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HomeMy WebLinkAboutRP24-092PEUMIT �t _� SECTION TYPE OF WORK JOB LOCATION OWNER CONTRACTOR ,SST. COST Ce #� TCO # -y / c DATE: ci- D(P: /Q 2- FEE � DATE �NSrECAm RECORD I DATE INSP FOOTING FOUNDATION FRAMING RGH FRAMING INSULATION PLUMBING C� RGH PLUMBING GAS 0 SPRINKLER ELECTRIC LOW -VOLT O ALARM CI AS BUILT ED FINAL 3 OTHER APPROVALS ARB BOT PB ZBA OTHER QyE BRn l(J G lCG4,°�a�J J G CCU.(Go c � VILLAGE OF RYE BROOK MAYOR 938 King Street, Rye Brook,N.Y. 10573 ADMINISTRATOR Jason A. Klein (914) 939-0668 Christopher J. Bradbury www.!yebrookny.gov TRUSTEES BUILDING & FIRE INSPECTOR Susan R. Epstein Steven E. Fews Stephanie J. Fischer David M. Heiser Salvatore W. Morlino CERTIFICATE OF COMPLIANCE September 19,2024 Michele Toll 203 Ivy Hill Crescent Rye Brook,New York 10573 Re: 203 Ivy Hill Crescent, Rye Brook,New York 10573 Parcel ID#: 129.76-1-10 Roof Permit#24-092 issued on 8/12/2024 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 ��% BUILDING DEPARTMENT For office use on j �, PERMIT# -0 —' VILtk, OF RYE BROOK ISSUED: �' � U S F P 1 2024 �_ KING STRE � 11YE BROOK,NEw YORK 10573 DATE: - _ _ 9 -0668t)% FEE: PAID VILL.AGH OF RYE BROOK w t ov BUILDING DF-PARTVENT APPLICATION OR 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 ■►rssss►ssssrsrrss♦ss►•s•■s«rasss■iris♦sirs••rsss►s■s■srr■r•r«■rsrrsrs■s►ss rrrssrsr■•r+s•tss•»srgssapssssssrrssrssrs ssrsr Address: 2_6� V Occupancy/Use: 1 I Parcel ID#: Zone: Owner: ` CiV►R,l �� f 70? / , Address: J �V� t7,�/ Cfepdej�A P.E./R.A.or Contractor: Address: arson in responsible charge: Address: kpplication 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 iaw STATE O(F��NEW YORK.COUNTY OF WESTCHESTER as: �j- 'wing duly sworn,deposes and says that he/she resides at 2�3 +V �f' Crefced tPrint Name Applicant) (No.and Street) in _ Q, ,in the County of wes es in the State of ,that (City/Town/Vatagei 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_n_' Z 03 for the construction or alteration of. 1 t/�I') �O 0 F Deponent further states that he/she has examined the approved plans of the structure/work herein referred to for which a Certificate o Occupancy/Compliance is sought,and that to the best of his/her knowledge and belief.the structure/work has been erected/completed ir 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 Rve Brook. Sworn to before me this Sworn to before me this .ray of � , 2UQ� day of 120 Signature of roSignature of Applicant r'Lk' ner N 17 cf Property Owner Print Name of Applicant Notary blic Notary Public SliARI MEL ILLO Notary Public,State of New York No.01ME6160063 Qualified in Westchester County 2 Commission Expires January 29,20_ �yC BRC�v�. 1952 BUILDING DEPARTMENT ❑BUILDING INSPECTOR 2<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 : �� ' y DATE: 1 JZ 7 PERMIT# \ LI �"1 Z- ISSUED: i'SECT: 6 BLOCK: LOT: y LOCATION: I( 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 _ N �I 00 v o a o W aA = O 0 x owaoc � ° _ $ ° b Cl) rV1 e r C a v = Y O 0 0 zLn �,Z0 'o � � . f� oQ O A U t 7 W \ e v eq U � W � wo W a w H a ; v v v o ' H P.f� � a o rb °' � 40Q � yw V 0 x Q a a0-4 N U Z F' © U za °a adv � U W H Q z O z U w O V U Z u O W s W O ® � � � ° 0 V 4) _ _ _ D BUILD MENT VI E OF RYE OK AUG - 9 2024 938 KING ET RYE BR �€ NY 10573 -0 T VILLAGE OF RYE BROOK ov BUILDING DEPARTMENT FOR OFFICE USE