HomeMy WebLinkAboutBP19-235PERMIT #
SECTION
TYPE OF WORK
10B LOCATION
OWNER
CONTRACTOR
T. COST
CO #
TCO #
FOOTI N G
FOUNDATION
FRAMING
RGH FRAMING
INSULATION
PLUMBING C�
RGH PLUMBING
GAS O
SPRINKLER
ELECTRIC 0
LOW -VOLT C7
ALARM M
AS BUILT �.
FINAL
EXP:
�OT
FEE DATE
INSPECTION RECORD
DATE
INSP
OTHER APPROVALS
ARB
BOT
PB
ZBA
OTHER -
�QyE BR1
. 19
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4 J,e4C'V W V
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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
David M. Heiser
Donald T. Krom,Jr.
Salvatore W. Morlino
CERTIFICATE OF COMPLIANCE
December 2,2025
Jack Gigh&Anna Maria Macchia
15 Maywood Avenue
Rye Brook,New York 10573
Re: 15 Maywood Avenue, Rye Brook,New York 10573
Parcel ID#: 135.67-2-66
Building Permit#19-235 issued on 10/31/2019 for a Replacement Window
This certifies that the new window,installed under the above captioned permit,has been satisfactorily
completed.
Sincerely,
Steven E. Fews
Building&Fire Inspector
/to
BRC�V�
O Zm
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1932 BUILDING DEPARTMENT
O BUILDING INSPECTOR VILLAGE OF RYE BROOK
❑VILLAGE ENGINEER 938 KING STREET RYE BROOK,NY 10573
❑ASSISTANT BUILDING INSPECTOR (914)939-0668 FAx(914) 939-5801
- - - - - - - - - - - - - - - - - - - - - INSPECTION REPORT - - - - - - - - - - - - - - - - - - - --
ADDRESS: DATE:
PERMrr# ( ISSUED: f 0 " I Z SEcc BLOCK: LOT:
LOCATION: W 1 !�. � U lf,/�1 n �n�-ric,
OCCUPANCY:
❑ VIOLATION NOTED THE WORK IS... J ACCEPTED ❑ REJECTED/REINSPECTION
❑ SITE INSPECTION REQUIRED
0 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
❑ FINAL
❑ OTHER
R
0 j For office use onl :
BUILD >� #�A 2 MENT PERMIT# A35
�AN 3 � ED 1 N IL OF RYE I3(20�OK ISSUED:g� KING STREE Y.9 BROOK,NE%Y YORK 10573 DATE:VILLAGE ODF R BMEOO (914)9 �'939-5801 FEE: PAID
BUILDING o or
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
t#tttttiiittt►iitiittiitti##ii#iiittlii######;##i###i;##rtrtrt#**rtii#*rt#rtrt####ti#*#####i####;;i;i#;#####ii#**######rt##rt#########
Address: IS m a 2 w c-o d f g y t
Occupancy/Use: tr""'/ ---yrr__ Parcel ID#: / 3�. �7 — Co �P Zone:
Owner: A 10, m n CL(�+l! Address: /E MA-Awao-o( Ayt
P.E./R.A.or Contractor: � Address:at/SS P,l rs heir- Ad 1Wn� f4 b
� 303�`7
Person in responsible charge: �&("t L' - Ci-10 Address: /0
a�,o33
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 YOM COUNTY OF WESTCHESTER as:
PrVXVNA m o'-C�k l-�O' being duly swom,deposes and says that he/she resides at (,S- lM a�P&4 AC
(PrinZt-
e of Applicant) (No. nd Street)
in BC*6°1r— ,in the County of 0 t R4-c"0-0'— in the State of �J Y ,that
( ty/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:$ f` is ,
for the construction or alteration of o ' �.. - A-1
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 I' Sworn to before me this 44%
day f , 20 2-0 day of J 01Y1 u�_, 20� O
ti
FU I 1a&&C'^
St afore of Property Owner Sig-na-t�uof Applicant
%
Print Nam f Property Owner Print Name of Applicant
Notary Pu tc G \otary Public r
DENISE COSTA •/Il�hp�l�
NOTARY PUBLIC,State of New Y0* ALEXANDRA N.FRANK
No.01 C06104128 Notary Public,State of New York
Oualified in Westchester Coun No.OiFR6363711
Commission Expires 01/12/20 Qualified In Westchester County,
ommission Expires August 28,20 _j
Building Permit Check List&Zoning Analysis
Address: SBL:
Zone: '-t-2- Use: t o Const.Type: Other.
