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HomeMy WebLinkAboutBP24-194PERMIT # _A r SECTION TYPE OF WORK JOB LOCATION OWNER S CONTRACTOR f ST. COST ) DATE: l d � 1 / fxp: BLOCK Z LOT, /IG 1, /O i§LIMOW 7." • 1227 qt TCO # FEE DATE "" INSPECTION RECORD DATE i NSP FOOTING FOUNDATION FRAMING RGH FRAMING INSULATION PLUMBING RGH PLUMBING GAS SPRINKLER ELECTRIC O LOW -VOLT (] 4P_AR.M AS ^'WLT 4:i11%4AL lova C31/7)933-3777 P/�Cq/ /)937 atz/a79 OTHER APPROVALS ARB BOT PS ZBA OTHER E BRCS t� 19 VILLAGE OF RYE BROOK MAYOR 938 King Street, Rye Brook,N.Y. 10573 ADMINISTRATOR Jason A.Klein (914) 939-0668 Christopher J.Bradbury www.ryebrookny.eov TRUSTEES BUILDING& FIRE INSPECTOR Susan R. Epstein Steven E. Fews David M.Heiser Donald T.Krom,Jr. Salvatore W.Morlino CERTIFICATE OF COMPLIANCE June 30,2025 Askar Djabbarkhodjaev&Karina Babakulova 7 Winding Wood Road Rye Brook,New York 10573 Re: 7 Winding Wood Road, Rye Brook,New York 10573 Parcel ID#: 129.82-1-8 Building Permit#24-194 issued on 9/10/2024 for Replacement Windows This certifies that the seven new window,installed under the above captioned permit have been satisfactorily completed. Sincerely, Steven E.Fews Building&Fire Inspector /to �E BRo l7 1932 BUILDING DEPARTMENT ❑BUILDING INSPECTOR E 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 : 7 I D l V V VV 00t> 1` l� • N DATE: PERMIT# j!W / -/!9 ISSUED: /D d SECT: /Z g•BLOCK: LOT:$ LOCATION: ,,/ OCCUPANCY: ❑ YJ 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 ,QLo-,ct/✓1G �/N�0 � ❑ L.P. GAS ❑ FUEL TANK ❑ FIRE SPRINKLER ❑ FINAL PLUMBING ❑ CROSS CONNECTION FINAL OTHER w�ftftws . : : a � o ON c N v o 4� Cn cn 0.4 OF 0 av � v � v o z p t j Fi) A o �p F-i 00 41 14 z z ^ Q V 8 u C c� x z p � O w o z ° ° -� vab o 0-4 o w O M W cn w � a U V G� V W wQw o A 00 U q o11 "7 Q OO oG ' Uo � C v � z p U p coo ' FBI ~ C7 O A Z O 00. En C334 ° a 0 [� A - .. BUIUETRVEBRJ�' TMENT D VIYE OOK 938 KING NY 1057306( SEP - 6 2024 JD ov VILLAGE OF RYE BROOK �9£12 BUILDING DEPARTMENT ADMINISTRATIVE EXTERIOR BUILDING PERMIT APPLICATION FOR EXTERIOR WORK WHICH DOES NOT REQUIRE VILLAGE ARCHITECTURAL REVIEW BOARD APPROVAL FOR OFFICE USE ON Y:_ APPROVAL DATE: E #: / APPLICATION FEE: / DQ pb APPROVAL SIGNATURE: PERMIT FEES: 4/ 53 " Lb/ H.Q.A.APPROVAL: DATE: DISAPPROVED: R OTHER: Application dated: 7—6—()q is hereby made to the Building Inspector of the Village of Rye Brook,NY,for the issuance of a Permit for the construction of buildings,structures,additions,alterations or for a change in use,as per detailed statement described below. 1. Job Address: '7 wig in Wpo•.- Rot J 2. Parcel ID#: Zone: 3. Proposed Improvement(Describe in detail): -Sh S tt ll r7 ne L j � A f U U .�'�� w;n �S. c t 11P Is �- t n-Lk W i/kS-0 -S (--hwre, t�j 1'l �3e,kru� -3 s�; ;P�y 1�Jc.il�3 I D�ni,na EUc�n - a s�`ldlol� lS ✓I�[s4vr ruo,� 4. Property Owner: 0�Ck h +eo le— t_oi SJ,J-43 ►rQi `' W i �v�- o /'b r je '�CPi1}a Address: Phone# 3��7— �33— �')? Cell# e-mail S 1SCl,r. ►CX p�J r��t,�.tv^- List All Other Properties Owned in Rye Brook: Applicant: 0 Address: L43 q W n vc� `�`u (+ C e_ r (Ij ( 6 5-D 3 Phone# 91 L(-q 3 Cell# e-mail s} u Q 9 fMr1• Architect: Address: Phone# Cell# e-mail Engineer: Address: Phone# pp Cell# e-mail General Contractor: 06 "Ile, Address: 3 nW 1 rq VyL d l+ C A V r a 7 3 I Phone# Cel1# e-mail !S �1- ��r .c/ 1�� (I) 6/1/2024 5. Occupancy;(1-Fam.,2-Fam.,Commercial.,etc...)Pre-construction: rv-1 Post-construction: 6. Area of lot: Square feet: 11 1 6 