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HomeMy WebLinkAboutBP24-222PERMIT # /=�- 10�- DATE�U �y OR SECTION 1 (D O BLOCK TYPE OF WORK �t I7 O/ OJ � JOS LOCATJON __ _/0 7 Ze /i7 Sow OWNER/CO, / 1�)el rPlQ Ton Sn 3 CONTRALTO E10 O* TCO � FEE DATE LOT FOOTING FOUNDATION FRAMING RGH FRAMING INSULATION PLUMBING 02 RGH PLUMBING GAS 0 SPRINKLER DATE L2.- b -Zol>( INSP dw Z 0 ELECTRIC O IOW -VOLT O ALARM C� AS BUILT O FINAL 1 2 a2S �A3S2—?� Q� s� C9/41)341e- 0s8/p !iSS1V el/4 ( W)7/S 7aS OTHER APPROVALS ARB BOT ZBA OTHER VILLAGE OF RYE BROOK WESTCHESTAR COUNTY, NEW YORK No• 25-013 �_ f32� 0 Certificate of Occupaucp This is to certify that T�Q�/ f'lff AVY1 - l/I�/�j'J0 4 JtJ11' _ (YP 'j'JQy//'� &C1_7 of, Bkno Je, ! ) 7 having duly filed an application on C_a4 U 'p-a 4440, 20 requesting a Certificate of Occupancy for the premises known as, "/ /i(/1 n �QY Rye Brook,NY, located in a Zoning District and shown on the most current Tax Map as Section: / V Block: / Lot: , and having fully complied with the requirements of the Building Code and the Zoning Ordinance under Building Permit No. 2y , issued 20_C�V, such authority and permission is hereby granted to the property owner to lawfully occupy or use said premises or building or part thereof listed under the following New York State Classifications, Use: G Construction: , for the following purposes: 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 ' t shall be made,nor shall the building be moved from one location to another until a permit to accomplish such change\as be n obt ' fro e gilding Inspector. Building Inspector,Village of Rye Brook: Date: Ali/.26a.- BUILQBROOK, For office use nl PERMIT# VIL ISSUED: �" 938 KING STREYORK 10573 DATE:JAN - 6 �t,s., FEE: i ��PwID 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: ss►srss►►►►►►//►��►ss►►►►►ss►►►►►►rrwwrssrrrsrrrrrrrrrrrssrrssrrr►►►►►r►s►srs►►►►♦ss►sgss►►►ssr►►►►s♦►►ss►wwrr►r►rw►rs►s►►►►s►►s ( Vlki A Occupancy/Use:: '— >/L arcel ID#: — Zone: Owner: t`-"`F°`-C( *_Vw-'A Address: P.E./R.A.or Contractor: J 5 14 Uv1-C Address: 03 1 1 to 0 Pv � Aw . (Ar"c Aw%CU Lc r 0(dr6 Person in responsible charge: Re'F ( Address: (0 k W:yUA sv v (L Q 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: Lj� A 4 e"�" being duly sworn,deposes and says that he/she resides at 64 w I'A A SD V 1p (Print Name of Applicant) (No.and Street) in la.-� VaV" _ ,in the County of �� �� in the State of��,that (City/Town/Village) he/she has supervised the work at the location indicated above,and that the actual total cost of the work,including all site improvements, labor,materials,scaffolding,fixed equipment,professional fees,and including the monetary value of any materials and labor which may have been donated gratis was:S 7 3 '�_v O • 0 U for the construction or aheration of: 6,f'Av%9,�VA Deponent further states that he/she has examined the approved plans of the structure/work herein referred to for which a Certificate of Occupancy/Compliance is sought,and that to the best of his/her knowledge and belief,the structure/work has been erected/completed in accordance with the approved plans and any amendments thereto except in so far as variations therefore have been legally authorized,and as erected/completed complies with the laws governing building construction.Deponent further understands that it shall be unlawful for an owner to use or permit the use of any building or premises or part thereof hereafter created,erected,changed,converted or enlarged,wholly or partly,in its use or structure until a Certificate of Occupancy or Certificate of Compliance shall have been duly issued by the Building Inspector as per§250-IO.A.of the Code of the Village of Rye Brook. Sworn to before me this Sworn to before me this tL_ day f ;y 0, V1 U , 20 day of ,20 /t 15 S Lion a Pioladirty Owner Signature of Applicant �� e vw-" � ltPr t Name of Property Own Print Name of Applicant No ublic Notary Public SHARI MELILLO Notary Public,State of New York No.01MIE6160063 6/I/202a Qualified In Westchester County,7� Commission Expires J�ru. y 29,20— _yE BRC��. 