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HomeMy WebLinkAboutRP24-136kfPERMIT # c� �' (v DATE: %l gyp; // HnON / c749 i_5 c4 _ BLOCK LOT TYPE OF WORK _4� L JOB LOC----A--T��IIO-ON OWNER0 4174AZXrl CONTRALTO EST. v/CO # TCO # DATE FOOTING FOUNDATION FRAMING RGH FRAMING INSULATION PLUMBING 0 RGH PLUMBING GAS SPRINKLER ELECTRIC LOW -VOLT C� ALARM 0 AS BUILT O FINAL C:l FEE DATE INSP 3�073a-3 y Ih 64400ri%eri C9/y) a'/`/ 7— S`24'6) OTHER APPROVALS ARB BOT PB ZBA OTHER BR � VILLAGE OF RYE BROOK MAYOR 938 King Street, Rye Brook,N.Y. 10573 ADMINISTRATOR Jason A. Klein (914)939-0668 Christopher J.Bradbury www.ryebrookny.gov TRUSTEES BUILDING & FIRE INSPECTOR Susan R. Epstein Steven E. Fews Stephanie J. Fischer David M.Heiser Salvatore W.Morlino CERTIFICATE OF COMPLIANCE December 23,2024 Jonathan Bartlett&Wilma Bartlett 994 King Street Rye Brook,New York 10573 Re: 994 King Street,Rye Brook,New York 10573 Parcel ID#: 129.52-1-26 Roof Permit#24-136 issued on 12/11/2024 to Re-Roof Existing Building This certifies that the new roof,installed under the above captioned permit has been satisfactorily completed. Sincerely, Steven E. Fews Building&Fire Inspector /to \1 E D `" BUILDING DEPARTMENT IT For office use onlv�: VILLAGE OF RYE BROOK P SUED DEC 11 2024 938 KING STREET,RYE BROOK,NEW YORK 10573 DATE: VILLAGE OF RYE BROOK (914)939-0668 FEE: �_�(� — PAID1W BUILDING DEPARTMENT n•wvv.ryebrookny.�ov 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 ttiiftiRrt#RR##Ri RRR4R#RtR#R44R444irt#itttiRtRi#ttt4RR4t##itiftiittrttrt4iRittt#4ff44iitttftitrttfiiittRtii#ifiiftt#itt#tiRiiiitRR Address: q C�4 t k.Ro' Occupancy/Use:"k Parcel ID#: / a 9 S a . �"—a Zone: Owner: ��—�—� 1 r�'� Address: 9 P.E./R.A. or Contractor: S �e��.r 1 Ctc —� Address: 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 YORK,COUNTY OF WESTCHESTER as: �f '/ /C��✓ ���,�i Sri being duly swum,deposes and says that he/she resides at 7/ /jj'/ 41 W h4 rI1"i (Prints Name of Applicant) (No.and Street) in /-f'4L,-/'i s o.l ,in the County of in the State of�,that (City Town Villa@e) 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 ! u0 for the construction or alteration of: Pil e.) ,eoc::' yf' 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§250-10.A.of the Code of the Village of Rye Brook. Sworn to before me this _ 1 j ih Sworn to before me this day of , 20 day of D&U2446 20 It ���HRISTOPHER J.13RADBURY --���il/l Iotary Public,State of New York Sigttatur of Property(honer NO.016FId15,c;85 Si to ppticant �_�t�I Qualifi-d in Westchester County-�—� / /� na � & Tw �Ommission Expires January 29,20�_l �- 2 v C,41rl Print Name of operty Ch Ant Name of Applicant Nytar}flub tare Pu is / JACLYN M PINO NOTARY PUBLIC-STATE OF NEW YORK No.01LA6186161 Qualified in Westchester County My Commission Expires 04-28 a8 �yE BRC�v� 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 : 1 1 L/ r } Z � /(,tf DATE: L Q r1 C J I .-� PERMIT# 1 9 ISSUED:1-#-lSECT: BLOCK: LOT: L LOCATION: �l _� �' 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 D ►n o w A aWC x u s W c i`nn W W a r. 0, Q. �'Q : a F+ ~ wr ci a ye n rC: W = _ - N L19 w �•J N o :� � '� � f �y 0 2 p � © C) N C Q00 I�1 z N Lnen i W g o O Cs ago a 7 v 0 000 �•LI � � � w Q Z � o, Q ° � � w � vo Uz CN a Z H V C � U W 00 v 04 AG N a 17 u F W A °' 0 � •a �' z (� Mig © v o L V zQ [ �� vet �i- u a z o � a � � avo CN z H ° :" � � z d W. i 9 u xQ.' vi � dab BUILDING DEPARTMENT VILLAGE OF RYE