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HomeMy WebLinkAboutRP24-098PERMIT # / Q DgTE; `� Ed(pc1c1 c�S SECTION `S't 3 BLOCK T of TYPE OF WORK �- �X 1! fl1 JOB LOCAT ON OWNER C6,621ClOG(/S U/S t CONTRACTOR M/ /4 C/P llDlY7.e,. n i elLyre lls —41? T. COST I FEE V V CO # FEE4 P v DATE TCO # FEE DATE - INSrECTION RECORD I DATE INSP FOOTING FOUNDATION FRAMING RGH FRAMING INSULATION PLUMBING RGH PLUMBING GAS O SPRINKLER ELECTRIC O LOW -VOLT ALARM AS BUILT C] FINAL - 30 yAq>4e 305--10 ` /9 r� S17/4;1�7 c/y)a7/- 9ii9 OTHER APPROVALS ARB BOT PB ZBA OTHER BR. 19 J j�1 �l��oc'wyi J O 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 3,2024 Howard Louis&Barbara Louis 21 Birch Lane Rye Brook,New York 10573 Re: 21 Birch Lane, Rye Brook,New York 10573 Parcel ID#: 135.43-1-5.27 Roof Permit#24-098 issued on 8/29/2024 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 p BUILDING DEPARTMENT Fur uflicc use unl �: Q i PERMIT# ge& VILLAGE OF RYE BROOK ISSUED: PS 2-a9 a SEP 2 0 2024 DD 38 KING STREET,RYE BROOK,NEW YORK 10573 DATE: _40—� (914)939-0668 FEE: PAID VILLAGE OF RYE BROOK www.ryebrooknv.gov 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: 21 l rc h L ne 2Ltc IS In=L, '4 O;cupancy/Use: L! I IC{4/y Parcel ID#: 35i — 1 1 a 7 I Zone: Owner: ( r 6ot.ra Loy tS Address: 21 61 rcL I.r1 K Ru e 3r � c PP.-E./R.A. or Contractor: r rac�e o p — IoV�lW ddress: Person in responsible charge: o zQ, Address: Application is hereby made and submitted to the Building Inspector of the Village of Rye Brook for the issuance of a Certificatt of Occupancy/Certificate of Compliance for the structure/construction/alteration herein mentioned in accordance witli law: STATE OFNEW YORK,COUNTY OF WESTCHESTER as: . _& f ct rm L u f S being duly sworn,deposes and says that he/she resides at 21 (Print Name ot•Applicant) rf ( (No.and Street) .r in fZv v 'Rr(ro L in the County of w e57c�es{-cC in the State of W y that r Il'it�"ION\n/Village) he/she has supervised the work at the location indicated above,and that the actual total cost of the work,including all site improvements, labor,materials,scaffolding,fixed equipment,professional fees,and including the monetary value of any materials and labor which may have been donated gratis was: S tv,,qQo (' I for the construction or alteration of re o r,n a r opt r,In.t n A Ie S 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 accordante with the approved plans and any amendments thereto except in so far as variations therefore have been legally authorized,and at,erected/completed complies with the laws governing building construction.Deponent further understands that it shall be unlawful for an owner to use or permit the use of any building or premises or part thereof hereafter created,erected,changed,converted or enlarged,wholly or partly,in its use or structure until a Certificate of Occupancy or Certificate of Compliance shall have been duly issued by the Building Inspector as per§250-10.A.of the Code of the Village of Rye Brook. • Sworn to before me this ?_/0 Sworn to before me this C_ day of S , 20 a,�_ day of , 20 S nature of Property Owner Signature of Applicant Print Name of Property Owner Print Name of Applicant I/- Notary ublic Notary BEATA JANKOWSKI BEATA JANKOWSKI NOTARY PUBLIC OF CONNECTICUI NOTARY PUBLIC OF CONNECTICUI MY COMMISSION EXPIRES 06/30/2025 MY COMMISSION EXPIRES 06/30/2025 �yE fiRC�k 193 - 6 BUILDING DEPARTMENT V LDING INSPECTOR ISTANT 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 : ` R C�� C..AJ - DATE: PERMIT#?1 Z q - 17- ISSUED:'/SECT: 3 BLOCK: _LOT:.