1982 BUILDING DEPARTMENT ❑BBWLDING INSPECTOR BASSISTANT 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 : In VV 1 ��(7 QOC C'1 DATE: - / / - Z, OLs PERMIT# y\ 29 Z,-2,Z- ISSUED: /y-Z Z- Z%SECT: BLOCK:_LOT: LOCATION: n 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 / /� �yE BRQ) cu � 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 : L 1 W I rj � O r DATE:! _ ;p - L c.1 L V PERMIT# ?a q ! / t/ ISSUED: SECT:13 S ,6, BLOCK: LOT: 2 6 LOCATION: Se( -�,� A y I o) � _ ��l OCCUPANCY: ❑ VIOLATION NOTED THE WORK IS... E ACCEPTED ❑ REJECTED/ REINSPECTION ❑ SITE INSPECTION REQUIRED ❑ FOOTING ❑ FOOTING DRAINAGE ❑ FOUNDATION ❑ UNDERGROUND PLUMBING NOTES ON INSPECTION: 0 ROUGH PLUMBING ❑ ROUGH FRAMING ❑ INSULATION ❑ NATURAL GAS ❑ L.P. GAS ❑ FUEL TANK ❑ FIRE SPRINKLER ❑ FINAL PLUMBING ❑ CROSS CONNECTION ❑ FINAL ❑ ,OTHER s N N CV N N � �u,� • P-4 CD cn ►-i A W 0 a ^� � � m z a � a v 0 nov p� W to ILA • aCN v d f rl e 0 0 A w° T _ �Qj ►�+ n O O g o v L W a O W O C CA © w M CA W 4 ", bQ � V - Q H x z w v w MA � Q W CA � v rC Ada .5 n � : W w w o zz 71 � v �••� H O 0 z oA y V ° ° � w � Z v p v �• ° Ug � y ed W cn O w BUILDING DEPARTMENT ECENE VILLAGE OF RYE'. OOK SEP 12 2024 938 KING STREET RYE BRt�,NY 10573 („ 4 0668 VILLAGE OF RYE 'BROOK wrwi t 'ov BUILDING DEPARTMENT INTERIOR BUILDING PERMIT APPLICATION FOR OFFICE USE ONL Approval Date: SE 1 2 -2024, 4/4 t 0"Application Fee:$ M0, Approval Signature: Permit Fees: Disapproved: Other: L Application dated: �� —3 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 fora change in use,as per detailed statement described below. �/ ,-1. Job Address: b� I ry� ©� {� SBL:/13�1��`d�0 Zone: 40 2. Proposed Improvement.(Describe in detail): C.G1ell/lxcf. -F M S i �10 0 V S , UatlO 'flub 1 SI/10WP—V, St& kV' i V'e. S 0w kU If`p tt-f la(.Q K-A u 3. Does the proposed improvement involve a Home-Occupation as per§250-38 of the Code of the Village of Rye Brook? No: ✓ Yes: If yes,indicate: TIER 1: TIER 11: TIER III: 4. Will the proposed project require the installation of anew,or an extension/modification to an existin 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;(I fam.,2 fam.,comm.,etc...)Prior to Construction: After Construction: 6. MY State Construction Classification: N.Y.State Use Classification: 7. Propetty Owner:�r" K.Vveyk Address: 0 WLLOSOV O0k L.!N_y Phone#-LL~3Lt 110' jL4 - Cell# lS Owe-) email: - f' a J C Inner►t (�C0 vv► 8. Applicant: Address: Phone# Cell# email: 9. Architect: Address: Phone# Cell# email: 10. Engineer: Address: Phone# Celli# email: 11. General Contractors 0,9tAro�pli�it 'C re �� C /�3 S .f �✓pp,7Lw1�H C'iT Phone#,,-173—7),5--70&-1 Cell# /u S Si l yeil-A 12. Estimated cost of construction $ �31 5-0 0 ' (NOTE:'fhe estimated cost shall include all iabor,material,scaffolding,fixed equipment,professional fees,and material and labor which may he donated gratis.) 