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HomeMy WebLinkAboutBP24-217PERMIT # joZ SECTION TYPE OF WORK JOB LOCATION CONTRACTOR EST. COST vcO #� TKO # 7 DATE: i� a� cxp; /o 7`3 BLOCK I LOT, 0 FEE DATE INSPECTION RECORD I DATE 1 NSP FOOTING FOUNDATION FRAMING - RGH FRAMING INSULATION / PLUMBING I _ ISO zoot (�i RGH PLUMBING GAS SPRINKLER 77 E ELECTRIC cJV_�J LOW -VOLT I� "'(ALARM O I` IS" Zo2S DSO- •D AS BUILT O �; , t pZS 61JjS2 FINAL Q0-3) 533-307, >���� -/� l/� ►/i�o✓).�te��t../ Diu �► d,�y � �Pa7�ii14 OTHER APPROVALS ARB BOT PB ZBA OTHER VILLAGE OF RYE BROOK WESTCHESTER COUNTY, NEW YORK NO: 25-007 Certif irate of ®crupaurp his is to certify that Lcc--, ZL iJami(, of, 4— Lakl having duly filed an application on 7 20 requesting a Certificate of Occupancy for the premises known as, Rye Brook,NY, located in a ��i� Zoning District and shown on the most current Tax Map as Section: / .73 Block: /. Lot: , and having fully complied with the requirements of the Building Code and the Zoning Ordinance under Building/Permit No. �" , issued L(? 20�- , such authority and permission is hereby granted to the property owner to lawfully occupy or use said premises or bu' ding or part thereof listed under the following New York State Classifications, Use: - / Construction: for the following purposes:_ lak'V16y' Subject to all the privileges, requirements, limitations, and conditions prescribed by law, and subject also to the following: This certificate does not in any way relieve the owners or any person or persons in possession or control of the premises, building,or any part thereof from obtaining such other permits or licenses as may be prescribed by law for the uses or purposes for which the building or premises is designed or intended. Furthermore, it does not relieve such owners or persons from complying with any lawful order issued with the object of maintaining the premises or building in a safe and lawful condition. No changes or rearrangement in the structural parts of the building or in the exit facilities shall be made, and no enlargement, whether by extending on any side or by increasing in height shall be made nor shall the building be moved from one location to another until a permit to accomplish such change h n obta' ed fro a Building Inspector. Building Inspector,Village of Rye Brook: Date: I ►co boas QR,19 4 JVC'V �J 'C 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.Qov TRUSTEES BUILDING& FIRE INSPECTOR Susan R. Epstein Steven E. Fews Stephanie J. Fischer David M. Heiser Salvatore W. Morlino CERTIFICATE OF COMPLIANCE January 16,2025 Lee Bergstein&Jamie Meidman 24 BelleFair Road Rye Brook,New York 10573 Re: 24 BelleFair Road, Rye Brook,New York 10573 Parcel I D#: 124.73-1-5 8 This document certifies that the work done under Mechanical Permit#24-141 issued on 10/31/2024 for the installation of a new range hood and vent has been satisfactorily completed. Sincerely, Steven E. Fews Building&Fire Inspector /to p EC ENE rDATE ffice use nl�: JAN - 9 2025 BUILDING DEPARTMENT IT# 7 VILLJ►�IE OF RYE BROOK ED: 938 KING S1'REE)I�1IRYE BROOK, YORK 10573 : — 5 } VILLAGE OF RYE BROOK (914)93y-U6t►8 J �, r— PAID� BUILDING DEPARTMENT ttwµ,rf0cpuk1ps--Poi APPLICATION FOR CERTIFICATE OF OCCUPANCY,CERTIFICATE,OF COMPLIANCE, AND CERTIFICATION OF FINAL,COSTS TO RESUBMITTED ONLY UPON COMPLETION OF ALL NORIC, AND PRIOR TO THE FINAL INSPECTION ............................................................................................................................. Address: 29 (4 11 C )c,, v �41 _ Occupancy/Use: /�/f'1 Parcel ID#: �01 Y. 7 3 — /— s& Zone: 2 U Owner: ( k I c ,;I mc,r,, i t rLj Lee naS 1 e t,1_ Address: 29 lie I i e C-Al v Rid P.E., Z.A.or Contractor: j r yi l c w �,t S(f�,ct Address: 2 B 6 tyci t to y 5 v.1't 201 !OS to b C r C b$o? Person in responsible charge: 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 YOM COUNTY OF WESTCHESTER as: /oi t &C W us S L In,�_ being duly swom,deposes and says that he/she resides at 2 8�r VCt I I c 7 P—H S (Pnnt\.meof Appli:m,tl (No and Srrev) in e L S (CV) in the County of fct,t- fie Icy intheStateof e`i that IC'u�Town. \'dLtgcl he%she has supcmised 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 60t coo,CO for the construction or alteration of. J n 4 r rl U v I< , FC h e n f'v r)n k: :1 I,,et' Deponent further states that hc'she has examined the approved plans of the structure/work herein referred to for which a Certificate of Occupancy i 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 hereaRer 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 lmpcctor as per§250-10.A.of