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HomeMy WebLinkAboutRP19-027SECTION 00 it . y • : LO 10 �Ord MINOR �w�PEQTION RECORD DATE FOOTING FOUNDATION FRAMING RGH FRAMING INSuLAnON PLUMBING Cl RGH PLUMBING GAS 0 SPRINKLER Q ELECTRIC LOW -VOLT 0 ALARM AS BUILT FINAL EX� _ �c W (} I 1 > �^- INSP �"1 L- 2oz.y FD a3se .— nth 51-633-4171 OTHER APPROVALS ARB BOT PB ZBA OTHER MA I c �yE QR(� VILLAGE OF RYE BROOK MAYOR 938 King Street, Rye Brook,N.Y. 10573 ADMINISTRATOR Jason A. Klein (914) 939-0668 Christopher J. Bradbury www.ryebrook.org TRUSTEES BUILDING& FIRE INSPECTOR Susan R. Epstein Steven E. Fews Stephanie J. Fischer David M. Heiser Salvatore W. Morlino CERTIFICATE OF COMPLIANCE March 19,2024 Robert Limb&Wendy Min 16 Milestone Road Rye Brook,New York 10573 Re: 16 Milestone Road Rye Brook,New York 10573 Parcel ID#: 124.65-1-73 Roof Permit#19-027 issued on 9/16/2019 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 DC E N E BUILDING DEPARTMENT For office use onl PERMIT# 1 �—o a7 VILLAGE OF RYE BROOK ISSUED: 9-/Ca/9 MAR - 8 2024 938 KING STREET,RYE BROOK,NEW YORK 10573 DATE: 3—e -4/ (914)939-0668 FEE:,APAm4& VILLAGE OF RYE BROOK www.rvebrook.ora BUILDING_DEPARTMENT 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 *sssssss**sssss**ssssssssss*sssss**ss*ss*ss*ssssss*****sss**s*ssssssss*s*sr*s*sssasssssssss*ssssssss*ssss*ssssssssssssss*sss* Address: 16 M��P5*brse �2u 2 Sao �!`( k 6 ;13 e ^M.t ...L�_ Occupancy/Use: Res�i-e..tsG.,1 Parcel ID#: 12t{-,65-f-Z'3 Zone: `//1 U/J Owner: We". j M-(n Address: P.E./R.A. or Contractor: Address: Mt� ri� 10Z5 Person in responsible charge: Q 5C�r (iv ca Address: Lj e,-t bt,T, Mf 11 $g o - s AQ g 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: n�c�tcuf Fo ;t-�) e Id STATE OF , COUNTY OF WE-&- �R as: Rdber>z l:rmlo *Weed 1.1-`� y being duly sworn,deposes and says that he/she resides at 16 M�4s+rn Q . (Print Name of Applicant) I ' (No.and Street) in Rye prba ,in the County of We 5t-Ine4-I-tr- in the State of Nam( ,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:s 11,0 00 for the construction or alteration of R.'� 5 ^5�e s 01 U A-t-e-r- y-e F k w C�Q,A-CA-'' 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 Sworn to before me this eQ day of b(-Iorrl 20?-44_ day of C ,20 Z _ at a of P erty wner Signature of Applicant bey ke 46 ;n Print ame of Prop wner Print ar s p cant 9 L�ubfl'c,"�St A VE A Nota to of nnec No b ° Notary ic,State of Connecticut No M minission Expires 04/30/2025 a/12/_o21 QyE BR(�k. 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 I I� e S 10 DATE: J / Z Z 0 1 / PERMIT# �R 1 ISSUED: SECT: BLOCK: _LOT: LOCATION: ICoo OCCUPANCY: ❑ Violation Noted THE WORK IS... PASSED ❑ FAILED REINSPECTION ❑ SITE INSPECTION REQUIRED ❑ FOOTING ❑ FOOTING DRAINAGE ❑ FOUNDATION ❑ UNDERGROUND PLUMBING NOTES ON INSPECTION: ❑ ROUGH PLUMBING ❑ ROUGH FRAMING ❑ INSULATION \ } ❑ Natural Gas C= �00 ❑ L.P. Gas ❑ FUEL TANK ❑ FIRE SPRINKLER ❑ FINAL PLUMBING ❑ CROSS CONNECTION FINAL OTHER 9/13/2-019 Your Proposal �UALI USA OMES Quality Homes USA, Inc. 1025 Old Country Rd, Suite 401 • Westbury, NY 11590 • Phone: (844) ROOF-NOW - Fax: (516) 430-6444 Wendy Min and Robert Limb 9172325535 107-03 86 Ave 16 Milestone Road, NY 10573 Print-date: 9-13-2019 Thank you for contacting Quality Homes USA, Inc.A visual inspection of your home was conducted by a Quality Homes USA representative. In consideration of the work to be performed and based on the information that has been shared with me, the following proposal has been created for you detailing the work to be performed and accompanying costs. Thank you for allowing us to provide you with a proposal and we look forward to doing business with you. Attached Files: Price Breakdown Description Qty/ Unit Supply and Install Owens Corning(Duration Shingle) Roofing System which includes: 1850 1)Complete tear off of all existing layers of shingles down to plywood Replace any soft or rotted plywood up to 250 square feet at no additional cost.Additional over 250 square feet will be an extra charge of$2.97/square foot. 2)Supply and Install F Style Drip Edge Along Eaves and Rakes 3)Supply and Install Owens Corning Ice and Water Protection Along Eaves and Rakes.Also use in Valleys and around Chimney, Skylights and Vents. 