Submittal Date G Revisions Submittal Dates:
Applicant: A
Nature of Work: 1/� ti�� — ►� U4 C 6-
Reviews:ZBA: n r T 2 9(1 t 0 PB: BOT: Other.
NEED OK
(/ ( ) FEES:Filing. 7 BP: C/O: Legalization:
( ) (,/, PP: Dated: Notarized: -- SBL: Mass 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 7S3#: Dated: N/A:
( ) ( ) HIGH-VOLTAGE ELECTRICAL:Plans: Permit: N/A: Other.
( ) ( ) LOW-VOLTAGE ELECTRICAL:Plans: Permit: N/A: Other.
( ) ( ) FIRE ALARM/SMOKE DETECTORS:Plans: Permit: H.W.I.C.:_Battery._Other:
( ) ( ) PLUMBING Plans: Permit: Nat.Gas: LP Gas: N/A/: Other.
( ) ( ) FIRE SUPPRESSION:Plans: Permit: N/A: Other.
( ) ( ) H.V.A.C.: Plans: Permit N/A: Other.
( ) ( ) FUEL TANK:Plans: Permit: Fuel Type: Other.
( ) ( ) 20I7 NY State ECCC: N/A: Other.
( ) ( ) Final Survey Final Topo: RA/PE Sign-off Letter. As-Built Plans: Other.
( ) ( ) BP DENIAL LETTER: C/O DENIAL LETTER: Other:
( ) ( ) Other.
( )ARB mtg.date: approval: notes:
( )ZBA mtg.date: approval• notes:
( )PB mtg.date: approval• notes:
REQUIRED EXISTING PROPOSED NOTES O C T 2 5 2019
Area: Date:—
Circle:
Fro�¢e
Front:
Front:
Sides:
Rear.
Main Cov:
Accs.Cov:
Ft.H Sb:
Sd.H Sb:
GFA:
Tot :
Ft.Imy:
Paz ' .
Height/Stories:
notes:
Mk Home Improvement Agreement: Pagel
Home Depot License #'s - For the most current listing www.Homedepot.com/LicenseNumbers
NY: Amherst HI-04712, Lockport 2395; Buffalo LT12-10023782, City Tonawanda 33257, East Hampton 4499, Long Beach
4917, N. Tonawanda 368.16, Nassau County H1171050000 - H1771053000, New York City 0900456-DCA, 900457-DCA,
0900458-DCA, 0910621-DCA, 0910622-DCA, 0920734-DCA, 0922474-DCA, 0968605-DCA, 1003822-DCA, 1003823-
DCA, 1003825-DCA, 1003828-DCA, 1003830-DCA, 1003833-DCA, 1026224-DCA, 1075580-DCA, 1129555-DCA,1129556-
DCA, 1129557-DCA, 1129562-DCA, 1129564-DCA, 1133444-DCA, 1152032-DCA, 1152034-DCA, 1152035-DCA, 1152036-
DCA, 1152038-DCA, 1152039-DCA, 1152040-DCA, 1178447-DCA, 1186042-DCA, 1212045-DCA, 1223272-DCA, 1251871-
DCA, 1318292-DCA , Niagara Falls 971, Putnam County PC 689, Rockland County H-06464, Southampton 1-002442,
Suffolk County 47874-ME, 55323-ME, 53429-H, 57713-H, 54888-MP, 50222-MP, Town of Tonawanda: 1854, Westchester
County WC18484H06, Yonkers 5675, 47874-ME
Rocco Deleo
Salesperson Name: Registration No. (if applicable):
Home Depot U.S.A., Inc. ("Home Depot") or Service Provider named below will furnish, install and/
or service the equipment listed below at the price, terms and conditions as outlined on this form.