ONLY: ; Approval Date: P00nit# f D/ ems—; Application# Approval Signature: ARCHITECTURAL REVIEW BOARD: Disapproved: Date: BOT Approval Date: Case# Chairman: PB Approval Date: Case# Secretary: ZBA Approval Date: Case# Other: Application Fee: Permit Fees: 41/,5V1pb ROOF PERMIT APPLICATION Application dated: 8/9/24 _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: 203 Ivy Hill Crescent SBI.: /�19, 7& _/_IO Zane:16"b Property Owner: Michele Toll Address: 203 Ivy Hill Crescent, Rye Brook Phone#: Cell#:917-749-6265 email: MicheleToll@gmail.com 2. Applicant: Perry Verrone Address: 12 Center St, Pleasantville Phone#: 914-747-7663 Cell#: email; marls er fin erroneroo .com 3. Roofing Contractor: Perry Verrone, LLC Address: 12 Center St Pleasantville NY Phone#: 914-747-7663 Cell#: email: maria@perryverroneroofing.com 4. Job Description,list all Methods&Materials: Roof removal and replacement- 8 sq 5. Estimated Cost of Job: S 6,250.00 (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 comer property,indicate street frontage: 7. Construction Type: NYS Construction Class: S. Number of stories: Height: 9. Is garage being re-roofed:No:( )•Yes:( )Attached No:00•Yes:( )Number of Cars: 10. Is roof peaked,hip,mansard,flat,etc: peaked 11. Estimated date of completion: Mid August -1- 611/2024 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 YORK,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 befigm—mc this AA vf5T day of , 20 day of , 20 Wflq��-. d ignature of Pro rty Own Signature of ApplicantT ry h t i luZ '� I f V I`e . ame of Property Owner Print Na a of pplicant ���t�aGt�V1h"prlx �/ tt t t I t r Public N� yyz�� �, Mile- AN ,p $; ► \ �� STATE _ OF NEW YORIx% i�., NOTARY PUBLIC y 5 \ 01PA6WM2 / N E-xT rr1t111100 -2- 61112024 e a I e V I e W Premium Report g 7/31/2024 Brook,20/ Ivy Hill Cres, Rye -.. TABLE OF CONTENTS Images .................................................................•...1 LengthDiagram.........................................................4 PitchDiagram............................................................5 AreaDiagram............................................................6 NotesDiagram...........................................................7 ReportSummary........................................................8 MEASUREMENTS Total Roof Area =896 sq ft Total Roof Facets =3 Predominant Pitch =8/12 Number of Stories >1 Total Ridges/Hips =20 ft Total Valleys =3 ft Total Rakes =72 ft Total Eaves =47 ft In this 3D model,facets appear as semi-transparent to reveal overhangs. PREPARED FOR Contact: Perry Verrone Company: Perry's Roofing, LLC Address: 12 Center Street Pleasantville, NY 10570 Phone: 917-578-8242 Measurements provided by www.eagieview.com Certified Accurate www.eapleview.com/Guarantee.aspx c,2008-2024 Eagle V e Technologies,Inc.and Pictometry International Corp.-All Rights Reserved-Protected try European Patent Application No.10162199.3-Covered by one or more of U.S.Patent Nos.8,078,436;8,145,578; 8,170,840;8,209,152;8,515,125;8,825,454;9,135,737;8,670,961;9,514,568;8,818,770;8,542,880;9,244,589;9,329,749;9,599,466.Other Patents Pending. —i Premium Report' r — e ag_ 7/31/2024 204 Ivy Hill Cres, Rye Brook, NY 10573 Report: 60609676 IMAGES The following aerial images show different angles of this structure for your reference. Top View 1 i .Y aa4 1 � ♦ 1f4 , . • .c.2008-2024 Eagle View Technologies,Inc.and PKtometty Intematlonal Corp.