-5 • Z LOCATION: OCCUPANCY: ❑ VIOLATION NOTED THE WORK IS... ❑'r 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 J ❑ FUEL TANK ❑ FIRE SPRINKLER ❑ FINAL PLUMBING ❑ CROSS CONNECTION Q FINAL 0 OTHER CN gr LL72 v -v 0 (L� �I o`o °O u y �iIxa o vi z Cl z oLr) boe, - N F `° A o a ° ° © cn p� r••� "'a Q a w H E� m Z H� W rl oo a O C 0 6D H z W S <G ' o p Cn ON � o oa z O w w © (� W ao � '� O w � � A � t a w Cf, Em - � Q°qu Z L � a O ° O km o v m � y 4r Z ° ' E. � a a a w a a 1-4 CA zo W z 0 Z O a,`a � `• �I p U p Q [= o V u o u ; zo A z x 9 " OC a,°-u', °J : r BUILDING DEPARTMENT Q IE C IM `—' ffD VILLAGE OF RYE BROOK AUG 2 $ 2024 938 KING STREET RYE BROOK,NY 10573 (914)939-0668 VILLAGE OF RYE BROOK \a.rycbrookny.gov BUILDING DEPARTMENT FOR OFFICE USE W Approval Date. e �� Application# Approval Signature: ARCHITECTURAL REVIEW BOARD: t)iu�t�ler�i�c�1: Date: BOT Approval Date: Case# Chairman: PB Approval Date: Case# Secretary: ZBA Approval Date: Case# Other: 11 Application Fee:y r Permit Fees: o ROOF PERMIT APPLICATION Application dated: -c -��1 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. r t� t. Jsab Address: ( tre� h Rye_ �SraU N i SBL: f 3S ��—� c)�Zone: v , , , i r Y. Property Owner: H oWeLrj 4 _e>arbyc o- L-U.t 5 Address: -z+I F�tr4 y��f 2Y��ro�,l�, N y Phone 3(3 S - C4 (9 Cell#: email: y►rq��ew 5£s @ qua; •coyv, z. Applicant: B cat r_a rz%_ Lew -(-out 5 Address: z 1 $t r^cL [o,h c R.Q 13r Phone#: q I'A - 3oS- 64 11 Cell#: 9(i+-575-9l t C* email:, Ml L( sg Q �Mck i( .etit o+ 3. Roofing Contractor: M1rac(le". HCW e_ � rnyewten s ress: 6ans.t PostpAdd _20to AIs� ! �ro+� llt �K,NY Phone#: Q 14- 2-I 1-I 111 Cell#: r email: Wwtrnc(eAnme 1 CO t et-,zor,.v'b--- • • -4. Job Description,list all Methods&Materials: �ew+avtV) �t�stt' r4 514i (es QAu reh( (' WCTL. Q Ar- -Ci w�6<r�t�,e +(D Z - 5. Estimated Cost of Job: $ (�S, goo. Qd 6. If corner property,indicate street frontage: 1. Construction Type: NYS Construction Class: 8. Number of stories: 2 Height: 9. Is garage being re-roofed:No:( }•Yes:( )Attached No:( )•Yes: ( )Number of Cars: 10. Is roof peaked,hip,mansard,flat,etc: peat kedt %11. Estimated date of completion: 6J112024 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. *.� x *����x�*x�#*�*��**�********�x� :xxMxxx���rxFxxx�KYKxxxKxxxx STATE OF NE�9RK,COUNTY OF ER ) as: f-�. " / L , being duly sworn, deposes and states that he/she is the applicant above named, (print name of individual signing as the applicant) and further states that (s)he is the legal owner of the property to which this application pertains, or that (s)he is the for the legal owner and is duly authorized to make and file this application. (indicate architect,contractor,agent,attorney,etc,) That all statements contained herein are true to the best of his/her knowledge and belief,and that any work performed,or use conducted it the above captioned property will be in conformance with the details as set forth and contained in this application and'in auy accompanying approved plans and specifications,as well as in accordance with the New York State Uniform Fire PreventioU& 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_44 day of , 202-(-/ S gnature of Property Owner Signature of Applicant Print Name of Property