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HomeMy WebLinkAboutRP24-100PERMIT # 1`/�O QATE; 3 c�JI ®(p� `7 3A� SECTION 3 J % BLOCK r� LOT TYPE OF WORK Me- 10o1r 4/ r7 ��14/1 /.� J013LOCoATIO / ND/d �e r2,7L OWNER Q �i� re `z�Zq v,041es sQ .SQn C i0 —7rPZzq CONTRACTOR EST. COST & - FEE c) 9 00 ✓C• # FEE I� DATEto TCO # FEE DATE INSPECTION RECORD DATE INSP FOOTING FOUNDATION FRAMING RGH FRAMING INSULATION PLUMBING RGH PLUMBING GAS M SPRINKLER ELECTRIC 0 LOW -VOLT O ALARM C7 AS BUILT O FINAL S OTHER APPROVALS ARB BOT PS ZBA OTHER DR 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 March 18,2025 Mark Trezza&Vanessa Asencio-Trezza 101 North Ridge Street Rye Brook,New York 10573 Re: 101 North Ridge Street, Rye Brook,New York 10573 Parcel ID#: 135.67-2-8 Roof Permit#24-100 issued on 9/3/2024 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 ECENE 0 BUILDING DEPARTMENT For office u on! : J NN 31 2025 VILLAGE OF RYE BROOK PERMIT# �/ ISSUED: VILLAGE OF RYE BROOK 9P8 KING STREET,RYE BROOK,NFw YORK 10573 DATE:/-3/-3_� BUILDING DEPARTMENT (914)939-0668 FEE: }f Z`5-4- PAmPj www.ryebrookny.gov 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: 101 North Ridge Street Single family ' Occupancy/Use: RPgir(Pntial Parcel ID 5#: 3 + & 7 _ ) Zone: Owner: Mark Trezza Address: 101 North Ridge Street P.E./R.A. or Contractor: Perry Verrone, LLC Address: 12 Center St, Pleasantville, NY 10570 Person in responsible charge: Perry Verrone Address: 12 Center St, Pleasantville, NY 10570 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 s tru cture/cons truction/a Iteration herein mentioned in accordance with law: STATE OF NEW YORK, COUNTY OF WESTCHESTER as: Perry Verrone being duly sworn,deposes and says that he/she resides at 12 Center Street (Print Name of Applicant) (No.and Street) in Pleasantville in the County of Westchester in the State of NY ,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,professional fees,and including the monetary value of any materials and labor which may have been donated gratis was:S 10,900.00 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 of Occupancy/Compliance is sought,and that to the best of his/her knowledge and belief,the structure/work has been crected/completed in accordance with the approved plans and any amendments thereto except in so far as variations therefore have been legally authorized,and as erected/completed complies with the laws governing building construction.Deponent further understands that it shall be unlawful for an owner to use or permit the use of any building or premises or part thereof hereafter created,erected,changed,converted or enlarged,wholly or partly,in its use or structure until a Certificate of Occupancy or Certificate of Compliance shall have been duly issued by the Building Inspector as per§250-10.A.of the Code of the Village of Rye Brook. Sworn to before me this ;_� Sworn to before me this day of n 1" , 20 day, }1 n. r ,20 �.J Signature of Property YOwner y , -- Signature of Applicant Loyl Mark Trezza Pe Verrone Print Name of Property Owner Print Name of Applicant f cxAU Notary Public Notary Public QyE BRC��, 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 ` N�q-, Ly DATE: PERMIT# J 2 �A - 1 J y ISSUED: SECT: 13.