MACCHIA ANNA Long Island 1-MSWZ91P
Customer Last Name Customer First Name Store # / Branch Name Customer Lead/ PO#
15 Maywood Avenue Rye Brook NY 10573
Customer Address City State Zip
(914) 490-5499 annamariam2002@yahoo.com
Home Phone# Work Phone# Cell Phone# Customer Email Address
NOTICE OF RIGHT TO CANCEL: YOU MAY CANCEL THIS AGREEMENT WITHOUT PENALTY
OR OBLIGATION BY DELIVERING WRITTEN NOTICE TO HOME DEPOT AT:
40 Oser Avenue Suite 17 Hauppauge NY 11788
Address City State Zip
Or Email; customercancellationnortheast@homedepot.com
Service Provider Email Address
BY MIDNIGHT ON THE THIRD BUSINESS DAY AFTER SIGNING, UNLESS THE STATE
SUPPLEMENT PROVIDES A DIFFERENT CANCELLATION PERIOD. THE STATE SUPPLEMENT
CONTAINS A FORM TO USE IF ONE IS SPECIFICALLY PRESCRIBED BY LAW IN YOUR STATE.
YOUR PAYMENT(S) WILL BE RETURNED WITHIN TEN (10) BUSINESS DAYS AFTER HOME
DEPOT'S RECEIPT OF YOUR NOTICE. YOU MUST MAKE AVAILABLE FOR PICKUP BY HOME
DEPOT OR SERVICE PROVIDER, AT YOUR SERVICE ADDRESS, AND IN SUBSTANTIALLY THE
SAME CONDITION AS WHEN DELIVERED, ANY MERCHANDISE OR MATERIALS DELIVERED
TO YOU. OR YOU MAY CONTACT HOME DEPOT FOR INSTRUCTIONS REGARDING RETURN
SHIPMENT AT HOME DEPOT'S EXPENSE.
THE LAW REQUIRES THAT OME DEPOWC
YOU A NOTICE EXPLAINING YOUR RIGHT
TO CANCEL. PLEASE SIGM�XWTO
CKDGE THAT YOU HAVE BEEN GIVEN ORAL
AND WRITTEN NOTIC L.
Acknowledged by: 10/19/2019
er's Signature Date
Contract Price and ent Schedule : Payment of the Contract Price is due upon signing unless a
different payments edule is required by law, specified below or in a payment addendum.
Contract Price: $ 11494.50 Includes all applicable taxes. Excludes finance charges.*
Sales Tax: $ 10.00 (If applicable)
*Maximum deposit ONL Y applicable in MD, MA, ME (33%), NJ, W/ (99%)
Dep. 125.0 % Deposit Amount $ 373.63 Remaining Balance $ 1120.87
The Home Depot-2455 Paces Ferry Road, N.W. Bldg. B-3, Atlanta, Georgia 30339-Customer Care: 1-800-466-3337
460FI HIDE Customer Agreement(24 Jul.18) v 0 1 8
WINDOW SPECIFICATION SHEET - Spec.Sheet N:1-MswzglP Sheet:1 of 1
Customer:ANNA MACCHIA Job M:1-Mswz9HP Consultant: Rocco Defeo Date: 10/1912019
New Window
Hinge Locations
Existing window Measurements Grids FToducl Options Labor Options From out pule.
Left to Right
BayS,Bo-
L-110. Color Rough Opening N of bars a of bars Csmnls,I Pnl,
use L.RorS
Glass Mi.Items
Hardware Cone For doors use
_ _ _ Mull '$'=stationary or
w operating
Y. . g w 4 q sq
Room Floor Code (YM) Style Cade Series Code — 3 = 5 ✓+ V a t T
STD,White,GlassPaCk. WRAP,LSR
1 BED 2nd DH Y DH 6100 �Wl �W- 2< 38 62 S, WNW C TOP 2 Standard
GBG H
STD,White,IMP:Full, WRAP,LSR
2 BATH 1st DH Y DH 6100 WH �Wl 16 32 16 Obscure Glass Full,
G lass Pack.Standard
SPECIAL CONSIDERATIONS'.