Owner/ 'Tint Name ofApplicant •.'Notary ublic Notary Public BEATA JANKOWSKI NOTARY PUOLiC OF CONNECTICUT BEATA JANKOWSKI PRt COMt",1551ON EXFIi�ES O6130(2025 NOTARY PUBLIC Of CONNECTICUT MY COMMISSION EXPIRES 06130,'2025 • 5. r _2_ 6/1/2024 G/Zipracle Biome 9m ptovements ROOFING • SIDING • WINDOWS • DOORS • DECKS • GUTTERS/LEADERS • SKYLIGHTS • STORM DOORS _ 7 J —: �r'M 91�MNW uni Robert & Mary Sniffen 2010 Albany Post Road Croton-on-Hudson, NY 10520 Phone (914) 271-9119 Fax (914) 827-9327 miraciehomel@verizon.net www.miraciehomeimprovements.com License Numbers: WC #104151-199 / RC #H-12519/ PC #1817/Yonkers #3807 August 27, 2024 Proposal Submitted To: Ms. Barbara Louis 21 Birch Lane Rye Brook, NY 10573 (914) 305-6419 Mdblew58@gmail.com Andersen`w THERMARTRU �ImberTech MASTIC SELECT ��� » ooas.000ns DOORS am pww'q Products . cs DEALER: ROYAL C via Kingspan s u P R M E WRACN IM VEAL We hereby propose to furnish the materials and supply the labor necessary for the improvements to 21 Birch Lane, as follows: Roof Remova//Installation • Remove existing shingles down to sheathing ♦ Inspect, remove and replace any rotten wood where necessary (1/2"plywood will be priced at$110.00 per sheet and 3/4"plywood replaced will be priced at$125.00 per sheet subject to current market value) ♦ Apply GAF® Weather Watch®Leak Barrier shield starting above gutters 6' up and to all valleys ♦ Install GAF®Deck Armor®Roof Deck Protection (to provide an extra layer of protection between your shingles and your roof deck)to all areas ♦ Install GAF® Weather Blocker® Eave/Rake Starter Strip ♦ Install new pipe/vent boots as needed • Install new drip edge to all edges(color: White) • Install GAF® Timberline HDZrM Lifetime High-Definition Shingles(Color: TBD) ♦ Install GAF®Cobra Exhaust Vent, please take precautions to cover belongings in attic due to the chance of saw dust and debris from installation ♦ Install new GAF® TimberTex Premium Ridge Cap Shingles • Apply Karnak#19 flashing cement around base of chimney • Reuse, re-secure and clean existing gutters and leaders ♦ Complete disposal of all job-related debris Total Cost: Eighteen Thousand,Nine Hundred Dollars($18,900.00) (Price does not include any additional wood, including plywood) *Note:Miracle Home Improvements not responsible for any cracked sheetroc•k due to roof installation. If town requires a permit to do the work,it will be an additional cost, and the responsibility of property owner to obtain permit Authorized Officer Signature: _Rgbert 911. Snien The officers of Miracle Home Improvements(MHI)reserve the right to withdraw this proposal in 5 days. Due to the volatile economy and continuing price increases, estimates are valid for only 5 days. All work to be performed in a professional manner. All job-related debris to be removed from job site. Any alteration or deviation from the above or attached specifications involving extra costs will become an extra charge,over and above this proposal amount.All agreements are contingent upon strikes,accidents or delays beyond our control. *Warranty on Entire Roof Only' Guarantee of Workmanship on GAF Timberline shingles is a Golden Pledge Limited Warranty. Overall coverage period is lifetime, upfront (100%)coverage period,covers roofing system. Cost of installation and labor included for first 25 years, lifetime for manufacturing defects only. Transferrable warranty included. Miracle