ci Acres: 7. Dimensions from proposed building or structure to lot lines: front yard: rear yard: right side yard: left side yard: other: 8. If building is located on a corner lot,which street does it front on: 9. Area of proposed building in square feet: Basement: P,fl: 2"'fl: 3'fl: 10. Total Square Footage of the proposed new construction: 11. For additions,total square footage added:Basement: P fl: 2nd fl: 31 fl: 12. Total Square Footage of the proposed renovation to the existing structure: 13. N.Y. State Construction Classification: N.Y. State Use Classification: 14. Construction Type&Location:O Typical Western Lumber Frame;O Timber Frame[TC];O Wood Truss[TT]; ()Pre-engineered wood[PW];Located;O Floor Framing[F];O Roof Framing[R];O Floor&Roof Framing[FR];Other: 15. Number of stories: l Overall Height: Median Height: 16. Basement to be full,or partial: finished or unfinished: 17. What material is the exterior finish: 18. Roof style:peaked,hip,mansard,shed,etc: Roofing material: 19. What system of heating: 20. If private sewage disposal is necessary,approval by the Westchester County Health Department must be submitted with this application. 21. Will the proposed project require the installation of a new,or an extension/modification to an existing automa}c fire suppression system?(Fire Sprinkler,ANSI,System,FM-200 System,Type I Hood,etc...)Yes: No: V (if yes,applicant must submit a separate Automatic Fire Suppression System Permit application&2 sets of detailed engineered plans) 22. Will the proposed project disturb 400 sq.ft.or more of land,or create 400 sq.ft.or more o impervious coverage requiring a StotTr►water Management Control Permit as per§217 of Village Code? Yes: No: Area: 23. Will the proposed projey require a Site Plan Review by the Village Planning Board as per§209 of Village Code? Yes: No: V (ifyes,applicant must submit a Site Plan Application, &provide detailed drawings) 24. Will the proposed project require a Steep Slopes Permit as per§213 of Village Code Yes: No: ✓ ff yes,you must submit a Site Plan Application,&provide a detailed topographical survey) / 25. Is the lot located within 100 ft. of a Wetland as per§245 of Village Code? Yes: No: (if yes, the area of wetland and the wetland buffer zone must be properly depicted on the survey&site plan) / 26. Is the lot or any portion thereof located in a Flood Plane as per the FIRM Map dated 9/28/07? Yes:-No: (if yes, the area and elevations of the flood plane must be properly depicted on the survey&site plan) 27. Will the proposed project require a Tree Removal Permit as per§235 of Village Code?Yes: No: V (if yes,applicant must submit a Tree Removal Permit Application) 28. Does the proposed project involve a Home-Occupation as per§250-38 of Village Code? Yes: No: NZ Indicate:TIER 1: TIER II: TIER III: (fyes,a Home Occupation Permit Application is required) 29. What is the total estimated cost of construction: S "f Y Note:estimated cost shall include all site improvements, labor, material,scaffolding,fixed equipment,professional fees, including any material and labor which may be donated gratis.If the final cost exceeds the estimated cost,an additional_fee will be requiredprior to issuance of the C/O. 30. Estimated date of completion: Se 6" ;)-b+' (2) 6/l/2024 BUILD MENT VIL E OiF`RY OOK 938 KING Q ET RYE BR N, Y 10573 -0 ov AFFIDAVIT OF COMPLIANCE VILLAGE CODE §216 - STORM SEWERS AND SANITARY SEWERS THIS AFFIDAVIT MUST BEAR THE NOTARIZED SIGNATURE OF THE LEGAL PROPERTY OWNER AND BE SUBMITTED ALONG WITH ANY BUILDING OR PLUMBING PERMIT APPLICATION. ANY BUILDING OR PLUMBING PERMIT APPLICATION SUBMITTED WITHOUT THIS COMPLETED AND NOTARIZED FORM WILL BE RETURNED TO THE APPLICANT . STATE OF NEW YORIK, COUNTY OF WESTCHESTER ) as: I, AS k m f 0 ' .