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HomeMy WebLinkAboutBP24-199PERMIT # 6L SECTION TYPE OF WORK JOB LOCATIO OWNER 0 CONTRACTOR,[ EST. COST �` fC0 #�.� Tre # — 9 9 DATE 9 / o� BLOCK LOT, o 4 /fCo## zwnj i/0�C4es 900 eZ us FEE L112 DATE FEE DATE _ ir.iccF�TION RECO� i DATE INSP FOOTING FOUNDATION FRAMING RGH FRAMING INSULATION PLUMBING C] RGH PLUMBING GAS SPRINKLER ELECTRIC ED LSW-VOLT O ALARM AS BUILT C7 FINAL aT 2�'I ile oiJq s3) a Ll 9- 9 86 OTHER APPROVALS ARB BOT PS ZBA OTHER �Qy�.4R19 �t��lr aaJJ+ ur CCCr.CCu 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 17,2025 Roberto Baez 58 Bowman Avenue Rye Brook,New York 10573 Re: 58 Bowman Avenue, Rye Brook,New York 10573 Parcel ID#: 141.28-1-26 Building Permit#24-199 issued on 9/19/2024 for Replacement of Basement Entry Door This certifies that the new basement entry door,installed under the above captioned permit has been satisfactorily completed. Sincerely, Steven E. Fews Building&Fire Inspector /to p Lff, BUILDIrid DEPARTMENT For office u e only: PERMIT# of 95 JAN 2 1 2025 VILLAG1r OF RYE BROOK ISSUED: — _a 38 KING STREET,RYE BROOK,NE�V YORK 10573 DATE: —Q,/ VILLAGE OF RYE BROOK (914)939-0668 FEE: )�f —n— PAIDJR BUILDING DEPARTMENT www.i-yebrookumov 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: 58 NjLC--'-)e- Occupancy/Use: 1-Fam Res Parcel ID 4: 41 ,2'1�1)— ► Zone: Owner: Roe, 1: h> tZ Address: 56 P.E./R.A. or Contractor: Renewal by Andersen Address: 421 West Avenue, Stamford CT 06902 Person in responsible charge: Franklin Barahona Address: 421 West Avenue, Stamford CT 06902 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: Franklin Barahona being duty swom,deposes and says that he/she resides at 421 West Avenue (Print Name of Applicant) (No.and Street) in Stamford CT 06902 in the County of Fairfield in the State of CT that (Ciryrrown/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 1-f I for the construction or alteration of: 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 and,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-I O.A.of the Code of the Village of Rye Brook. Sworn to before me this ��5� Sworn to before me this St day of /Saolyotry ,20?-J� day of --5anV� 20 25' C-1-, Signature of Property Owner Signature of Applicant I (nt) f�AID Z Franklin Barahona Print Name of Property Owner Print Name of Applicant Notary Public Notary Public BRIAN MACDONALD BRIAN MACDONALD NOTARY PUBLIC NOTARY P9J9IIC State of Connecticut State ofConnecticttt My COMMISSION EXPIRES Oct 31 202t' My COMMISSION EXPIRES Oct.31202E �yE BRC�j�• O� 2m 1982 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 : .S V �uJ {-Ill i (' 1\ V DATE: r 1-i Z Ci l PERMIT# ' ISSUED:'- I� - Z y SECT: BLOCK: LOT: LOCATION: ,C e(,J\ OCCUPANCY: ❑ VIOLATION NOTED THE WORK IS... ❑ IACCEPTED ❑ REJECTED/REINSPECTION ❑ SITE INSPECTION REQUIRED ❑ FOOTING ❑ FOOTING DRAINAGE ❑ FOUNDATION ❑ UNDERGROUND PLUMBING NOTES ON INSPECTION: ❑ ROUGH PLUMBING ❑ ROUGH FRAMING ❑ INSULATION ❑ NATURAL GAS ❑ L.P. GAS ❑ FUEL TANK ❑ FIRE SPRINKLER ❑ FINAL PLUMBING ❑ CROSS CONNECTION FINAL ❑ OTHER x a a N w tT—1 N p ty O N yr a w N p e CN 2 a w a H _= vi O z ww, � a p r►-1c W 0J �. 'G U on. c��' v� c. H z ° " C4 x ` b H _ v OC J w U a [� /wy \a �o W � Ato x O W O ,� y " W a v � O w /� rT. a cn O O Q; U O z � v ^ W 0Ln � z ,n z a w H z N p Ifo ° o9W un W 00 A U - u C) 7 a N z W � � � Q v O cn 00 �^ a r--� W �~ r CN W V N (Aun a "° r +� a o zz u p z a w O °k' o � �' ° W = - � v w E'' Z 0 U a' $ a v o w cn z Z a� VQ H � U �= 8 ° y au ` U e .� _ U O U Z pG a = C7 , A Z O Q �, Nav °, = 40 2 H wC . 