BROOK APR 15 2o2o 938 KING STREET RYE BROOD,NY 10573 (914)939-0668 FAx(914)439-5801 VILLAGE OF RYE BROOK BUILDING DEPARTMENT W%VNN,►�_ehr flk.c�rg.FOR OFFICE USE ONLX: Approval Date: Permit it �d`� ��tG' Application# Approval Signature: ARCHITECTURAL REVIEW BOARD: Disapproved: Date: BOT Approval Date: Case# Chairman: PB Approval Date: Case# Secretary: ZBA Approval Date: Case# Other: Application Fee: Permit Fees: ROOF PERMIT APPLICATION Application dated: is hereby made to the Building Inspector of the Village of Rye Brook,NY,for the issuance of a Permit to Re-Roof an Existing Building,as per detailed statement described below. 1. Job Address: `t Imo[ti s SBL:: �i Zone: Property Owner: l e--Y-q. Address: t ?yt bra. �L1 Phone#: 11 /� Cell#: It3 7_ .3[�"2 email: I t^?�tr ( 4 /��t Crr+fc 2. Applicant: 1 r, �. (�y/'✓'/rn^/ Cj_, � 6W Address: 0 .4 A W y 40 Phone#: Cell#: /t Y Y W 7 s Q/ 4 i r r t 9—Pt, ^fL f eo r,-i 3. Roofing Contractor: _676 Cy ep er1t rc'lrl- Address: Yl 174. T„�, /�.f�6y/�c Y'/'��,A,Y� Phone#: //y 5/�1;7 J fd�� Cell#: SG '0 email: 4. Job Description,list all Methods&Materials: �'�`.✓ l r� l��y' p e-j-L le— -43( Lq r'J 5. Estimated Cost of Job: $ � i D O ' � � (NOTE:The estimated cost shall include all site improvements,labor,material,scaffokling.fixed equipment,professional fees,and material and labor which may be donated gratis.) 6. If corner property,indicate street frontage: 7. Construction Type:. NYS Construction Class: S. Number of stories: Height: 9. Is garage being re-roofed:No:( ) Yes: ( )Attached No: ( ) []Yes: ( )Number of Cars: 10. Is roof peaked,hip,mansard,flat,etc: 9� -��- 11. Estimated date of completion: 4- 312111% Please note that this application must include the notarized signature(s) of the legal owner(s) of the above-mentioned property, in the space provided below. Any application not bearing the legal property owner's notarized signature(s) shall be deemed null and void, and will be returned to the applicant. STATE OF NEW YORY,COUNTY OF WESTCBESTER ) as: being duly sworn,deposes and states that he/she is the applicant above named, (print name of individual signing as the applicant) and further states that (s)he is the legal owner of the property to which this application pertains, or that (s)he is the for the legal owner and is duly authorized to make and file this application. (indicate architect,contractor,agent,attorney,etc.) That all statements contained herein are true to the best of his/her knowledge and belief, and that any work performed, or use conducted at the above captioned property will be in conformance with the details as set forth and contained in this application and in any accompanying approved plans and specifications,as well as in accordance with the New York State Uniform Fire Prevention & Building Code,the Code of the Village of Rye Brook and all other applicable laws,ordinances and regulations. Sworn to before me this /� */ Sworn to before me this day of y, / L , 2Q.24 day of � i,i l , 20 �Z_C� G ignature of Property caner Signatu a of Applicant Print Name of Property Owner Pnnt Name of Applicant Notary Public Notary Public D Lg� � APR 5 20?8 VILLAS QQkDING D PY RAR-rYE 19FN 7 -2_ 30119 APR 16 2020 [4[lte VILLAGE OF RYE BROOK BURPING 0EPARTNEN-F 19 VILLAGE OF RYE BROOK MAYOR 938 King Street, Rye Brook, N.Y. 10573 ADMINISTRATOR Paul S Rosenberg (914) 939-0668 • Fax (914) 939-5801 Christopher J Bradbury www rye rook org TRUSTEES