the Code of the Village of Rye Brook. Sworn to before me this (!1 Sworn to before me this `+ day of 20 25 day of 20 Si ature upert),Owner u/ icon/t , Print Namc of Proptxty Owner Paint Netno of Applicant Notary Public Notary Public KARINA BRACHLOW NOTARY PUBLIC,STATE OF NEW YORK CONOR MCLAlJGHLIN Registration No, 01BR0019201 Notary Public State of New York Qualified In Westchester County No.01 MC6400842 Commission Expires Dec.29,20 Qualified In Oueens County Commission Expires November 25,20_._,7 QyE 4RO' 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.or� - - - - - - - - - - - - - - - - - - - - INSPECTION REPORT - - - - - - - - - - - - - - - - - - - - ADDRESS : Z `I I C 1 ol� 1 r DATE: PERMIT# W Z ) (0 � ISSUED: SECT: '.73 BLOCK: :f LOT: LOCATION: OCCUPANCY: ❑ 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 f , ) ❑ NATURAL GAS ❑ L.P. GAS !C I G V a- ! J ❑ FUEL TANK ❑ FIRE SPRINKLER I - [} FINAL PLUMBING � `J V J A Ste. ❑ CROSS CONNECTION ❑ FINAL 747 ❑ OTHER QyE BR ' Zm •T�O� '9°2 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 : L Li 1, e DATE: I- IS 2 0 L PERMIT# -GP Z y - 1 ISSUED: lam'v-I-j SECT: I Z`r-73 BLOCK: LOT: S LOCATION: 1 OCCUPANCY: ❑ 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 t ❑ L.P. GAS ❑ FUEL TANK ❑ FIRE SPRINKLER ❑ FINAL PLUMBING ❑ CROSS CONNECTION g FINAL ❑ OTHER �E BRC�v� o`` tim 1982 BUILDING DEPARTMENT ❑7 BUILDING INSPECTOR p SSISTANT 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 :-Z 4 27�)f-L Le �c., Iz a G O DATE: .. PERMIT# 2� Z U _ I ' ISSUED: SECT: BLOCK: LOT: LOCATION: 1� �( 9 OCCUPANCY: ❑ 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 ❑ L.P. GAS ❑ FUEL TANK ❑ FIRE SPRINKLER ❑ FINAL PLUMBING ❑ CROSS CONNECTION ❑ FINAL ❑ OTHER N 00 M cd a O. 2 rya i O uq w L CA CA a, o a co o00 w � 0. � � O � �+ M Z o y ° W C N L W Wo i, sa O•-IE M '1 O ° V X O ova ^ LO w +. 0-9 en Q W o0 ^ U N M W A v v C V Z enw `�-� O a a = M C7 A z � H w z aA o � � _ L 6 00 a O G\ d v� N • a ~ F•+ d 6 a O w z d ca Woo 5 L W V � 'h 84 W � � b L L L C L BUILD MENT L� NT L E OF R OK SEP 3 0 ZQ24 938 KINGID ET RYE BR NY 10573 -0 , ���� VILLAGE OF RYE BROOK ov BUILDING DEPARTMENT INTERIOR BUILDING PERMIT APPLICATION FOR OFFICE USE ONLY: Approval Date: OCT 7 2�24 ermitr Application Fee:$ .--- -ZQ Approval Signature: Permit Fees:$tea_ 11,IV2- Disapproved:_ Other: Application dated: / _:SQ c 7 / is hereby made to the Building Inspector of the Village of Rye Brook,NY,for the issuance of a Permit for the interior alteration of an existing building,or for a change in use,as per detailed statement described below. 1. Job Address: 1H �e ICfa�Y �C� SBL: A) I 73 —/—59 Zone: 2. Proposed Improvement.(Describe in detail): IAVC riO'Y ) i Kheh we lnoyc,Vi van 3. Does the proposed improvement involve a Home-Occupation as per§250-38 of the Cade of the Village of Rye Brook? No: Yes: If yes,indicate: TIER I: TIER H: 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 I Hood,etc...) :No: Yes: (If yes,please submit a separate Automatic Fire Suppression System Permit application&2 sets of detailed engineered plans) 5. Occupancy;(1 fan.,2 fam.,comm.,etc...)Prior to Construction: After Construction: 6. N.Y State Construction Classification: N.Y.State Use Classification: 7. Property Owner: Aa m i e k�e_ i A M CA i Address: 2 e 1 e t t i r p d Phone# 919 - 4 714 - 5 940 0 Cell# email: V_ 1 e 16 m C-1 n 6 VhCA (,Cc^I 8. Applicant:AnciY(w o a 0x) paA pTi F Z0S+?�'rXddress: 2199 witu '� COS (c)b CT DC 7 -7 Phone#_ Z03 -533.307 b Cell# email. 0-V L e&d rf roX WIC.,JAf t r.-# 9. Architect: Address: Phone# Cell# email: 10. Engineer: C t Address: 1W 1/A L Li IRA cos Cob CT MX Phone# 709-S33- 30710 Cell# -email: MI J(,k&dt-f 4'uY.tMUJI J .ne J- 11. General Contractor: VTF F_oSC0nLk*\t-LLC- Address: 7 T VMUC4 2d COS (OVJ C T 01. Phone# ?JD5- 5S-3-307 b Cell# email: 01��ce �l f f SF yrtt7un t�/tt� 12. Estimated cost of construction $ 50 U (NOTE:The estimated cost shall include all labor,material,scaffolding,fixed equipment,professional fees,and material and labor which may be donated gratis.) l ` 13. Job Timetable: Start: "1 L�•l Finish: (I) 6/t/2024 D IECIEW L $VILD V A WNENT SEP 3 0 2024 ViL OF, (Nl OF RY 1K 938 KING ET RYE BR ' NY 10573 VILLAGE OF RYE BROOK t41 -0( BUILDING DEPARTMENT w ♦r*ataar*arraaa*rarrarraaarr,►s*a#r,iernt*rarr,rra�►aataaaata,tta#*:rraa**rira*as,��,xwK+rRrx.rr���rfi��*k�,�arar rrra AFFIDAVIT OF COMPLIANCE VIL&—AGE CODE §215 • STORM SEWFRS AND SANITARY SL'WFRS THIs AFFIDAVIT MUST BEAR THE 1g0T&RIZ= 8IMhTU-qx OF Ty$ LY.CAL PROPERTY OP1 W AM BE StIMXTTRD ALONG WITH ANY BUILDING OA PLUMBING PFRUIT APPLICATI014. ANY WnMrW OR PLUMBING PXMIT APPLICATION SUBMITTED WITHOUT THIS COUMTBn AND NOTARIZED TORN WILL a% ARTMWED TO TRZ ABPLze"T. ,STATE OF NEW YORK,COUNTY OF WESTCHESTER } as: � L. _ �)� 0 ,residing at, � � __UV o k� ��cr.