HomeMy WebLinkAboutRP24-093PERMIT # /t;�/
SECTION JS
TYPE OF WORK
JOB LOCATIYN _
�T. CwST
CO #.
TCA #
I �e7//
� DATE 3 �" E?(P;
BLOCK �fOT,
-•I
FEE DATE
W§EL" YM REOOF3
DATE INSP
F*OTING
FOUNDATION
FRAMING
RGH FRAMING
INSULATION
PLUMBING C�
RGH PLUMBING
GAS a
SPRINKLER
ELECTRIC 0
LOW -VOLT CO
ALARM 0
AS BUILT 0 oZ,4 q C
FINAL
8 7S7
OTHER APPROVALS
ARB
BOT
P$
ZBA
OTHER
OQyE DR19
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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
September 23, 2024
Michael Lelia&Valerie Lelia
47 Greenway Lane
Rye Brook,New York 10573
Re: 47 Greenway Lane, Rye Brook,New York 10573
Parcel ID#: 129.84-2-36
Roof Permit#24-093 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
D E C M W E �R c For office use only.
BUILD ARTMENT PERMIT# N
93
SEP 16 2024 VIL4 OF RYE BROOK ISSUED: TJ
93 1 KING STREET; YE BROOK, 1W YORK 10573 DATE: -
VILLAGE OF RYE BROOK (9 4)939-066 FEE: PAID
BUILDING DEPARTMENT wwwxyebrookny.2ov
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
suss*s*sss*Js+sts*ssss*s«*«ss**+*+**s«ssss+«««+*«+«++++*ts«+s++sss++s««*«+««s*+s«*s++««+*+ts+«sttttarrttttt**+-*+sttsts+**stss+
Address: `7 Pap Aroal CC 1057
Occupancy/Use: - 00) Parcel ID #: U - :3 Zone: L�
Owner:-M/(Ifial L�J/ �. Address: /� k
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:
Lh(,e L L e i being duly swom,deposes and says that he/she resides at
(P Name of Applicant) (No.and Street)
in cl^/e 3'OD�, ,in the County of w C h in the State of ty ^„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,pro�fjssional fees,and including the monetary value of any materials and labor which may
have been donated gratis was:$ � 5610 JI ,
for the construction or alteration of. kJ-eyI Ile U J-�
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.o�e Code of the Village of Rye Brook.
Sworn to before me this Sworn to before me this
day of £m e�, 2011 day of , 20
Signature of Property Owner Signature of Applicant
01v Chet�-L Le fl �-
firiLlName of Property Own e r. Print Name of Applicant
n
i
Nota-FFPublic SHARI MELILLO Notary Public
Notary Public,State of New York
No.01ME6160063
Qualified In Westchester County.7
Commission Expires January 29,20 C
QyE BR(��•
• 1932 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 :- �I T-e& J lA�-�_ DATE: 1
rI
PERMIT# ? `I 1_ I _') ISSUED: l/$ECT: . OW BLOCK: LOT: �o
LOCATION: OCCUPANCY:
❑ VIOLATION NOTED THE WORK IS... ❑ ACCEPTED ❑ REJECTED/ REINSPECTION
❑ SITE INSPECTION REQUIRED
❑ FOOTING
❑ FOOTING DRAINAGE
❑ FOUNDATION
❑ UNDERGROUND PLUMBING NOTES ON INSPECTION:
❑ ROUGH PLUMBING
❑ ROUGH FRAMING
❑ INSULATION
❑ NATURAL GAS j
❑ L.P. GAS ;J
❑ FUEL TANK
❑ FIRE SPRINKLER
❑ FINAL PLUMBING
❑ CROSS CONNECTION
❑ FINAL
❑ OTHER
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BUILDING 'ARTMENT21 VI E OF RYE BROOK AUG - 9 2021E
93$ KING E T RYE BROOK,NY 10573 311 939-01618 VILLAGE OF RYE BROOK
++�cW. ow BUILDING DEPARTMENT
FOROFFICE U`l04
Approval Date: � �' I'.�i it ': Application#
Approval Signature: ARCHITECTURAL REVIEW BOARD:
Disapproved: = Date:
BOT Approval Date: Case# Chairman:
PB Approval Date: Case# Secretary:
ZBA Approval Date: Case#
Other: ,\ /! �, 1
Application Fee:0/00 -;� U� Permit Fees:v� 60—L)V e
�f ROOF PERMIT APPLICATION
Application dated: r�� a / 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. nn
1. Job Address: L17 6reellW&ISBL: Zone: �.U
Property Owner: / (,a Address: e Al
Phone#: Cell#: email:
2. Applicant: l Qe 11 / ddress: q7
Phone#: -3-1 G " ] Cell#: email: C661t 7
3. Roofing Contractor: Address:
Phone#: Cell#: email:
4. Job Description, list all Methods&Materials:
14 s , fuTimberline
5. Estimated Cost of Job: $ (No I li: l he estimated cos shall include all site
Ned d ecluipnlent.professional fees.and material and hN)r%�hich nia\ be donated gratis.)
