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HomeMy WebLinkAboutSP24-005PERMIT # 'r,/ SECTION �i of 7 -+ BLOCK LOT TYPE OF WORK 9 �� •� JOe LOCATION lkf ZA,4 Lf I OWNER CONTRACTORS;(? eSlNqe� C1410n /9 EST. COST �4' �, 500 o V FEE wA V/CO # GCS Le44 FEED l0 So P% DA1 TCO # FEE DATE SATE FOOTING FOUNDATION FRAMING RGH FRAMING INSULATION PLUMBING C7 RGH PLUMBING GAS L7 SPRINKLER ELECTRIC C� LOW -VOLT I� ALARM AS SUILT 0 FINAL INSP J 7 Cto�7 c%C9iy)932 &3&o OTHER APPROVALS ARB �u9U�S7- a/, aoay BOT ZBA OTHER BR J G ayC4.°J °Ji v 1�u4 vyj VILLAGE OF RYE BROOK MAYOR 938 King Street,Rye Brook,N.Y. 10573 ADMINISTRATOR Jason A.Klein (914) 939-0668 Christopher J.Bradbun- www.tyebrookny.gov TRUSTEES BUILDING& FIRE INSPECTOR Susan R. Epstein Steven E. Fews Stephanie J. Fischer David M.Heiser Salvatore W.Morlino CERTIFICATE OF COMPLIANCE September 27,2024 Win Ridge Realty LLC c/o Alena Hakanjin 24 Rye Ridge Plaza Rye Brook,New York 10573 Re: 9 Rye Ridge Plaza,Rye Brook,New York 10573 Parcel ID#: 141.27-1-6 Sign Permit#24-005 issued on 8/23/2024 for a New Awning This certifies that the new awning;"SLT",installed under the above captioned permit has been satisfactorily completed. Sincerely, Steven E. Fews Building&Fire Inspector /to MCMWE SEP 17 2024 DD For office use onh VILLAGE OF RYE BROOK BUILD TMENT PERMIT# —pi7S BUILDING DEPARTMENT VIL .OF RYE �6poK ISSUED: 938 KING STRE YE BROOK, E. YORK 10573 DATE: — 7—J 9 ^Q FEE: —PAIDW 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 .....................................................................................................................0....... Address:—q klAL /a 00, Occupancy/Use: Parcel ID#: 1,Vl,a 7 Zone:C Owner:1A IA 4CCt 7�f LLG Address: n P.E./R.A. or Contractor: /G7t) bE5/L�� JC f+4 n11,tJCf Address: /(D_ JJI p g 6 1Q _ f / yPo r eSi 3 Person in responsible charge Sic }� (�fi..t�?�=l_ Address:�f 0 /.t1�f 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: 'Jpszw h duly swom,deposes and says that he/she resides at 4o d I,� u�1��"f t fiJe- (Print Name n IA-pplic�""' l / INo and Strcctl in P(rP r i!\ S{ _,in the County of 1/��S"I - in the State of ,that wityrrown 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:.£ for the construction or alteration of: s1 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 orpremises orpart 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�m-e7tthis 1>. Swom to before me this (O day of ��c i+1/3G- - , 20 2T day o'r t1 afore of prope C)v►rfllr/r(�y/� Signature of Applicant PrintAX=e of Prorry, Print Name of Applicant h I/ i717�m— Notary Public Not6y Public LOIS NIETO ALENAHATEOF IN NEW PORK NOTARY PUBLIC, STATE OF NEW YORK " NOTARY PUf3UC.STATE OF N Registration No,01HAO013645 NO. O1 N14899825 Qualified in Westchester County My Commission Expires9t1912027 QUALIFIED IN WESTCHESTER COUNTY COMMISSION EXPIRES DECEMBER 3, 2026 QyE BRC�j�. -c 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 : e 1= 1 DATE' PERMIT# _Y Ly no ISSUED: SECT: Z 7 BLOCK: LOT: LOCATION: ? S'T� S t ! OCCUPANCY: ❑ VIOLATION NOTED THE WORK IS... O 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 ❑ OTHER 1 n n n n fr n x u n