(f` IJ� ;c)y7 J (Print name) (Addren wbera you five) being duly sworn,deposes and states that(s)he is the applicant above named,and&rther states that(s)he is the legal owner of the property to which this Affidavit of Compliance pertains at; IN 1'e C., WV \os-? .. ,Rye Brook,NY, (Job Addum) 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 cress-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. (Sign 11t1fV Of P11111CUL ON'tltif(8)) Li' ?-.JL'C)54rc i Print Name of Property ou nerm) Sworn to before me this day of ,20 Z 4 (Notury u JORDAN VERA I Pol>wlc,State of Conne ow Commission Eames a4/3U/2D25 (2) 6/In024 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 ratumed to the applicant. Please note that application fees are non-refundable. STATE OF NEW YORK,COUNTY OF WESTCHESTER ) as; 6mdxu� Ut5C1r&A A. being duly sworn,deposes and states tlwhe/she is the applicant above named, (print❑amaofindividuala*,Insm A applicant) and $>,rther states that (s)he is the legal owner of the property to which thi,,i application pertains, or that (s)he is the for the legal owner and is duly authorized to make and file this application. (indicate atchitett,(�ontraator,agent,etturncy,etc.) 'Chat 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 colmectiom or sources of infiltration into the sanitary sewer system on or from the subject property. th Swum to before me this _ �' .� Swum to before me this 2.9 t� _ day of 20`� slsy of A U'll V 5 , ZQ 9-H� Sfgnettue f PropertyOwner SignaiurC u Aiipp iit i n It- c k, Print Name of Property Owner Print Vern of Applimm >> 'A' -L)k Notary Pub s '—"� G. tg Atz Notary Public CONOR MCLAUGHLIN KARINA BRACHLOW Notary Public State of New York. NOTARY PUBLIC,STATE OF NEW YORK No.of MG6400842 Registration No.O1 BROO19201 Qualified in(Qaeens County Commission Expires November 25,26 Qualified In Westchester County Commission Expires Dec.29,201] (4) b/l/2024 a� s s = 00 a O N {:: W v�i °• V i 6L.00 r' ,• �n a, � , aSLn W rq CN N W O til U 1 Ln w W h Z m Q ✓" UCN � �j V W v 00 A z o U > -_ V eq w Q O a d � � v h+y U '-' U '" 9 U g x ►. W w x z E" k. o Z z �' E O p t V a W rj a Q� O r . F 8 ►" a � Z �✓,• A r Z Q O r �""� .. cr. = cv A w z w -I P* oA .a 09 W a. s U E E L1 FLE� jD BUIL , MENT viz „ OK EOC 2 2 2024 IN 938 K ' ,NY 10573 VILLAGE OF RYE BROOK w BUILDING DEPARTNIENT ELECTRICAL PERMIT APPLICATION Westchester County /Master Electricians License Required FOR OFFICE USE ONLY BP#: / — �� / EP#: 011 2 2024 l Approval Date: Permit Fee: $ L Approval Signature: Other: *********************************** ************************************************************** DO NOT START WORK or CONSTRUCTION UNTIL A PERMIT HAS BEEN ISSUED BY"ITIE BUILDING INSPECTOR. THE ADMINISTRATIVE FEE FOR WORK PROGRESSED OR COMPLETED WITHOUT A PERMIT 1S 12%OF THE TOTAL COST OF CONSTRUCTION WITH A MINIMUM FEE OF$750.00 Application dated, s hereby made to the Building Inspector of the Village of Rye Brook NY,for the issuance of a Permit to install and/or remove electrical equipment,wiring,fixtures, or to perform other high or low voltage electrical work as per the detailed statement described below. By signing this document, the applicant & property owner agree that all electrical work performed will be in conformance with all applicable Federal,State,County and Local Codes. 1.Address: I� >�►�c 4�C �oeJ.-�"1.0 f�oY '7 ) n ^� - .Ir IaS SBL: /�`;• 73 —/—S� Zone: Pub 2.Property Owner:��. Le �'I t e.� �tCLtA'Iddress: Phone#:GI%X 8'0 3 Cell#: S 1 to 6S-*,1%1-V- email: i e e. Lr�l;'t2►�� '�G� (•�o� 3.Master Electrician/Licensed Installer:An-t n Un'y `ASS V Address:n-) bc;c q J-2-- 'AYonuy) N 11 Lic.#15 Phone#1(4-'� I -021�b Cell#: email:[1eC ky\CCYVet1L W h ► n(- . Cp vv, Company Name:WC' 'ICl Uj)i I In L Address: 4.Proposed Electrical Work/Fixture Count:0 I YlS-Ia k I YfWC tr C_y'O 5 .or FY 1Ga._ EGL Y e,y hoca . ex I S-h 12q QUA I-e-A s of l.v k re s •Fur •A hC S'►n �I Lsodsa't' to I Y S ka l I neck Q v-t CcAtiarts -I h 5.3"Party Electrical Inspection Agency: V'Q11CAC STATE OF NEW YORK,COUNTY OF WESTCHESTER ) as: Ana Y1b nKA1 R lam►S'�-b being duty sworn,deposes and states that he/she is the applicant above named,and does further (print name of individuk signing as the ap licant) state that(s)he is the M C% Y It° A1' lQYlfor the legal owner and is duly authorized to make and file this application. (Master Electrician/Licensed