�._ , residing at, (Print name) (Add Ms where you live) being duly sworn, deposes and states that(s)he is the applicant above named, and further states that(s)he is the legal owner of the property to which this Affidavit of Compliance pertains at, I n,f��(;n y w�:!+� 0.("k. A), 4( , Rye Brook, NY. (Job Address) Further that all statements contained herein are true, and that to the best of his/her knowledge and belief, that there are no known illegal cross-connections concerning either the storm sewer or sanitary sewer, and further that there are no roof drains, sump pumps, or other prohibited stormwater or groundwater connections or sources of inflow or infiltration of any kind into the sanitary sewer from the subject property in accordance with all State, County and Village Codes. 60"�­ (Signatilre of Pr(fgerty Owner(s)) (Print Name of Property Owner(s)) Sworn to before me this MELANIA lfiRABOVSKY NOTARY PUBUC.STATE OF NFW YORK day of yo Cn S , 20 Registr h1 114 RR` 1'>...i59 Quaff) Vlr,: .,res5la °.aunty UJI, Ccmrn r�ion ..xai: ,, J5/il4/27 (No a 'F �iic i (3) 6/1/2024 This application must be properly completed in its entirety by a N.Y. State Registered Architect or N.Y. State Licensed Professional Engineer & signed by those professionals where indicated. It must also include the notarized signature(s) of the legal owner(s) of the subject property, and the applicant of record in the spaces provided. Any application not properly completed in its entirety and/or not properly signed shall be deemed null and void, and will be returned to the applicant. Please note that application fees are non-refundable. STATE Q]F NEW YORE„ OUNTY OF WESTCHESTER ) as: k2_�I { at i "`l ;'/wcl, 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 C,I\ for the legal owner and is duly authorized to snake and file this application. (indicate archit t,contractor`ygent,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. By signing this application, the property owner further declares that he/she has inspected the subject property, and that to the best of his/her knowledge there are no roof drains, sump pumps or other prohibited stormwater or groundwater connections or sources of infiltration into the sanitary sewer system on or from the subject property, Sworn to before me this L Sworn to before me this day of_ A t~1�J , 20- day of / , 20 Signa e of Property Owner Signature of Applicant Print Name of Property Owner Print Name of Applicant cAin I A'J 1 .4-1 A MEL.ANIA HRABOVSKY f ry Nota Pu lic o Public NOTARY PUBLIC,STATE OF NEW YORK Registration No.OIHR6324159 Qualified in Westchester County Commission Expires 05/04/27 (`t) 6/1/2024 �3 For office use onlv: D (� �� 1 BUILDI `li-E TNIENT PERMIT# —//q V s VILL"Ji E OF RYE BOOK ISSUED:9—/O 5 I MAY 2 2 2025 1 t w- 938 KING STRE�(�YE.BROOK,!