6. If comerproperty,indicate street frontage: IiV1�///-tlTTT
7. Construction Type: NY1/AS/Construction Class:
8. Number of stories: Height: /V nn�
9. Is garage being re-roofed:No: •Yes:{ )Attached No:( )•Yes:( )Number of Cars: 9
10. Is roof peaked,hip,mansard,flat,etc:
11. Estimated date of completion:
-t-
6/1l2024
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 YOU K COUNTY OF WESTCHESTER ) as:
ferle �!I a ,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
7 for the legal owner and is duly authorized to make and file this application.
(indicate architect,cekactor,ag nt,Ittorney,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 ►,� , 20_�-11 of , 20).-1,
Signature of Property Owner V V / Signature of Applicant
MONel Lelia, 1&&;e Lelia MINd Lebo , 16koc lelia
A
Pr erty Owner Print Name of Applicant
tary
JOSHUA E. BALSAM
NOTARY PUBLIC,STATE OF NEW YORK JOSHUA E. BALSAM
Registration No.01 BA4994963 NOTARY PUBLIC,STATE OF NEW YORK
Qualified in Westchester County Registration No, 01 BA4994963
mission Expires January,31,2028 Qualified in Westchester County
Commission Expires January, 31, 2028
-2-
6/1/2024
Q FIE,Cc; C f]``� E
AUG 1 2 2024 I
VILLAGE OF RYE BROO�h Arbors Homeowners' Association
BUILDING DEPARTMENT
" 173 '/2 Ivy Hill Crescent
Rye Brook, NY 10573
August 9, 2024
Michael and Valerie Leila
47 Greenway Lane
Rye Brook, NY 10573
Re: Entire Roof Replacement —47 Greenway Lane
Dear Mike and Valerie,
This letter serves as confirmation that the Architecture & Grounds (A&G) Committee
has reviewed and accepted your application for the above-named work. This approval is
valid for six (6) months from today's date.
If any changes need to be made to the original plans submitted to A&G either before or
during construction, the Committee must be notified in writing and your application must
be amended. Work must stop and cannot proceed until you receive written approval for
those changes.
A permit from the Village of Rye Brook must be presented to the property manager
before work begins. You are also required to inform the Property Manager when work
begins. When the project is complete. the Property Manager must again be notified so
that an inspection may take place. Please include a photograph of the work as well.
Failure to comply with these procedures will result in fines and/or work stoppage.
If you have any questions, contact me at: Property Manager.
Nicholas Salzarulo
Property Manager
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LELIA-1
1114 O CERTIFICATE OF LIABILITY INSURANCE D08109/202ATE YYI
�� 0810912024
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 endorsements .
PRODUCER 845-368-2700 C214TACT
Licata Management Corp PHONE FAx
98 Lafayette Ave/PO Box 98 (A/C,No,Ext) 845-368-2700 (A/C,No):845-368-2302
Suffern,NY 10901 ADDREss.
INSURERJSJ AFFORDING.COVERAGE NAIC a
INSURER A Mid Hudson Co-Operative Ins CO
INSURED INSURER B
Lelia Electric Corp.
47 Greenway Lane INSURER
Rye Brook,NY 10573 INSURER D
INSURER E
INSURER F
COVERAGES CERTIFICATE NUMBER6 REVISION NUMBER!
THIS IS TO CERTIFY THAT THE POLICIES OF INSURi�NCE 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, T-iE 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 SUER POLICY NUMBER POLICY EFF POLICY EXPLTR LIMITS
A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE_ $ 1,000,000
CLAIMS MADE X OCCUR L4522994 12/14/2023 12/14/2024 DAMAGE TO RENTED 100,000
PREMISES(Ea occurrencei .F
MEO EXP(Any one person, 5 10,000
PERSONAL d ADV INJURY 1,000,000
.GEN'L AGGREGATE LIMIT APPLIES PER -GENERAL AGGREGATE ,$ 3,000,000
X POLICY JE LOC PRODUCTS_COMP(OPAGG E 2,000,000
OTHER
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT
(Es=denll _-3
ANY AUTO BODILY INJURY jPer person)
OWNED SCHEDULED
_AU�T�OpS ONLY AUTOS
SSyy Ep BODILY INJURY(Pe(accident).f
AUTOS ONLY AUTOS ONLY PROPERTY DAMAGE
(Pe'acaden:; S
UMBRELLA LIAR OCCUR
EACH_(�CC,SJRRENCE -E
EXCESS LIAR CLAIMS-MADE ,AGGREGATE_.