1.While,2:White
Wrap Color
.terror C-ani Type
Bay or Bow window,
eatboard material(vinyl only-Birch or Oak)
ay Project Angle(30 or 45)
ay Flanker Type(DH,SH,or Csmnl)
Top 01 window to soffl(inches)
I lied to soffl.color of soffit material I have reviewed arld agree with all the job specifications above arW the
onslrucl Roof(Yes or No)' Special Terms and Condition on the following page
Garden window:
eatboard Mal-al(vinyl only While%mte.Birch or Oak)
1
a! � I:
Ai
I tip;;
' . . .- ,
a far,
II ■a�l .• M�
�...• `.� i
wow-ot-
6100 Series
,. & 1
0 1��
ao to0 o 11 1 e �,1►
uVanta ePointe-
40
rLWindows and Doors By OSIMONTON'
■ Combines the best from two of America's leading companies; F `
Simonton4i Windows and The Home Depot"
■ Features award-winning quality construction,
beauty,style options,value,and energy-efficiency '
�: st
■ Learn more at vantagepolnto.slmonton.com ;
6100 Series Windows
■ Contoured window frame blends with any style of home
■ Double Step Sloped sill drives water away from the window y_
4i
■ Low gloss white or tan finish always looks like freshly painted wood
■ Dual panes of single strength glass create a strong thermal barrier
Glass package with Soft Coal Low E' r1
with Argon Gas meals ENERGY STAR
tt qualificalions in most styles
Casement windows(above)provide maximum ventilation and add an air of contemporary style
Strong and Durable
■ Multi-chambered construction with Styles Colors Grids
nine separate air chambers create -
a much stronger window than Double Hung
standard vinyl windows Slider
,i Picture )tJ lllmm,m
I
■ Interlocking meeting rail forms a tight eau Round r;,!
seal to virtually eliminate air and :.•.rt, ---•-�' � ■
water infiltration yl , Casement White Flat White
R. Awning
■ Meets AAMA's standards for air _ Bay
and water infiltration,forced entry w `i Bow
and energy efficiency [casement Hopper
Garden Window
Easy to Operate and Clean
■ Constant Force Balance System maintains the window Patio Door Tan Flat Ten
in any open position and never needs lubrication or adjustment
■ Low profile tilt latches allow both Double-Hung window sashes r
mited Lifetime Warranty"
to tilt in for easy cleaning Guaranteed protection for you and your home
duct
Peace of Mind le Lifetime Warranty,on vinyl parts covers peeling,flaking,
ng,WlstwN&corrosion
■ We know you have a choice when it comes to home improvement leLHetlmewarrantyarhardware&parts(kodcs,fasteners,roiiars,
projects.That's why we're committed to providing quality es,etc.)covers peding&conoskan
e LHetime Screen Warranty trovsra ttre alurninurn frame 8 tl>eproducts and installation services with our complete solution— ss meshagamslwars,penclums&nseddafragefrom start to finish ftsmanship
Lifetime Craftsmanship warranty ensures the prstallatJm was done right
■ To ensure your peace of mind,we stand behind the entire fur as long as you om your home
installation with Limited Lifetime Product and Craftsmanship
warranties."
SUfI r:uHl L.aW E glaa6lt rtlgtllffld In aUfrly arena IU IIINHI Hlleigy GndH IHgllir afflfltlla. ".�iNN actual wet,of lUHS to,delella.All It I SLailudoll RflrvICMH ptlfforn ltl(t through The I'fame Depat pwonriad by indopandwit wntrncloil .
License numbers hold by or on behalf or THD A"r•HOMF.SIERVICES,INC..AL:106515,Sub S43105:A7.'ROC193323,ROC21800.ROG223472.ROC254479,ROC254482:CA Hoofing/Fencing/883602,;CT:
HIC.0565522;DC Contract Only 6148;DE:1997112310;FL:CRC046858.CGC 1507093,CCCO58327;I0RCE-18527;IA.CO87256;KS'.KS10-1239,IL:Roofing 104-014925:LA:HI.0660419;ME:CO2439:MO:52036,
MA:126803;MI:2104158225;MN.CR208257;MS:RO.5788:NV:0057766,(106577,'1,066778;NJ:13VI-101056300 8,L063476;NM' 351405;NC.54706;NO 29346 Class D;OR:158651;PA'.PA002232;RI:16427;SC:
22647 w,d G115673;TN.68337;UT 5604067-5501,VA 2705073411A;WA.HOMED"972RO;WV:WV033268,Wt.850869,Oualifluf 1066645;Columbus,0I'1.HIC-4992 and G6519;Toledo,OR:8TR 05603HRC,OK:
80000018;BuBelu.NY.536671 Sub Cunlraclor,Suffolk Cty 2.7587-H,Phllodelphia.PA 21855:Rockland County,NY H-09403.86-UU-UU:NYC 1201002;Nassau Cnly,NY H18(;lg5000U;Yonkers,NY 3802;Hammond,
IN Lic19030.Other Ilcenae numbers available upon request.Services may not be available In all areas.Colors shown are reproduced by lithographic procees and may vary from actual colors. Changes to product(s)may
havo occunod since Lima of pdnling. Consult your THD Al-Noma Servlcos ioproaontallvo prior to purrhaaing.'AAMA-and d)o MMA logo to a roglulorod trademark of the American Architectural Manufacturers ALaodallon.