�fW YORK 10573 DATE: � `s9,14)939-06680;� FEE: /SU— PAMJII VILLAGE OF RYE BROOK �, a W�y�yr-o6lrn�2ov BUILIJ_ ING nFPARTNIENT 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 litisttt\►i\iWWiit#iippi►tiff►itfifii►f►fffRifWWftf R\fi►i►Rki••t#ii#k##t#iiiWi\►W►►►►if Wifff►►ifW►Wf►\i►tii#ff\i#tiRtR#tt►Wfkk► Address: Occupancy/Use: re�i c �-h g I Parcel ID #: 1�3 Gq . — 1 7 Zone: Owner: Askar o1cf6 Address: '7 L`' ;/1��i.nJvec,� IDack lUyil-f1t P.E./R.A. or Contractor: 0U L_ P2 Address: -7( �ti Person in responsible charge: go �-&-t < 7P,�M�/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: t-7 / being duly sworn,deposes and says that he/she resides at / �`,,?6017v c ' ° A (Print Name arApplicant) (No.and Street) in I,ZIr{� 'w&) In the County of LUC�' �-C� - in the State of 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 D C U , for the construction or alteration of: t_,J W j,ej ,L �,J,S 12 4t Zk� 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.of the Code of the Village of Rye Brook. Sworn to before me this_ Sworn to before me this day of a , 20 MELANIA HRABOVSKY ay of , 20 NOTARY PUBLIC,STATE OF NEW YORK Registration No. 01 HR6324159 Sig Lure of Property Owner Qualified in Westchester County ign, ure of Applicant Commission Expires 05/04/27 Print Name of Property Owe *0 , Prim Name of Appli n ublic 6/1/2024 LICENSE NUMBER "THE ORIGINAL" CR Westchester WC36200H23 pOU LE Family Owned And Connecticut 0668826 R Operated Since 1960 All Home Improvements — EST. 1960 439 Willett Ave. Port Chester,N.Y. 10573 Tel#(914)937-4279 Fax(914)937-4172 http://www.DoubleRwindows.com Askar Djab Aug 9, 2024 7 Windingwood Road North Rye Brook NY 10573 347-933-3777 askar.diab(ftmail.com Insurance: All work involved within the following proposal is covered by Workmen's compensation,Public Liability,and Completed Operations Insurance. Andersen 100 series windows contract Labor and material for the following • Double R to supply and install 7 new Andersen 100 series windows. 6 are gliding windows, 1 is a picture window. • The windows are white interior/white exterior, made with low E argon filled gas for energy efficiency, and come with full screens. No grids. • Windows to be installed are: -Bedrooms: 3 sliding windows (From inside, daughter's room 1 opens to the left, 1 opens to the right. Son's room will open from right to left.) -Dining room: 2 sliding windows, glass will be tempered. (From inside both windows will open from 1 left 1 right.) -Master bed: 1 triple unit window with sliders on left and right with a fixed window in center 1 picture window • We will cart away any job-related debris. Labor and materials total $8,440 **Please note,Andersen windows have a warranty of 20 years on the glass and 10 dears on all other materials. If something goes wrong,the windows will be replaced at no charge, including labor for the same period of time.** Terms: Painting,and windows cleaning to be done by others.Hidden rotten wood not included. Standard industry cash term,one half with the order,balance due upon completion. Terms may be modified to meet special conditions. Past due balances are subject to a monthly service charge of 1 1/2%(18%per annum). If the account becomes delinquent,we agree to pay any legal or collection fees expended by Double"R"arising from collection of the account.Permit&Application fees not included.Due to the fluctuating prices in plywood,we reserve the right to adjust price. Double"R"is not responsible for reconnecting existing alarm systems on windows and doors. You the owner may cancel this transaction at any time prior to midnight of the third business day. After the date of this transaction,such Cancellation must be made in person,at the offices of community improvements,or in writing postmarked prior to the fourth business day.We accept VISA or Mastercard with a 3%convenience surcharge