Installer) The undersigned further states 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 r PA Sworn to before me this _� (v day of 40e-&&r,,20 e _ day ofCC 20� Signature of Property Owner AgIn6ture of Applicant Lee-"DtTS W%, i- ICI ) t2�-cSSb Print Name of Property Owne Print Name * icant Notary Public Public C(0)NOR LAUGHLIN Notary Public State of New York No.01 MC6400842 Noah, ,,�uW10,19"at Nam(* 4 Qualified In Queens County Z7 t, tl1 ;CA920110 Commission Expires November 25,20_ C)u�tt�;r;y In P~ft"I r; , .,,►xiatl040"may STATE WIDE INSPECTION SERVICES, INC. Service With Integrity 080 • • SWIS JOB APPLICATION0. • Office Use Elect. Permit# �/ , Date Bldg Permit# p��y d/ 7 S9 Ft Plumbing Permit# Final Certificate# City/Village r� ��e V Zip Building Dept. County Address 2y I e�! F� t� Rd Cross Street Section Block Lot Owner Name+/Address(If different than above) L e Contact Number ❑Basement ❑ 1st Fl. ❑2nd Fl. ❑3rd Fl. ❑More Than 3 Fl. ❑Garage ❑Attic ❑Outside ❑Residential ❑Commercial Receptacles Special Recept GFCI AFCI Switches Dimmers Smoke Alarms C/0 Detector Hood Trash Compact Amt Amps Range(s) Cooktop(s) Oven(s) Dishwashers Refrigerator Disposal Microwave Luminaires Generator Transfer Switch SERVICE Amperage #Panels 1P 3P # Meters # Disconnect ❑Underground ❑ New ❑ Reconnect ❑ Repair ❑Overhead ❑ Upgrade ❑ Disconnect Utility ID# ❑Con Ed ❑ NYSEG ❑Central Hudson ❑ Orange/Rockland PHOTOVOLTAIC SYSTEM PV Modules Inverters AC Disconnect Junction Box Combiner Box Load Center PV Monitor Energy Storage System DC Disconnect ❑Legalization 1 ❑ Safety Inspection ❑Consultation - d1S T // '� /✓e`�1 C�fCJT3 �u/ -ltdye, Al /rs�Ngt Re) k s �Se Ctr4 - �o � fJfr�o.sw/ �J,sh +'• sti�r. oca t L V1Sfo I� �CvJ pNtGts IVL e)e154-1v1q �OCa 7ro45, f r) biC4c _Q� [ �� G ��G I OCT 2 2 2024 VILLAGE OF FRY 'OOK BUILDIrJG DEPART ENT ; This application is valid for one(1)year from the date received by SWIS.This application is intended to cover the above listed items to be inspected,if at anytime of inspection additional items have been installed,you are authorized to make the inspection and adjust the fee for the additional items inspected.The applicant declares that there is no open applications for the above address with any other inspection company.The applicant, owner or authorized agent agrees to all the above terms and conditions as set forth for the application. Email Address t-/nar 1 , cowl Name 4r1 License# /5- S/ Date to/72`1 Signature Address (OQ &se 732- A f w City/State rJ l/ t Zip Code/USo y Company WC'i (aw,,vA yR G- Phone # YG / 1499's State Wide Inspection Services CA 1080 Main Street JAN - 7 2Q25 Fishkill, NY 12524 Tb AWAK U 3 845 2 Phone 914-219-119-1062 Fax STATE WIDE INSPECTION SERVICES Email: office(�)swisny.com Website: www.swisny.com Service With Integrity BY THIS CERTIFICATE OF COMPLIANCE STATE WIDE INSPECTION SERVICES CERTIFIES THAT: Upon the application of: Upon Premises Owned by: Wetlawn, Inc. Lee Dergtrus P. O. Box 732 24 Bellefair Road Armonk, NY 10504 Rye Brook, NY 12508 Located at: 24 Bellefair Road, Rye Brook, NY 12508 Section: Block: Lot: Electrical Permit Number: EP 24-208 124.73 1 78 Certificate Number: 2024-9244 Building Permit Number: BP 24-217 A visual inspection of the electrical system was conducted at the Residential occupancy described below.The electrical system consisting of electrical devices and wiring is located in/on the premises at: 24 Bellefair Road, Rye Brook, NY 12508 The First Floor Kitchen was inspected in accordance with the NYS and NFPA 70-2017 and the detail of the installation, as set forth below,was found to be in compliance on the 301' Day of December 2024. Name Quantity Rating Circuit Type GFCI 06 AFCI 02 Range 01 Dishwasher 01 Refrigerator 01 Disposal 01 Officer: Frank J. Farina This certificate may not be altered in any way and is validated only by the presence of a seal at the location indicated.This certificate is valid for work performed on the date of inspection only. s 1 44 • �' N N N W a aN x w w x Q w" V = o 0-4 O , L , UZ_ c7 r O a°o V oC > � W 00 t/) 0 " ►-� _, ►'� 7 x o � z � O � :w U v � C4 as Q o0 cn V W x oa a W Z udi a FFD) yE, 4Rnv� v BUIL E MENT VIL E OF RYE OK 1 OCT 2 2 2024 938 KIN ET RYE B ,NY 10573 - VILLAGE OF RYE BROOK BUILDING DEPARTMENT n . oV PLUMBING PERMIT APPLICATION L FOR OFFICE USE ONLY BP#: PP#: ��7 Approval Date: OC T 2 4 Permit Fee: $� V `/ Approval Signature: ` _ Disapproved: (fees are non-refundable) DO NOT START WORK or CONSTRUCTION UNTIL A PERMIT HAS BEEN ISSUED BY THE BUILDING INSPECTOR.THE ADMINISTRATIVE FEE FOR WORK PROGRESSED OR COMPLETED WITHOUT A PERMIT IS 12%OF THE TOTAL COST OF CONSTRUCTION WITH A MINIMUM FEE OF$750.00 Application dated,/D —ac1.gd is hereby made to the Building Inspector of the Village of Rye Brook NY,for the issuance of a Permit to install and/or remove Plumbing as per detailed statement described below.The applicant&property owner,by signing this document agree that said plumbing work will be in conformance with all applicable Federal,State,County and Local Codes. 