4)Supply and Install Owens Corning Pro-armor Synthetic Roof Underlayment 5)Supply and Install Owens Corning Starter Strip Plus Shingle Along Eaves and Rakes 6)Supply and Install Owens Corning Duration Shingle with Surenail Technology 7)Supply and install Ventsure Ridgevent where needed. 8)Supply and install Owens Corning Ridge Cap Shingle 9)Flash Where necessary 10)Counter flash around Chimney Duration Shingle Color- Location-replace all asphalt shingles on main structure. Includes Owens Corning 50 Year Non Prorated, Transferable Warranty. Installation and haul away of all job related debris Included in price Seamless Gutters with Hidden Fasteners 125 https://buildertrend.net/Leads/LeadProposalExternal.aspx?leadlD=f5ZYOvSBCjO&proposalld=XdLo7OfdbK8&openPrint=True 1/4 9/13/2019 Your Proposal Location-replace existing only Lifetime warranty Includes Labor and Materials Downspouts 180 Location-replace existing only No Interest for 12 months Payment Factor 3.5% 1 No Pre Payment Penalty Monthly payment is$1000 month Total Price: $12,000.00 It is agreed and understood by and between the parties that this written agreement constitutes the entire understanding between the parties,and replaces any and all prior negotiations,representations,or agreements,either written or oral.Buyer(s)hereby acknowledges that Buyer(s)has read the entire agreement and understood its terms.Any alteration or deviation from the above specifications,involving extra cost will be executed only upon written orders,and will become an extra charge over and above the Agreement purchase price.If Buyer(s)fails to pay for the services when due,Contractor has the option to treat such failure to pay as a material breach of this Agreement,and may cancel this Agreement and/or seek legal remedies. YOU,THE BUYER(S),MAY CANCEL THIS TRANSACTION AT ANY TIME PRIOR TO MIDNIGHT OF THE THIRD BUSINESS DAY AFTER THE DATE OF THIS TRANSACTION. Buyer(s)Representations and Responsibilities:In addition to making timely payment to Contractor according to the conditions of this Agreement,Buyer(s) represents and warrants that(a)Buyer(s)owns the premises where the products and/or services are being provided by Contractor,Buyer(s)will provide Contractor with unrestricted access to the premises at all reasonable times for the purposes of taking measurements,performing the work,and for any subsequent remedial work,if required,including access to electrical outlets as me be required by Contractor;(b)Buyer shall be responsible to obtain any necessary permits before work is begun;(c)Contractor shall not be responsible for any damages arising in whole or in part from strikes,fires,accidents,floods,governmental actions,or any other causes beyond control of Contractor;(d)Contractor shall not be responsible for any unintentional damage to window treatments,shutters,blinds,alarm systems, household items,landscaping,satellite dish,gas lines,condensation pipes,electrical wiring,plumbing,and telephone installations.It being understood that Buyer(s) is responsible at its own cost for all preparations,protection and/or moving of such items prior to Contractor's commencement of the work;and(a)Buyer(s)is responsible at its own cost for removing and/or refitting/reconnecting Buyer(s)'home security system or the costs associated with removing and/or refitting/reconnecting Buyer(s)'home security system.