on total amount being charged. Accentance: The above prices,specifications and conditions are satisfactory and are accepted. Double"R"is authorized to do the work as specified. Contractor Performance Warranty: Double"R"proposes to furnish and install labor and material in accordance with above specifications in order that the above qualifies for the Manufacturer's Long-Term Warranty. In addition,all labor provided by Double"R"is unconditionally warranted for a period of Two years from the date of installation. Approximate Start Date: Approximate Completion Date: Customer: $8,440.00 (Amount) Date: 6% (Sales Ta-v)0 Double "R'% $8,440.00 (Total Amount) Date: $4,220.00 (Deposit) $4,220.00 (Balance Due Upon Completion) Return original contract to Double"R", retain a copy for your records. Visit Our Showroom Located At 439 Willett Avenue Port Chester, N.Y. 10573 zIX � � 2 \ o % f p AJ Q § j § 7 q \ = m C c c a.LLJ § G \ � CO ƒ / R / « � 2 u 3 % CLO < 2 w o t § a i $ = E < 4 \ b � � - Ec � Q LL a zz .§ / Ak \ \ ƒ (D o f b ® c of � \ / / s £ \ i / \ k\ \ \ \ E | w j \ x a t % q e \ E « x o 2 n p | 0 ? \ mgm = � | R to coui .9 §ƒ | ~ 2 O N � -� E E ' + @e > O w \ \ V)U) 0 \ \ C14 q q � g O z 2 = U- U- I $ k K LOL J E 722 as > 0 _ 'IT _ u -i x k = x x = « LLI e < 2 \ § \ / z / c U c \ \ 00 ~ o w a @ < 7 2 o x x R \ ° z 3 575 00 D � / » En a § 2 c N \ U) a 0- 0 0 \ | < > c c 0 / G < D .0 (5 Z5 C) j 7 E u . -� G / n ! 2 \ R � � _% c ± . ƒ 2 z \ / - 2 \ ( U) U) / j \ § � j \ 1 ƒ \ \ c / / > 0 co 4 _£Cl) . —) 0 ® 3 'a $ w & 0 z 7 2 �® n � w / ® �3 § = u q ] kt & " = xE = m emz | a G O t � Q)cl) 0 ; 0me - eew m 7462 q o CL (n (D cc / / ° 2 \ / < \ 5s � � \ k O | $ � � _ U) � f M q § LU ƒ - \ Cl) CZ ¥ = z - LL | n = ° 5 w ./ 0 (if / � 0 � \ | \ � Q c C ca CL � N L N Cl. .0 V m O = O = O O ._, X C �, X C N C W Q7 C w m z> pm Lim a > (CD M o' J FLU ac7 g LLw Q CO tt Q � JU >t O C X O > C F_ X N = > r O (n N ui ccm I O N N W e lL N ^ i x R W �_ a. ca u � R W CL cN0 LL V W V O Q1 - N > 0) Q M U 0 >L >«� m Q J X > O > O N O J X > O > N � i N O �_ .n r- N - Y LL (n Y Il M i C) CD N M 0 C Q mX�i C O E? 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V X c`Q U � 1 N Z N L) N C Q x N m O C Q X N Q r Q N Y O O N Y O O N O w 0 c 0 \ a . x c 0 I O L O O L O i J (� N > J m N > O c aiU �- c3 � aiU J _ E6 a) a j Z) Ea Q) Q i m N U) H , m O U) H J .. r. x w m o � .. x ci L) c, i Cl� N X O (n — >- O N X O cn - U` ! O 0 �- CD z cp .` c W ca c W d 0 U m W i Ci X U m w i N N O °' — U dl CD c) CD dI CDN O > 3: 0 Cl) c U i c U i r- G _- _ - T O c0 I N i M t b n 0 i N Iag U- ( M �J �Ii i 47 j ! O CY CL o \ 7 \ # \ f % \ / # \ k a L / � E 0 P < g a 0 k§ \ k \ / §\ w K 2 2 2 b § : � k ` w � m cc CD § z \ � 0 k co 2 $ n r E 5 k \ m k e2 E _ E ƒ 2 § ® (n k c (n 2 § n E \ � E § 2 § a) / = p E m U _ \ 2 6. E \ \ ( / M 0 cu f /c CD / � m E � &_ E7 5Q) _ & — u cm R -D\ (D \ / � \b E b � / s � $ co x 2 m | oc / � | z / / / G q u , 2 6 - E / E | x $ < a aqCD CD » ƒ 2 ° ± 2 @ L /0 2 •� 2 U) E � O O n 2 f = 0 i \ Q = f 0 0 9 $ k 0 o (n \ 2 / q w fU)00 0 ƒ/ _ / ® o U) n o \ � ? 7 p J 2ik U - b ,.�- 'F. 1. `r :r �� :`r' i- f '•: .`� �, �.�: I � C O _ 0. 7 v�i r O LO N J O y 0 iQ!