1.Address: 2 a C t k t f CA;r fZ j3 SBL: 12�-/, 7 3 - I -5 g Zone:AM 2.Proposed Work: e4 44w4C L o A+;Q 0. a—locoM' 156 jz 3.Property Owner: _��+vn i e k(e i d Ki-)a✓1 t-L C C [�C S t5daress: 211 Q e l l c{ct( r Q cal Phone#: Cell#: &'i 1 4)14 7 4/ ` 5 1 (c G email: ► K 1 P_�cl mA✓1 Ama I. Covh 4.Master Plumber: f Y(n v1 K De v1 tt Address: '%U (,Un.A F1,0 D(i ve Starvtfpvd,(T 069o2- Lic.#: 132 Phone#: Cell#: 91 N Lit)) 7923 email: f n d ey Af'1 A 9rnc+3,(0&i Company Name: G n v, r G✓%MCA ArA 1 1 CAM HtgAddress: '?U Lori at 01 t 1 Dri v e S+C'm FC.'d, GT U bAju2 INDICATE FIXTURES&LINES TO BE INSTALLED AS PER THE FOLLOWING SCHEDULE: Location Water Urinals Drinking Sinks Showers Bath Laundry Domestic Fire Sanitary Natural/ Other* Total Closets Fountains Tubs Tubs Service Service Sewer LP Gas Basement 1 st Floor IL I 2nd Floor 3`d Floor 4's Floor 5th Floor Exterior 5.*List Other Equipment/Provide Details: (Notarized Signatures Required Next 2 Pages) -1- 6/1/2024 STATE OF NEW YORK,COUNTY OF WESTCHESTER ) as: rr(An K l7t'.n Ce ,being duly sworn,deposes and states that he/she is the applicant above named, (print name or IndivWunt signing as the applicant) find further states that(s)he is the Master Plumber for the legal owner and is duly authorized to make and file this application. 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 i/ Sworn to before me this t I rh day of 20_�(�_ day of Q C F D 'r ,20 2.9 Sign<ofwner Signatur of App Icant Le-C�CN, Print Name of Pro er Owner Print a e Y_ ©� C p Y I rail Name of Applicant Nona 'ublic �at i,t't6t �cgCC.f l t•�t�"j Notary Public ']'his application nnlst be properly completed in its entirety and must include the notarized signattire(s)of the legal owner(s)of the subject property, and the applicant of record in the spaces provided. Applications not properly completed in its entirety and/or not properly signed shall be deemed null and void and will be returned to the applicant. KARINA BRACHLOW NOTARY PUBLIC,STATE OF NEW YORK Reglstratlon No.01BR0019201 CONOM MCLAUGHLIN Quallfled In Westchester County (votary puh11c State of New York Commission Expires Dec.29,2027 No.01 MC840o842 ()ualified In Queens County Commission Expires November 25,20_znl -2- G:I%1Q2d BVIL MEN'T OCT 2 2 2024 L O YE UOK 938 KING T >�'Aft,BR NY 10573 L-- •-�r' VILLAGE OF RYE BROOK � I BUILDING DEPARTMENT ***ir*iJ:*•k**kh*isk•ki:**hJr****+'r**i:********,P.t***w•k****Yr****k•kk**•k**ir*******A•**•M*.k**•R•k***•k*******hf.*h******** AFFIDAVIT OF COMPLIANCE VILLAGE CODE §216 • STORM SEWERS AND SANITARY SEWERS THIS AFFIDAVIT MUST BEAR THE NOTARIZED SIGNATUR.4: 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 6Y. RETURNED TO THE APPLICANT. STATE OF NEW YORK,COUNTY OF WESTCHESTER ) as: , residing at, add`7rt'TCw let toy (On} (i'riol wore) (Address 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; �Y-'— 3C•►oK , ))� 3 , Rye Brook,NY. (-!oh J%udrvs�) 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. (Signature:of Prc>{icily Oaner(s)) - — W . l Name of Property( wn.r(s)) -- - Sworn to beE'ore me this CONOR MCLAUGHLIN Notary Public State of Now York day o P— �� _ 2-�-_ No.0 i MC6400842 Qualified in Queens County Commission Expires November 25,20V (Notay Public) -- -3- 6!I n024 x i x = a W � C a 3 � k Y z w Zo O. rr N M PG Gv wu QJ cn 4J ■ O � rTl � � g � -� .� � o c1. ,2� Lin 0 ell a xCA ■ W / vt M fR W = v O ed v �T O J a � q V O N a. F oA 'd C. a V w z wz '� '� � R ° Z ' , Q Acn. w e 9 oz � — F- z W F o z ° . wo v L o oW _ V 8 y u O i x c yEQRnI� D VILL OF BROOK BUI NG DEP MENT OCT 3 O 2024 3D 938 KING T YE K,NY 10573 VILLAGE OF RYE BROOK (914)939 rookn . ov BUILDING DEPARTMENT APPLICATION FOR PERMIT TO INSTALL, MODIFY AND/OR REMOVE MECHANICAL E UIP NT OFFICE USE ONLY; _/ Permit#: �/� -/ Building Inspector:_ _ Date of Approval: OCT 3 1 2024 Permit Fee: � � Bldg/Use Class: Res.( ); Comm. ( ); DO NOT START WORK or CONSTRUCTION UNTIL A PERMIT HAS BEEN ISSUED BY THE BUILDING INSPECTOR.THE ADMINISTRATIVE FEE FOR WORK PROGRESSED OR COMPLETED WITHOUT A PERMIT IS 12% OF THE TOTAL COST OF CONSTRUCTION WITH A MINIMUM FEE OF$750.00 it*dtkkkkkkkkkkkkkkkkkkkkkkkvk*kkkkkkkkkkkkkk*ieitk*kit*kkkkkkkkkkkkkkkkkkkkkkkkkk##k*kkk#kkk REQUIREMENTS FOR RELEASE OF PERMIT: (A CERTIFICATE OF COMPLIANCE Is REQUIRED TO CLOSE OUT THIS PERMIT) 1. Properly Completed&Signed Application. 