n n n n n n x w x n n n n n n n n u n w n n n n n n u n n n x n u u n n n x n n n n n x n n n n n n n n VILLAGE OF RYE BROOK PERMIT#:SP 24-005 rr fr fr BUILDING DEPARTMENT ISSUED: 8/23/2024 938 KING STREET, RYE BROOK., NY 10573 EXPIRES: 8/23/2025 11 rl (914) 939-0668 www.ryebrookny.gov rr n n SIGN INSTALLATION PERMIT r' rr Ott NEW AWNING; 44SL►1-"" �il 11 lift ;E AT: 9 RYE RIDGE PLAZA - RYE RIDGE SHOPPING CENTER 0. rf BUILDING CLASSIFICATION & PARCEL ID#: BUSINESS GROUP—B ,/ 141.27-1-6 fr lift Ift PROPERTY OWNER: WIN RIDGE REALTY LLC (914) 701-4005 Ift rf x 1f1 LICENSED CONTRACTOR: SIGN DESIGN &JC AWNING (914) 937-6360 a Ift 1p EMERGENCY CONTACT: SUE BONCI (914) 937-6360 If VALUATION OF WORK: $15500.00 FEE PAID: $625.00 rf 1ft HOURS of OPERATION OF CONSTRUCTION EQUIPMENT/VILLAGE CODE§158-4:WEEKDAYS-8:OOAM To 6:00PM OR DUSK,WHICHEVER IS EARLIER; 1 „ SATURDAYS-9:OOAM TO 4:OOPM; - SUNDAYS&HOLIDAYS-No CONSTRUCTION ACTIVITY ALLOWED Ift This permit is valid for a period not to exceed twelve(12)months from the date of issuance.The approved plans must be kept on the job site&be made available for xo 1ft review by the Building Department upon demand.Separate permits are required for any electrical,plumbing,fire sprinkler,fire/smoke/carbon monoxide lift detectors/alarms,or any other work not covered under this permit.Any amendments or changes to the approved plans must be designed by your architect/engineer ift and submitted to the Building Department for review and approval prior to performing any work. 1D A Certificate of Occupancy or Certificate of Compliance is required in order to close out this permit. it rr lift n ru '� If rr Other Approvals: Architectural Review Board 8/21/2024 ff u fr Steven E. Fews If It Building& Fire Inspector • rr rr Ift THIS PERMIT MUST BE CONSPICUOUSLY POSTED AT THE JOB SITE " 1/ 1� r 11. If fl 11 11 11 rl rl N ff ff rf rr Ir I n Ir Ir Ir r1 rr �Y If Ir 11 f1' u 11 x 11 11 11 u 11 n f1 a 11 w Ir x x Ir 11 11 f1 n u x n IE 11 n f1 n N x n If D BUILDI<N6.69PARTMENT VILI�qE OF RV ;LOOK JUL 18 2024 938 KING ET RYE BR66k,NY 10573 �� _pig ; VILLAGE OF RYE BROOK ov BUILDING DEPARTMENT twtt**t*w*w*wtwtww*wtt**rtrtrtrtrtrtrt*rt****t*******t*rtrtrtrtrtrtrtrtrtrtrtrtrtrtrtrtrtrtrtrtrtrtrtrtrtrtrtrtrt*trtrt****rtrttrt******t***t******t* FOR OFFICE USE ONLY: AUG 2 Approval Date: Per Application# Approval Signature: ARCHITECTURAL REVIEW BOARD: Disapproved: Date: BOT Approval Date: Case# Chairman: PB Approval Date: Case# Secretary ZBA Approval Date: Case# Other: Application Fee: Permit Fees: d e) TS—60 rtrtrtrtrtrtrtrtrtrtrtrtrtrtrtrtrtrtrtrtrtrtrtrt*rtrtrtrtrtrtrtrtrt*rttrtrtrttrtrtrtrt*tt***************:R**t*****************t******t****t*t******** SIGN PERMIT APPLICATION Application dated: 2—1 8-D`7 is hereby made to the Building Inspector of the Village of Rye Brook,NY,for the issuance of Permit for the construction/installation of a sign in accordance with Village Code§250-35 as per detailed statement described below. ,,rr p 1. Address: �1d� SBL: 141 .a1�-��(G+ Zone:C// 2. Property Use or Business Name: CT_ 3. Proposed Sign(s){Describe in detail including number of signs,types,sizes,exact