- N y C L N iR L 4� '�•.. i O O • gi C'7 aLLI � ° Y a Z ° ° se06- ction _�t.. �- t7 W a E Q o w W J J U) Lo L:7 c O ' J � J W a LQ O U O o wee ale a oz a � v fl > A c° \ i 9 a th :••�>" \` :. F � y � � r s N z L y 1 h ti•' •A �v ACORO® CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDD/YYYY) �� 2/20/2024 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 GUNIACT NAME: Betty Reyes FAX Agency The Willett Insurance Ag y PHONE A/C,No,Ext: 914 481-5599 (AIC.No) ti . - 338 Willet Ave ADDRESS: bettyreyesCthewillettinstuance.us INSURER(S)AFFORDING COVERAGE NAIC# Pon Chester NY 10573 INSURER A: Westchester Insurance Company INSURED INSURER B: USLI Insurance Company Double R PBJ,LLC INSURER C: 439 Willett Ave INSURER D: INSURER E: Port Chester, NY 10573-3179 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. LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER (MMIDD/YYYY) (MM/DD/YYYY) LIMITS x COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE � cu OCCUR PREMISES(Ea occurrence) $ 100,000 MED EXP(Any one person) $ 5,000 A 1' FSF17526960 12/13/2023 12/13/2024 PERSONAL SADVINJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2.000,000 x POLICY JECOT- LOC PRODUCTS-COMP/OP AGG $ 2.000,000 OTHER: $ AUTOMOBILE LIABILITY $ (Ea accident) ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY Per accident $ AUTOS ONLY AUTOS ( ) HIRED NON-OWNED FIROPLK I Y UAMAG t $ AUTOS ONLY AUTOS ONLY (Per accident) x UMBRELLA UAB �dCLAIMS-MADE OCCUR EACH OCCURRENCE $ 3,000,000 EXCESSLIAB CUP1572208 03/16/2023 03/16/2024 AGGREGATE $ 3,000,000 DED I I RETENTION$ $ ORKERS COMPENSATION STATUTE ER ND EMPLOYERS'LIABILITY Y/N NY PROPRIETOR/PARTNER/EXECUTIVE FFICER/MEMBER EXCLUDED? ❑ N/A E.L.EACH ACCIDENT $ Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ f yes,describe under ESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN The Village of Rye Brook ACCORDANCE WITH THE POLICY PROVISIONS. 938 King St AUTHORIZED REPRESENTATIVE Qt{}y Rryey Rye Brook NY 10573 ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD PORK Workers' CERTIFICATE OF STATE Compensation NYS WORKERS' COMPENSATION INSURANCE COVERAGE Board la.Legal Name&Address of Insured(use street address only) tb.Business Telephone Number of Insured Double R PBJ,LLC 914 410-7771 439 Willett Ave Port Chester,NY 10573 1c.NYS Unemployment Insurance Employer Registration Number of Insured 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 921106938 2.Name and Address of Entity Requesting Proof of Coverage 3a.Name of Insurance Carrier (Entity Being Listed as the Certificate Holder) NYSIF The Village of Rye Brook 938 King St 3b.Policy Number of Entity Listed in Box"la" Rye Brook,NY 10573 25829110 3c.Policy effective period 19!9cion9'i to n19!24/2n24 3d.The Proprietor,Partners or Executive Officers are included.(only check box if all partners!officers included) 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 Stale 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". Will the carrier notify the certificate holder within 10 days of a policy being cancelled for non-payment of premium or within 30 days if cancelled for any other reason or if the insured is otherwise eliminated from the coverage indicated on this certificate prior to the end of the policy effective period? ZYES [)NO 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: Betty Reyes (Print name of authorized representative or licensed agent of insurance carrier) Approved by: (Signatur ) (Date) Title: Insurance Representative Telephone Number of authorized representative or licensed agent of insurance carrier. 914 481-5599 Please Note: Only insurance carriers and their licensed agents are authorized to issue Form C-105.2. Insurance brokers are NQT authorized to issue it. C-105.2 (9-15) www.wcb.ny.gov