2. Payment of Application Fee: Residential =$100.00; Commercial =$250.00(fees are non-refundable) 3. Site/Staging Plan as required by the Building Inspector. 4. Sealed Construction/Installation Documents&Specifications as required by the Building Inspector. 5. Copy of Licensed Contractor's Liability Insurance. (Village of Rye Brook must be listed as certificate holder)& Workers Compensation Insurance on a NYS Board form (Form#C105.2 or Form#U26.3/or NY State Workers Compensation Waiver) 6. Payment of Permit Fee: Residential=$18.00/1000.00 of Construction/Materials Cost with a minimum fee of$150.00. Commercial=$25.00/1000.00 of Construction/Materials Cost with a minimum fee of$275.00. 7. Inspection by Building Department for removal and/or installation. fax hour notice required) 8.Any electrical work requires a separate Electrical Permit and Electrical Inspection. 9.Any gas/plumbing work requires a separate Plumbing Permit and Plumbing Inspection. kkkk*kkkk*kk*kkttkkkkkkkkkkitkdt itkkkkkkkkkkkkkkkkkkkkkkkkkkkk*kkk*kkkkkkkkkkkkkkkkkk**fit�It4t Application dated, is hereby made to the Building Inspector of the Village of Rye Brook,NY,for a permit for the installation,modification,and/or removal of the specific Mechanical Equipment as listed below.The applicant and property owner,by signing this document agrees that said equipment will be installed and/or removed in conformance with the approved plans,and with all applicable Local,County,State&Federal laws,codes,rules and regulations. I.Address: Z 4 &-kke-fau r V-a SBL: i 2-H•-7 - I ' S$ Zone: i2- -3 2.Property Owner: )ojy�k( K 106 ty\Gin c.hd Lc e 6C�9Stet►n Address: 2� Q I1P4G1iV '�.cl Phone#: 9iL4 47LI - 5960 Cell#: email: Re lnCdgrnc.,l,l6w\ 3.Contractor: DTT RQSCYYI t-) L(,C Address: 2bS VOLMy Rd &L CUb CT 06WI Phone#: S33`3M to Cell#: email: O-M(f I-osci tc on-t,ne } 4.Scope of Work:New Installation( ) Replacement )•Removal( )•Other( ) 5.Type of Equipment: - _ hp 6.Location of Equipment: K� k1 M,ey�, 7.Cost of Equipment including Installation Cost: $ 3.,0 0 00 1 6/1/2024 STATE OF NEW YORK,COUNTY OF WESTCHESTER ) as: v dteuu a ySChtc DRA I?IF RoyrnNxx►t i.l.C,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 Mechanical Equipment Contractor for the legal owner and is duly authorized to make and file this application,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&Buiiding 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 `2-`I th day of ,20 Z.- dayof_6(,tObCr ,20 'I'l y SignatunS of Property Owner St ahir of Applicant L2Q_-3'eA) '-tf�kJ AA View yt�tyiniG Print Name of Property Owi r Print Name of Applicant J)" St'�k6'- Notary Public Notary Public 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. KARINA BRACHLOW CONOFI MCLAUGHLIN NOTARY PUBLIC,STATE OF NEW YORK Notary Public State of New York Registration No.01 BR0019201 No.of MC6400842 Qualified in Westchester County Qualified In Queens Coun Commission Expires Dec.29,2M C.ommission Expires November 2 20 2 C/Ii2024 VC16B36ZS - 36-INCH CUSTOM INSERT Thermador MASTERPIECE® SERIES PROPERTIESGENERAL Operating Mode Ducted or Recirculating Maximum CFM(Blower) 600 CFM Motor Location Integrated Motor Number of Speed Settings 4-Stage Number of Lights 2 Bulb Type LED Light Lumens 100—150 C&S 0HomeConnect Light Color 3500-4000K Total Power of the Lamps 6 W Damper Included Yes FEATURES & BENEFITS Suitable for standard cabinet depth applications Grease Filter Material Dishwasher Safe Aluminum Four fan speeds Grease Filter Type Perimetric Built-in'clean filter'reminder light illuminates after 40 hours of Home Connect®(Wi-Fi Enabled) Yes operation Auto mode allows the hood to adjust its speed according to TECHNICAL DETAILS the cooking style Watts 338 W Delayed shut-off tackles lingering odors for up to 10 minutes Current 3.3 A -Powerfully quiet®ventilation systems Volts 120 V -Equipped with the Thermador Connected Experience by Home Frequency 60 Hz Connect® Plug Type Hardwire Power Cord/Conduit Length N/A ACCESSORIES •• • DIMENSIONS Recirculation Kit&Replacement Charcoal Filter Overall Appliance Dimensions 10 1/2"x 321/2"x CHFVC136ZS-For VC13B36ZS and VC16B36ZS Masterpiece® (Width of Canopy Included)(HxWxD)(in) 10 5/8" Custom Inserts only Minimum Distance Above Gas/Electric 24" Electric/30"Gas Remote Control Panel Cooking Surface REMCPW-Ability to vertically install on cabinetry or wall to Diameter of Air Duct(Top) 8" control hood in a convenient location Net Weight 27 lbs. WARRANTY Limited Warranty Parts and Labor 2 Years 1 2 a < .1. 