(0 Buyer(s)will remove,secure,or otherwise protect all items of value or concern to avoid any accidental mistakes or slippage as the Contractor will not be liable for replacing or repairing other household items in the work areas;(g)Buyer(s)shall be responsible for the preparation,moving,and reinstalling of wiring,water lines,power lines,plumbing,and the moving of any scrubs,plants,or other items as required by Contractor under this Agreement;(h)Buyer(s)has reported to Contractor all conditions known to Buyer(s)which may not be apparent to Contractor and which might significantly increase cost of the Work or delay completion.These concealed conditions include,but not limited to,hazards on the job site,existing of cedar shingle and/or cedar sheathing,prior defective work of others,latent defects in the plans or specifications,earlier attempts to do similar or related work,and obligations imposed by the government or other governing bodies,and(i)if Contractor's work requires consent and/or approval from any Homeowner's Association or any other legal entity or voluntary association that enforces covenants,conditions,and restrictions on the property,Buyer(s)is responsible to submit any required forms and obtain approval for the work to be done and to keep Contractor informed as to the approval status;0)Contractor is authorized to make minor changes in the Work which are in the interest of Owner,do not materially alter this Agreement contrary to the law of the stale of NY shall not invalidate other parts of this Agreement.If a provision of this Agreement is held to be invalid or unenforceable provision is emitted. Delay/Unknown Conditions:Contractor's failure to perform any term or condition of this Agreement as a result of conditions beyond its control such as,but not limited to strikes,fires,floods,acts of God,manufacturer's delay material shortages,Buyer(s)'inability to qualify for or obtain financing,delays by local government authorities in issuing or otherwise approving inspections,permitting,or other required authorizations do not constitute abandonment and are not including in calculating time frames for performance by Contractor,Contractor and Buyer(s)have determined that a definite start date and completion date are approximate and are subject to change. Lien Rights:Any contractor,subcontractor or material-man who provides home improvement goods or services pursuant to your home improvement contract and who is not paid may have a valid legal claim against your property known as a mechanic's lien.Any mechanics lien filed against your property may be discharged. Payment of the agreed-upon price under the home improvement contract prior to filing a mechanic's lien may invalidate such lien.The owner may contact an attorney to determine their rights to discharge a mechanic's lien. Late Cancelation of Custom Ordered Products:Custom Ordered Products are products that are custom,specialty made,uniquely altered,shaped,sized,or otherwise uniquely designed or fitted to accommodate the requirements of a particular space or environment.If Buyer(s)cancel or repudiate a Custom Ordered Product after midnight of the third business day after the date of this Agreement and after product has begun on the Custom Ordered Products,the Buyer(s)agree to pay all of the Contractor's material costs,plus a cancelation fee of 50%to offset a portion of Contractor's Incurred labor cost,overhead,and lost profit.The parties agree that quantifying losses arising from the late cancelation of Custom Ordered Products is inherently difficult,and therefore stipulate that the agreed upon sum is not a penalty,but rather a reasonable measure of damages given the nature of loses that may result from a late cancelation. Contractor's Right to Cancel:In the event that Contractor determines that this Agreement cannot be performed as intended by the parties due,for example,to incorrect pricing,unforeseen structural defects,or pre-existing conditions to Buyer(s)Property,Contractor may cancel this Agreement with(45)days of its execution, notify Buyer(s)of such cancelation in writing,and return all monies paid by Buyer(s). Substantial Completion:Upon Substantial Completion of Contractor's work under this Agreement,Buyer(s)shall pay all amounts due under this Agreement without any right of set-off or retention.Substantial Completion is defined as the stage in which progress of the work,where