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HomeMy WebLinkAboutBP25-003PERMIT* / �S �(� 3 Dam % 9 Sp• SECTION Z doil i /r�—% BLOCK 71PT770777 J/TYPE OF WOR 2aY/ CQ/ Q CPS JOB LOCATI OL�Ty7 e (- OWNER s E7�0� CONTRALTO CLc Cio� LLC vpE�T. COST ��(7, U O FEES = D o o . —��. FEE ' IODATE TCO # FEE DATE INSPECTION RECORD DATE INSP FOOTING FOUNDATION FRAMING RGH FRAMING INSULATION 2, z Zo2 PLUMBING YA�So RGH PLUMBING 1 ZZ' Zo2� GAS ED SPRINKLER ELECTRIC �Q a �a� S 5 LOW -VOLT _ 20 Z p$SP ALARM 2 AS BUILT 0 FINAL /Pas 00(0 JQ114meS /0,7l95s m �i/y �ex "1 oo3/,Bay E/ems-ic�l C'o�ac,�� OTHER APPROVALS ARB BOT PB ZBA OTHER VILLAGE OF RYE BROOK WESTCHESTEIR COUNTY, NEW YORK Certificate of Occupancp This is to certify that k, PU of, ax P having duly filed an application on �20�requesting a Certificate of Occupancy for the premises known as, C �t�� , Rye Brook,NY, located in a � Zoning District and shown on the most current Tax Map as Section:141 • Block: Lot: r and having fully complied with the requirements of the Building Code and the Zoning Ordinance under Building Permit No. 5 -Vn3, issued 20 , 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: &61 Construction: , for the following purposes: Ik14if Y l G V Ye0C) V 170Y)S le V e yy eG�/ra- 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 exi acilities shall be made, and no enlargement, whether by extending on any side or by increasing in height, hall be mad ,no E.Vall the building be moved from one location to another until a permit to accomplish such change has en btained in t e uilding Inspector. Building Inspector,Village of Rye Brook: Date: MAR 0 4 20h R WE3D R For office use only: BUILD MENT PERMIT# CPds Od 3 FEB 21 2025 VIL _OFANE OK ISSUED: 938 KING STRE YE B�ipOK YORK 10573 DATE: — a `c. � VILLAGE OF RYE BROOK 9: .: q6 O�c FEE: SU PAID BUII_DII`,J!r ni=°.�RTMENT 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 ss»s»+»sssststtssstssssstssssstsstssssst*t*t**wssssess*t**sww*wwswts*»»ss»»ss+s*sttssssssts*sstssssssswst+stt*ss+w»sstsr*w»ss Address: 90 South Ridge S7�--ee Occupancy/Use: Medical Practice Parcel ID #: 7 — — 9 Zone: Owner: /ems P b rOtw p , L.L C. Address: 'i 0 S• IW 5e 5� Rye 13 m k NY P.E./R.A. or Contractor: Scully Construction Address: 141 Lafayette Ave, White Plains, NY Person in responsible charge: Marek Rief Address: 33 Davis Ave, White Plains, NY 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: Marek Rief being duly sworn,deposes and says that he/she resides at 41-43 39th PL (Print Name of Applicant) (No.and Street) in Sunnyside in the County of Queens in the State of NY 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:$ 'Dgi 000 for the construction or alteration of: 4v_r/O1­ /) ✓a'74,o S D ,L d We,-- PV 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 erectecL'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 Xt /6 to day of J0./I tAo , 20 a 5*' day of J n 20 Q.S Signat roperty Owner Signature of Applicant /:7,.r. kph. �1�b•,.0 c� /'1�,��t /> Print Name of Property Owner Print Name of Applicant jy't� Q� Notary Public Notary Public \ cILEEN ALEXA DELIZ �etar, Public-State of New York EILEEN ALEXA DELIZ �.01 DE0029612 LtNotary Public State of New York 6/I/20'4 apse in WestchesterCounty NO.O1DE0029612 A. om;: s1on Expires Oct 4, 2028 ed in Westchester County � � mission Expires Oct 4, 2028 QyE BRC��. 