'NFRC-and the NFRC logo ale rugiatHred trardmnarka of tho National F rnuslra8on Rating Coundl.'The Home Duput'to a reglst wit hednnwd(of I lumen TLC.Ina 02GOO-2014 Humor TLC,Inc.All rights reserved.
THD-103(5/14)
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ACo CERTIFICATE OF LIABILITY INSURANCE D02/1112019
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
MARSH USA,INC. NAME:
PHONE - _ FAX
TWO ALLIANCE CENTER c No Ext: (A/C,No):
3560 LENOX ROAD,SUITE 2400 E-MAIL
ATLANTA,GA 30326 ADDRESS: _
INSURER(S)AFFORDING COVERAGE NAIC If
CN101642069-HomeD-GAW-19-20 INSURER A:Old Republic Insurance Co 24147
INSURED HOME DEPOT U.S.A.,INC. INSURER B:New Hampshire Ins Co 23841
D/B/A THE HOME DEPOT INSURER C:HomeRisk Captive Insurance Company
2455 PACES FERRY ROAD INSURER D:
BUILDING C-20
ATLANTA,GA 30339 INSURER E:
INSURER F
COVERAGES CERTIFICATE NUMBER: ATL-004353266-17 REVISION NUMBER: 3
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 SUER POLICY NUMBER POLICY EFF YY M DD EXP
LIMITS
LTR
A X COMMERCIAL GENERAL LIABILITY MWZY314574 03/01/2019 03/01/2022 EACH OCCURRENCE $ 1,000,000
DAMAGE TO RENTED
CLAIMS-MADE rxl OCCUR PREMISES Ea occurrence $ 1,000,000
X SIR:$1.000,000 MED EXP(Any one person) $ EXCLUDED
PERSONAL&ADV INJURY $ 1,000,000
GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 1.000.000
POLICY PRO ❑
JECT LOC PRODUCTS-COMPIOP AGG $ 1.000.000
X
OTHER: $
MBINED SINGLE LIMIT
acci
A AUTOMOBILE LIABILITY MWTB314573 03/01/2019 03/01/2022 COEa dnt
$ 1000000
e
X ANY AUTO BODILY INJURY(Per person) $
OWNED SCHEDULED SELF INSURED AUTO PHY DMG BODILY INJURY(Per accident) $
AUTOS ONLY AUTOS
HIRED NON-OWNED PROPERTY DAMAGE $
AUTOS ONLY AUTOS ONLY Per accident
$
UMBRELLA LIAB OCCUR EACH OCCURRENCE $
EXCESS LIAB CLAIMS-MADE AGGREGATE $
DED RETENTION$ $
B WORKERS COMPENSATION WC 012717099 AK,NH,NJ,VT) 0 X STATUTE ER
AND EMPLOYERS'LIABILITY
B Y/N WC 012717100(WI) 03/01/2019 03101R020 5,000,000
OFFCERMEMBEREXCLUDED?ECUTIVE a N/A E.L.EACH ACCIDENT $
(Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 5,000,000
If yes,describe under Continued on Additional Page E.L.DISEASE-POLICY LIMIT $ 5,000,000
DESCRIPTION OF OPERATIONS below
C Excess Auto 297110011002019 03/01/2019 03/01/2020 Limit: 4,000.000
A Excess General Liability MWZX 314580 03/01/2019 03/01/2022 Limit: 8.000.000
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required)
VILLAGE OF RYEBROOK IS INCLUDED AS ADDITIONAL INSURED IF REQUIRED BY WRITTEN CONTRACT ON THE ABOVE GENERAL LIABILITY AND AUTOMOBILE LIABILITY POLICIES,BUT ONLY
WITH RESPECT TO LIABILITY ARISING OUT OF THE OPERATIONS OF THE NAMED INSURED.