BUILDING& FIRE Susan R. Epstein INSPECTOR Stephanie J Fischer Michael J Izzo David M Heiser Jason A Klein PROPERTY OWNER SINGLE WORKER CERTIFICATION r iease appropriate box complete 8 sign this form and return it to the Building Department for processing I do not wish to cuntintic/commence wur J i I wish to continue•/continence work I HEREBY CERTIFY, that I am the owner of the property listed below,and that I am aware of the Governor's Executive Orders 202.6 and 202.8 and subsequent Guidance issued by NN'S Empire State Development (1?SD) on March 27, 2020 with respect to essential businesses and services,available at httl.)s:/: c��Ln ►i_'l;uidancc-cx�Cuti�c uril�r '��_'(,, issued in response to the COVID-19 pandemic, and that I will not allow work to proceed at the property except in compliance with such Executive Orders and F.SD Guidance including but not limited to the following requirements related to construction; (i) social distancing and best practices for cleaning/disinfection shall be maintained at all times, and (ii) no more �anthan one empl,n-ee/worker will be allowed on the job site located at 991f Kt N6— a/• , Rye Brook, NY at any given time while such restrictions remain in place by New York State, Westchester County or the Village of Rye Brook I further acknowledge and understand that violation of these requirements may result in the issuance of a Stop Work Order and/or Police enforcement. Datcd: Apr, t 1 5 ,2020 Signed: Print \ame:SA1Ai -9 tffK &eaA 7 -\ddre.;: 91? 7 Kl N(r r Ay�r- ��iQ110 / v Permit #: y APR 16 2020 VILLAGE OF RYE BROOK 19 BIIiLRII�.v t-r�:?ARTI:�ENT VILLAGE OF RYE BROOK MAYOR 938 King Street, Rye Brook,N.Y. 10573 ADMINISTRATOR Paul S. Rosenberg (914)939-0668 • Fax(914) 939.5801 Christopher J Bradbury www ryebrook org BUILDING&FIRE TRUSTEES INSPECTOR Susan R. Epstein Michael J. Izzo Stephanie J Fischer David M. Heiser Jason A Klein CONTRACTOR SINGLE WORKER CERTIFICATION Please check the appropriate box,compse:e&sign this form and return it to the Budding Department for processing do not Sri%h to continue/commence work r' I wish to contintsr;'c �nimrncc work I HEREBY CERTIFY, that I am the e.,". / contractor for the job listed at the address below, and that I am aware of the GovcmOes Executive Orders 202.6 and 202.8 and subsequent Guidance issued by NYS Fmptre State lle%-clopment (ESD) on :March 27, 2020 with respect to essential businesses and services, available at lit t ��: _�'���"ti��at.�" guidwicc-cwcuti-s"c-urdrr-2 120, issued in response to the COVID-19 pandemic,and that I will maintain full compliance with such Executive Orders and ESD Guidance including but not limited to the following requirements related to construction; (i) social distancing and best practices for cleaning/disinfection will be maintained at all times,and (ii) no more than one employee/worker will be on the job site located at y'Lt �t♦ �- ��ov �C , Rye. Brook, NY at any given time while such restrictions remain in place b}" New York State, Westchester County or the Village of Rye Brook. I further acknowledge and understand that violation of these requirements may result in the issuance of a Stop Work Order and/or Police enforcement. Dated: �� / /J .20 ;'oo Signed: Print Namc: _Ale h Permit #: (:ompany: V :Address: Vl �`j n !G S� -ARV,14UBBV IDIRECTIED TO STOP ALL WORK AND TO OTHERWISE E� AIX UNLAWFUL USE OF TAIS PROPERTY/PREMSE S- AT gyp oo F • i q4(14 � '�• i2�_ r 46•. . Mike Izzo From: Mike Izzo Sent: Wednesday, April 15, 2020 10:56 AM To: Iralphgurrieri@me.com'; 'jmarkbartlett@gmail.com' Cc: Steven Fews; tgerardi@ryebrook.org; Laura Petersen Subject: 994 King Street Roof STOP WORK ORDER Attachments: Roofing Application 944 King Street.pdf; 944 K.jpg; Single-Worker Certification 4.6.2020.pdf Importance: High Gentlemen, The Building Department is in receipt of an application to legalize the premature commencement and eventual completion of the new roofing installation at the subject property.A copy of that application and of the$75.00 check is attached hereto.Also attached is a copy of the STOP WORK ORDER issued to the property owner Mr. Bartlett on 4/7/2020 for allowing such work to commence on his property without a roofing permit as required by Village Code, and in violation of the Governor's Executive Orders restricting such work at this time. Pursuant to the Executive Orders the Building Department cannot issue permits for non-emergency work unless that work can be performed by a single worker.A total re-roofing job is not considered emergency work,neither can it be performed safely by a single worker,therefore total re-roofing jobs are not permissible at this time. However the Building Department does consider the repair of a leaking roof to be an emergency repair and has determined that in most cases such repairs can be completed by a single worker. You may consider such work only if both the homeowner and contractor agree to the single worker initiative.Please note that the Village does not require a permit to repair a leaking roof. To that end, I have attached hereto the Single Worker Certification Forms which must be reviewed and signed by the property owner as well as by the contractor then returned to the Building Department for review and approval. Once we receive and review the completed forms we will contact you regarding commencement of the repair work. Unless I hear otherwise from Mr. Bartlett or Mr. Gurrieri, the Re-roofing Permit Application and$75.00 check will be held here at the Building Department for future processing should the Executive Orders be modified or rescinded. Thank you. lffjc�aej(l Izzo Building&Fire Inspector Village of Rye Brook,NY Phone—(914)989-0668 Fax—(914)959-5801 mizzoAryebrook.org 1 f _• rr � r► • A R - t fl F p _ 'all 400 all r �E BRnuk Certified Mail ❑ BUILDING DEPARTMENT Hand-6 ivere p--) VILLAGE OF RYE BROOK 1982'��p� 938 KING STREET • RYE BROOK,NY 10573 (914) 939-0668 FAx (914) 939-5801 www.ryebrook.org NOTICE OF VIOLATION AND ORDER TO REMEDY SAME OWNER: J � Violation#: 2052 NOTICE#: dos 7 The following violations of the Code of the Village of Rye Brook, and/or the New York State Uniform Fire Prevention & Building Code (NYSUFP&BC) were found to exist at. . . y �t -S,-r parcel I.D. # located in an, zone, in the County of Westchester, Village of Rye Brook, NY on, �' 20Zz--n, , at - o'clock AM / PM CODE SECTION TITLEMESCRIPTION ------------------------------------------------------------------------ - -----------_----------------------------------- I-1.. '�-J�-----------�--�- - ----------���i'CZ-' �C-�-�-------- L--'��--------------------------------------------------------- - --------------- ---- L-- ---------- --------------------------------------------------------------------------------------------------------------------- ------------- ----------------------------------------------------------------------------------------------------------------------------------- ----------------------------------------------------------------------------------------------------------------------------------- -----------"--- --------------------- - ---------- -------�S---' --- - -��------ 