1932 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 (D Sos4 DATE: PERMIT# ISSUED:)-9-u SECT: ql- 27 BLOCK: LOT: LOCATION: eow e,_ ko VLc OCCUPANCY: ❑ VIOLATION NOTED THE WORK IS... ACCEPTED [I REJECTED/ REINSPECTION ❑ SITE INSPECTION REQUIRED ❑ FOOTING ❑ FOOTING DRAINAGE ❑ FOUNDATION ❑ UNDERGROUND PLUMBING NOTES ON INSPECTION: ❑ ROUGH PLUMBING ❑ ROUGH FRAMING ❑ INSULATION ❑ NATURAL GAS tit NS/c C T fJ'T"' t zL W'e4 ❑ L.P. GAS ' i� ., o ✓ �J !.� / s ❑ FUEL TANK ❑ FIRE SPRINKLER ❑ FINAL PLUMBING ❑ CROSS CONNECTION E] FINAL ❑ OTHER f3R(��y 1982 BUILDING DEPARTMENT ❑BUILDING INSPECTOR -EKSSISTANT 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 :�� DATE: ? - Z y- Z OZ S PERMIT# Z S ISSUED: SECT: . Z % BLOCK: LOT: 1 LOCATION: SP rV Ul P OCCUPANCY: ❑ VIOLATION NOTED THE WORK IS... B ACCEPTED ❑ REJECTED/ REINSPECTION ❑ SITE INSPECTION REQUIRED ❑ FOOTING ❑ FOOTING DRAINAGE Cl FOUNDATION ❑ UNDERGROUND PLUMBING NOTES ON INSPECTION: ❑ ROUGH PLUMBING ❑ ROUGH FRAMING ❑ INSULATION ❑ NATURAL GAS ❑ L.P. GAS ❑ FUEL TANK ❑ FIRE SPRINKLER Er FINAL PLUMBING ❑ CROSS CONNECTION ❑ FINAL ❑ OTHER aE'BROv- tim 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 : V �l DATE: ' I Z Z 2 PERMIT# �P 2S-O o �o ISSUED: SECT:L • 27 BLOCK: LOT: LOCATION: O W(-'A V Q� 1 'F.' C(�) 0-Pft LQ OCCUPANCY: ❑ VIOLATION NOTED THE WORK IS... ❑ ACCEPTED ❑ REJECTED/ REINSPECTION ❑ SITE INSPECTION Pno16,Q REQUIRED ❑ FOOTING ❑ FOOTING DRAINAGE ❑ FOUNDATION ❑ UNDERGROUND PLUMBING NOTES ON INSPECTION: ❑ ROUGH PLUMBING ❑ ROUGH FRAMING ❑ INSULATION ❑ NATURAL GAS JU p L.P. GAS n CL ❑ FUEL TANK ❑ FIRE SPRINKLER ❑ FINAL PLUMBING ❑ CROSS CONNECTION f� ❑ FINAL N� J �A CAA/D� S (ilti� ❑ OTHER C J )� _ = M y � v 1,4 rn rA 0-4 Il CA r � rJ w x a � 6' � W ►�i W i roger cnJQ CIS - O ( oo00 cry d o o a ZI Cn � DovwE V a o � W O �l A F"CN � 00 vO a div) o x w 2 � u - �/ X O O p z v (� �! V O V W O C V � " � � `r _� ] y �.tad �] C :j [A 14 y U R" �� � g Mrd � v 114. cs 00 - z _ •• a � W W ] � � a� a `� _ BUILD{ MENT VIL E OF 11 OOK J 4�f - 6 �r:'. 938 KING ET RYE$R ,NY 10573 4 -0 w ov _ INTERIOR BUILDING PERMIT APPLICATION FOR OFFICE USE ONLY- n Approval Date: \ i # / �� Application Fee:$ Approval Signature: Permit Fees:$ Disapproved: Other: U 6` Application dated: is hereby made to the Building Inspector of the Village of Rye Brook,NY,for the issuance of a Permit for the interior alter ation of an existing building,or for a change in use,as per detailed statement described below. r� 1. Address:90%- &064- Sr. Ylf A de lowDoc_ SBL: 1AA c)7— Zone: 0AS`A- 2, ,Proposed Improvement.(Describe in detail):k/h /A,115ft L- I Q/rQfi(91ly ' R1t1/y 12l,6'. 1 &ft l z 9 c]/l tyPr►42S_ 941UMMU t/AA4_ r, t? r)V T L6'r- 3. Does the proposed improvement involve a Home-Occupation as per§250-38 of the Code of the Village of Rye Brook? No:_z'� Yes: If yes,indicate: TIER 1: TIER II: TIER III: 4. Will the proposed project require the installation of a new,or an extension/modification to an existin automatic fire suppression system(Fire Sprinkler,ANSL System,FM-200 System,Type 1 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 fwn.,comm.,etc...)Prior to Construction: 00APf6V1N4--After Construction: d*1 &X_ 6. N.Y State Construction Classification: N.Y.State Use Classification`:) }� 'A Property Owner: A5 D t4)fta 1,4 L Address: AD Phone# Cell# 5&iM, a email: S. Applicant: 14)JO'f{p0-13f Address: q0 S i?1 ,1 Phone# 21 S 8 8 Cell# `$ • 73 W- $3?