4'g _ A Z p; V 0 BUILDING DEPARTMENT p 1E C EN E VILLAGE OF RYE BROOK DD 938 KING STREET RYE BROOK,NY 10573 SEP 17 2024 (914)939-0668 www.n,ebrookny&ov VILLAGE OF RYE BROOK BUILDING DEPARTMENT INTERIOR BUILDING PERMIT APPLICATION FOR OFFICE USE ONLY: Approval Date: SEP I K2124,, Application Fee:$ Approval Signature: Permit Fees:$. Disapproved: Other: �,**���,r����,c,�����*>4•r����*�***,r�r.���***�,c�t t:**�r�*��t*****a�**t��****�t�,�,r<��****r,�*a**���a�r**i**��������,�� Application dated: 09/0912024 is hereby made to the Building Inspectorofthe Village ofRye Brook.NY,for the issuance ofa Permit for the interior alteration of an existing building,or for a change in use,as per detailed statement described below. 1. Job Address: 58 Bowman Avenue,Rye Brook,NY 10573 SBL: 141.28-1-26 zone: 2. Proposed Improvement.(Describe in detail): Installation of(1 )Exterior replacement basement Entry Door into existing opening with no structural alterations. 3. Does the proposed improvement involve a Home-Occupation as per§250-38 of the Code of the Village of Rye Brook? No: x Yes: If yes,indicate: TIER L TIER 11: TIER III: 4. Will the proposed project require the installation of a new,or an extension/modification to an existing automatic fire suppression system(Fire Sprinkler,ANSL System,FM-200 System.Type l Hood,etc...) :No: x Yes: (If yes,please submit a separate Automatic Fire Suppression System Permit application& 2 sets of detailed engineered plans) 5. Occupancy;(1 fam..2 fam.,comm.,etc...)Prior to Construction: 1 Family After Construction: 1 Family 6. N.Y State Construction Classification: Residential N.Y.State Use Classification: Residential 7. Property Owner: Rob Baez Address: 58 Bowman Avenue,Rye Brook,NY 10573 Phone# NIA Cell# (347)539-1373 email: catteagableek@gmail.com 8. Applicant: Erin Branch Address: 2261 Market Street STE 10301,San Francisco,CA 94114 Phone# N/A Cell# 315-335-8730 email: updates+rba@permitflow.com 9. Architect: NIA Address: N/A Phone# NIA Cell# N/A email: NIA 10. Engineer: NIA Address: N/A Phone# NIA Cell # NIA email: NIA 11. General Contractor:Fairchester Custom Windows LI_C Address: 421 West Ave,Building 1 I Stamford,CT 06902 Phone# Cell # (203)249-1986 email: Franklin.Barahona@rbawestchester.com 12. Estimated cost of construction $ 9 0 (NO IL 1-he estimated cost shall include all labor.material,s-affiduing.axed equipment,prntesstonal lccs,and material mid labor which mac tx donated grans I 13. Job Timetable: Start: TBD Finish: TBD (1) 611/2024 BUILDING DEPARTMENT VILLAGE OF RYE BROOK 938 KING STREET RYE BROOK,NY 10573 (914)939-0668 ����'w.nchrookn . 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 YORK, COUNTY OF WESTCHESTER ) as: 1, Rob Baez , residing at, 58 Bowman Avenue , Rye Brook, NY 10573-2804 IPrinl nail 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; 58 Bowman Avenue Rye Brook, NY. 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. ISiCnafurcutPl 1 ii,- Rob Baez I Print\',rnrr,�f-ITr,h::n•, +h,•. - State of Florida, County of Broward Sworn to before me this gth Type of ID : Driver License Notarized remotely online using communication technology via Proof. day of September -)Q 24 by Rob Baez Sky Il r`e DIANA FERMIN Notary Public-State of Florida , Dlana Ferm n V c;_ Commission N HH 159422 =,•r Old •�� P.'�� Expires on Auq.,:r 2025 yy�nlonll Fr;o\��� 611/2024 This application must be properly completed in its entirety and must 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 OF NEW YORK,COUNTY OF WESTCHESTER ) as: Erin Branch , 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 Agent _ 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. 