-AllRights Reserved-Protected try European Patent Application No.10162199.3-Covered by one cr more of U.S.Patent Nas.8,078,436:8,145,578;8,170,840; 8,209,152;8,515,125;8,825,454;9,135,737;8,670,961;9,514,568;8,818,770;8,542,880;9,244,589;9,329,749;9,599,466.Other Patents Peming. PAG E 1 Premium Report e ag _ 7/31/2024 204 Ivy Hill Cres, Rye Brook, NY 10573 Report: 60609676 IMAGES North Side Kw' v 4. eaglevi Pi South Side i +;.,i:7ie View Technologies,Inc.and Wtorretry International Corp.-All Rights Reserved-Protected by European Patent Application No.10162199.3-Covered by one or more of U.S.Patent Nm 8r078.436 8,145,578;8,170,840; 8,209,152;8,515,125;8,825,454;9,135,737;8,670,961;9,514,568;8,818,770;8,542,880;9,244,589;9,329,749;9,599,466.Other Patents Pending, PAGE 2 —i Premium Report - e ag_ 7/31/2024 1' Ivy Hill Cres, Rye Brook, 1 ' 'p• 616196 IMAGES East Side ti a - • West Side r / 40 00 ,t 4 d` v 2008-2024 Eagle :-:.. .. ,.;;retry international Corp.-All Rghts Reserved- Protected Dy European Patent Application No.10162199.3-Co- by one or more of U.S.Patent Nos,8,078,436;8,145,578:8,170,840; 8,209,152;8,515,125;8,825,454;9,135,737;8,670,961;9,514,568;8,818,770;8,542,880;9,244,589;9,329,749;9,599,466.Other Patents Pendrng. PAGE 3 Premium Report e ag l e v i e w 7/31/2024 _ 204 Ivy Hill Cres, Rye Brook, NY 10573 Report: 60609676 LENGTH DIAGRAM Total Line Lengths: Valleys = 3 ft Flashing = 10 ft Ridges = 20 ft Rakes = 72 ft Step flashing = 35 ft Hips = 0 ft Eaves = 47 ft Parapets = 0 ft 18 1 21 -- io 1 .s 25 10 w N s E Note: This diagram contains segment lengths (rounded to the nearest whole number) over 5.0 Feet. In some cases, segment labels have been removed for readability. Plus signs preface some numbers to avoid confusion when rotated (e.g. +6 and +9). E 2008-2024 Eagle View tecnnologles,Inc.and Pxtometry International Corp.-All Rights Reserved- ProtecteU oy European Patent Application No.10162199.3-Covered try one or more of U.S.Patent Nos.8,078,436;8,145,578;8,170,840; 8,209,152;8,515,125;8,825,454;9,135,737;8,670,961;9,514,568;8,818,770;8,542,880;9.244,589;9,329,749;9,599,466.Other Patents Pending. PAGE 4 —E Premium Report — e ag_ 7/31/2024 204 Ivy Hill Cres, Rye Brook, NY 10573 Report: 60609676 PITCH DIAGRAM Pitch values are shown in inches per foot, and arrows indicate slope direction. The predominant pitch on this roof is 8/12 F8 8 —. +8 —� w N S E Note: This diagram contains labeled pitches for facet areas larger than 20.0 square feet In some cases pitch labels have been removed for readability. Blue shading indicates a pitch of 3/12 and greater. ''d 2008-2024 Eagle Vkw Technologies,Inc.and Plctornetry ea International Corp.-All Rights Reserved-Protected try European ()Patent Application No.10162199.3-Covered try one or n ore of U.S.Patent Nos.8,078,436:8.145.578:8.170.840 8,209,152;8,515,125;8,825,454;9,135,737;8,670,961;9,514,568;8,818,770;8,542,880;9,244,589;9,329,749;9,599,466.Other Patents Pending, PAGE 5 Premium Report e ag l e v i e w 7/31/2024 _ 204 Ivy Hill Cres, Rye Brook, NY 10573 Report: 60609676 AREA DIAGRAM Total Area = 896 sq ft, with 3 facets. 341 465 +90 w N S E Note: This diagram shows the square feet of each roof facet(rounded to the nearest Foot). The total area in square feet, at the top of this page is based on the non-rounded values of each roof facet(rounded to the nearest square foot after being totaled). c 2008-2024 Eagle view Technologies,Inc.and PKtometry Onernatronal Corp.