or municipal department. board, commission or office authorized or required by law to issue any permit for or in connection with any work involving the employment of employees in a hazardous employment defined by this chapter. and notwithstanding any general or special statute requiring or authorizing the issue of such permits. shall not issue such permit unless proof duly subscribed by an insurance carrier is produced in a form satisfactory to the chair. that compensation for all employees has been secured as provided by this chapter. Nothing herein. however. shall be construed as creating any liability on the part of such state or municipal department, board. commission or office to pay any compensation to any such employee if so employed. 2. The head of a state or municipal department. board, commission or office authorized or required by law to enter into any contract for or in connection with any work involving the employment of employees in a hazardous employment defined by this chapter, notwithstanding any general or special statute requiring or authorizing any such contract. shall not enter into any such contract unless proof duly subscribed by an insurance carrier is produced in a form satisfactory to the chair, that compensation for all employees has been secured as provided by this chapter. C-105.2 (9-17) REVERSE