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HomeMy WebLinkAboutAbandoned Application Q Building Permit Check List&Zoning Analysis Address: - l ` vi d V F SBL Zone:-- S Use Const. Submittal Date: 2\ Z I Revisions a Applicant: Nature of Work: Reviews:ZBA:OCT 2 6 2021 PB: BOT: Other. Xjp OK ( ( ) FEES:Filing. 7 S•:ta, BP: C/O: Legalization: ( ) (4 P: Dated: ✓ Notarized 7 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: ite P otection: S/W Mgmt.: Tree Plan: Other. ( ) (-SURVEY:Dated , ' Z-0 Current: ✓ Archival Sealed Unacceptable: ( ) ( ) PLANS:Date Stamped: Sealed Copies: Electronic: Other. ( ) (�License: ✓ Workers Comp: Liability. ZComp.Waiver. Other. CODE 753#: 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: I-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.(� ( ) r. mtg.date: approval notes: (- LBA mtg.date: approval notes: ( )PB mtg.date: approval notes: REQUIRED EXISTING PROPOSED NOTES Area: Circle: From Front: Front: Sides: Rear. Main Coy: Accs.Cov Ft.HS : S .HS : S� Tot : 007 . (o zZ Z L Z Z l F Im : 4 ! L , o > Z S'-0 -3 Z . J, • 'Z, P Hight/Stories: � notes: 75$O - (o (�i . (- 1 o zs0 tz 2 ara-G t� r-�,j(c, v Eli r 0 w s 1._ V ✓mil_ 2 0 BUILD D MENT VIL OF RY> OOK OCT 21 2021 938 KING ET RYE BROOK,NY 10573 14)939-0668 VILLAGE OF RYE BROOK k.or BUILDING DEPARTMENT 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: Date of Submission: Parcel ID#j j6-t 7 2 -c)'V Zone: Proposed Improvement(Describe in I detail): APPLICANT CHECK LIST: MUST BE COMPLETED BY THE APPLICANT following items must be submitted to the Building CF rtment by the applicant-no exceptions. Property Owner: Completed Application T o ) ets of sealed plans. (one full size {maximum Address: Towable plan size=36"x 42"}and one I I"xl7") I Phone# opies of the property survey. 4. ( )Two(2)copies of the proposed site plan. Applicar6appeanng be ore the Board: 5. ( )One electronic/disc copy of the complete H a application materials. �p 6. ( )Filing Fee. Address: O 7. ( )Any supporting documentation. Phone# 7� l / a 8• ( )HOA approval letter. (if applicable) 9. ( )Photographs. Architect/Engineer: 10.( )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 arty application not meeting the requirements contained herein. �Vl Sworn to before me this Sworik to before me this "t day of , 20�LL day4 O20 6 Re,� til 1 Signature of Property Ownerr j 1 a oApplicant n /� ✓�'- / t P Name of Property O e M I R I A M P G O M E Z ame of Applicant Notary Public, State of Ncw York Registration #01G06078902 u -Qualified In Westche er aunt Tic Commission Expires blic (t III 8/12/2021 BUILDMG DE-'ARTMENT D ECI VILLAGE OF RYE fitOOK 938 KING S1 EET RYE BRgoic,NY 10573 OCT 2 1 2021 3D (914),5 9-Ob68 www ,f o"rg VILLAGE OF RYE BROOK BUILDING DEPARTMENT *********************************************************************************************************** FOR OFFICE USE ONLY: Approval Date: Permit# Application# Approval Signature: ARCHITECTURAL REVIEW BOARD: Disapproved: BOT Approval Date: PB Approval Date: ZBA Approval Date: Other: Application FeJ Permit Fees: . EXTERIOR BUILDING PERMIT APPLICATION Application dated:/V is hereby made to the Building Inspector of the Village of Rye Brook,NY,for the issuance of a Permit for the construction of buildings,structures,additions,alterations or for a change in use,as per detailed statement described below. 1. JobAddress: l O 0 2. Parcel ID#: . 7 Zone: - C 3. Proposed Improvement(Describe in detaA): ` w (kr hQ� 1 � ITU 4. Property Owner: P Address: Phone# Cell# e-mail List All Othe Properties Owned in Rye Brook: Applicant: Address: Phone# Cell# e-mail A+ Architect: Address: Phone# Cell# e-mail Engineer: Address: Phone# Cell# e-mail General Contractor: 60) Address: i Phone# - Cell# e-mail ',y�� ► C`-„ " / (1) 8/12/2021 5. Occupancy;(1-Fam.,2-Fam.,Commercial.,etc...)Pre-construction: Post-construction: 6. Area of lot: Square feet: ) Acres: 7. Dimensions from proposed building or structure to lot lines: front yard: rear yard: -516 right side yard: left side yard: & other: 8. If building is located on a comer lot,which street does it front on: 9. Area of proposed building in square feet: Basement: 1"fl: 2°d fl: 31 fl: 