13. Job Timetable: Start: Finish: (1) 6/I/2024 Q BUILDING DEPARTMENT DD VItET OF RYE $ROOK SEP 12 2024 938 K[Nc RYF,BR00�,NY 1057339_()lVILLAGE OF RYE BROOK ov BUILDING DEPARTMENT 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: I, A�A E L , residing at, cl IN I Qb S 0 K (Prini name) (Address where you like) 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; wINoso�_ tb ) �" e ji taooy, NL( tG��l_� , Rye Brook,NY. (Job Addre,�) 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. L'i � L( — (Signat re of Property Owner(s)) (Print Name of Property Owner(s)) Sworn to before me this of 20�� (Notarc Public) SHARI MELILLO ,Votary Public,State of New York No.01ME6160063 Qualified In Westchester County Commission Expires January 29,20L (2) 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. STOAT MOFN YORK,COUNTY OF WESTCHESTER ) as: G1 � 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. 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 Sworn to before me this day o , 20 day of , 20 Signature of Property Own er Signature of Applicant Ra;lf'� ( Pr ame of Property Owner +1\�I Print Name of Applicant Notary Publi�HARI MELILLO Notary Public Notary Public,State of New York No,01ME6160063 Qualified In Westchester County Commission Expires January 29,203j, (4) 6/1/2024 S 3 N N OL �' N N "� • 0-4 z v� I W J CL N O w y k � 000 ^ E �7 ` I-I W O IZ N p O C4 (L W a ■ � � z LL: QC0.4 L a iM—. z ..a 96 On co V oc zw , � C7 r aoc w a O F 'g ~ ` zo aG S .� w w w Ln 09, x CN H o u A w � w = � w [7, BULL EPARTMENT VILLAGE OF RYE BROOK NOV 2 6 2024 ,—P 938 KING STREET RYE BROOK,NY 10573 \\� 4)939-0668 VILLAGE OF RYE BROOK vt�.Up.�rookny.gov RUll_F)!N(7, DEPAR—IMENT PLUMBING PERMIT APPLICATION FOR OFFICE USE ONLY 13P #: Approval Date: �� �� Permit Fee: $ /5 G C Approval Signature: Disapproved: NZ (fees are non-refundable) 00 NO SIAKT �kORK or CQNSI RL,C 110,A USN I iL A Pt.i0,11 I HAS BIA. N (SSULD BN 111L BUILDING INSPECTOR. THE ADMINISTRATIVE FEE FOR WORK PROGRESSED OR COMPLETED WITHOUT A PERMIT IS 120/, OF THE TOTAL COST OF CONSTRUCTION WITH A MINIMUM FEE OF S750.00 Application dated, 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. —7 1.Address: , r 9 ti� fav� SBL: /3 i 6Q O— —C e0 Zone: )r/�— / 2.Proposed Work: � ( +��n (A i �+o: t�- O�z 5:n',',�/ o►^a.. S"Uj tr 4+Le. q �u 3.Property Owner: Af e d ��(/ Address: G5 w' Phone#: Ap 3—1600-'631y Cell#: email: I Gov►' 4.Master Plumber: MoerG /V`o,Wort Address: 15f 13r0AAg e_rc, R_n( Lic.#: 1409 PhAonAe#: Cell#: clo ?a7-_7,9a_email: ✓ \g IY+o n a/�►( ,e Company Name: Y v 1 --,ram F k wmvk rT__Address: ) �3 ro r,,,,�r+�rc,r,� lQ 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 2nd Floor 1 i s 3'd Floor 4'1'Floor 51'Floor Exterior 5.* List Other Equipment/Provide Details: �LOW t.,— V G v Y✓� G I (Notarized Signatures Required Next 2 Pages) -I- 6/l/2024 STATE OF NEW YORK,COUNTY OF WESTCHESTER ) as: �Aa M A 14 h h ,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 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/b�effi e e this � ` Sworn to before me this d of VC ,20 _ day of d C �JC—f ,20 e—`- 4 1;&e h4�� , - ture o r Signature o pltcant "( P A;11 y A LZ 4D/U int Name of Property Owner Print Name of ican Pq otaPblic,State of New York N u t No.01ME6160063 G�t Qualified In Westchester County Commission Expires January 29,20� 1 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. 