location(s),and illumination method(s)if applicable.) lA separate Electrical Permit will be required for any associated electrical work.l \ - T - ►-fir-e� -� �.4. Height from grade to highest point of sign: ,to lowest es point of sign: 5. Property er: ' Address,- 4 Lic etd_Q e_ Pla.2gr t? me— Phone# r- Cell# IrNQ_t %f d9c,Go ftl 6. Applicant i 'Address: L 6 4 1,, lotfDC 145.7 Phone# - d Cell# email: •60 rry 7. Architect/Engineer: Address: Phone# Cell# email: 8. Sign ContracT : A l 1 T 1 Win)-+ .��- tL1 h t�Address:9,64 W Ua/Ile-. c1 f�L&5kc 1,j � !45 7 3 Phone#/1 1 �� '(� 4�) Cell# emaiL Z t�7��0 .6"Y\ 6/l/2024 9. Will the proposed sign require a Site Plan Review by the Village Planning Board as per§209 of Village Code? Yes: No:�_ (If yes,you must submit a Site Plan Application,&provide detailed drawings) 10. Does the proposed sign involve a Home-Occupation as per§250-38 of Village Code? Yes: No: If yes,indicate: TIER L—TIER I1: TIER III: (If yes,a Home Occupation Permit Application is required) 11. If building is located on a comer lot,which street does it front on: 12. Property frontage: 13. Property size: Sq. Ft.: Acres: 14, What is the total estimated cost of construction: $ 4 T00-Q e) (The estimated cost shall include all site improvements,labor,material,scaffolding,fixed equipment,professional fees,including any material and labor which may be donated gratis.) 15. Estimated date of completion: This application 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: 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 at the above captioned property will be in conformance with the details as set forth and contained in this application and in any accompanying approved plans and specifications, as well as in accordance with the New York State Uniform Fire Prevention & Building Code, the Code of the Village of Rye Brook and all other applicable laws, ordinances and regulations. Sworn to before me this + Sworn to before me this day of , 20 day of 20-�2 ignanirc of Propc4y @wrer V29�jj SigtlalltrC4licalt t�Ifi & �I�G�i SN 'IVN Prm W e of Prop ,I, /fir , Print Name of Applicant I n `act No Public Notary Public LOIS NIETO M R �CN�I" NOTARY PUBLIC, STATE OF NEW PORK p�Mhstemew C NO. O 1 N 14899825 QUALIFIED IN WESTCHESTER COUNTY COMMISSION EXPIRES DECEMBER 3, 2026 r- 6/1/2024 .f3u�ldin t Check LjstA "Loring Analysu Address: SBL• Zonc - Use: Corot Type: Oncer. Subnuttal Dace. ` Revutoro S4bmirtal I) es: Applicant S� Nature of Work Rrne s ZBA: I% BOT: Other. NEED QK (V n/ ( -1 .FEES:Filing. BP: V C/O Flood Plane: Legaluinon ( ) ( PP: Dared ✓Notanzed+--� SBL SFr us I.D. Cross Connection: H O A. ( ) ( ) Scenic Roads. Steep Slopes: Wetlands: Storm Water Review: Street Opening. ( ) ( ) ENIRC>V . Long Short Fees: N/A: ( ) ( ) SITE PLAN:Topo: Site Protection: S/W Mgmt.: Tree Plan Other. ( ) ( ) SURVEY:Dam& Current ArchivaL Sealed Unacceptable: ( �( S� Date Stamped: Scaled Copies:16� I-lecrroniG Other. ( ) License: Workers Comp: Liability Comp.Waiver. Other: O CODE 753#: Dated. N/A: ( ( ) HIGH-VOLTAGE ELECTRICAL•Plans: Permit N/A Other ( ) ( ) LOW-VOLTAGE ELECTRICAL Plans: Permit N/A: Other. ( ) ( ) FIRE ALARM/SMOKE DELI