(f email: 02-t WP KbGP/ .t�2Cr 9. Architect:_ Tat /� .c k7� Address: Phone# Cell# email: 10. Engineer: Address: /j'hone# Cell# email: 1. General Contractor: SOMaY C,-_M,ar(*JaZJAddress: Aw GorAptYnt-9 t Phone# 9Ig- Cg.l-gOFSg, Cell#4iy-+1 jy__1 fly email: in_c,S/ CV9o' (fg,j 12. Estimated cost of construction $ (NOTE:The estimated cost shall include all labor.material,scaffolding,fixed equipment,professional tees,and material and labor which may be donated gratis.) 13. Job Timetable: Start: .454,+0 Finish: /)j)P (1) 6/1/2024 BUILD MENT VIL E OF RY OOK JAN - 6 938 KING ET RYE BR NY 10573 -,c w ov 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, k -),, /44 ,residing at, 17,E rint name) (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; 7 DOcL ;o�SP J�t�'e , 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 al I State, County and Village Codes. (5ignatu mperty Owner(s)) (Print Name of Pr erty Owner(s)) Sworn to before me this io day of 6 IAQ 20_s2S- .'&'_1 0,6& (Notary Public) Elt EFN 41E (2) Notary Nu iic,State°/New Qualified in01DE0029612 York ty Ccrnmtsst°ExAih ss=er C°only 6!1/1024 On 4,1018 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. STATE OF NEW YORK,COUNTY OF WESTCHESTER ) as: /�149 A ,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 1 044 l _(JF _GJ 0aJ,9pK f 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 MI day of L Jamdck 20 Qs— day of , 20 a5= Signat er � Signature of Applican a►H k Print Name of perry Owner Print Name of Applicant _ZZ44� alt4�_ Notary Public Notary Public ,.w.AD•.r EILEEN ALEXA DELIZ Public 0 101 DE0029612ew York in Westchester County ;lion Expires Oct 4, 2028 rt#.yt w i EILEEN,ALEXA DEL12 notary Public-state of New York No. O1DE0029612 C:.ahFed in Westchester County iv.'.en:n.ission Expires Oct a, 2028 wr• �:.r (4) 6/1/2024 ' f 1 = O N N N W • s N CV N N cz ri w f 3 G xL Z 0. f ►"r', C' ' s O Z c ^ C w o N � = A N H rA O e. 00 pQ PLO w A � z � W w a N > O 8 V ' � � z Ci w o `�° w Z � z �' P" o A C; c A ►-.+ C W w v A z a MM � I�1 W k O H � A rn a 0 Q z n. V ' xy U y O c o < x N � o v Q BUILD D` MENT 9 VILL- E o_ J": �3g OK 938 KiN �S " r k2YB�E }B C�-rot<,NY 10573 W W3do ny.gov ELECTRICAL PERMIT APPLICATION Westchester Cotuity Master Electricians License Required FOR OFFICE 11SI: UN Y BP#: �� 003 L �� _ 03 1� Approval Date: 1 P#:I� 2� Permit Fee: Approval Signature: OtIter: _. .. gar +par t*a� � .*s rt .+w ►.r +r�rx �r>lr sr w,rr+�� +r�, +r. + t ++� **41*6 M h 11 DO NOT STA111'WORI(or CONSTRUCTION UNTIL A PERN111'ETAS BEEN ISSUED BY'1'HE BU1LDiRC INSPECTOR TIM AWHINISTItATWE FEE FOR WORK PROCRFSSCD Oil CO1'1PLETED WI141OUT A PE411 IIT IS 12% OF THE '1'0'1'AL COS'r OF CONSTRUCTION WITH A MINIMUM FEE;OF S750.00— -- - Application dated, 1-7-:2 is hereby made to the BuildingInspector nspector of the Village of Rye Brook NY, for the issittance of a Permit to install and/or remove electrical equipment,wiring,fixtures,or to perform other high or tow 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: 90 5a.jr)f C�. .�.,:i r. SBL: � I ��� Zone: 2.Property Owner: "LSPg.-'I-ew LLC1 Address: l�L' 'i z,x: .2:1-) R,jei -,VY 10kS,? 0 Phone#: Cell#: ql y- `zx -//2l 0 elllail: 3.Master Electrician/Licensed Installer: �I c I t 5 ����,�G Address: (Y cl N[ 7�4-t., Lic.#: CZ,Q-&I Phone#: SIN -ZtN 9yf CelI #: `1iLl 9o-SC4 entail:t_ e -rcbrcLir� « , Company Name: ig w'\, ;F kr'c�Vv e1- I LL.GAddress: Ci qdj t�,l ✓ar e. wgi!