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. -2- 6/1/2024 BUILDING D"TMENT VIL AGE OF RYE BROOK 938 KING STREET RYE B1104 NY 10573 NOV 2 6 2024 (914)9 0668�:/ VILLAGE OF RYE BROOK "oN BUILDING DEPART VENT 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 O,FF NEW tY,ORK,COUNTY OF WESTCHESTER ) as: 35, P-1�" Q/t (_�' VV4114- , residing at, I&II -OV (Print name) (Address where you liN c) 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; \Ai I A�)a, ��',� 6VU _ �� l C j , Rye Brook,NY. (Job Address) Further that all statements contained herein are true, and that to the best of his/her knowledge and belief,that there are no known illegal cross-connections concerning either the storm sewer or sanitary sewer, and further that there are no roof drains, sump pumps, or other prohibited stormwater or groundwater connections or sources of inflow or infiltration of any kind into the sanitary sewer from the subject property in accordance with all State, County and Village Codes. (Signature of Property Owner(s FCL,'1 (Prin Namc ot'Property Owner(s)) Sworn to before me this day of � , 20 c��1 (Notary Public) SHARI MELILLO Notary Public,State of New York No,01ME6160063 Qualified In Westchester County y� Commission Expires January 29,20(� / 3- 6/1/2024 c� diing,Permit Check List&Zonin Anal is Address: _l \ 0 UN SBL• Zone:- Use: 2 V Const.Type: Off; Submittal Date \Z I \2�` Revisions Submittal Dates: Applicant: t ( 1�a Nature of Work t_j (Df r� C-�1 V4 cX—b Reviews:ZBA:S F P 0 BOT: Other: NEED OK ` Q° ) Z (�l�FEES Filing: BP: �� 3 C/O Flood Plane: ( ) (� Legalization: APP: Dated: �Notari7xd �SBL Truss I.D. Cross Connection: H.O.A.: ( ) ( ) Scenic Roads: Steep Slopes: wetlands: Storm Water Review Street Opening: EI%IVIRO: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: ( ) ( ) Dated N/A: (� ( ) HIGH-VOLTAGE ELECTRICAL.•Plans: Permit: N/A: Other; 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•dates approval: notes: ( )ZBA mtg.date: approval:- notes: ( )PB mtg.date: approval:- notes: REQUIRED EXISTING PROPOSED NOTES S E P 1 2 2024 Area. Qate: Circle: Fronta C Front: Front: Sides: Rear. Main Cov: Accs.Cor. Ft.H Sb: Sd.H Sb: GFA: Tot Lmw P� Height/Stories notes- Laura Petersen From: Rafael Herrera <rha2009@gmaii.com> Sent: Friday, October 18, 2024 5:21 PM To: Laura Petersen Subject: Re: 69 Windsor Road - Interior Building Permit Application for Bathroom Attachments: Mateus certificate .pdf, DBL COI JS HOME TO RAFAEL.pdf;WC COI JS HOME TO RAFAEL.pdf Hi Laura, Here is the requested contractors information; �X v � o 1) Contract's contact name: Mateus Silveira. Phone number: (203)7157065 2), 3), 4)See attachments 5)Completed payment today. Have a great weekend. Regards, Rafael On Mon, Oct 7, 2024 at 8:47 AM Laura Petersen <LPetersen ryebrooknv.gov>wrote: Good morning, Once I receive the information (which can be emailed) it should only take a day or two. Payment can also be made on our website ryebrookny.gov. Thank you Laura Laura Petersen Office Assistant Village of Rye Brook 938 King Street Rye Brook, NY 10573 (914)939-0668 1 From: Rafael Herrera<rha2009@gmail.com> Sent:Sunday, October 6, 2024 10:31 AM To: Laura Petersen<LPetersen@ryebrookny.gov> Subject: Re: 69 Windsor Road - Interior Building Permit Application for Bathroom Laura, Thank you. How much time does it take from the moment I send you the info you need to issue the permit?Also can I sent you this info via email and pay over the phone? Regards, Rafael On Fri, Sep 20, 2024 at 11:51 AM Laura Petersen <LPetersen@ryebrookny.gov>wrote: Good afternoon, The building permit application has been approved by the Building Inspector. Before I can issue the building permit the following items must be submitted to our office, 1. General contractor's contact name (first and last) & phone number. 2. Copy of general contractor's valid Westchester County Home Improvement License. 