-All Rghts Reserved- ?r. '1 by European Patent APPIKatlon No.1016: - .�d by one or more of !!ent Nos.8,078,436;8,145,578;8,170,840. 8,209,152;8,515,125;8,825,454;9,135,737;8,670,961;9,51,,568;8,818,770;8,542,980;9,244,589;9,329,74, 466.Other Patents Pendmy. PAGE 6 Premium Report e gleview7/31/2024 204 Ivy Hill Cres, Rye Brook, NY 10573 Report: 60609676 NOTES DIAGRAM Roof facets are labeled from smallest to largest (A to Z) for easy reference. B C A w N S E Note: This diagram also appears in the Property Owner Report. ,�3w Vew 7echnoloq�,Inc.and PKtornetry Internatrona. ;;: a,-p-IS Reserved ;-"tI ;r�Oy lur,��1.:Vn Patent Appl-t,on No.10162199.3-Covered by ore Or mwe Or U.S.Paten[Nos.8,078,436;8,145,578;8,170,840; 8,209,152;8,515,125;8,825,454;9,135,737;8,670,961;9,514,568;8,818.770;8,542,880;9,244,589;9,329,749;9,599.466.Other Patents PeWrw. PAGE 7 � Premium Report e ag_ 7/31/2024 204 Ivy Hill Cries, Rye Brook, NY 10573 Report: 60609676 REPORT SUMMARY All Structures Areas per Pitch Roof Pitches 6/12 8/12 Area (sq ft) 89.5 806.0 of Roof 10% 90% _ The table above lists each pitch on this roof and the total area and percent(both rounded)of the roof with that pitch. ComplexityStructure Simple Normal Complex CalculationWaste NOTE: .. .. pitch or greater. For total measurements of all pitches,please refer to the Lengths,Areas,and Pitches section below. Waste % 00/0 3% 6% 8% 10% 13% 18% 23% 28% Area (Sq ft) 896 923 950 968 986 1013 1058 1103 1147 Squares* 9.00 9.33 9.66 10.00 10.00 10.33 10.66 11.33 11.66 Measured Suggested * Squares are rounded up to the 1/3 of a square Additional materials needed for ridge, hip, and starter lengths are not included in the above table. The provided suggested waste factor is intended to serve as a guide—actual waste percentages may differ based upon several variables that EagleView does not control.These waste factor variables include, but are not limited to, individual installation techniques, crew experiences, asphalt shingle material subtleties, and potential salvage from the site. Individual results may vary from the suggested waste factor that EagleView has provided. The suggested waste is not to replace or substitute for experience or judgment as to any given replacement or repair work. All Structures Totals Lengths,Areas and Pitches Property Location Ridges = 20 ft(1 Ridges) Longitude = -73,6767307 Hips = 0 ft(0 Hips). Latitude = 41.0314727 Valleys = 3 ft(2 Valleys) Notes Rakes' = 72 ft(6 Rakes) This was ordered as a residential Eaves/Starter` = 47 ft(3 Eaves) property. There were no changes to Drip Edge(Eaves+ Rakes) = 119 ft(9 Lengths) the structure in the past four years. Parapet Walls = 0 (0 Lengths). Flashing = 10 ft(1 Lengths) x Step flashing = 35 ft(4 Lengths) Predominant Pitch = 8/12 Total Roof Facets = 3 Total Area (All Pitches) = 896 sq ft t Rakes are defined as roof edges that are sloped(not level). $ Eaves are defined as roof edges that are not sloped and level. g 20OB-2024 Eagle Vl Technologies,Inc.and Pktlinetry Interratlonal Corp.-All Rights Reserved-Protected try European Patent Application No.10162199.3-Covered try one or more of U.S.Patent Nos.8,078,436;8,145,578;8,170,840; 8,209,152;8,515,125;8,825,454;9,135,737;8,670,961;9,S14,568;8,818,770;8,542,880;9,244,589;9,329,749;9,599,466.Other Patents Pending, PAGE 8 "�r>,��w•xr'�;__ >..w• \_ �w _ ti.