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HomeMy WebLinkAboutBP25-001PERMIT # J� Y—� 0 L DAm S SECTION BLOCK l LOT TYPE OF WORK e4e / %ip�2 A; e2eAs JOB LOCATION is I CJ CONIMACTOR< Zo T. COST � #Q3� TCO # FOOTING FOUNDATION FRAMING RGH FRAMING INSULATION PLUMBING RGH PLUMBING GAS O SPRINKLER ELECTRIC 0 LOW -VOLT 0 ALARM [� AS BUILT FINAL Lc�Q7 o� l/s 4.&y4.5 /`i)�3%O3L/S C q/y) 93 '7-o 3 VS' FEE FEE DATE INSPECTION RECORD DATE I NSP ZB OTHER APPROVALS ARB BOT PS A OTHER VILLAGE OF RYE BROOK WESTCHESTER COUNTY, NEW YORK Certificate of Occupaucp This is to certify that&1h0 pin S �16ho- CsDII�OS '. �I,a Jr. oe'do �p,nosa �c eaas of, Pme B-00�_Pj NY having duly filed an application on rfC Lq u.p-� go 20 a5 requesting a Certificate of Occupancy for the premises known as, 50 BLQt-na AViee)L Ae , Rye Brook,NY, located in a Ra-E Zoning District and shown on the most current Tax Map as Section: 141.a8 Block: Lot: c,24 and having fully complied with the requirements of the Building Code and the Zoning Ordinance under Building Permit No.6?5-00 I , issued -Q 20 c25 , 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: �?'3 / JWO- Agn-7 Construction: JCS for the following purposes: New 6 407eon CGabloc-AS s 00601 ME1410rhb, 7_ 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 i e g t shall be made,nor s all the building be moved from one location to another until a permit to accomplish such change b ta' the u ldin ctor. 7 Building Inspector,Village of Rye Brook: Date: AUG 1 2 2025 D E C h W E CYE `' For office unonBUILA�2TMENT PERMIT#AUG - 8 2025VILE OK ISSUED: 8 KING STREK,' YORK 10573 DATE:VILLAGE OF RYE BROOK 6y�0� FEE: PAID BUILDING DEPARTMENT 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 #ifi##i#}ikkfk#i#it}itiiktikttiitt}iktt#tik}tti#####iikii#iii#####kiiiit#i####4###}}kkkkkkk##4########*i#**###i***##i###tkik# Address: t v , 13 Occupancy/Use: Parcel ID Zone: Ownef �i!!D Address: P.E./R.A.or Contractor: 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: oe�01/,l/O gS�14- S,4being duly swom,deposes and says that he/she resides at`5f) 4/� (Print Name of Applicant) (No.and Street) in yr2 (� _ ,in the County of ��p�Qa/ 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:$ a , for the construction or alteration of: G! S 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 y Sworn to before me this day of �ls , 20 aJ day of 920 -��� +� Signature'of Property Owner Signature of Applicant m e of Property Owner Print Name of Applicant Notary Public Notary Public SHARI MEULLO Notary Public,State of New York 6/l/2024 No.01MM60063 Qualified In Westchester County Commission Expires January 29,207� �Qyt✓aRCd1,�. O ym Q � BUILDING DEPARTMENT �❑0/1111T a►aNG INSPU43-ott f�A.sSESTA V 191T IPING INSPECTOR VILLAGE OF RYE BROOK ❑CODA a;Nl+oMt:xt�►fq;N.t()I�I+I(;Iclt 938 Kil ig Si:rcct•Rye Brook,NY 10573 (914)939-06681II&X.(914)939-5801 v_w(ryd►rjwkog - - -- - - --- - - - - _ - - - - ._ - INSPECTION REPORT - - - - - - _ -. - .- - - -- - - - - - - AI)I)REs,s:. SO Zow m�V_._. Ave . _DxrE:�p___l�- 202j-- PRIt]VII'I' '._ ? _1ssULII):_'- 131,ocx:_ I.^ LOT. LOCA'.l'ION: OCCUPANCY: ❑ VlolaHon NoW 'ftmi WORK IS... @00*0PASSED ❑ FAILED /REINSPECTION ❑ SITE INSPECTION REQUIRED ❑ FOOTING ❑ FOOTING T)R.A.INAGE ❑ FOUNDNVION ❑ TTNDI.RGR()T.TIVD PI.UMIDING N(>`.l.".l.?,S ON INSPECTION: ❑ ItOUGII PI:1TH19INI4 ❑ ItOUGII PR.AIIIING ❑ INSULATION ❑ Ni►tllx:ll(R:4R ❑ LA Gies ❑ FUEI,TANK -- A' •I -_- n❑ .FIR)',SPRI]VRLI.R ❑ I'INAi,1.LiJ7YIIlIN(: a /�. • ❑ CROSS CONN7:.C'.1-ION �T�INA I, ❑ OTHER ■ ■ 6 N W a C Ln aS v N \ N ena v-4 Q N 'oai y 0-4 20 ►- U] 7 a t' yy" a W F-i O z a L w V N aq O b o w v bA x ■ Cl)Ln ■ cn O W o (n , W M et -� M ■ed Q 4-4 1 � LL c� C7 N z �n n , o 14 Lt a V en g o 'u w � " � 00 a � � H W a4 I—I Wes, x z Q W a d a b C W wA P-4 ClnLl © o Q oz � awe u1-4 E� A W d U S w Cc) Z O w C7 A 114 z 0-4 •• '� P4 '� 0 'Lf a r BUILD MENT D E C E IJ�E VIL E OF RY OOK 938 KING ET RYE BR ,NY 105 DEC > > 202� 0 w� ov VILLAGE OF RYE BROOK BUILDING DEPARTMENT INTERIOR 1311ILDING PERMIT APPLICATION FOR OFFICE USE ONLY: ��yy�� Approval Date: 1(�024tit#: J f C�J/ Application Fee:$ �' Approval Signature: Permit Fees:$ ' f� Disapproved: Other: Application dated: is hereby made to the Building Inspectorof the Village of Rye Brook,NY,for the issuance ofa Permit for the interior alteration of an existing building,or for a change in use,as per detailed statement described below. NII /��� 3 1. Job Address:-50 bawmc to 4J�! rLl/e b foc) SBL: /-.Y/r 4R � .Zone: 2. Proposed Improvement.(Describe in detail): ke e IIG<G e r-Gl."'b i ^ e L! ' I'n It%'hr-h e jrT \ C. S c, C_ CU r 1 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[I: TIER III: 4. Will the proposed project require the installation of a new,or an extension/modification to an existing automatic fire suppression system(Fire Sprinkler,ANSL System,FM-200 System,Type I Hood,etc...) :No: Yes: (If yes,please submit a separate Automatic Fire Suppression System Permit application&2 sets of detailed engineered plans) 5. Occupancy;(1 fam.,2 fam.,comm.,etc...)Prior to Construction: After Construction: 6. N.Y State Construction Classification: N.Y.State Use Classification: 7. Property Owner: Fen,I.Q Address: W howmon ALL. (k)rc bracrk dy Phone#(q/1y_) q; ,7 03 t1 5 Cell # email: 8. Applicant: Address: Phone# Cell# email: 9. Architect: Address: Phone# Cell# email: 10. Engineer: Address: Phone# Cell# email: 11. General Contractor: Address: Phone# Cell# email: 12. Estimated cost of construction $ CO.t Ubo (MOTE:The estimated cost shall include all labor,material,scaffolding,fixed equipment,professional fees,and material and labor which may be donated gratis.) 13. Job Timetable:Start: Finish: (1) 6/l/2024 BUILD _ TMENT VIL (AGE OF RYE BROOK 938 KING EET RYE B11001 ,NY 10573 `:(9114� 39-0668 AFFIDiAVIT 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, Cr►m IN n p bQ S! ,residing at, So bQ tynnr:, n A y P aye b Cook c A (Print 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 �0 Q w e A n 14,E 1 LY t° h CUB I" Y j [? 3 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. (Signatur o Property Owner(s)) (Print Name of Property Owner(s)) Sworn to before me this day of h((�{ qJ64 , 20 (Notary P . 'c) GREGORY M.RIVERA Notary Public,State of New York No.OIR16441398 (2) Qualified In Westchester County j j Commission Expires September 26,2(1'l 6/V2024 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: n G S 0-- ,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 "A,I t"() 4&n A �`for the legal owner and is duly authorized to make and file this application. (indicate architect,contractor,agent,attorney,a c� 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 I I Sworn to before me this day of , 20 day of , 20 Signature of Property Owner Signature of Applicant Print Name of Property Owner Print Name of Applicant A)", Notary Notary Public GRE QRY M.RIVERA NoSary Public,State of New York No.01 RI6441398 i Qualified In Westchester County Commission Expires September 26,20_41.1^ (4) 6/l/2024 m3ou :sauols 1LI ia�..