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 10 ph Sworn to before me this 9th day of 51fP ''"b ,20 7� day of September 2® 24 Signature of Property Owner Sti3w ojeonnecdcut Signature of Applicant My COMMISSION EXPIRES OcL 312026 Rob Baez Erin Branch Print Name of Propem Owner Prints Name of Applicant Notary Public �: ''� ` Notary Public �••.• State`of Texas County of Denton This instrument was acknowledged before me by means of an interactive two-way audio and video communication on 09/09/2024 by Erin Branch. (4) bn nn24 f n»s aals YOUR PROFESSIONAL-CLASS PRODUCT via I.s°.�a „ Legacy 20-Ga;:ge �.•t ooth Steel Entry Door QUOTE INFORMATION .. Tag:Basement •.. e DETAILS Legacy Single Entry Dow Ia FrarneSaver Fume -t Width 80'hommai Height Una Size 29'x 90 3r4' Frame Depth 4 9116' 2'Standard Brickmold Right Hand Inswing-inside Loolung Out pot Style 204Gauge Smooth Steel Door Tudor Brown Inside and Outside Mardtira M Hardware in Satin Nckel Finish Gewglan Lockset Thumbturn Deadbolt Fraaae Textured Tudor Brown Ak,minum Fame Cladding Tudor grown Inside Frame Mill Finish ADA Compliant Threshold outsm VK 5 SM"Threshold Depth Sat Nickel Ball Bearing Hinges Security Plate f at: f►--1,,tiff•-- • U....✓NH• -aI• OUTSM 0.17 0.01 �• J �'� iT .. 0.00 :i '. 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AMU- 96 1 r." h ♦.' do F3 � 1 d-s - l ��� Agreement Document and Payment Terms ��/ DBA:RENEWAL BY ANDERSEN OF WESTCHESTER AND FAIRFIELD COUNTY Rob Baez IM Legal Name: Fairchester Custom Windows LLC 58 Bowman Avenue RENEWAL CT HIC#.0667292,WC-35743-H22,Putnam#51220 Rye Brook,NY 10573-2804 byANDERSEN 421 West Ave,Building 11 Stamford,CT 06902 C:(347)539-1373 Phone:203-406-0545 1 Fax:203-406-0828 sales@rbawestchester.com Rob Baez 08/27/24 BUYER(S)NAME CONTRACT DATE 58 Bowman Avenue , Rye Brook, NY 10573-2804 (347)539-1373 BUYER(S)STREET ADDRESS PRIMARY NUMBER SECONDARY NUMBER carteagableek@gmail.com PRIMARY EMAIL SECONDARY EMAIL NOTES: Buyer(s)hereby jointly and severally agrees to purchase the products and/or services of Fairchester Custom Windows LLC d/b/a Renewal By Andersen of Westchester and Fairfield County("Contractor"),in accordance with the terms and conditions described in this Agreement Document and Payment Terms, any documents listed in the Table of Contents,and any other document attached to this Agreement Document,the terms of which are all agreed to by the parties and incorporated herein by reference(collectively,this"Agreement"). Buyer(s)hereby agrees to sign a completion certificate after Contractor has completed all work under this Agreement. \ Q�ply 1 0� / L.� TOTAL JOB AMOUNT: $9,948 By igning this Agreement,you acknowledge that the Balance Due,and the Amount Financed ust be made by personal check,bank check,credit card,or cash. DEPOSIT RECEIVED: $2,000 BALANCE DUE: $7,948 We schedule installations based on the date of the signed contract and secondarily on the date in which we complete the technical measurements.The installation date that we are providing at AMOUNT FINANCED: $0 this time is only an estimate.We will communicate an official date and time at a later date.Rain and extreme weather are the most common causes for delay. METHOD OF PAYMENT: Cash Check NOTES: Buyer(s)agrees and understands that this Agreement constitutes the entire understandings between the parties and that there are no verbal understandings changing or modifying any of the terms of this Agreement.No alterations to or deviations from this Agreement will be valid without the signed,written