� • 6 7 BLOCK: Z LOT: U LOCATION: Q-n I OCCUPANCY: Z /0 ❑ VIOLATION NOTED THE WORK IS... Q 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 D OTHER x x N _ O d' © -o p� a ua i e a c a; o N e� w �I C; a a Q" W N P4 I Z Q x �c o Ig Lei 0 w �aoaa°c �p p4 R. � P� S0 m x j H W g ocs x a LO En - � A '� /hey L n G1 . P. a •. r� wv . oaao C� z ICI en W cn -o a e� A C7 M a � C~ w d 0 0 z d Q w w > A - V o z P.4 0 u W ��t r1 H 2 5 N U O Co. V V O ►.i ^ , +y� " F�1 C1� 7 0 BUILD MENT VI E OF RY OK AUG 3 2024 938 KING ET RYE BR NY 10573 -0 `� VILLAGE OF RYE BROOK BUILDING DEPARTMENT ov ._ �_. FOR OFFICE USE ONLY: Approval Date: 9—3- Zo2.44 Permit# P'�21-100Application# Approval Signature: ARCHITECTURAL REVIEW BOARD: Disapproved: Date: BOT Approval Date: Case# Chairman: PB Approval Date: Case# Secretary: ZBA Approval Date: Case# Other: 77�� q ,p Application Fee: ` - PI-) Permit Fees: /4 —P s ROOF PERMIT APPLICATION Application dated: cf-3"q is hereby made to the Building Inspector of the Village of Rye Brook,NY,for the issuance of a Permit to Re-Roof an Existing Building,as per detailed statement described below. I. Job Address: 101 N Ridge St SBL: 43 t47_7—D-�? Zone: Property Owner: Mark Trezza Address: 101 N Ridge St Phone#: (914) 610-9088 Cell#: email: Trezza49@gmaii.com 2. Applicant: Perry Verrone Address: 12 Center St, Pleasantville Phone#: 914-747-7663 Cell#: email: maria@perryverroneroofing.com 3. Roofing Contractor: Perry Verrone, LLC Address: 12 Center St, Pleasantville Phone#: 914-747-7663 Cell#: email: maria@perryverroneroofing.com 4. Job Description,list all Methods&Materials: Roof removal and replacement- 14 s 5. Estimated Cost of Job:$ 1.0,900.00 (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: Single family NYS Construction Class: Residential 8. Number of stories: Height: 9. Is garage being re-roofed:No:( •Yes:( )Attached No:O•Yes:O Number of Cars: 10. Is roof peaked,hip,mansard,flat,etc: Peaked 11. Estimated date of completion: First Week of September -t- 61I12024 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 Swom to before me this I"1n day of S C 20 of AtA w Sl , 20 _:�L ,�` PAL •. Signature of Property, pA���,,�! �- ature of Applicant I STATE STATE�` �� I/OF NEWYORK\ Mark TreZZa`�Rrb—cWYORK\� _ = t NOTARY t Perm' Verrone PHNNof Proye4 t tI PUBLICI ' oW t of Applicant eirAd3+twz / �\DIPA&%4?112N �'�.,���SfaN \4 `\, f f/��,/S�O�N�EK�VRi\ � N ary bliC �0fiitM110`\ -2- 6/1/2024 Perry Verrone, LLC 12 Center Street Pleasantville, NY 10570 info@per!yverroneroofing.com Office: (914)747-7663 Fax: (914)747-7665 License WC 21701 H09 8/27/24 Prepared by Perry Mark Trezza 101 N Ridge St. Rye Brook, NY 10573 (914) 610-9088 Trezza49@gmail.com PROPOSAL ROOF REMOVAL AND REPLACEMENT Shed Excluded • All existing asphalt roofing removed and carted from job site • Antenna removed and carted from job site • Remove and frame over skylights (interior finishing work not included) • 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: ) • NO RIDGE VENT • GAF LIBERTY Base&Cap sheet installed on two (2) low-pitched roof sections • GAF TimberTex hip and ridge shingles installed on all ridges • Aluminum vent pipe boots installed over all vent pipes Page 1 of 5 Initial& Date: • Aluminum drip edge flashing installed around entire perimeter of roof • GAF Weather Blocker starters installed on all perimeter edges • GAF Lifetime Material Warranty included • Perry's Roofing"10 Year Workmanship Warranty"included • Village of Rye Brook Building Permit for an additional cost TBD The price for the aforementioned work,which includes labor and material (excluding any additional plywood),totals to the sum of. $10,900.00 PRICE EXPIRES 90 DAYS AFTER ESTIMATE DATE ADDITIONAL WORK OPTIONS 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 ❑ Timberline UHDZ (Ultra High Definition) shingles installed for an additional $22.00 per square ❑ Step flashing fabricated and installed to meet current building code standards (aluminum or copper) for an additional cost TBD, if needed ❑ Perry's Roofing is a GAF Master Elite Installer which allows us to offer you top of the line warranties directly from GAF for a minor additional cost,please contact