� :d I-3 :�•1 .L :y3DJ :qS H'PS :qS H'4d :AOD S»y :eoD u►ew ='d :sap!s �uos3 juos3 :easy S O—N aFISOW'dd J1� �32i :salou :Ienosddr :;nrP 81<u gd( ) Mnou :Ienosdde mvp•81tu VUZ( ) :salou :Ienosdde 'a3rP•8=ggy( ) =Tpo ( ) ( ) =XPo :'UHI LHI TVINHQ O/D :2I=TI TvgN'gQ dg ( ) ( ) :law :weld almg-sd :sa1nal JJo-uBiS Eld/d2I :odo.L JUM :,(ansnS jum ( ) ( ) :saTpo :d/N :DDDII a1v3S kN OZOZ ( ) ( ) aaw :a&l Tana u?uuad :gucId:,INV.L-IHnA ( ) ( ) :321po b/N uT'=d :RId :•D•V•A'H ( ) ( ) Uagpo :y/N nT uzad :SuvId:NOISMddf1S H'dH ( ) ( ) =TPO :/d/N :mJ dI =11J 1eN uiuuad :m9d�DNIg➢ nld ( ) ( ) :saw— 6sa11eg—: I I� anusad : Id:S2IO LDH LHQ H?IOWS/W2Id"Id 9UL3 ( ) ( ) :sacpO :y/N unusad :mod:Zd'JRI DH IFI ffDVJ--IOA-AkO-I ( ) ( ) UJ'PO 'V/N :3 uUUM :gueId:I` DrILLD9IFI UDVIIOA-HDIH ( ) ( ) :y/N :Pnea :#Cse aaOD ( ) ( ) sayaO saniem duioD h?pgerl :duioD ssaslsoM asm:)rl ( ) �4) satllO anionaalg :saidoD :PaleaS TadumS 31eQ:SNVId ( ) ( ) algelda�aeun TaleaS :Iennl'sy auassn� -pa1eQ:,gA dClS ( ) ( ) :Jaw =7d aasZ :•1ui8w IA/S =S ( ) ( ) :y/N :saa3 u1offs SunradO 1aa4S :mainaZl Salem uuo1S :spuepaA :sadoI- daa1S :sPeoZl Diva)S ( ) ( ) y O H uop,auuoD ssos:j Q I smul — :Igs-- pazuelON :Pa3eQ :ddy,�') ( ) u09=7271 :aid Poold :O/D l :dg CjaaN =ILPO :109 :gd \4, Z\ -V Z:sm2TA3;g ks� S�L S auwTIddy :sa3eQ IellnugnS saoisrA3 d \IA MrCl In3?mgnS sages adM(1 lsuoD ZZ �sn �- � auoZ •IgS (� _ :ssasPPd T i-mv uiuoZ?g lsc-I 3f alqf5 liuuad_P L I fr��,,. I[i 1 I / �S 1 1' t • �1w dpp, t" 0 �. i ,r 3`i 7 �I � it I.Lt • 4 titpop -— n J i Y t J a LL) Lin LU ,V - as 0 cu z z w ' C loss coalm (;) T CL � �.. --j Ll 0 0 ` 7- u u tLl t� ley — - \ h CERTIFICATE OF LIABILITY INSURANCE DATEJ%IMDD/YYYY) 9/25/2024 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 pollcy(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 endorsoment(s). PRODUCER Sharp Insurance Services Inc NAYEAC Moises Rosales 128 N Main St PHONE 2032479524 FAX 2036638200 Port Chester NY 10573 Lkr—No.Ext1 (A.0 No) ADDRESS A mrosales@sharpsvcs.com ADDR INSURERS)AFFORDING COVERAGE NAIC a INSURER A Obsidian Specialty Insurance Company 16871 INSURED EMILIO&SONS LANDSCAPING INC INSURER B 50 BOWMAN AVE RYE BROOK NY 10573 INSURER C 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 LTIR POLICY NIMNER POLICY EFF POLICY MA2Di!X► LIMITS INSR TYPE OF INSURANCE ADOL SUB COMMERCIAL GENERAL LIABILITY si EACH OCCURRENCE $1.000.000 fl AIMS4AADL ✓1 :CUR DAMAGE TO RENTED 50.000 PREMISES(Ea oocllrehoe) $ SCB-GL-000062706 07/04/2024 07/04/2025 MEDEXPI"one person) $5,000 A PERSONAL a ADV INJURY 5 1,000.000 GENE AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE s 2,000.000 ✓ POL ICY❑PPERC4T LOC PRODUCTS.COMPIOP AGG $2,000.000 OTHER $ AUTOMOBILE LIAeRm Li Lit $ soaowr) ANY AUTO BOOILY 04JLIRY(Per Pwsm) $ OWNED SCHEDULED BODILY INAIRY(Per RrndeM) $ AUTOS ONLY AUTOS AUTOS ONLY AUTOS ONLY (� RDAMAGE $ $ UMBRELLA LW OCCUR EACH OCCURRENCE $ EXCESS LW pAIlMS4AADE AGGREGATE $ DED RETENTIONS S WORKER!COM►El13ATKN1 AND EMPLOYERS'LIABILITY YIN S ATVTE U ER ANYPROPRIE TOR.PARTNER1EXECUTTVE I I E L EACH ACCIDENT $ OFFICERAAEMBEREXCLUDEO7 N,A J1111w sW7 N1 NN) E L DISEASE-EA EMPLOYEE $ n yap Aearllbe uMer DESCRIPTION OF OPERATIONS bk. E.L DISEASE-POLICY LIMIT S as as DESCRIPTION OF OPERATIONS+LOCATIONS/VEHICLES (ACORD 101 Addltronal Remarks Schedule,maybe anached if more space is requuedl The Commercial General Liability Insurance is endorsed naming"VILLAGE OF RYE BROOK"its officers,partners.shareholders,employees and costumers as additional insureds. CERTIFICATE HOLDER CANCELLATION VILLAGE OF RYE BROOK 938 KING ST SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE RYE BROOK NY 10598 THE EXPIRATION DATE THEREOF. NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS AUTHORIZED RE PRESENTATIVE MOISES ROSALES PRODUCER 1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD Produced using forma BI—Wph•ohwarp www FormsEloss com,';Impressive Publishing 800.208.1977 17 \\ NYSIF New York State Insurance Fund PO Box 