consent of both the Buyer(s)and Contractor. Buyer(s)hereby acknowledges that Buyer(s)1)has read this Agreement,understands the terms of this Agreement,and has received a completed,signed,and dated copy of this Agreement,including the two attached Notices of Cancellation,on the date first written above and 2)was orally informed of Buyer's right to cancel this Agreement. NOTICE TO BUYER: Do not sign this contract if blank.You are entitled to a copy of the contract at the time you sign. YOU, THE BUYER, MAY CANCEL THIS TRANSACTION AT ANY TIME NOT LATER THAN MIDNIGHT OF 08/30/2024 OR THE THIRD BUSINESS DAY AFTER THE DATE OF THIS TRANSACTION, WHICHEVER DATE IS LATER. SEE THE ATTACHED NOTICE OF CANCELLATION FORM FOR AN EXPLANATION OF THIS RIGHT. � rt Nam, SIGNATURE OF SALES PERSON SIGNATURE SIGNATURE John Damascus Rob Baez PRINT NAME OF SALES PERSON PRINT NAME PRINT NAME 08/27/24 Page 2 / 32 �� Itemized Order Receipt DBA:RENEWAL BY ANDERSEN OF WESTCHESTER AND FAIRFIELD COUNTY Rob Baez Legal Name: Fairchester Custom Windows LLC 58 Bowman Avenue RENEWAL CT HIC#.0667292,WC-35743-H22,Putnam#51220 Rye Brook,NY 10573-2804 byANDERSEN 421 West Ave,Building 1 I Stamford,CT 06902 C:(347)539-1373 Phone:203-406-0545 Fax:203-406-0828 1 sales@rbawestchester.com ROOM: SIZE: DETAILS: PRICE. ow Misc: Misc. Miscellaneous Job Items. Lead Safe Work 0 H Practices, Quantity 1. EPA requires contractors that disturb painted surfaces in homes, built before 1978 to be certified and follow specific work practices. ow Misc: Misc. Permit Fees, Town of Rye Brook- Estimated 0 H Permit Fees. Quantity 1. Renewal by Andersen will facilitate the application of the building permit to the Town of Rye Brook. Homeowner is responsible for any outstanding permit applications or code violations that may prevent Renewal by Andersen from procuring permit. Renewal by Andersen is not responsible for any historical or architectural review applications and approvals that may be required as pre- requisite for a building permit. 101 Back Door ow Misc: Misc, Miscellaneous Job Items. Pro-Via Door. Quantity 0 H 1. Details of ProVia door specifications to be provided on supplemental agreement. 102 Basement Door ow Misc: Misc, Miscellaneous Job Items. Pro-Via Door, Quantity 0 H 1, Details of ProVia door specifications to be provided on supplemental agreement. WINDOWS: 0 PATIO DOORS: 0 ENTRY DOORS: 0 SPECIALTY: 0 MISC:4 TOTAL $9,948 Renewal by Andersen is committed to our customers'safety by &� complying with the rules and lead-safe work practices specified by the EPA. 08/27/24 Page 3 / 32 lit•�w-f 'AAA'.." �'.a'w4• A w ? @� ^FPe;� \A"PH V, + V,:.. r G ' cd�' v11 frGGt ,rr _. ; to». �L•-;>a rr: �i� rV�. :„ q 4r V !r r�% tiler r�1�V rrl�rr 4t rV ._t_.3- �L i_v Jf...4•L� '� -L'L_. .F_,:a�. .��.�.s�_ - �.+._=�G •t' r O . George Latimer � Sto, James Maisano Westchester County Executive Director,Consumer Protection �1 lY o» Department of Consumer Protection Home Improvement License 41 ?: FAIRCHESTER CUSTOM WINDOWS, LLC g` 2041 WEST MAIN STREET `_ \ STAMFORD,CT-06902 L` � 1 �, �i(o)i �its)s7 This license is issued in accordance with Article X VI of the Westchester County Consumer Protection Code and is valid only upon 4`S�y presence of the official department seal.Proof of citizenship or immigration status is not required for issuance of this license. -r- ♦ NOT FOR FEDERAL PURPOSES Consu� DLO License Number rF m Date of Expiration 0 09/20/2024 a<o>►.,, WC-35743-H22 o v •,, AfOhQsterC0\° r \ tlo». `�^-�: �..-r.._R:�•-:: :.c-:e^-.r.� r�.:�_._�-.c��--••--s�-�.-,_s:�-::: •. �.,-�e..:�,a:a-„ -�-n•;,_-^ ,-•-ra;.a�.