�:j ' .- I jG,u s (l ►043 4.Proposed Electrical Work/Fixture Count: f--."t•- �� ;r, ���• ram��_f'z r .�. Z � -j✓ r ,..� -, ).f i C\,Qol 00 n S.3r1 Party Electrical inspection Acrency: ?;?;:l•3:'::':?:9::4:t:l•/:A::A:':?;:': 'A?:)::Y 4::':-F,sY:4:4:Y?:R?:y��y:4?:?:?;*,Y:Y•k:Y!h i*�!;';:Y:4 R•d dt:Y';::,4-,'::4:•:`.:t:':`.'::4^:Y?::4.�?:i::t?::4:Y:':�?::Y:4:4:t:;:Y?;3?;?;;Y:'; •?:k:4 STATE OF NEW YORK,COUNTY OF WESTCHESTER ) as: C(16, 1- r S 6e being du{y sworn,deposes and states that lie/she is the applicant above named,and does further (print awne ol'individuat signing as the npplicant) state that(s)he is the r—v,s I gt i- I(-n..,•,hZ`_for the legal owner and is duly authorized to make and file this application. (Master Electrician/Licensed lncta)lcr) The undersigned fttrther 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 Ryc Brook and all other applicable laws,ordinances,and regulations. Sworn tQ..hcforc n �1e this Sworn to before me this day of-j 20 day of ( / 20 = _ Cw x 5ia o �G? 1 er EILEEN ALEXA DELIZ lllatlll' of AprltL'alll �--- ...:.... �. �_.. Notary Public-State of New York 0,0 4! k74n�S2 No.OIDEO029612 C�c,Y -e 5 �� Print Name of Prrynty Owne' Quahiie''inWestchester Ccu'ty/� } My Comrrassion Expires Oc s. 02SPrint Name of Applicpt Y� � �.Y�1 !z Notary Public Notary Public STATEWIDE • Service With bilegritv 121 Main Street,Fishkill, NY 12524 1 email:office@swisny.com SWIS JOBAPPLICATION tel845.202.7224 • • 1•21 SWISNY.com I SWISTraining.com Office Use Elect.Permit# C l�� t�'� �O� Date Bldg Permit#6 Utility ID# Final Certificate# lJ City/Village r Zip r --1 Township County Address ` C7\SOv t—� C, Cross Street Section Block Lot Owner Name/Address(If different than above) y v (_L C_ U Contact Number t (1 _ c v , �, �? ❑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 Carbon Monox Hood Trash Compact vC �l 1 Amt Amps 1 Range(s) Cooktop(s) Oven(s) Dishwashers Refrigerator Disposal Microwave Warm Draw Incandescent Fluorescent SERVICE Amperage Voltage 1 P 3P #Meters #Disconnect ❑Underground ❑New ❑Reconnect ❑Overhead ❑Change ®Visual Re-Inspection ❑ Safety Re-Inspection ❑ Re-Inspection Additional Information r 1 C f -� I J IN - 9 >.5 This application is valid for one(1)year from the date received by WAS.This application is intended to toyer the above listed items to be inspected,if at any time 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 dedares that there is no open applications for the above address with any other inspection company.The applcant,owner or authorized agent agrees to all the above terms and conditions as set forth for the application. Inspector Date Finalized Inspector# Company Name Date x L, Signature A Address City/State �. Zip Code License# Phone# i D � ����� State Wide Inspection Services cj ---> FEB 2 0 2025 1080 Main Street Fishkill, NY 12524 a _.._ FRY 845 202 7224 Phone VILLAGEOE BROOK 914-219-1062 Fax STATE WIDE INSPECTION SERVICES _BUILDING ►EPARTMENT Email: officeCcbswisny.