ECI ORS: Plan: Permir H W.1.0: Baaety_Other. ( ) ( ) PLUMBING Plans Permit Nu Gas: LP Gas: N/A/_ Other. ( ( ) FIRE SUPPRESSION:Plans: Pamir N/A: Other. ( ) ( ) I-V.A.0 Plans: Permit N/A Other: ( ( ) FUEL TAN PL.. Permit: Fu K el'l'ypc: Other. ( ( ) 2020 NY State ECCC N/A: Other. ( ( ) Final Survey Final Topo: RA/PE Sign-off Letter. As-Built Plans: Other. ( ) P DENIAL L.1.,-17I 1TL C/O DITIIAL L I-I'ER Other. ( ` Other ( mtg.due J approval; ?mot notes: — ZT— rJ ( )ZBA mtg.dam- approvaL• notes. PB mrg.due: approval• notes: REOUIRED EX]SEING PROPOSED NOIES Date:_ Am: Frc e From FrvnG Rear. Main Cow Acm C s' -- Ft H/Sb: - H Sb: AFA: Toc�Imv: 1 FL lmy — P Haght/Stones notes: R IEC IEE WE BUILDE 11p ,RTMENT JUL 18 2024 VIL OF RY 6 OOK 938 KING$* ET RYE BR NY 10573 VILLAGE OF RYE BROOK 4)9 9-0 1 BUILDING DEPARTMENT ww o ov ##k##kkkkkk#kk################kk#kkk#k###k#####k#####k#k#k#kk#kkk##kkk###kkkkkk#kk##k#k#kk####k###k#kk###k# ARCHITECTURAL REVIEW BOARD CHECK LIST FOR APPLICANTS This form must be completed and signed by the applicant of record and a copy shall be submitted to the Building Department prior to attending the ARB meeting. Applicants failing to submit a ,copy of this check list will be removed from the ARB agenda. Job Address:- �I1_�t 0.�( Date ubmission: Parcel ID#: 1;4 1,d 7- -4 Zone: Proposed Improvement(Describe in detail): 1 -7�t ► APPLICANT CHECK LIST: nn� MUST BE COMPLETED BY THE APPLICANT Su nlY,,a lo- 0-hQ0 - at�t�l -Rib IL The following items must be submitted to the Building 1-7 Department by the applicant-no exceptions. Property Owner: WA t1 C t C�A e. CpA.�-�-V L,L�+ 1. Completed Application ,//�� Q 2. Two(2)sets of sealed plans. (one full size{maximum Address: P tL{lt Y�t3,Z_y f�J k�N allowable plan size=36"x 42"1 and one 11"xl7") 3. ( )Two(2)copies of the property survey. Phone# QI 1 'y I D.� ' � � 4. ( )Two(2)copies of the proposed site plan. Applicant appearing before the Board: 5. V40ne electronic/disc copy of the complete ! S application materials. 6. bt4Filing Fee. Address: 0 / 'J 7. ( )Any supporting documentation. 8. ( )HOA approval letter. (ifapplicable) Phone# - � �3 Q 9. Photographs. Architect/Engineer: 10.F)Samples of finishes/color chart.(a sample board or model may be presented the night of the meeting) Phone# By signature below, the owner/applicant acknowledges that he/she has read the complete Building Permit Instructions&Procedures,and that their application is complete in all respects. The Board of Review reserves the right to refuse to hear any application not meeting the requirements contained herein. Sworn to before me this Swom to before me this 1 -7 day of 1' , 20 14- day of-_JtG l , 202? ure 4P. t]ivwec r/;��t i of p cant Print Name of Property Print Name f Applicant I v !�O Notary Public Notary Public J ANA��N LOIS NIETO [111�TAR! LIPuel,c STA*r�r"I'M"PI, NOTARY PUBLIC, STATE OF NEW YORK NO. 01 N14899825 l myCommiss ion Fxpins911912027 QUALIFIED IN WESTCHESTER COUNTY COMMISSION EXPIRES DECEMBER 3, 2026 6n,12024 SAE DROO Village of Rye Brook ML voe MR O� yAgend FB ,/ SE Architectural Review Board Meeting AC AD Wednesday,August 21,2024 at 7:30 PM Village Hall,938 King Street I JM SF /? 