►� ;k^Y�i - h�.� `..7 '�w� i » \ �� ,�;•'i�c�i;� �;,'�'�'�,�, 1 �yy)i�c � �;�•Y��, ��pJ'���yc)'�'�'�r:a j.�'�'��'' ., ...«�•%,. l6,tlai#)1 NNE ui .NHi��••s .>".. �� ��,. a," ► -�,NHS:. , �•.rfs:�� ��::-. :� �l:.. s t(o)> WE CO '•= o w LO 4. .O. c o " O i c c .,� -�•:� ^it � O c � cn 'J yLO v Q c it : ah •Ais )� Iy r,.► G� +r W Z_ W } o •Y a otiectionr" ,?�` f 1 V1 - •E �V Lam= W 0 CD <co) O W r a+ W N r O d w oP I11' a J J 0 CL El cu �r• Q [� 1• Qr 3 c �' _ "'����: >_ A •v a �` "tea � '2 r 7 co m \ .J;• .y�_ �7 ate'+ 'C �-^ � r n,, 4a \ �. •a. C N O � � r, N 0 V U `• ' � Z - ./ 4 - ♦ u 1 :i 0 VA .r -gip. - ': 1p -�� .�p' _� �� �p - �p� � �p�iky•� PERRVER-01 CDOLCE AC ORL7 DATE(MMIDD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 6127/2024 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 CONTACT Kevin Kelley Levitt-Fuirst Associates, LTD PHONE 520 White Plains Road A/C,No,Ext):(914)457-4200 FAX No):(914)457-4200 2nd Floor E DRIE :info@levittfuirst.com Tarrytown,NY 10591 INSURERS AFFORDING COVERAGE NAIC# 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 TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP TR IN SD WVD POLICY NUMBER MMID /YYYY MM/DO/YYYY LIMITS A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE S 1,000,000 CLAIMS-MADE FX OCCUR CA000045827-03 7/1/2024 711/2025 DRMAGETORENTEDnce S 300,000 occurreMED EXP(Any one erson S 5,000 PERSONAL&ADV INJURY S 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER. GENERAL AGGREGATE S 2,000,000 POLICY�X JE� LOC PRODUCTS-COMP/OP AGG S 2,000,000 OTHER S AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Ea accidenU S ANY AUTO BODILY INJURY tPerperson) $ OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY Per accident S HIRED NON.pWNED PROPERTY DAMAGE AUTOS ONLY AUTOS ONLY Per accidentl S S B UMBRELLA LIAB X OCCUR EACH OCCURRENCE S 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 R YIN ISTATUTE ANY PROPRIETOR/PXCLUDE/EXECUTIVE E.L.EACH ACCIDENT $ (Mandatory In ER EXCLUDED) ❑ N/A (Mandatory In If yes,describe under E.L.DISEASE-EA EMPLOYEE S DESCRIPTION OF OPERATIONS below E.L-DISEASE-POLICY LIMIT 5 C NYS Disability DBL358637 5/10/2022 5/10/2025 Limit-Statutory DESCRIPTION OF OPERATIONS/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. 938 King St 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 Workers' YORK , CERTIFICATE OF STATE Compensation NYS WORKERS' COMPENSATION INSURANCE COVERAGE Board 1 a.Legal Name&Address of Insured(use street address only) 1 b.Business Telephone Number of Insured 914-867-1747 Perry Verrone LLC DBA Perry's Roofing 1c.NYS Unemployment Insurance Employer Registration Number of 12 Center Street Insured Pleasantville, NY 10570 Work Location of Insured(Only required if coverage is specifically limited to 1d. 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 31b. Policy Number of Entity Listed in Box '1 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) Z 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: Steven Diamond(President) (Print name of authorized representative or licensed aqent of insurance carrier) Approved by: �t¢u� �aC�l�2 BrLG✓ 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 NOT authorized to issue it. C-105.2 (9-17) www.wcb.ny.gov