I11-t1 RFTFNTION%
WORKERS COMPENSATION PER OTH-
AND EMPLOYERS'LIABILITY YIN .SIATU.TE .ER
ANY PROPRIETOR/PARTNERIEXECUTIVE EL EACH ACCIDENT S
pFFICER/MEMBER EXCLUDEDI NIA
(Mandatory in NH) E L DISEASE.-EA EMPLOYEE $
If es descr De cnde'
I w Y LIMIT
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached If more space Is rsciulred)
CERTIFICATE HOLDER CANCELLATION
VILLOFR
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
Village of Rye Brook THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
9 Y ACCORDANCE WITH THE POLICY PROVISIONS,
Building Department
938 King Street AUTHORIZED REPRESENTATIVE
Rye Brook, NY 10573
ACORD 25(2016/03) J 1988-2015 ACORD CORPORATION. All rights reserved.
The ACORD name and logo are registered marks of ACORD
NYSIF
New York State InSU ran(e Fund PO Box 66699,Albany.NY 12206
nysif.com
CERTIFICATE OF WORKERS' COMPENSATION INSURANCE
o a
n AAA AA 845141878 � +
LICATA MANAGEMENT CORP
98 LAFAYETTE AVENUE DaL'
PO BOX 98
SUFFERN NY 10901 SCAN TO VALIDATE
AND SUBSCRIBE
POLICYHOLDER CERTIFICATE HOLDER
LELIA ELECTRIC CORP VILLAGE OF RYE BROOK
47 GREENWAY LANE BUILDING DEPARTMENT
RYE BROOK NY 10573 938 KING STREET
RYE BROOK NY 10573
POLICY NUMBER CERTIFI SATE NUMBERT POLICY PERIOD DATE
W2533 220-6 2.'354 12/16/2023 TO 12/16/2024 8/9/2024
THIS IS TO CERTIFY THAT THE POLICYHOLDER NAMED ABOVE IS INSURED WITH THE NEW YORK STATE INSURANCE
FUND UNDER POLICY NO. 2533 220-6. 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 'OLICYHOLDER'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/CERTICERTVAL.ASP.THE NEW
YORK STATE INSURANCE FUND IS NOT LIABLE IN THE EVENT OF FAILURE TO GIVE SUCH NOTIFICATIONS.
THIS POLICY DOES NOT COVER CLAIMS OR SUITS THAT ARISE FROM BODILY INJURY SUFFERED BY THE OFFICERS OF THE
INSURED CORPORATION.
PRESIDENT
MICHALL LtLIF
OF LELIA ELECTRIC CORP(1 OF 1)
THIS CERTIFICATE IS ISSUED AS �� MATTER CF 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 S7NCE FUND
/
DIRECTOR,INSURANCE FUND UNDERWRITING
VALIDATION NUMBER 1019517303
U 26.3
Renewal House & Home Policy Declarations Q) Allstate
.
Your policy effective date is August 12,2023
Page 1 of 4
Total Premium for the Policy Period Information as of June 21,2023
Premium for property insured $1,481.03 Summary
Premium for Scheduled Personal Property Coverage 234.00 Named Insured(s)
Premium for Water Back-Up 50.00 Michael Lelia,Valerie A Lelia
Total $1,765.03 Mailing address
47 Greenway Ln
• Workers'Compensation And Employers'Liability Coverage For Residence Employees Rye Brook NY 10573-1516
Coverage Form Included in Total Policy Premium Policy number
978 800 798
Discounts (included in your total premium) Your policy provided by
Protective Device $23.28 Renewal $140.70 Allstate Vehicle and Property
Multiple Policy $653.02 Claim Free $8.02 Insurance Company
A Stock Company
Home Buyer $4.30 Allstate Easy Pay Plan $66.64 2775 Sanders Road
Protective Device(SPP) $12.00 Northbrook, IL 60062
Total discount savings $907,96 Policy period
Beginning August 12,2023 through
August 12,2024 at 12:01 a.m.standard
Surcharge (included in your total premium) time
Your Allstate agency is
Claim rating $58.87 Frank Campo Agcy
572 Warburton Ave
Hastings On Hud NY 10706
Insured property details* (914)478-4959
Please review and verify the information regarding your insured property. Please FrankCampoCa>allstate.com
refer to the Important Notice(X73182-1)for additional coverage information.
Contact us if you have any changes. Some or all of the information on your
Policy Declarations is used in the rating
Location of property insured: 47 Greenway Ln, Rye Brook, NY 10573-1516 of your policy or it could affect your
Location zone: NY0573 eligibility for certain coverages.Please
Your location zone is based on the location of the insured property and is one of many notify us immediately if you believe
factors used in determining your rate. that any information on your Policy
Declarations is incorrect.We will make
Dwelling Style: corrections once you have notified us,
Built in 1979;1 family;1269 sq.ft.;end townhouse-2 stories and any resulting rate adjustments,will
Foundation: be made only for the current policy
Below grade basement,100% period or for future policy periods.