our office for details and pricing Payment schedule is as follows: 50% 3 Days Prior to Start 50% Due the day of substantial completion 5% Retention may be held for resolution of unresolved issues 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 and debit cards.All card transactions over$2,000.00 are subject to a 3%service fee. Payments of$4,000.00 or more are accepted via ACH/wire transfer upon request. Any monies not paid as specified above will be subject to accrue interest at a rate of 1.5% monthly,and 18% per annum. All material is guaranteed to be as specified above. All work to be completed in a workmanlike manner according to the standard practices.Any alteration or deviation from the above specification involving extra costs will be executed upon a written change order Page 2 of 5 Initial& Date: 101 N Ridge St, Rye Brook, NY 10573 (1) • QuickMeasure August 20, 2024 Roof Reports in Under an Hour Prepared For: Perry's Roofing A r� E=3\ a a Contents Measurements Overview 1 Roof Area 1,444 sq ft Top View 2 Roof Facets 16 Side Views 3 Predominant Pitch 10 / 12 Lengths 4 Ridges/Hips 59 ft Pitches 5 Valleys 14 ft Areas 6 Rakes 148 ft Summary 7 Eaves 132 ft Materials 8 Bends 27 ft U QuickMeasure Top view Roof Reports in Under an Hour e . +n - ter- t. - ►' - ._ y- 'r r • .. t r fhl � , wM r. Prepared For: Perry's Roofing © 101 N Ridge St, Rye Brook, NY 10573 (1) QuickMeasure Side Views Roof Reports in Under an Hour North r. I c A Prepared For: Perry's Roofing © 101 N Ridge St, Rye Brook, NY 10573 (1) QuickMeasure Lengths Roof Reports in Under an Hour AFlash Step Drip N I Bend Eave JW Hip Rake Ridge Valley 27 132 6 148 l 14 Lengths in feet Prepared For: Perry's Roofing 101 N Ridge St, Rye Brook, NY 10573 (1) QuickMeasure Pitches Roof Reports in Under an Hour A N a a 3 03 Pitches in inches per foot Prepared For: Perry's Roofing © 101 N Ridge St, Rye Brook, NY 10573 (1) QuickMeasure Areas Roof Reports in Under an Hour A N 0 m2222 Areas in square feet Prepared For: Perry's Roofing 101 N Ridge St, Rye Brook, NY 10573 (1) QuickMeasure Summary Roof Reports in Under an Hour Pitch 2 3 8 9 10 Area 274 376 13 66 715 Percent 19% 26% 1% 5 50% Suggested Waste 0% 8% 11% 13% 15% 18% 23% Area 1,444 1,559 1,603 1,632 1,661 1,704 1,776 Squares 15 16 17 17 17 18 18 Roof Area 1,444 sq ft ARoof Facets 16 N Pitch 10 / 12 Bends 27ft Eaves 132ft Hips 6 ft Rakes 148ft ® a Ridges 54 ft a Valleys 14 ft Flash 45 ft ® Step 79 ft Drip Edge 281 ft Leak Barrier 451 ft Ridge Cap 59 ft Starter 281 ft Penetrations 4 Pen. Area 61 sq ft Pen. Perimeter 72 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 roof edges and excludes areas around penetrations.6)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 101 N Ridge St, Rye Brook, NY 10573 (1) QuickMeasure Building' s Roof Reports in Under an Hour ® O O Roof Area 1,361 sq ft 83 sq ft Roof Facets 12 4 Pitch 10 / 12 3 / 12 Bends 12 ft 15 ft Eaves 117 ft 15 ft Hips 6 ft 0 ft Rakes 126 ft 22 ft Ridges 46 ft 7 ft Valleys 14 ft 0 ft Flash 45 ft 0 ft Step 79 ft 0 ft Drip Edge 243 ft 37 ft Leak Barrier 399 ft 52 ft Ridge Cap 52 ft 7 ft Starter 243 ft 37 ft Penetrations 4 0 Pen. Area 61 sq ft 0 sq ft Pen. Perimeter 72 ft 0 ft Prepared For: Perry's Roofing 0 101 N Ridge St, Rye Brook, NY 10573 (1) QuickMeasure Roofing Materials Roof Reports in Under an Hour Suggested Waste 0% 8% 13% 18% Shingle Products HDZ, UHDZ, Natural Shadow, ASII, bundle 45 48 50 52 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 Quick-Start roll 9 10 10 11 Roof Deck Protection Deck-Armor, Tiger Paw, FeltBuster 10 sq roll 2 2 2 2 Shingle-Mate roll 4 4 5 5 VersaShield roll 5 5 5 5 Leak Barrier StormGuard, WeatherWatch 2 sq roll 7 8 8 8 WeatherWatch 1.5 sq roll 10 10 