66699,Albany, NY 12206 1 nysif.com CERTIFICATE OF WORKERS' COMPENSATION INSURANCE ft..4k., n A AAAA 815166066 SHARP INSURANCE SERVICES, INC 120 N.MAIN ST-2ND FLPORT CHESTER NY 10573 SCAN TO VALIDATE AND SUBSCRIBE POLICYHOLDER CERTIFICATE HOLDER EMILIO &SONS LANDSCAPING INC VILLAGE OF RYE BROOK 50 BOWMAN AVENUE 938 KING ST RYE BROOK NY 10573 RYE BROOK NY 10598 POLICY NUMBER CERTIFICATE NUMBER POLICY PERIOD DATE W2412 022-2 686566 03/18/2024 TO 03/18/2025 9/25/2024 THIS IS TO CERTIFY THAT THE POLICYHOLDER NAMED ABOVE IS INSURED WITH THE NEW YORK STATE INSURANCE FUND UNDER POLICY NO. 2412 022-2, 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:INVWW.NYSIF.COMICERT/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 CLAIMS OR SUITS THAT ARISE FROM BODILY INJURY SUFFERED BY THE OFFICERS OF THE INSURED CORPORATION. VICE-PRESIDENT EMILIO E HERRERA EMILIO&SONS LANDSCAPING INC 1 OF 1 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 STAT S7NCE FUND V DIRECTOR,INSURANCE FUND UNDERWRITING VALIDATION NUMBER:211672194 U-26.3 Affidavit of Exemption to Show Specific Proof of Workers' Compensation Insurance Coverage for a 1, 2, 3 or 4 Family, Owner-occupied Residence **This form cannot be used to waive the workers'compensation rights or obligations of any party.** Under penalty of perjury, I certify that I am the owner of the 1, 2, 3 or 4 family, owner-occupied residence (including condominiums) listed on the building permit that I am applying for, and I am not required to show specific proof of workers' compensation insurance coverage for such residence because (please check the appropriate box): I am performing all the work for which the building permit was issued. ❑ I am not hiring,paying or compensating in any way,the individual(s)that is(are)performing all the work for which the building permit was issued or helping me perform such work. ❑ I have a homeowners insurance policy that is currently in effect and covers the property listed on the attached building permit AND am hiring or paying individuals a total of less than 40 hours per week (aggregate hours for all paid individuals on the jobsite) for which the building permit was issued. I also agree to either: ♦ acquire appropriate workers' compensation coverage and provide appropriate proof of that coverage on forms approved by the Chair of the NYS Workers' Compensation Board to the government entity issuing the building permit if I need to hire or pay individuals a total of 40 hours or more per week(aggregate hours for all paid individuals on the jobsite)for work indicated on the building permit,or if appropriate,file a CE- 200 exemption form; OR ♦ have the general contractor, performing the work on the 1, 2, 3 or 4 family, owner-occupied residence (including condominiums)listed on the building permit that I am applying for,provide appropriate proof of workers' compensation coverage or proof of exemption from that coverage on forms approved by the Chair of the NYS Workers' Compensation Board to the government entity issuing the building permit if the project takes a total of 40 hours or more per week(aggregate hours for all paid individuals on the jobsite)for work indicated on the building permit. A:WW_ /21/l12q (Signature of Homeowner) (Date Signed) l%/f'/ /,/l0 Home Telephone Number (Homeowner's Name Printed) so 04000 a •i M/y Property Address that requires the building permit: aiL-L i2y e b i'ov[4 n1 Y . �_S �3 Notary Public,State of New York No.01 R16441398 Qualified In Westchester County Commission Expires September 26,20 Once notarized,this BP-1 form serves as an exemption for both workers'compensation and disability benefits insurance coverage. BP-1 (12/08) NY-WCB