Home Improvements is not responsible for any electrical or plumbing work, connection or reconnection of alarm systems or removal of any existing satellite dishes. Miracle Home Improvements not to be held responsible for nails going through unseen wires behind or under any sheathing, sheetrock, walls or exterior structures.The homeowner is responsible for removing all wall hangings such as pictures, mirrors,shelves and shelf content,signs,etc.before the start of any work to be performed by Miracle Home Improvements. Miracle Home Improvements is not responsible for any of the above being damaged due to any work being performed by Miracle Home Improvements. Miracle Home Improvements is not responsible for cleaning any dust or debris or for any damage to items in attic due to roof removal/installation. If Miracle Home Improvements are asked by the home owner to move any property or personal items before,during or after work being done Miracle Home Improvements will not be held responsible for any damage to the property or items. Miracle Home Improvements is not responsible for wires coming into house, such as cable, internet, phone, etc. Homeowner is to carry fire and tornado insurance; Miracle Home Improvements to supply Workman's Compensation and Liability. Homeowner has three(3) business days from date of contract signing to withdraw contract approval. Any cancellation made by homeowner after material has been ordered,or any labor has been performed,homeowner, or homeowner's estate to be responsible for all job material and labor costs in full. Contract payment is due in full on day of job completion. Personal and bank checks are accepted as well as credit cards as follows:VISA:a>, MasterCard®,American Expresso with a 4.00%additional charge above final estimate cost. If paying by business or international credit card,an additional charge of 4.97%will be applied. Warranties on all wood and fiberglass products will be rendered null and void if the manufacturers'specifications for painting,staining or sealing are not followed by the homeowner. All work described above is classified as a capital improvement,therefore sales tax is omitted. A Certificate of Capital Home Improvement stating this will be mailed out after job completion for your signature and returned to us. Miracle Home Improvements is required to charge the appropriate sales tax for tangible property,and for labor if it is determined that the work is a repair, therefore not qualifying as a capital improvement Respectfully submitted by: rWobert 911. Sniff en fen 08-27-2024 Miracle Home Improvements Date Robert M. Sniffen, President Acceptance of Proposal The above conditions and specifications are satisfactory and are hereby accepted. Payments will be made as specified in the proposal and estimates of services. Signature of Customer Date Roof RemovaVInstallation ($18,900.00) If needed, the following materials will be priced per foot as follows subject to current market value: Primed Pine: Douglas Fir: Pressure Treated: Azek' PVC: 1 x4 @ $10.00 2x4 @ $10.00 2x4 @ $12.00 1 x4 @ $12.00 1 x6 @ $14.00 2x6 @ $14.00 2x6 @ $16.00 1 x6 @ $16.00 1 x8 @ $16.00 2x8 @ $16.00 2x8 @ $18.00 1 x10 @ $20.00 1x10 @ $18.00 2x10 @ $18.00 2x10 @ $20.00 1x12 @ $26.00 1x12 @ $20.00 2x12 @ $22.00 2x12 @ $24.00 5/4x4 @ $14.00 1x16 @ $24.00 4x4 Post @ $20.00 5/4x6 @ $16.00 6x6 Post @ $26.00 5/4x8 @ $20.00 5/4x10 @ $24.00 jY d w' is �igt�i ;1•fYA•��p''F2y.. ��G-+ f.