Please also notify us immediately if you
Interior details: believe any coverages are not listed or
One builders grade kitchen One single fireplace are inaccurately listed.
Two builders grade full baths One softwood straight staircase
Exterior wall type:
100%wood siding
Interior wall partition: cc
0
n
(continued) >
z
Sri,.
Renewal House&Home Po icy Declarations Page 2 of 4
Policy number: 1978 800 798
Policy effective date: August 12,2023
Insured property details*(continued)
100%drywall
Heating and cooling:
Average cost central air conditioning, Oil hot water heating,100%
100%
Additional details:
Standard wood sash with glass,100% Interior wall height -8 ft,100%
Two exterior wood doors
Laminated windows- no
Fire protection details:
Fire department subscription-no 1 mile to fire department
Roof surface material type:
Composition
•100%asphalt/fiberglass shingle
.................................................................................................................................................._.
:Roof details:
:Predominant roof type:Composition Age of roof-5 years
:Roof geometry-Gable
:Metal Roof Surfaces Cosmetic Damage Exclusion:
:Your policy does not provide coverage for cosmetic damage(damage that only changes
:the appearance of your roof)caused by hail to a metal roof surface.
......................................................................................................................................................
Mortgagee
UNITED WHOLESALE MORTGAGE LLC ISAOA
P O Box 202028, Florence,SC 29502-2028
Loan number:0159596857
Additional Interested Party:
The Arbors Homeowners Association Inc
1731/2 Ivy Hill Crescent, Rye Brook, NY 10573-1604
`This is a partial list of property details.If the interior of your property includes custom
construction,finishes,buildup,specialties or systems,please contact your Allstate
representative for a complete description of additional property details.
r
c
Coverage detail for the property insured
Coverage Limits of Liability Applicable Deductible(s)
Dwelling Protection $351,376 •Hurricane Deductible Applies"
•$1,000 All other perils
Other Structures Protection $35,138 •Hurricane Deductible Applies**
•$1,000 All other perils 5
Personal Property Protection $175,688 • Hurricane Deductible Applies— C
a
•$1,000 All other perils C
Additional Living Expense Up to 24 months not to exceed$70,276
a
Family Liability Protection $500,000 each occurrence s
Guest Medical Protection $5,000 each person
Building Codes Not purchased*
C
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Affidavit of Exemption to Show Specific Proof of Workers' Compensation Insurance
Coverage for a 1, 2, 3 or 4 Family, Owner-occupied Residence
**Thu form cannot be used to waive the workers'compensation rights or obligations of any party.**
Under penalty of perjury, I certify that I am the owner of the 1, 2, 3 or 4 family, owner-occupied residence
(including condominiums) listed on the building permit that I am applying for, and I am not required to show
specific proof of workers' compensation insurance coverage for such residence because (please check the
appropriate box):
I am performing all the work for which the building permit was issued.
AI am not hiring,paying or compensating in any way,the individual(s)that is(are)performing all the work
for which the building permit was issued or helping me perform such work.
❑ I have a homeowners insurance policy that is currently in effect and covers the property listed on the
attached building permit AND am hiring or paying individuals a total of less than 40 hours per week
(aggregate hours for all paid individuals on the jobsite) for which the building permit was issued.
I also agree to either:
♦ acquire appropriate workers' compensation coverage and provide appropriate proof of that coverage on
forms approved by the Chair of the NYS Workers' Compensation Board to the government entity issuing
the building permit if I need to hire or pay individuals a total of 40 hours or more per week(aggregate hours
for all paid individuals on the jobsite)for work indicated on the building permit,or if appropriate,file a CE-
200 exemption form; OR
♦ have the general contractor, performing the work on the 1, 2, 3 or 4 family, owner-occupied residence
(including condominiums)listed on the building permit that I am applying for,provide appropriate proof of
workers'compensation coverage or proof of exemption from that coverage on forms approved by the Chair
of the NYS Workers' Compensation Board to the government entity issuing the building permit if the
project takes a total of 40 hours or more per week(aggregate hours for all paid individuals on the jobsite)for
work indicated on the building permit.
(Signature of Homeowner) (Date Signed) / (/
C kae L C.e ( :I c- Home Telephone Number /�� � (�C�J3 7, 7
(Homeowner's Name Printed)
o- -oI
Sworn to before arse this � ` day of �
Property Address that requires the building permit:
2
Qualified In Westchester county
County f;1+�IEtyabary Public.)
�/L Notary Public,State of New York
No.01ME6160063
Ir \
V Commission Expires January�9,2t��_ /
Once notarized,this BP-1 form serves as an exemption for both workers'compensation and disability benefits insurance coverage.
BP-1 (12/08) NY-WCB
i