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: Bay Electrical Systems LLC RSP Group LLC 8 Sunset Place PO BOX 217 Hawthorne, NY 10532 Rye, NY 10580 Located at: 90 South Ridge Street, Rye Brook, NY 10573 Section: Block: Lot: Electrical Permit Number: EP25-003 141.27 1 9 Certificate Number: 2025-0515 Building Permit Number: BP25-003 A visual inspection of the electrical system was conducted at the Commercial occupancy described below.The electrical system consisting of electrical devices and wiring is located in/on the premises at: 90 South Ridge Street, Rye Brook, NY 10573 The First Floor: Office 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 23rd day of January 2025. Name Quantity Rating Circuit Type Duplex Receptacles 06 *Removal of MRI Machine, associated equipment and wiring. 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. N C14 O N N � ■ N N A \ \ tt w N N C W a r to H O m w EA � U � VJ C! a. a (A ' F+� v Q u ►� 4 ZCD H 0D .- CS00 ITT u cn $� r� oo W o eq w OF c 8 R� O V x CA w ? r V c, w w aocn .� w V A ►... c_n MM Z ✓� W O ar, F 0 - F _ 5 a w g H a a r" cnu PLO z V W Z a o z z L6 tA M ON y� [3RCv D � �W EU� BUIL G MENT VIL GE OF RYE OK 5 938 KIN BEET RYE B ,NY 10573 JAN 2 8 202 4"939 0- VILLAGE OF RYE BROOK eb7 ' ov BUILDING DEPARTMENT HLECTRICAL PERMIT APPLICATION Westchester Coun Master Electricians License Required FOR OFFICE USE ONLY BP#: �� C� EP#: "S__ O / Approval Date: ' Permit Fee: $ �J Approval Signature: k2L Other: DO NOT START WORK or CONSTRUCTION UNTIL A PERMIT HAS BEEN ISSUED BY THE BUILDING INSPEC'1'01t. THE ADMINISTRATIVE FEE FOR WORK PROGRESSED OR COMPLETED WITHOUT A PERMIT IS 12% OF TH1 TOTAL COST OF CONSTRUCTION WITH A MINIMUM FEE OF$750.00 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 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: qb $OtiZ 1�t�9 S rliL SBL: l q j s 777 Zone: 2.Property Owner: S Q Y ,i� L LG Address: P d k3X 2:27 4, rn 2 0 Phone#: I Cell#: 5Iq tl a email: 1 3.Master Electrician/Licensed Installer: GLto..v 1-c Address: t&!104 r,l. Rj'_'J . WI,t'-e, J��v►1•��/ Lic.#: e( Phone#: 5q 21q gkl q Cell#: 1 Q 101 1 email: Company Name: �iA_��tLl�.� (�_a�ry kE;��ddress: 1. 4.Proposed Electrical Work/Fixture Count: 5 to,s I1 5.31 Party Electrical Inspection Agency: 5 ********************************************************************************************************* I- STATE OF NEW SYORK,COUNTY OF WESTCHESTER ) as: Gh4w[c4 ]D► t��t. ." ,being duly sworn,deposes and states that he/she is the applicant above named,and does further (print name of individual signing as the appl' ant) state that(s)he is the for 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 ofthe Village of Rye Brook and all other applicable laws,ordinances,and regulations. Sworn before me this /% Sworn 4 efore me this � _ day o ,20 day ,20' Signature of Property Owner Signature of Applicant � e Po ry ublio O e ofA c, t *Notaryi 6/I/ 24/� STATE WIDE INSPECTION SERVICES, INC. •.• • • • ; APPLICATION • •. • SWIS Office Use Elect. Permit# Date Bldg Permit# ,( V — VO�� Sq Ft Plumbing Permit/# Final Certificate# City/Village jl j�� o Zip Building Dept. County (��5 fi'LI�YS��✓ Address J 11�� tV/ S Cross Street Section I Zi Block Lot Q Owner Name/Address(If different than above) LG (t Contact Number y 1�3 0 0 g l ❑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 10 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 ❑ Safety Inspection ❑Consultation �rov I � 1�1� v� } �✓ `� 5wc .-k c D IEC FP, Q�� FiAN 2 8 2�5 VILLAGE OF RYE BROOK BUILDING DEPARTMENT 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 (�O, c c i ` j t c [d Name G(,) License# Date r l 5 Signature Address p O City/State 14 �I d✓v�C N Zip Code Company L Phone# `, 1/27/25,8:38 AM Mail-Webmail 7.0 IN Mail search. Q- O Date ff WFI190S.Ridge © s Openln new tab Close Kevin Lillis Jan 2.1 proces��d-7�-/I9i=4"7HD=9819-5AW4WW7gQ10yple Awme-R.