-,-.:: r,�r pr.V I�i� +tj)F�`1tytiGVp '414,` :e:�VNIS.;vpy'.6E(n two,:+'y'({" +,t�,� ^ IV 14AS)1�r�. .1 r�•,!^ ♦1� i+1rA �i t�A♦ .,JtlA\�0� �.♦ r;i[�A'tTi. j�/Aii� •1, �iywN•^ ♦1.rS T'ilAFY„ .1 r�'Pw�*A •♦ �^TI u � 'G..e' dY ✓ L �C W FAIRCUS-01 PSMITH ,�►coizo` CERTIFICATE OF LIABILITY INSURANCE DAT87/2 D/YYYY) /7/2024 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT Theresa Brandon A ME MBI Company Group LLC. HONE 280 State Street (A/C,No,Ed):(203)288-3401 LAIC,No):(203)281-0414 North Haven,CT 06473 ni o'E :theresa.brandon@mbi-ins.com INSURERS AFFORDING COVERAGE NAIC• INSURER A:Selective Insurance Company of America 12572 INSURED INSURER B: Fairchester Custom Windows LLC dba: Renewal by Andersen INSURERC: Fairchester 421 West Avenue, Building 1 INSURERD: Stamford,CT 06902 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADDL SUBR POLICY NUMBER POLICY EFF POLICY EXP LIMITS LTRA X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE OCCUR X S 2516791 8/12/2024 8/12/2025 DAMAGE TO RENTED n 500,000 MED EXP(Any oneperson) 15,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 3,000,000 POLICY❑X jPa ❑X LOC PRODUCTS-COMP/OP AGG $ 3,000,000 OTHER: A AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT 1,000,000 (Ea accident) $ ANY AUTO S 2516791 8/1212024 81l2/2025 BODILY INJURY Perperson) $ OWNED X SCHEDULED AUTOS ONLY AUTOS WN BODILY INJURY Per accident $ X AUTOS ONLY X AUTOSONLY PP eoraEcc ent A M A G E X Comp Ded$500 1 X Collision Ded$500 A X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 4,000,000 EXCESS LIAB CLAIMS-MADE X S 2516791 8/12/2024 8/12/2025 AGGREGATE $ 4,000,000 DIED I X I RETENTION$ A WORKERS COMPENSATION X I PER X I ER OTH- AND EMPLOYERS'LIABILITY YIN WC 9099063 8/12/2024 8/12/2025 500,000 ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT ��FICER/MkMBER EXCLUDED? ❑N N I A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 500,000 If yes,describe under 500,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Village of Rye Brook is Additional Insured as required by written contract per the endorsements included with this certificate. 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 9 Y ACCORDANCE WITH THE POLICY PROVISIONS. 938 King Street Rye Brook, NY 10573 AUTHORIZED REPRESENTATIVE ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD NEW YORRK Workers' CERTIFICATE OF STATE Compensation Board NYS WORKERS' COMPENSATION INSURANCE COVERAGE 1 a. Legal Name&Address of Insured(use street address only) 1 b.Business Telephone Number of Insured Fairchester Custom Windows LLC. 203406-0545 dba: Renewal by Andersen Fairchester 1c.NYS Unemployment Insurance Employer Registration Number of 421 West Avenue, Building 1 Insured Stamford,CT 06902 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 88-2855660 2.Name and Address of Entity Requesting Proof of Coverage 3a. Name of Insurance Carrier (Entity Being Listed as the Certificate Holder) Selective Insurance Company Village of Rye Brook 3b. Policy Number of Entity Listed in Box"1a" 938 King Street Rye Brook, NY 10573 WC9099063 3c. Policy effective period 08/12/2024 to 08/12/2025 3d.The Proprietor,Partners or Executive Officers are QX 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 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: Patricia Smith (Print name of authorized representative or licensed agent of insurance carrier) Approved by: 8-9-2024 (Signature) (Date) Title: Agent Telephone Number of authorized representative or licensed agent of insurance carrier: 203-288-3401 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