10. Total Square Footage of the proposed new construction: 11. For additions,total square footage added:Basement: 1"fl: 21 fl: 3`d fl: 12. Total Square Footage of the proposed renovation to the existing structure: 13. N.Y.State Construction Classification: N.Y.State Use Classification: 14. Number of stories: Overall Height: Median Height: 15. Basement to be full,or partial: finished or unfinished: 16. What material is the exterior finish: 17. Roof style;peaked,hip,mansard,shed,etc: Roofing material: 18. What system of heating: 19. If private sewage disposal is necessary,approval by the Westchester County Health Department must be submitted with this application. 20. 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...) Yes: No: (if yes,applicant must submit a separate Automatic Fire Suppression System Permit application&2 sets of detailed engineered plans) 21. Will the proposed project disturb 400 sq.ft.or more of land,or create 400 sq.ft.or more of imperv'ous coverage requiring a Stormwater Management Control Permit as per§217 of Village Code? Yes: Ni :7 Area: 22. Will the proposed proje require a Site Plan Review by the Village Planning Board as per§209 of Village Code? Yes: No: (ef yes,applicant must submit a Site Plan Application,&provide detailed drawings) 23. Will the proposed project require a Steep Slopes Permit as per§213 of Village Code Yes: No: (if yes,you must submit a Site Plan Application,&provide a detailed topographical survey) / 24. Is the lot located within 100 ft.of a Wetland as per§245 of Village Code? Yes: No. (if yes,the area of wetland and the wetland buffer zone must be properly depicted on the survey&site plan) 25. Is the lot or any portion thereof located in a Flood Plane as per the FIRM Map dated 9/28/07? Yes: No: (tf yes,the area and elevations of the flood plane must be properly depicted on the survey&site plan) / 26. Will the proposed project require a Tree Removal Permit as per§235 of Village Code? Yes: No: (if yes,applicant must submit a Tree Removal Permit Application) 27. Does the proposed project involve a Home-Occupation as per§250-38 of Village Code? Yes: No: Indicate: TIER I: TIER H: TIER III: (if yes,a Home Occupation Permit Application is required) 28. List all zoning variances granted or denied for the subject property: 29. What is the total estimated cost of construction: $ ( q 0 0/ a Note:The estimated cost shall include all site improvements, labor,material,scaffolding,fixed eq ipment,professional fees,including any material and labor which may be donated gratis.If the final cost exceeds the estimated cost a�ndditional fee will be requiredprior to issuance of the CIO. 30. Estimated date of completion: , 71- , 04 (2) 8/12/2021 BUILDING DEPARTMENT VILLAGE OF RYE BROOK 938 KING STREET RYE BROOK,NY 10573 (914)939-0668 IMPERVIOUS COVERAGE RATIOS RESIDENTIAL DISTRICTS Address: Section: Block: Lot: Zone: I1TERVIOUs SURFACES (Definition): All buildings, as defined herein, and all areas on the ground or elevated above the ground which are comprised of materials through which water cannot readily flow, including, but not limited to asphalt, concrete, masonry, wood, gravel and clay, and which consist of elements including, but not limited to, court yards,sports courts, swimming pools,patios,sidewalks,ramps,terraces and driveways. TOTAL MAXIMUM PERMITTED MAX. PERMITTED COVERAGE Zoning IMPERVIOUS LOT AREA BY IMPERVIOUS SURFACES District COVERAGE IN FRONT (sq.ft.) For Base Lot For Lot Area YARD(%) Area(sq.ft.)* Over Base R-35 15 Lot Area % R-25 20 0 to 4,000 0 55 R-20 30 4,001 to 6,000 2,200 35 6,001 to 12,000 2,900 27 R-15 35 12,001 to 16,000 4 520 26 R-15A 35 16,001 to 20,000 5,560 25 R-12 40 20,001 to 30,000 6,560 24 30,001 to 40,000 8,960 23 R-10 45 40,001 &larger 11,260 22 R-7 40 R-5 30 R2-F 30 *"Base Lot Area"is the minimum end of the lot size range in the"Lot Area"column 6 3 t Area of lot: 49 sq.ft. Existing Allowed Proposed Total impervious coverage = '.ft. . ft. .0 S .ft. Front impervious coverage = % % % I attest to the best o my knowledge and belief,the above information is correct. chitect's Signature (4) 8/12/2021 7 D BUILDING OARTMENT VILLApE of RY)0$11100K OCT 21 2021 938 KING ET RYE-BROM