�. •� .\\F •�� F9, 'i..7rr, r 1 r/�' "\� '4•" t �"♦ r.�w. t y. "' i'f� A � .1�..TI• nt�''/j. •!�✓ ,.rE� � r.�t.,. 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Y� - '�tr—.,�� 17`19fv N.. � ��A ."' f '�'�1 -y �D�'�, n^�a �•d�� 1i �'D� -: �. _ ���'..,.�: - t; Fj�r�v-q„ .w. � r, � '�`z ea V�(a.�- y .f-..va:'fl ���-�y��,.q�iQ.3.','�,�Y'.w�yi l a;'¢'w'Cl-•�, `�� � v�jF�: a .• A�Rl7® CERTIFICATE OF LIABILITY INSURANCE DATE(MMJDDlYYYY) 8/28/2024 THWCERTWICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATNELY AMEND, EXTEND OR At-TER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTTRITE 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 poliicy(les) must have ADDITIONAL INSURED provisions or be endorsed. if SUBROGATION IS WANED, subject to the terms and conditions of the policy, certain policies may require an endorsement, A statement on Otis certificate does not confer rights to the certificate holder in Beu of such endorsement(s MODUCER c0A EAcT TONY CIRINO Anthony Cirino �1ONE (860)329-0103 AxAIC,Nn: (850)Ii20-0504 426 Norttti Main Street insguy@aal.com Southington,CT U6489 Nsu S)AFFORDING COVERAGE Laic s MSURHRA: FARM FAMILY CASUALTY INSURANCE 4408-131103 FUSu"* BEANHEAD INC. NBURERB; UNITED FARM FAMILY INS COMPANY 29963 INSURER C: DBA MIRACLE HOME IMPROVEMENTS NSURER o: 2010 ALBANY POST ROAD INSURER E GROTON ON HUDSON,NY 10520 NY 10520 POURER 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 CERTIF1CAiE 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 CLAJMS. • lL SR i TYPE Of INSURANCEiA POLICY EFF POLICY EXP POLICY NUMBER : MWDD ( MM/DDrYYY'Y LIMITS X COMMERCIAL C-AERAL LIABILITY i EACH OCCURRENCE S 1,000,000 > CLAR.tSartADE OCCUR CA �iTY6"R�NTEI�` ,PREMISES(Ea OGUYXI'BrYCe I S 250,000 MED UP(Am one Pena) Is 5,000 A I� - X Y 316OX0728 1115M23 11/512024 PERSONAL&ADV INJURY S_1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER GENERALAGGREGATE —�$ 2,000,000 v !X I POLICY F jEGT LOC PRODUCTS-COMPJOP AGG Is 2,000,OpO -' 7HER I 15 - ---- AUTOMOBILE GIABILFTY COMBINED SINGLE LIMIT S 1,000,000 ANY AUTO - �� -- ' e001LY INJURY(Per person) S ov*D SCHEDULED B AUTOS ONLY �X�AUTOS 3101 C2542 11/5/2023 11/512024 BODILY INJURY(Per accident);$ • I HIRED I NON-OWNED PA PPR�DA.MAGE X l AUTOS ONLY E i AUTOS ONLY Per seei6eM $ f $ xj UMBRELLA LIA9 X OCCUR EACH OCCURRENCE $ 4,000,000 A EXCESsuA8 CLAIMS-MADE; 3101E2319 1115/2023 11f5/2024 AGGREGATE )+$ 4,000,000- OED X RETENTION S 10,000 $� ;WORKERSCOMP£NSAnoN �/ PER OTH- AND EMPLOYERS'LIABAICY YIN x TA7 rp �--- _ !JN PROPRIETORJAARTNERJEXECUCIVE ;E.L EACH AGG@ENT I$ 100,000 A- FFICERNEMB£REXCLUDE[)? a N!A 3160VVW17 11/52023 11/512024 - I(Mar,dedory in NN) j i E.L DISEASE-EA E]IAFLDYEQ$ 100,p0O 1(yya,draibc under - - �_-_—.._.__ DF^ ,RIPTION OF OPERATIONS Galow EL.DISEASE-POLICY LIMIT $ 560,000 I ; b I , DESCRIFMN OF OPERATIONS I LOCATIONS I VEHICLES(ACORU 101,Additional Remarka Schedule,may be attached if more apace is required) VILLAGE OF'RYE BROOK IS INCLUDED AS AN ADDITIONAL INSURED 9 CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES OF CANCELLED BEFORE VILLAGE OF RYE BROOK HE EXPIRATION DATE THEREOF, NOTICE W11.1. BE DELIVERED IN 938 KING STREET CCORDANCE WITH THE LICY PROMS! s. RYE BROOK NY 10573 TA P a 01988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD o A Workers' .. CERTIFICATE OF :. . srxrE Compensation NYS WORKERS'COMPENSATIONANS.URANCE