1 1. ITEMS: 1.1. ARB24-084(Consent Agenda) Jeffrey Mensch&Hannah Mensch 10 Red Roof Drive Rooftop solar array. 1.2. ARB24-093 (Consent Agenda) Giuseppe Castellano&Alicia Castellano 8 Hunter Drive Rooftop solar array. 1.3. ARB24-094(Consent Agenda) Mitchell Greenspan&Caryn Cherlin 23 Berkley Lane 4'and 5'high black chain link fence and gates. 1.4. ARB24-095 (Consent Agenda) Joshua Shaw&Melissa Shaw 12 Birch Lane Replace bluestone walkway in kind. Consent Agenda Approvals: Motion Second Abstention Aye; Nay; Adjournment; Notes 1.5. ARB24-096 Win Ridge Realty LLC 9 Rye Ridge Plaza New awning,"SLT" Approvals: Motion Second J4'-",3 Abstention Aye; S Nay; _ Adjournment; Notes Page 1of3 Architectural Review Board - August 21,2024 1.6. ARB24-097 Paul Tyler&Linda Tyler 16 BelleFair Boulevard New deck. Approvals: Motion Second Abstention Aye; Nay; Adjournment; Notes 1.7. ARB24-098 Wesley Canhedo&Orival Canhedo 11 Beacon Lane 1 story addition&demolish roof over patio. Approvals: Motion Second Abstention Aye; Nay; Adjournment; Notes 1.8. ARB24-099 Jay Swartz&Lisa Swartz 69 Tamarack Road Replace existing decking and railings. Approvals: Motion Second Abstention Aye; Nay; Adjournment; Notes 1.9. ARB24-100 Joseph Nerenberg 9 Country Ridge Drive Widen full length of driveway and install storm water management system. Approvals: Motion Second Abstention Aye; Nay; Adjournment; Notes Page 2 of 3 Architectural Review Board August 21,2024 1.10. ARB24-101 Michael Rifelli&Lauren Webber 43 Rock Ridge Drive Second story addition and interior alterations. Approvals: Motion Second Abstention Aye; Nay; Adjournment; Notes 1.11. ARB24-102 Randy Hamlet&Anne Marie Hamlet 21 Country Ridge Circle Deck,circular driveway,legalize patio and remove concrete patio. Approvals: Motion Second Abstention Aye; Nay; Adjournment; Notes NEXT MEETING: Thursday,September 19,2024 Page 3 of 3 A6" CERTIFICATE OF LIABILITY INSURANCE DATE / Y) � os/1717/2024o2a TH'F!'Ef'TIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFIGj%TE 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►. CONTACT Joanne Sirico PRODUCER NAME: Borrelli Partners Insurance Agency PHONE (914)939-7900 FAX No: (914)407-5088 AI C No Ext 287 Bowman Avenue ADDRESS: I$IrICO@bOffelllpartnerS COm Suite 406 INSURER(S)AFFORDING COVERAGE NAIC N Purchase NY 10577 INSURER A: Travelers Casualty Ins Co of America 19046 INSURED INSURER B: Travelers Indemnity Co 25658 Lanza Corporation dba Sign Design&J C Awning INSURER C: 404 Willett Ave INSURER D: INSURER E: Port Chester NY 10573 INSURER F COVERAGES CERTIFICATE NUMBER: CL2451305722 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. POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER MMIDDIYYYY MMIDDIYYYY LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE a 5,OCCUR PREMISES Ea occurrence g 0,000 MED EXP(Any one person) $ 5,000 A 6805,1175092 06/05/2024 06/05/2025 PERSONAL&ADV INJURY s 1,000,000 GEN'LAGGREGATE LIMIT APPLIES PER GENERALAGGREGATE $ 2,000,000 j POLICY FX ❑ PRODUCTS-COMP/OPAGG $ 2,000,000 OTHER. CMBINED AUTOMOBILE LIABILITY Ea accidentSINGLE LIMIT $ ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS J S HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY Per accident UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 5,000,000 B X EXCESS LIAB CLAIMS-MADE EX5J175240 06/05/2024 06/05/2025 AGGREGATE $ 5,000,000 DIED RETENTION $ $ ER WORKERS COMPENSATION X STATUTE H ER AND EMPLOYERS'LIABILITY Y/N 1,000,000 B ANY PROPRIETOR/PARTNER/EXECUTIVE ❑ N IA UB5J175160 06/05/2024 06/05/2025 E.L.EACHACCIDENT $ OFFICER/MEMBER EXCLUDED? E.L.DISEASE-EA EMPLOYEE $ 1,000,000 (Mandatory in NH) If yes,describe under 1,000,000 DESCRIPTION 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) BLANKET M-OWNERS,LESSESS OR CONTRACTORS,AI-MANAGERS OR LESSORS OF PREMISES,AI-STATE OR POLITICAL SUBDIVISIONS PERMITS RELATING TO PREMISES,At LESSOR OF LEASED EQUIPMENT,PRIMARY&NON-CONTRIBUTORY WORDING,WAIVER OF SUBROGATION-WC POLICY INCLUDES BLANKET WOS CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN Village of Rye Brook ACCORDANCE WITH THE POLICY PROVISIONS. 938 King Street AUTHORIZED REPRESENTATIVE Rye Brook NY 10573 �--.�_- 9 ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD <YNOWorkers' ATE Compensation CERTIFICATE OF Board NYS WORKERS' COMPENSATION INSURANCE COVERAGE 1a.Legal Name&Address of Insured(use street address only) lb. Business Telephone Number of Insured Lanza Corporation 914-937-6360 DBA Sign Design and J C Awning 404 Willett Avenue 1 c. NYS Unemployment Insurance Employer Registration Number of Port Chester, NY 10573 Insured Work Location of Insured(Only required if coverage is specifically limited to certain locations in New York State, i.e.,a Wrap-Up policy) 1d. Federal Employer Identification Number of Insured or Social Security Number 13-3525268 Z.Name and Address of Entity Requesting Proof of Coverage 3a. Name of Insurance Carrier (Entity Being Listed as the Certificate Holder) Travelers Indemnity Company Village of Rye Brook 3b. Policy Number of Entity Listed in Box"I a" 938 King Street UB5J175160 Rye Brook, NY 10573 3c.Policy effective period 06/0 / 0 d to _ 061051917195 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"la"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 this Certificate of Insurance to the entity listed above as the certificate holder in box"2". send 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? ❑YES ®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: Joanne SlficO (Print name of authorized representative or licensed agent of insurance carrier) Approved by: _t�QK�L� �' � 06/17/2024 (Date) Title Sr Acct Mgr Telephone Number of authorized representative or licensed agent of insurance carrier: 914-939-7900 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 (9-15) www.wcb.ny.gov '4 r, v. _, M :-n= TI7 Cn ,- m `0 0 Ti 'a� � � � � < - r- M m . ' Ca? z c. > Z Z rn J -�1 a Z O (P N rnCZ rTrD cn, W rr'--� rr Q .n O C r. o rn j> rr Ln ►�; { cA i �4,• 6 U) J1 CL r M �� o CD IN �'w leT C c S:Im r--�� r R CD ' t =r "a v � t Iwo �jl mom owe jj � u 1w, Oo i t �m0 ----�� �, CA 0 �� d CD o Z a � 2 ��� n �_^ < "r N 11 P-4. Z Lf P. 90 P.O. -� cr m w CDD CD �' V =N Z zin 0 0 3 G'� m. z i f l M< -n zz a z J J! 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