NY 10573 VILLAGE OF RYE BROOK 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: 1 (9a ,residing at, 9 (Print n e) I (Address wher 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; ma• wood a-e- rl 1 OS—7�) ,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. U_� (Signature of Property Owner(s)) N EnY�z (Print Name of Property Own s)) Sworn t bef re me this MIRIAM P GOMEZ Notary Public, State of New York — Ay=24, 1L) da of L 20� ` Registration#01G06078902 y Clualified In Westchester Coaunt n 1 1 Commission Expires V� (No 7 C:� (6) 8/12/2021 This application must be properly completed in its entirety by a N.Y. State Registered Architect or N.Y. State Licensed Professional Engineer & signed by those professionals where indicated. It must also include the notarized signature(s) of the legal owner(s) of the subject property, and the applicant of record in the spaces provided. Any application not properly completed in its entirety and/or not properly signed shall be deemed null and void, and will be returned to the applicant. Please note that application fees are non-refundable. STATE OF NEW ORK,COUNTY OF WESTCHESTER ) as: p,1q o U .. 4)CU2 0- ,being duly swom,deposes and states that he/she is the applicant above named, (print name of individual signing as the applicant) and further s tes that (s)he i the legal owner of the property to which this application pertains, or that (s)he is the Con ' Q C P� 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 of�; C �2- , 20 day of , 20 J � Signature of Property Owner Sgnature of Applicant Print Name of Property Print ame of Applicant Notary Public tary Public Lynda Derenzis Notary Public-Connecticut My Commission Expires che November 30,2024 ,,.ft%dWwVWk ftO ALSON /inwSwinew CW win Ems Ap%3,20 (8) 8/12/2021 4040, 40. R I AL- ex sC � cr Pr lo, lfp�6cb�r �(,��ov owox ou,Z &dd 6 er 0 7ePO 7� �-��- w�l � �m�f n � i n 6� o tic/ C m �x Z cC� rLo- ,n 4 curb D L L ` / OCT 2 1 2021 D31 VILLAGE OF RYE BROOK BUILDING DEPARTMENT • Driveway 6 • ft • ■ • 4 CONCRETE • E OCT 2 1 2021 D3 VILLAGE OF RYE BROOK BUILPI-NG UE�'.ARTMENT ■ 1 M OCT 2 1 2021� VILLAGE OF RYE BROOK BUILDING DE.PARTMF_NT / i " — - --— --- -------- -- —- m y E X Ch I IV }' �• h `z- Vic' gC®Dcu yj f r✓j �\�'` �atc3ae)s"� �:1 4 i 6c DD PAO LLI to �aa�maHj LLj o ce X �, Quo 1r.1 'fit.'• �.� W W x . O W DLI < 11 4-o .. OC\l o CO / �`�• /sue i � 1 ' U j2 1�L'• � O a I '�ty`''F`�'ir'�'"a� ' � w •rn N it � � M I t. .C\:- .'fit � � � _t�•y SI. �'IItlA _ 'f-• ~ J,: � I i. `;'-•;, .fie,. - -- --- - ---- ---- -� a A� DATE(MMIDDIYYYY) �. CERTIFICATE OF LIABILITY INSURANCE 10/20/2021 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 be endorsed. If SUBROGATIONIS 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: FRAZAO INSURANCE LLC PHONE 203 459-9999 Fax 02024376 ( ) (203)459-9927 PO BOX 700 (A/C,No,Ext): (A/C,No): NORWALK CT 06852 E-MAIL ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC# INSURER A: Twin City Fire Insurance Company 29459 INSURED INSURER B: MR PAVERS LLC INSURER C: 28 CHAPEL ST GREENWICH CT 06831-5109 INSURERD: INSURER E: INSURER F COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADDL SUBR POLICY NUMBER POLICY EFF POLICY EXP LIMITS LTR INSR WVD M IDDIY COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $1,000,000 CLAIMS-MADE�OCCUR DAMAGE TO RENTED $1,000,000 PREMISES IEa occurrence) X General Liability MED EXP(Any one person) $10,000 A 02 SBA AJ1363 11/13/2020 11/13/2021 PERSONAL&ADV INJURY $1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $2,000,000 POLICY E]PRO- ❑LOC PRODUCTS-COMP/OP AGG $2,000,000 JECT OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Ea accident) ANY AUTO BODILY INJURY(Per person) ALL OWNED SCHEDULED AUTOS AUTOS BOOBY INJURY(Per accident) HIRED NON-OWNED PROPERTY DAMAGE AUTOS AUTOS (Per accident) UMBRELLA LIAB X OCCUR EACH OCCURRENCE $5,000,000 A EXCESS LIAB MADE CLAIMS- 02 SBA AJ1363 11/13/2020 11/13/2021 AGGREGATE $5,000,000 E X RETENTION$ 10,000 WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY STATUTE ER ANY YIN E.L.EACH ACCIDENT PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? NIA E.L.DISEASE-EA EMPLOYEE (Mandatory in NH) If yes,describe under