the work is sufficiently complete in accordance to this Agreement so that Buyer(s)can occupy or utilize the work for its intended use. 1.COMPENSATION AND METHOD OF PAYMENT I. Upon execution of the Contract,the Contractor will obligate the necessary funds for Owner to pay the Contract sum in accordance with the Contract.The Owner agrees to pay,from the obligated funds and only from the obligated funds,whereby such funds will be insured and bonded by a surety company agreement obtained by Contractor.Upon requested,and as provided by New York State law,the Owner has the right to see where all monies will be held and insured through bond.The Contractor for the full and faithful performance of the work pursuant to this Contract at a sum equal to the aggregate cost of work,labor,materials and supplies done and furnished at the price and rates set forth in the Contractors proposal.Contractor covenants and agrees to faithfully comply with and perform each and every obligation imposed upon the Contractor by the Contract and the term of the proposal,as accepted by the Owner. 2. Payment requests shall be made by the Contractor to the Owner for work that has only been performed,unless otherwise agreed upon by the Owner and accepted by the Contractor.The Contractor shall be entitled to a maximum of five partial payment request.Any additional Contractor payment requests to the Owner beyond the maximum number must be approved in writing by the Owner and the Contractor. 3. No payment will be made for any work which is not specified in this Contractor or any work that has not been specified via an official change order. 2. GENERAL CONDITION 1.Insurance.The Contractor and all subcontracts employed by the Contractor shall purchase and maintain insurance that will protect them from claims under NYS Workers Compensation Acts,and from claims for damages which may arise out of or result from the Contractors operations during construction,whether such operations be by the Contractor or by any subcontracts operations or anyone directly or indirectly employed by any of them.Certificates showing that the insurance will remain in force throughout the fife of the Contract may be required by the Owner at the time of Contract signing. 2. Licenses.As required by New York State law,the Contractor and all subcontractors must be licenses in New York and all other applicable regulatory agencies for the nature of work being performed.NYC:2028551-DCA Suffolk:H-55997 Westchester:WC-30606-Hl8 NJ:2203758 https://buildertrend.net/Leads/LeadProposalExternal.aspx?leadlD=f5ZYOvSBCjO&proposalld=XdLo7OfdbK8&openPrint=True 2/4 �f £ � ; \® CL . • _ - ��� L » elf , |IC! �\ y I �& . }} / o,�\ & , / _]j/00E-I _\ / \ 4,wcc TDom mnnn ncom oTn, p m N N m Ta U m v p mf ¢ o E Ecc Q Q o Wgg dmoo�' c V E 3 '2 N N N N N m m N N a)�a°� ❑❑❑ ❑ ❑❑ Ea o oN r m ; o c > � N Y � N m d m H m m m w o o_= m (D W m m rn O o O } U«« �.. — m U) Q p QQUUU U. 0' m r, NU \ Ln O (D a 0 rn a'Y, ro 3 - O r ru O ru 0 0 a, o E O = � Q � N M = o C U M o72 o 3 zLO M co h o 0 o - 1 — � Z �co = � ai 2 N o O LO N 'O coz CL .� H C3 N m O� 61 N m > Vic -° _ �, C 7 O � o E �oI00 Q s ,1 0) Z ri co E C+�-' O U 1 U 0 • U av�iQo ¢ S a L' i ■ ■ ■ QL �s C-i d - � o Q LL C� o y 0 (6 Z N U m 'E a CV)ii a-a. a t- N O Z - m W uN m F- LLJ0 -_ LLJ m W W = LL ai Z - O O Z O— c ( HMO r, J 0 a > m } _ m d �t (D Z m D m (D _ ru dru ru S cu V Q c +- m o N N IF -p Ln o- = N c O �a QyC DR . 