- 62 K8 Glenn Savino<SiennQuyllycory.com> U age:6 Date: 01/24/2025 O9:14AM _.l Y tO: QarNn $ca ecun .mm<garNrl aesecun .com> lames Sally<jim@scullycorp.com> Area prox 2,001 1 < -'harlry fiom Bay will run wiring.Will your team instal can move in February Ist. ! To y 1 h 1 d 2 T 1 _ IQ r Allm r � 1A tl ' JIT C7LA - m 1 r i L r r ' , I u https://webmail.aplus.net/#/mail/list/msg p IEC EWE State Wide Inspection Services cxz) + 1080 Main Street FEB 21 2025 ]D Fishkill, NY 12524 Q 845 202-7224 Phone VILLAGE OF RYE BROOK 914-219-1062 Fax STATE WIDE INSPECTION SERVICES Email: o BUILDING DEPARTMENT ffice@swisnv.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: Bay Electrical Systems LLC RSP Group LLC 8 Sunset Place PO BOX 217 Hawthorne, NY 10532 Rye, NY 10580 Located at: 90 South Ridge Street, Rye Brook, NY 10573 Section: Block: Lot: Electrical Permit Number: EP25-021 141.27 1 9 Certificate Number: 2025-1135 Building Permit Number: BP25-003 A visual inspection of the electrical system was conducted at the Commercial occupancy described below.The electrical system consisting of electrical devices and wiring is located in/on the premises at: 90 South Ridge Street, Rye Brook, NY 10573 The First Floor:Office, Hallway&Coat Closet were 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 21s' Day of February 2025. Name quantity Rating Circuit Type GFCI 01 Smoke Detectors 07 Horn/Strobe 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. a' a a t Vr N N 0 N N a 1 \ \ a U Y--1 M Z W v Cn � v p o w W Q o v ca a Ln col cn W �J ON 00 C� z M ~ `� w . OGIN . Hlet 0-4 Ono x o ZZ cn Q� C CHI � a Q 0.4 z � �, • z z i •• P. Q A a� t yE IRC�jB , � IE C IE � V EJ ► Bum NT VIL E OF RYK JAN 10 2025 938 KIN JET ET RYE Y 10573VILLAGE OF RYE BROOK BUILDING DEPARTMENT _ _.. PLUMBING PERMIT APPLICATION FOR OFFICE USE ONLY BP#: c� o PP#: 00(0 Approval Date: 1/4, 13 20X Permit Fee: $ Approval Signature: &d a Disapproved: (fees are non-refundable) DO iNOT START �' ORK or CONSI RUC I ION UN71L 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, /"1h 2!!�— 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: 17d SOVTN k7-b G E- S T, SBL: 1-411 i a 7--/—9 Zone: 2.Proposed Work: /a S r)A L I- yce-r ©s/ &--;k-/S Ti 7-iN/),& r Af F01 C- 9 4- D A'yL�/c 3.Property Owner: P 5 P Address: P, y 3y 2-72 P� YC A�)Z /49,L 6 Phone#: Cell#: C�'� (I- 9,D6 // O o email: 4.Master Plumber: Jl, 1 'RRl rah s Address: -� �..-� l Lic.#: 4 3 Phone#: 0 Cell#: email: JOU(o 6 Company Name: �i PivAtn- .` P 00 4 LLL-- Address: VL .) 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 3rd Floor 4d'Floor 5d'Floor Exterior 5.*List Other Equipment/Provide Details: (Notarized Signatures Required Next 2 Pages) -1- 6/1!2024 BUILD MENTF. , v v Vu, �: ! OOxJAN 10 938 K�tGIDI IR' ,NY 1057 2025 AGE OF RYE BROOK wtiv ovLDING_DEPAR T NENT ysyy yyY�: :.....:.y:.::.: ....s_�..�1�y.!._�;<::YZ��_T�Y��Ys,�sL.�•:kYX::Y��Y::::ys.�y....syF�i x.t..i<'Fj:XYX::*:C'..''F�:FX:�X.".:FX11�Y i..i.kyy�.ky AFFIDAVIT OF COMPLIANCE VILLAGE CODE M 6 • STORM SEWERS AND SANITARY SEWERS THIS AFFIDAVIT M1JST .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 RETURkTED TO THE APPLICANT . DRY,-, GOUNPf OF WESTCHESTER residing at,.. i�a lZr-el.