5-- - � -�2--- ---'---- --------------------`------------------------------------------------`--------- -------------------------------------------- Notes: �-D v I ,A - �Z v You are hereby directed to contact the Building Department, obtain all necessary permits and commence to correct the above captioned violation(s) immediately. Violations of the NYSUFP&BC must completely be remedied by, which is thirty (30) days after the date of this notice and are returnable at the rate of $1,000.00/day for each day of the continued violation, or imprisonment not exceeding one year, or both. A RE INSPECTION OF THE PREMISES LS REQUIRED BY LAW TO CONFORM COMPLIANCE WITH THIS NOTICE&ALL APPLICABLE CODES. FAILURE TO COMPLY WITH THIS NOTICE IS A CRIME PUNISHABLE BY FINE,I PRISO ENT OR BOTH. - i q� BUILDINi6INSPECTQR- -- ❑ ASSISTANT BUILDING INSPECTOR 0 CODE ENFORCEMENT OFFICER _l.. ���\ _.��� .��T^R� .��I�>.'S�. lAr`,` •21N'�yjy. � A���•�L�'PR4'�•!' yt2'.; 1 )► `'�"117�1 .11 �.- t -:.1 11 11 _ 111A/,• �'a9 :'i1�11j1. _ \; `1,�� ._ .. ;�' HI'zc'a ;:.u -�sr-:'.Nf1i ;. i � - ��Illb'' •�-"`444€€€ '- h v K AA a° 6 ` o rA C.. C <griroyT _ _ £ �+ r oo .. CN Lo Q) .. w a O Q $ L - e O > J G i I' (acRaR . j •3 O J W > o c ,c v � •b•mod. . V � � p � � � �o �� .t': 4•� W Q W > I F �(�T)T F7� .. � May (� U •V1 �:�,`+ .'J� C ob u co � y f � 1 i d j/ � 1 � � ���•^ tilhyz�a. ;1�'�•;�1 � ,. /)�h �h_ _�' 1 «o;�, O A ., i ♦ �• � tP I ACORD,,, CERTIFICATE OF LIABILITY INSURANCE D04/14/2020ATE ) PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION THE LANZA INSURANCE AGENCY INC ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 18 HALSTEAD AVENUE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR HARRISON NY 10528 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. PHONE: 914-835-6000 INSURERS AFFORDING COVERAGE NAIC# INSURED INSURER A:State Farm Fire and Casualty Company 25143 25143 GJG GENERAL CONTRACTING LLC INSURERS: 41 ADELPHI AVENUE HARRISON NY 10528 INSURERC: INSURER D: INSURER E: COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING ANY RE qth. OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PE General INSURANCE BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIE Commarc NGenera Liabilitysho dY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADD' Our polloies are Occurence based a POLICY EFFECTIVE POLICY EXPIRATION LTS General Aggregate Lima apples per POLICY NUMBER M T LIMITS A GENERAL LIABILITY98-CH-A221-9F 03/05/2019 03/05/2021 EACH OCCURRENCE Pr D Da age Legal Pia biity Limits X COMMERCIAL GENERAL LIABILITY PREMISES Ea occurrence limrc is typically$300,000.The Contractors policy limit is$100,000 CLAIMS MADE a OCCUR MED EXP(Any one person) for this coverage. PERSONAL&ADV INJURY Personal Injury and Advertising Injury are"' of the basic GENERAL AGGREGATE policy unless excluded.Unless excluded,the limit shown here should GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP A be the same as the Each Occurrence PRO- limit. X POLICY 7 JECT 7 LOC The General Aggregate and AUTOMOBILE LIABILITY Products-Completed Operat ons ot COMBINED SINGLE LIMIT Aggregate should be double the Each Automobile Liability Occurrenceexcluded. limit.It