11 11 Ridge Cap Seal-A-Ridge, Seal-A-Ridge AS bundle 3 3 3 3 TimberTex bundle 3 4 4 4 Z-Ridge bundle 2 2 3 3 TimberCrest box 3 4 4 4 Nails Cap Nails box 1 1 1 1 Coil Nails 1.25 in box 1 1 1 1 Step Flashing Step Flashing 10 ft piece 8 9 9 10 Step Flashing 8 ft piece 10 11 12 12 Drip Edge Drip Edge 1Off piece 29 31 32 34 Drip Edge 8 ft piece 36 38 40 42 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 laps.9)Liberty low slope roofing system should be installed as a system.For more information,see gat.com/liberty. Prepared For: Perry's Roofing U 101 N Ridge St, Rye Brook, NY 10573 (1) 3F°..• - s-S c 1 3%cd L*""..11/1�1j1�-:cL jr �1�11/1/ili'�'!.�.if_- '4 fl/ 1 .1/ / •'.' i i0 O ..;ram. • f o CC r Q r \ ♦� L J 1 t Sri 2 'Ix a0+ �1 _O T� .'�• ��f C 'rn J=: LO U ui w 0 r -ection _ • � •r_ Jam" it ri W 0 > W : O " w a J o :� WjJp aQ i.+ a CL o V O i..+ s�pyy Q --•, ' .< �. �� � M♦1 Y °�' it _ � w k cvv id tu p �_• } .. b � �j rn \, cn 11 1 WOMA PERRVER-01 CDOLCE AFRO CERTIFICATE OF LIABILITY INSURANCE DATEIMM/DD/YYYY) 6/27/2024 FRE CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS IFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES W. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED ESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. RTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must have ADDITIONAL INSURED provisions or be endorsed. ROGATION IS WAIVED, subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on rtificate does not confer rights to the certificate holder in lieu of such endorsement(s). R CONT CT Kevin Kelley irst Associates,LTD NAMEA PHONEe Plains Road (A/C,No.Ext):(914)457-4200 A/c,No):(914)457-4200 oor AFbmDAR'Ess.info levittfuirst.com Tarrytown,NY 10591 INSURERS AFFORDING COVERAGE NAIC N INSURER A:Admiral Insurance Company 24856 INSURED INSURER B:Accident Fund Insurance Company of America 10166 Perry Verrone LLC 12 Center Street INSURER C:ShelterPoint 81434 Pleasantville,NY 10570 INSURER D: 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 ADDL SUER POLICY EFF TR TYPE OF INSURANCE IN SD WVD POLICY NUMBER MM DD/YYYY MMIDDnYYY LIMITS A X COMMERCIAL GENERAL LIABILITY 1,000,000 EACH OCCURRENCE S CLAIMS-MADE �OCCUR CA000045827-03 7/1/2024 7/1/2025 DARMMGETORENTEDn e $ 300,000 ISESfEaMED EXP(Any oneperson) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER. 2,000,000 POLICY❑X PRO- GENERAL AGGREGATE $ OTHER LOC PRODUCTS-COMP/OP AGG $ 2,000,OOO . AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT S a a ident S ANY AUTO OWNED SCHEDULED BODILY INJURY Perperson) S AUTOS ONLY AUTOS .p BODILY INJURY Per accident S AUTOS ONLY AUUTO-0 ONED PROPERTY DAMAGE Per accident $ UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 5,000,000 X EXCESS LIAB CLAIMS-MADE GXL000147003 7/1/2024 7/1/2025 5,000,000 AGGREGATE $ DIED X RETENTION$ 10,000 WORKERS COMPENSATION $ AND EMPLOYERS'LIABILITY PER OTH- Y/N T TR ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ (Mandatory in NH) If yes.describe under E.L.DISEASE-EA EMPLOYEE $ DESCRIPTION OF OPERATIONS below C NYS Disability DBL358637 E.L.DISEASE-POLICY LIMIT S 5/10/2022 5/10/2025 Limit-Statutory DESCRIPTION OF OPERATIONS/LOCATIONS/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 f7_� / ".X ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD YORK Workers' CERTIFICATE OF STATE Compensation NYS WORKERS' COMPENSATION INSURANCE COVERAGE Board 1a.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 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 3b. Policy Number of Entity Listed in Box""la" 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) Qx 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 ,f 4G 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