3. General contractor's valid liability insurance (the Village Of Rye Brook must be the certificate holder) 4. General contractor's valid workers compensation on a NY State Board form (C105-2 or U26.3) 5. Building permit fee $423.00 (due once permit is issued and ready for pick-up) Please let me know if you have any questions. Thank you 2 ww 1 I O I O C V = LO O a 0 X O i C L N La C-4 1 O i E L i to N C . j L U cr� 1I W c00 � � HC N a _ o Qco�ection w W WV14 VT V j JJ �'' •'� W Q `o p 1•r '" cu Ga o»,�„ J • (� C O z 3 s cz. �o � atacs iLLJ UJ IV Q ^a Pico» Q �s y v 'o ' re m r ^.r 04 N I •• '• � � ti>7 � r, L I 'o y s ch / � A.d H o Cl) \ •r v C! L 1 d Y HCA JSHOMEI-01 EDASILVA ACORO CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY)s/25/2o2a 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 NAME: Mirante Agency LLC 272 Main Street Ste 1 (A//CC,,Lo,E:t):(203)778-9676 (AIC,No):(203)778-9902 Danbury,CT 06810 ADDRE S S: INSURERS AFFORDING COVERAGE NAIC A INSURERA:Ohio Security Insurance Company 24082 INSURED INSURER B: JS HOME IMPROVEMENT SERVICES LLC INSURER C: 113 S Water St Apt#2 INSURER D: GREENWICH,CT 06830 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 win wynPOLICY NUMBER POLICY EFF POLICY EXP LIMITS LTR A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE EK OCCUR BKS60621899 8/10/2024 8/10/2025 DAMAGE TISESO RENTED(Ea occurrencel $ 300,000 MED EXP(Any one arson $ 15,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 29000,000 X POLICY❑JECT LOC PRODUCTS-COMP/OP AGG $ 2'000'000 OTHER: $ AUTOMOBILE LIABILITY ccidentl COMBINED SINGLE LIMIT $ ANY AUTO BODILY INJURY Per arson $ OWNED SCHEDULED AUTOS ONLY AUTOS SSWNE BODILY INJURY Per accident $ AURT D ONLY AUTOS ONLY Per acEdRdentDAMAGE $ UMBRELLA LIAR OCCUR EACH OCCURRENCE $ EXCESS LIAR HCLAIMS-MADE AGGREGATE $ DIED 1 1 RETENTION$ $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY Y/N I ER TA TE ANY PROPRIETOR/PARTNER/EXECUTIVE ❑ N/A E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Job location: Rafael Herrera 69 Windsor Rd Rye Brook NY 10573 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 St Port Chester, 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 PORK Workers' CERTIFICATE OF STATE Compensation NYS WORKERS' COMPENSATION INSURANCE COVERAGE Board 1 a.Legal Name&Address of Insured(use street address only) 1 b.Business Telephone Number of Insured IS HOME IMPROVEMENT SERVICES LLC 914-619-4739 113 S Water St Apt 1 1 c.NYS Unemployment Insurance Employer Registration Number of Insured Greenwich, CT 06830-6800 N/A 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 94-2829040 2.Name and Address of Entity Requesting Proof of Coverage 3a.Name of Insurance Carrier (Entity Being Listed as the Certificate Holder) AmGUARD Insurance Company Village of Rye Brook 3b.Policy Number of Entity Listed in Box '1 a" 938 King St JSWC594275 Rye Brook NY 10573 3c. Policy effective period 02/18/2024 to 02/18/2025 3d.The Proprietor,Partners or Executive Officers are included.(Only check box if all partners/officers included) X❑ all excluded or certain partners/officers excluded. hYs ceR,?',es t at a insurance carrier indicated above in box"3" insures the business referenced above in box­1 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: Adam Edelstein (Print name of authorized representative or licensed agent of insurance carrier) Approved by � 10/21/2024 (Date) Title: President Telephone Number of authorized representative or licensed agent of insurance carrier: 800-673-2465 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