CERTIFICATE HOLDER CANCELLATION
VILLAGE OF RYEBROOK SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
BUILDING DEPT. THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
938 KING STREET ACCORDANCE WITH THE POLICY PROVISIONS.
RYEBROOK,NY 10573
AUTHORIZED REPRESENTATIVE
of Marsh USA Inc.
Manashi Mukherjee _1VLauDo� Lcn.r�.�c�
® 1988-2016 ACORD CORPORATION. All rights reserved.
ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD
I' INIEW Workers' CERTIFICATE OF
Compensation NYS WORKERS' COMPENSATION INSURANCE COVERAGE
Board _
la.Legal Name&Address of Insured(use street address only) 1b.Business Telephone Number of Insured
Home Depot USA,Inc. 770-433-8211
2455 Paces Ferry Rd.,C-20 1c.NYS Unemployment Insurance Employer Registration Number of
Atlanta,GA 30339 Insured
76011130
Work Location of Insured(Only required if coverage is specifically limited to 1d.Federal Employer Identification Number of Insured or Social Security
certain locations in Now York State,i.e.,a Wrap-Up Policy) Number
58-1853319
2.Name and Address of Entity Requesting Proof of Coverage 3a.Name of Insurance Carrier
(Entity Being Listed as the Certificate Holder) New Hampshire Insurance Company
3b.Policy Number of Entity Listed in Box"1a"
Village of Ryebrook WC0 1 271 7098
Building Dept.
938 King Street 3c.Policy effective period
Ryebrook,NY 10573 03/01/2019 to 03i01/2020
3d.The Proprietor,Partners or Executive Officers are
[ included.(Only check box if all partners/officers included)
all excluded or certain partners/officers excluded.
This certifies that the insurance carrier indicated above in box"3"insures the business referenced above In box 1a"for workers'
compensation under the New York State Workers'Compensation Law.(To use this form,New York(NY)must be listed under to--M-3-A
on the INFORMATION PAGE of the workers'compensation insurance policy). The Insurance Carrier or its licensed agent will send
this Certificate of Insurance to the entity listed above as the certificate holder in box"2".
The insurance carrier must notify the above certificate holder and the Workers'Compensation Board within 10 days IF a policy is canceled
due to nonpayment of premiums or within 30 days IF there are reasons other than nonpayment of premiums that cancel the policy or
eliminate the insured from the coverage indicated on this Certificate.(These notices may be sent by regular mail.)Otherwise,this
Certificate is valid for one year after this form Is approved by the insurance carrier or its licensed agent,or until the policy
expiration date listed in box"3c",whichever is earlier.
This certificate is issued as a matter of information only and confers no rights upon the certificate holder.This certificate does not amend,
extend or alter the coverage afforded by the policy listed,nor does it confer any rights or responsibilities beyond those contained in the
referenced policy.
This certificate may be used as evidence of a Workers'Compensation contract of insurance only while the underlying policy is in effect.
Please Note: Upon cancellation of the workers'compensation policy indicated on this form, if the business continues to be
named on a permit,license or contract issued by a certificate holder,the business must provide that certificate holder with a
new Certificate of Workers'Compensation Coverage or other authorized proof that the business is complying with the
mandatory coverage requirements of the New York State Workers'Compensation Law.
Under penalty of perjury,I certify that I am an authorized representative or licensed agent of the insurance carrier referenced
above and that the named insured has the coverage as depicted on this form.
Approved by: Lex Baugh
(Print name of authorized representative or licensed agent of Insurance carrier)
_ 2/5119
Approved by:
(Signature) (Date)
Title:
Authorized Representative
-
212-770-7000
Telephone Number of authorized representative or licensed agent of insurance carrier:
Please Note:Only insurance carriers and their licensed agents are authorized to Issue Form C-105.2.insurance brokers are NOT
authorized to issue it.
C•105.2(9-17) www.wcb.ny.gov