1-1. 10 11 S.. Installed in framed cabinets Installed in frameless cabinets Page 1 of 2 7/23 t VC16B36ZS 36-INCH CUSTOM INSERT Thermador. MASTERPIECE® SERIES HOOD DIMENSIONS CUTOUT FOR INSERT Measurements in inches(mm) Measurements in inches(mm) 31/4 83/ ( ) 257 /� (A) 4'/8(105) a..(203) 10'/4 A:Location of duct opening(from (260) back inside edge of cabinet) 317/e B:Min.height for vertical (810) discharge=15"(381 mm),min. height for horizontal discharge 105/e 321/2 70)'I (826) (B) or recirculation=27"(686 mm) (2 '' A:Total height 32(812) C:Pending model/blower size - With 6"duct transition= 123/4"(324 mm) - With 8"duct transition= 125/e"(321 mm) OPTIONAL ACCESSORIES REMOTE CONTROL PANEL REMCPW "214%" 2�s" (65) .......(A) Convenience at your fingertips:The remote control accessory offers the freedom to extend your hood controls to a more reachable spot (365) A:DBus Cable length:30 feet(9180 mm) measurements in inches(mm) HVI PERFORMANCE VALUES Pressure(in.H2O) Power(W) CFM Sones Exhaust High Working High Working I High Working High Working Duct Size Speed Speed Speed Speed Speed Speed Speed Speed Vertical 8 in. 0.01 0.01 345 79.4 520 170 10.5 1.0 Vertical 8 in. 0.25 .25 — — 500 — — — These warranties give you specific legal rights and you may have other rights that vary from state to state.Limited warranty from date of delivery.For complete warranty details,refer to your Use &Care manual,or ask your dealer. Specifications are for planning purposes only.Refer to installation instructions and consult your countertop supplier prior to making counter opening.Consult with a heating and ventilation engineer for your specific ventilation requirements.For the most detailed information,refer to installation instructions accompanying product or write to Thermador indicating the model number.Specifications are correct at time of printing.Thermador reserves the right to change product specifications or design without notice.Some models are certified for use in Canada. Thermador is not responsible for products that are transported from the U.S.for use in Canada. 1 800 735 4328 1 USA THERMADOR.COM I CANADA THERMADOR.CA 1 02023 BSH HOME APPLIANCES CORPORATION.ALL RIGHTS RESERVED. Page 2 of 2 7/23 .: o L� O O O •- 4--1 O E- O O � > O O � a O o Q) a) m � O O +' E � O Q > O E O O O (D m �= I � 00 Q) U N — N LL- Q O r-- O O O O C) r0 f "' N Q) O i O O O H O O z -0 X cv w M - > E -Ln CEO N Q� z rn ~ l/•1 O N OWN J Q0 W c J 0 �o Q O V a) � (n �I O a) O n cD \\ Building Permit Check �L�is�t/&Zoning Analysis 6 Address: Q 11(� Q 1 (— u SBL• _ Zone: �1 Const.Type: -- Other. Submittal Date: ZLI Revisions Submittal Dates: Applicant: Y \ % Q `^ \r Nature of Work: Y \ + \c1 1 (� 7 2024 Reviews: _. O C T — P& BOT: Other. NEED OK ) � � Q- (+� FEES:Filing. P: C/O: Flood Plane: Legalization: APP: Dated: Notarized: SBL: Truss I.D. Cross Connection: H.O.A.: ( � ( ) Scenic Roads: Steep Slopes: Wetlands: Storm Water Review: Street Opening. ( ) ( ) ENVIRO: Long. Short: Fees: N/A: ( ) ( ) SITE PLAN:Topo: Site Protection: S/W Mgmt.: Tree Plan: Other. ( ) ( ) SURVEY:Dated: Current Archival:- Sealed: Unacceptable: ( ) ( � PLANS:Date Stamped: Sealed Copies?� Electronic Other: License: Workers Comp: Liability Comp.Waiver. Other. ( ) ( ) CODE 753#: Dated: N/A: (L ( ) HIGH-VOLTAGE ELECTRICAL:Plans: Permit: N/A: Other. ( ) O LOW-VOLTAGE ELECTRICAL:Plans: Permit: N/A: Other. (� ( ) FIRE ALARM/SMOKE DETECTORS:Plans: Permit: H.W.I.C.:_Battery:_Other. (� ( ) PLUMBING Plans: Permit: Nat. Gas: LP Gas: N/A/: Other. ( ) ( ) FIRE SUPPRESSION:Plans: Permit: N/A: Other. ( ) ( ) H.V.A.C.: Plans: Permit: N/A: Other. ( ) ( ) FUEL TANK:Plans: Permit: Fuel Type: Other. ( ) ( ) 2020 NY State ECCC: N/A: Other- Final Survey Final Topo: RA/PE Sign-off Letter. As-Built Plans: Other. ( ) ( ) BP DENIAL LETTER: C/O DENIAL LETTER: Other. ( ) ( ) Other. ( )ARB mtg. date: approval:- notes: ( )ZBA mig. date: approval: notes: ( )PB mtg.date: approval:- notes: REQUIRED EXLSMNG PROPOSED NOTES Area: Circle: Sf FronjWe• Front Front: Sides: Rear. Main Cov Accs.Cov Ft.H Sb: Sd.H Sb: GFA: Tot-Imp: Ft.Imp: Parkmw. Height/Stories: notes: ". '��•'7, -•. "fi'A�4'r4 TS�A t• .SA>n. _.fin '� huh r i %%%aainnn��• $y h _ k,,y,: y�^y' Ay7�� >t.- - )'uq Y •} IfIF tt11)IIIIErT f163$ (7f 'tj11f1( 1�: ' �. 1)+�1'/ '/+� i�;f'all�lf t "ti _r r••i�yR" '� `%at 7s)i ysz�..,hl P! 3fdt - ' 1�• �,fl l 1 1 t.�af....:Li�l�Iv��l l�.Gs� /' to y ��.. 