COVERAGE ' Board ta:Legal Name&Address of Insured(use street address only) 1 b.Business Telephone Number of Insured P BEANHFAD INC 914-271-9119 DBA MIRACLE HOME IMPROVEMENTS 2010 ALBANY POST RD 1 c.NYS Unemployment Insurance Employer f2egistration Number of CROTdN ON HUDSON NY 10520 Insured Wait Location of Insured(Orly reg1~ITccwmge is avec&ftUylimiied to 1 d.Federal Employer identification Number of Insured or Social Security certain locations In Mew York ft*.LQ_a Map-Up P ako Number 13-4W5783 2 aao Address of Entity Requesting Pmof of Coverage 3a.Nam of Insurance Carrier a' (Entity Bahia,Listed as the C.ettiticate Hold } FARM FAMILY CASUAL.TY.INSURANCE COMPANY 3b,Policy Number of Entity U!Aed in-Box 019 AUILLAGE OF RYE BROOK 938 KING STREET 31tiaWI7 RYE BROOK NY 10573 aa.Pollgr eikWa,pertoa 11-Or2�xi to 11-05-2024 X The Proprietor,Partr►ers.dr Executive Officers are in"ed..(Only dw*bw gal panners Wlcem induct aN exduded ar certain parbmWoffimm axcduded. 'This cdrtifies that the insurance carrier indicated above in.box qX insures the business refereIr=d above M bi*i'1 a'°for wodmr coinOwmation underthe New York:StMe Worlmle.Compensation Law.(To rise this fonfn.NOWYoric(fM must be listed under Rem A an the INFORMATKM PAGE of ttte woriwW compensation blourance policy). The firm n um Carrier or its licensed agent will send this fiB of Insurance 10 the entity lured above as the oettffiCatte holler in box'2'_ The insurance ranter must notify the above Geri fic8tle holder and the Workers'Compensation Board within 10 days IF a policy is canceled. . due to nonpayment of prurniurm or within 30 days IF there are reasons other than nonpayment of prerniums ftd Lancet the policy or eliminate the insured from theaarerage indicated on this Certificate_(These notices may be sent.byreguW maB)Ofh LnNIse,this Certificate is valid for one yew after this form is approved by the insurance carrier or:its licensed ao.wl%or until the policy -expiration date ftst5ed in box"$c",whichever is earlier. This cattleale is issued as a matterof.k*wmation only.tend confers no rights upon the certificate holder.This certificate does not amend, extend or attar the coverage afforded by the pofcy listed,nor does it confer any rights or responsibilities beyond those contained in the nafteneed policy. This ate may'be used as evideride of a WorkeW Compensation contract of insurance onli :wl'nle the underlying policy is in effect. Please Nate:Upon cancellation of Vic wottcers'c*mpensation policy indicated on this f6rm,,'it:tltie busiis Dan c6i&nt ss to be . named on a permit- license or contract issued by a certificate holder,the business rreust provide that cerfficate holder with a new Cerfi kwft of Workers'Compensation Coverage or other authorized proof that the business is complying wi:ttt'the maridsbpry coverage requirements of the New York State Workers'Compensation Law. ,Under penalty,of perjury,I Certify f w3t 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. . . SABINE SCHENK ••'(Print name of prized reprererdA6ve or fimnw aguit at insurance cpirie) Approved by-, lam/►-I g-ZB-ZOZ4 Title: ACCOMMEXECLITIVE Telephone.Number of authorized representedve.Or licensed agent of insurance csniet: 86o-32$41D3... Please Dote:Only insurance comers and their licensed.aglprrts i# 4ulhori2e0 f issue Falm-6- 6&Z insurance brokers am-AM'' authorized to issue it C-1061(947) www.wcb.ny.gdv.