Foca r rs and trucks with State Farm,merk'Scheduled Enter the limit shown on the policy Completed Operations is excluded. Autos."Requests for'Any Auto"must be referred to tine,n-red has more than one veh this area should be left blank. Underwriting.ENOL/Hired Car can be provided by Auto limas,enter the lowest limn amount or Fire Policies.Complete this section if coverage is on separate certificates for the varnu an Auto Policy.if coverage is on the Film Policy,please use blank lines in the first coverage box under General Gar' Liability. BODILY INJURY Busi (Per accident) $ for a been added,the"Any Auto"box should be marked.THe°Auto Only-EA AccWnet lima mould PROPERTY DAMAGE be the same as the"Each Occurence"limit. (Per accident) $ GARAGE LIABILITY AUTO ONLY-EA ACCIDENT S ANY AUTO OTHER THAN EA ACC $ _ AUTO ONLY: AGG $ A X EXCESSILIMBRELLALIABILITY 98-BV-D135-3 F 08/28/2019 08/28/2020 EACH OCCURRENCE S 2,000,000.00 X OCCUR CLAIMS MADE AGGREGATE $ 2,000,000.00 DEDUCTIBLE $ RETENTION S $ WORKERS COMPENSATION AND O STATURY IMIT O R EMPLOYERS'LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? E.L.DISEASE-EA EMPLOYEE $ If yea,describe under SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT I$ OTHER DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS CERTIFICATE HOLDER AS ADDITIONAL INSURED CERTIFICATE HOLDER CANCELLATION VILLAGE OF RYE BROOK SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION BUILDING DEPARTMENT DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN 938 KING STREET NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL RYE BROOK, NY 10573 IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE STELLA DIDOMIZIO ACORD 25(2001/08) c',ACORD CORPORATION 1988 132849.1 04-16-2008 . /7--0,\-1*4& NYSIF New York State Insurance Fund WESTCHESTER ONE,44 SOUTH BROADWAY, 10TH FLOOR,WHITE PLAINS,NY 10601-4411 1 nysif.com CERTIFICATE OF WORKERS' COMPENSATION INSURANCE o, , a T f' ^^A^A^ 050624313 �� GJG GENERAL CONTRACTING LLC ATT: GINA GUERRIERI 0 41 ADELPHI AVENUE HARRISON NY 10528 SCAN TO VALIDATE AND SUBSCRIBE POLICYHOLDER CERTIFICATE HOLDER GJG GENERAL CONTRACTING LLC VILLAGE OF RYE BROOK ATT: GINA GUERRIERI 938 KING ST 41 ADELPHI AVENUE VILLAGE OF RYE BROOi:NY 10573 HARRISON NY 10528 POLICY NUMBER CERTIFICATE NUMBER POLICY PERIOD DATE W1476 494-8 142488 03/07/2020 TO 03/07/2021 4/14/2020 THIS IS TO CERTIFY THAT THE POLICYHOLDER NAMED ABOVE IS INSURED WITH THE NEW YORK STATE INSURANCE FUND UNDER POLICY NO. 1476 494-8, COVERING THE ENTIRE OBLIGATION OF THIS POLICYHOLDER FOR WORKERS' COMPENSATION UNDER THE NEW YORK WORKERS' COMPENSATION LAW WITH RESPECT TO ALL OPERATIONS IN THE STATE OF NEW YORK, EXCEPT AS INDICATED BELOW, AND, WITH RESPECT TO OPERATIONS OUTSIDE OF NEW YORK, TO THE POLICYHOLDER'S REGULAR NEW YORK STATE EMPLOYEES ONLY. IF YOU WISH TO RECEIVE NOTIFICATIONS REGARDING SAID POLICY, INCLUDING ANY NOTIFICATION OF CANCELLATIONS, OR TO VALIDATE THIS CERTIFICATE,VISIT OUR WEBSITE AT HTTPS:/fWWW.NYSIF.COM/CERT/CERTVAL.ASP. THE NEW YORK STATE INSURANCE FUND IS NOT LIABLE IN THE EVENT OF FAILURE TO GIVE SUCH NOTIFICATIONS. THIS POLICY DOES NOT COVER THE SOLE PROPRIETOR, PARTNERS AND/OR MEMBERS OF A LIMITED LIABILITY COMPANY. THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS NOR INSURANCE COVERAGE UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICY. NEW YORK STATE INSURANCE FUND DI RECTOR,INSURANCE FUND UNDERWRITING VALIDATION NUMBER: 691763862 U-26.3