11�11 -•�. t 1��4ff �y. L �.I+�a��i�Li �(0)1,. MS, pC ice C y �� C 21 LO LLI 0 Cl) ••+ f 1 ec p i~ d U aR. cn CD } U y E l^ y W m s Ew O LU Vl J CAO L� Q _ y • w M Q U C1 G LL) c�, U c > c z µ Toil- G� G� Xcome - 4 o C n. cc ; R so o O •� .0 U = _ V = E) k �tc�,,+w► ,L�"��' �:c-� r�r 1'�`�aR� . . ---rr. items)); ( E qA,/ 1 1+11�IItE __;�,11�11,1 .11IIIIIEE Vol got.. s ",• 'tt• ��� A� 1. Si ,`� �!`.11�A � / �+�, �^ �S .,F ♦1 ' 171�A '�i�y, I� P• A� tgt,E��� � A "C Of"'I 9�• �. qy ygS `k Nf. /�'d �{ .rv� ¢ & •1, yid g �E _T. 7,111%9 ' 111 ".'��u9' :-, •. .•yam vr�9+' DTFROSE-01 SCHASS ACORO CERTIFICATE OF LIABILITY INSURANCE FDATE D/YYYY) 4/17/21712024 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 CT `Susan ChassagnouX Cross Insurance—Westport �UMIEIE HONFAX One Turke Hill Road South A/c,No,Ext):(203)655-6974 118 (A/C,No): Westport,CT 06880 ADDRIE :susan.chassagnouX crossagency.com INSURE S AFFORDING COVERAGE NAIC N INSURER A:Selective Insurance Company of South Carolina 19259 INSURED INSURER B: DTF Rosemount LLC INSURERC: 288 Valley Road Suite 201 INSURERD: Cos Cob,CT 06807 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 POLICMlill DY EXP LIMITS A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE X OCCUR S 2512283 1/15/2024 1/15/2025 DAMAGE TO RENTED $ 500,000 MED EXP(Any oneperson) $ 15,000 PERSONAL&ADV INJURY $ 1,00000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 3,000,000 X POLICY❑jp& LOC PRODUCTS-COMP/OP AGG $ 3,000,000 OTHER $ A AUTOMOBILE LIABILITY COMaBBIINdEDtSINGLE LIMIT $ 1,000,000 X ANY AUTO 2512283 1/15/2024 1/15/2025 BODILY INJURY Per n $ OWNED SCHEDULED BODILY INJURY Per accident $ AUTOS ONLY AUTOS BODILY R AUTOS ONLY AUOTO�ONLY Pe�a�dent AMAGE $ A X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 5,000,000 EXCESS LIAO CLAIMS-MADE S 2512283 1/15/2024 1/15/2025 AGGREGATE $ 5,000,000 DED I I RETENTION$ A WORKERS COMPENSATION X PER OTH- AND EMPLOYERS'LIABILITYISTATUT ER ANY PROPRIETOR/PARTNER/EXECUTIVE Y/N C 9097880 1/15/2024 1/15/2025 f 1,000,000 WFIC ER/MEMBER EXCLUDED? ❑ NIA E.L.EACH ACCIDENT $ (Mandatory in NH) E.L.DISEASE-EA EMPLOYE $ 1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below _T E.L.DISEASE-POLICY LIMIT S 1,000,000 e DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Village of Rye Brook is shown as an Additional Insured on the General Liability policy as required in the written,signed and executed Agreement/Contract directly with the Named Insured subject to all terms,conditions,and exclusions of the insurance contract in place for 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 Street ACCORDANCE WITH THE POLICY PROVISIONS. Rye Brook,NY 10573 AUTHORIZED REPRESENTATIVE A 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 1 a. Legal Name 8 Address of Insured(use street address only) 1 b. Business Telephone Number of Insured 203-533-3076 DTF Rosemount LLC 288 Valley Road,Suite 201 Cos Cob,CT 06807 1 c.NYS Unemployment Insurance Employer Registration Number of Insured Work Location of Insured(Only required if coverage is specifically limited to 1 d. Federal Employer Identification Number of Insured or Social Security certain locations in New York State,i.e., a Wrap-Up Policy) Number 26-4035807 2. Name and Address of Entity Requesting Proof of Coverage 3a. Name of Insurance Carrier (Entity Being Listed as the Certificate Holder) Selective Insurance Village of Rye Brook 3b. Policy Number of Entity Listed in Box 1 a" 938 King Street Rye Brook,NY 10573 WC9097980 3c.Policy effective period 1/15/2024 to 1/15/2025 3d.The Proprietor,Partners or Executive Officers are ❑ included.(Only check box if all partners/officers included) Z all excluded or certain partners/officers excluded. This certifies that the insurance carrier indicated above in box"Y insures the business referenced above in box"1 a" 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: Susan Chassagnoux (Print name of authorized representative or licensed agent of insurance carrier) Approved by: 56Za� 4,17/2024 (Signature) (Date) Title: Commercial Account Manager Telephone Number of authorized representative or licensed agent of insurance carrier: 203-635-1084 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 z U) Z W U Z LLI i— P � O = O LO Z (n Q a 7 �"- Q 00 O Q ip p F-- a_ �(. *�-AllU �•. Y F' L ■ C'� ZOOr,.a > �1W-C' .�0� �G Oz LL O��oN O z xzz �.,�g°`� 3 ��. 1 1 ( °�� 06 O U 1 U W z _ _ W Z) p �(% J z F N � UMS Z t0 LL �" v�+✓� o w� z-j LO ' A W a O OUP v � / N �a W 0 -1 ®.-. M�1 O o F- ❑ w O mN > �, Q\ M o W z c� � z °D cr z v> W \ w_ O z = 0�UNo W W m m a WQO �6. �` € U z � C/) c� 00 � ., b Z W rx 2 �S `� p Z U W 00 o 2 W U N c"n W J it � _ w ow 0- CO) N F- Q a. 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