<- 121"y 'ey", 66k/!>%/dS�3 aint name:} wthua yw ival-- being duly sworn,-deposes and states that(s)he-is-the applicant above named,and fitrther--states-that(&)he is the legal owner of the property to which this Affidavit of Compliance pertains at; �0 5 It �,, �,;e, > ,Rye Brook, NY. (Jab ANC dss't 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 fizrther 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. i ,g:r_a�sre �r} O�crertsl) (Print Narw of Properly o�.wuer(s)) Sworn to before me this - ` day of tj 20 S� r � ` 7 tNokar,y Public) �J EILEEN ALEXA DELIZ Notary Public.State of New York NO.01DE002961.1 Qualified in Westchester County My Commission Expires Oct a, 2028 STATE OF NEW YORK,COUNTY OF WESTCHESTER ) as: 41,47 ,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 before me this Sworn to before me this day o ,20 °fir day of 20 6Lgnaturejo,Wroperty Owner Sign a of Applicant )1-7 MO T P ' ame of Pr rty Owner Pri e of Appl' nt otary Publi / Notary Public I This application m st be properly completed in its entirety and must include the notariz/ds g ature(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/I/2024 *16 ju r'4 cc jr 'far OLU o a � a w jd NO }, m :dw "" L U �. 00r r la i r VA U. 04 Ir i w F� LU Cr k. uj O >.b F.. �Iwo uj € < J m X Uj r �,► rl W uj ca 6 � �. FIRIF OAL LU Qc r V CL Ix LL r 4� uj s (n is .� Me 46� v / LL CC a x } Lt! j4N y cr.►l de LAJ 01 s O tz +v LU 13 9 i 0 i .. $ try 41 ui s CL �... CL PUJ IN [yam' LLJ C)Cl �■- .w�. 0, Z dWLL 35 r A wn �yy cc ,. LAJ Ti� to OUU ■` LI. W n 0: U) �1 lu J m cr iui L�y a ,y, asap w (n v y V �i x ,V rr � , ■7� 4y f L4. b p f i 17 - ti 1 - +`r Buildin Permit Check List&Zoningal An sis Address. y S l SBL: Zone: Use: Cont Type: ' Other. Submittal Date: Revisions Submittal Dates: Applicant: Nature of Work 1 V� - C C ! CQ Reviews:ZBA: �—�2 PB: BOT: Other. NEED OK/ (� V `� S;W. O ({�( FEES:Filing: �`�" BP: �� t C/O: Flood Plane: Legalization: (i 220 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: (� ( ) HIGH-VOLTAGE ELECTRICAL:Plan: Permit: N/A: Other. LOW-VOLTAGE ELECTRICAL:Plan: Permit: N/A: Other. FIRE ALARM/SMOKE DETECTORS:Plan: Permit: H.W.I.C.:_Battery._Other. ( ( ) PLUMBINC1 Plan: Permit: Nat.Gas: LP Gas: N/A/: Other. ( ) ) FIRE SUPPRESSION:Plans: Permit: N/A: Other. ( ( ) H.V.A.C.: Plan: Permit N/A: Other. ( ) ( ) FUEL TANK:Plan: Permit: Fuel Type: Other. O O 2020 NY State ECCC: N/A: Other. ( ) ( ) Final Survey Final Topo: RA/PE Sign-off Letter. As-Built Plan: Other. ( ) ( ) BP DENIAL LETTER. C/O DENIAL LETTER: Other. ( ) ( ) Other. ( )ARB mtg. date: approval: notes: ( )ZBA mtg.date: approval: notes: ( )PB mtg.date: approval: notes: REQUIItED EXISTING PROPOSED NOTES APPROVEDS Area 7 Cirde: Date:. Fron�tne: Front: Front: Sides: Rear. Main Cov: Accs.Cov: Ft.H Sb: Sd.H Sb: GFa Tot.Imp: Ft.Imp: Paz ' . Height/Stories notes: C-'l t o n n S S w 1 1 0- A�® DATE(MM Y) CERTIFICATE OF LIABILITY INSURANCE 01/03/2025/2025 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: Theresa DeBara Brown&Brown Insurance Services,Inc PAHICONf o Ext: (845)628-4500 A c,No): (845)628-1804 625 Route 6 E-MAIL Theresa.DeBara@bbrown.com ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC# Mahopac NY 10541 INSURER A: Valley Forge Insurance Company 20508 INSURED INSURER B: Continental Casualty Company 20443 Scully Construction,LLC INSURER C: The Continental Insurance Company 35289 