E.L.DISEASE-POLICY LIMIT DESCRIPTION OF OPERATIONS below EMPLOYMENT PRACTICES Each Claim Limit $10,000 A 02 SBA AJ1363 11/13l2020 11/13l2021 LIABILITY I I I I Aggregate Limit $10,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Those usual to the Insured's Operations. CERTIFICATE HOLDER CANCELLATION The Village of Rye Brook SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED 938 KING ST BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED RYE BROOK NY 10573 IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ©1988-2015 ACORD CORPORATION.All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD THE HARTFORD BUSINESS SERVICE CENTER THE 3600 WISEMAN BLVD HARTFORD SAN ANTONIO TX 78251 October 20, 2021 The Village of Rye Brook 938 KING ST RYE BROOK NY 10573 Account Information: Contact Us Policy Holder Details : MR PAVERS LLC Business Service Center Business Hours: Monday- Friday (7AM - 7PM Central Standard Time) Phone: (866)467-8730 Fax: (888)443-6112 Email: agency.services(abthehartford.com Website: https://business.thehartford.com Enclosed please find a Certificate Of Insurance for the above referenced Policyholder. Please contact us if you have any questions or concerns. Sincerely, Your Hartford Service Team WLTRO05 DATE(MMIDD/YYYY) �.. CERTIFICATE 4F LIABILITY INSURANCE 10/05/2021 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 be endorsed. If SUBROGATIONIS 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: FRAZAO INSURANCE LLC 02024376 PHONE (203)459-9999 FAX (203)459-9927 PO BOX 700 (A/C,No,Ext): (A/C,No): NORWALK CT 06852 E-MAIL ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC# INSURER A: Hartford Fire and Its P&C Affiliates 00914 INSURED INSURER B: MR PAVERS LLC INSURER C: 28 CHAPEL ST GREENWICH CT 06831-5109 INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADDL SUBR POLICY NUMBER POLICY EFF POLICY EXP LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE CLAIMS-MADE❑OCCUR DAMAGE TO RENTED PREMISES(Ea occurrence) MED EXP(Any one person) PERSONAL&ADV INJURY GEN'L AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE POLICY El PRO- ❑ JECT LOC PRODUCTS-COMP/OP AGG OTHER AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT ANY AUTO BODILY INJURY(Per person) ALL OWNED SCHEDULED AUTO S AUTOS BODILY INJURY(Per accident) HIRED NON-OWNED PROPERTY DAMAGE AUTOS AUTOS (Per accident) UMBRELLA UAB OCCUR EACH OCCURRENCE EXCESS LIAB CLAIMS- MADE AGGREGATE ED I RETENTION$ WORKERS COMPENSATION X PER OTH- AND EMPLOYERS'LIABILITY STATUTE I ER ANY YIN E.L EACH ACCIDENT $1,000,000 A PROPRIETOR/PARTNER/EXECUTIVE NIA 02 WEC AA91QZ 11/13/2021 11/13/2022 OFFICER/MEMBER EXCLUDED? E.L DISEASE-EA EMPLOYEE $1,000,000 (Mandatory in NH) If yes,describe under E.L.DISEASE-POLICY LIMIT $1,000,000 DESCRIPTION OF OPERATIONS below DESCRIPTION OFOPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Those usual to the Insured's Operations. CERTIFICATE HOLDER CANCELLATION The Village of Rye Brook SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED 938 KING ST BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED PORT CHESTER NY 10573-1226 IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE 01988-2015 ACORD CORPORATION.All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD THE HARTFORD BUSINESS SERVICE CENTER THE 3600 WISEMAN BLVD HARTFORD SAN ANTONIO TX 78251 October 5, 2021 The Village of Rye Brook 938 KING ST PORT CHESTER NY 10573-1226 Account Information: Contact Us Policy Holder Details : MR PAVERS LLC Business Service Center Business Hours: Monday- Friday (7AM - 7PM Central Standard Time) Phone: (866) 467-8730 Fax: (888) 443-6112 Email: age ncy.servicesathehartford.com Website: https://business.thehartford.com Enclosed please find a Certificate Of Insurance for the above referenced Policyholder. Please contact us if you have any questions or concerns. Sincerely, Your Hartford Service Team WLTRO05 Ticket Saved Your ticket number is Excavator ID: Cnmpary Tr)- 10041 -002-719 95634 157616 Version: 0 Z:1AKL\_projecti9 Maywood Ave 10573 Hyle 20-023-240\Dwg12020-03-18 9 Maywood Ave Hyle P-1.dwg 03/18/20 - 11.32am KrisbanFontanilla m 0 0 can � 3 a 0) M is -. 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