141 Lafayette Avenue INSURER D: Selective Insurance Company ofAmerica 12572 INSURER E North White Plains NY 10603 INSURER F COVERAGES CERTIFICATE NUMBER: 24-25 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 ILTR TYPE OF INSURANCE INSD WVD POLICY NUMBER MMIDDIYYYY MMIDD/YYYY LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE s 2,000.000 CLAIMS-MADE OCCUR PREMISES Ea occurrence $ 100,000 MED EXP(Any one person) s 1 5,000 A Y 5099147557 03/06/2024 03/06/2025 PERSONALBADVINJURY $ 2,000,000 GEN'LAGGREGATE LIMIT APPLIES PER. GENERAL AGGREGATE $ 4,000,000 POLICY ❑X JECTT LOC PRODUCTS-COMP/OPAGG $ 4,000,000 OTHER I I Pollution-Worksites $ 1,000,000 AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000 Ea accident X ANY AUTO BODILY INJURY(Per person) s Included B OWNED SCHEDULED BUA5099147512 03/06/2024 03/06/2025 BODILY INJURY(Per accident) $ Included AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE s Included AUTOS ONLY AUTOS ONLY Per accident Medical payments s 5,000 X UMBRELLA LAB X OCCUR EACH OCCURRENCE $ 10,000,000 C EXCESS LAB CLAIMS-MADE 5099147543 03/06/2024 03/06/2025 AGGREGATE $ 10,000,000 DED I X1 RETENTION S 10,000 $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY Y/N STATUTE ER 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 s Crime D B6055711 08/22/2024 08/22/2025 Limit 1,000.000 DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Village of Rye Brook is included as Additional Insured as required by written contract or written agreement. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN Village of Rye Brook Building Dept. ACCORDANCE WITH THE POLICY PROVISIONS. 938 King St. AUTHORIZED REPRESENTATIVE Rye Brook NY 10573 ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD N Y S I F PO Box 66699,Albany,NY 12206 New York State Insurance Fund nysif.com CERTIFICATE OF WORKERS' COMPENSATION INSURANCE A A A"" 134065227 Q ❑� SCULLY CONSTRUCTION LLC F 141LAFAYETTE AVE = WHITE PLAINS NY 10603 M SCAN TO VALIDATE AND SUBSCRIBE POLICYHOLDER CERTIFICATE HOLDER SCULLY CONSTRUCTION LLC VILLAGE OF RYE BROOK 141 LAFAYETTE AVE 938 KING STREET WHITE PLAINS NY 10603 RYE BROOK NY 10573 POLICY NUMBER I CERTIFICATE NUMBER POLICY PERIOD DATE I G 1172 704-7 783200 06/29/2024 TO 06/29/2025 05/15/2024 THIS IS TO CERTIFY THAT THE POLICYHOLDER NAMED ABOVE IS INSURED WITH THE NEW YORK STATE INSURANCE FUND UNDER POLICY NO. 1172 704-7, 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 AFFORDS COVERAGE TO THE SOLE PROPRIETOR, PARTNERS AND/OR MEMBERS OF A LIMITED LIABILITY COMPANY. JAMES SCULLY JR. BRIAN A. KEATING THE POLICY INCLUDES A WAIVER OF SUBROGATION ENDORSEMENT UNDER WHICH NYSIF AGREES TO WAIVE ITS RIGHT OF SUBROGATION TO BRING AN ACTION AGAINST THE CERTIFICATE HOLDER TO RECOVER AMOUNTS WE PAID IN WORKERS' COMPENSATION AND/OR MEDICAL BENEFITS TO OR ON BEHALF OF AN EMPLOYEE OF OUR INSURED IN THE EVENT THAT, PRIOR TO THE DATE OF THE ACCIDENT, THE CERTIFICATE HOLDER HAS ENTERED INTO A WRITTEN CONTRACT WITH OUR INSURED THAT REQUIRES THAT SUCH RIGHT OF SUBROGATION BE WAIVED. 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 DIRECTOR,I SURANCE FUND UNDERWRITING VALIDATION NUMBER 426136832 II�III�III�IIII!m0000000Ci00127lu oil u 9��IIIIIII IIIIIIIIiIII Form WC-CERT-NOPRIXT\'anon 3(OL2912019)IWC Miry-1 1 72 704 71 I'-26 256 100000000000127561597](0001-0000 1 17 2 704 7]($#G][16390-06](Ca_NOV-CERT_l;(OI-OWOI I