193 �L4Lw°JJw J�,GC'V4W V OY VILLAGE OF RYE BROOK MAYOR 938 King Street, Rye Brook,N.Y. 10573 ADMINISTRATOR Jason A. Klein (914) 939-0668 Christopher J.Bradbury www.ryebrook.org TRUSTEES BUILDING& FIRE INSPECTOR Susan R. Epstein Steven E. Fews Stephanie J. Fischer David M. Heiser Salvatore W. Morlino January 19,2024 Dear Rye Brook Building Permittee, It has come to the attention of the Building Department that your Building Permit has not been closed out in accordance with Village Code and is now expired.All Building Permits have a twelve (12) month lifespan starting from the date of issuance, and the permit expiration date is noted on the front of the permit. Please note that there is a non-waivable Expired Permit Fee of$500.00 now due in connection with your expired permit. Once payment is received,your permit will be reinstated for a period of six(6) months. Please be advised that it is a violation of Village Code to fail to close out a permit,and that a court summons could be issued, and fines may be imposed on the permit holder and/or property owner for failure to apply for and obtain a Certificate of Occupancy (C/O) or Certificate of Compliance (C/C),in accordance with Village Code section 250-10A. Please note that Temporary C/Os& C/Cs are available in accordance with Village Code section 250-10B should you require more time to perform whatever work remains in order to complete your project. Thank you for your attention in this matter, and please feel free to contact this office should you require any further information. �C- I Steven E. Fews Building&Fire Inspector stevefewsni ryebrook.org cc:Alfredo DiVitto,Assistant Building&Fire Inspector Tara A. 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QUALHOM-02 DLOCURT CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDfYYYY) 8/26/2019 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). CONTACT PRODUCER NAME: Libardi Service Agency Inc. (A/HCD,Nr o,E■q:(516)333-3611 F _ _ 100 Stewart Avenue E-MAIL (ac,No):(516)887-0816 Hicksville,NY 11801 ADDRESS:info@libardi.Com INSURER(S)AFFORDING COVERAGE - _ NAIC 0 INSURER A:Peleus Insurance Company 34118_ INSURED INSURER B Quality Homes USA Inc. INSURER C 1025 Old Country Road.Suite 401 INSURER D Westbury,NY 11590 INSURER E INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE IN IADDL SUBR POLICY NUMBER POLICY EFF POLICY EXP LIMITS LTR A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000'000 CLAIMS-MADE X OCCUR 103GLOO1843902 6/10/2019 6/10/2020 DAMAGE TO RENTED 100,000: PREMISES(Ea occurrence) _.$ MED EXPLAny one person) _ _$ 5,000 PERSONAL&ADV INJURY _ $ 11000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL_AGGREGATE -$ 21000,000 X POLICY 2,000,000 JRQ X LOC Ir PRODUCTS OTHER: CMPINE�.I $ AUTOMOBILE LIABILITY Ea accident)SINGLE LIMIT $ ANY AUTO BODILY INJURY(Per person) .$ OWNED SCHEDULED AUTOS ONLY AUTOS SSVyNEp BODILY INJURY(Per accident) $ AUTOS ONLY .AUTOS ONLY (Per accident)t DAMAGE ' b UMBRELLA LIAB OCCUR r_EACH OCCURRENCE__ $ EXCESS LAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ WORKERS COMPENSATION PER [ER ANDEMPLOYERS'LIABILITY Y/N E.L.EACH ACCIDENT _ $ ANY PROPRIIETgOERIPARTNERIEXECUTIVE _ _ (Mandatory In NHS EXCLUDED? NIA - E.L.DISEASE-EA EMPLOYEES$ If yes,descnbe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ � I it DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Village of Rye Brook THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 9 Y ACCORDANCE WITH THE POLICY PROVISIONS. 938 King Street Rye Brook,NY 10573 AUTHORIZED REPRESENTATIVE ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD YoaK Workers' CERTIFICATE OF TaTI Compensation Beard NYS WORKERS' COMPENSATION INSURANCE COVERAGE la.Legal Name&Address of Insured(use street address only) 1 b.Business Telephone Number of Insured (516)430-5880 Quality Homes USA Inc. 1c.NYS Unemployment Insurance Employer Registration Number of 1025 Old Country Road,Suite 401 Insured Westbury,NY 11590 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 New York State.i e..a Wrap-Up Policy) Number 47-5039291 2.Name and Address of Entity Requesting Proof of Coverage 3a.Name of Insurance Carrier (Entity Being Listed as the Certificate Holder) New York State Insurance Fund 3b.Policy Number of Entity Listed in Box"1 a" Village of Rye Brook 938 King Street 23737240 Rye Brook,NY 10573 3c.Policy effective period 10/12/2018 to 10/12/2019 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"I a"for workers' compensation under the New York State Workers'Compensation Law.(To use this form,New York(NY)must be listed under Item 3A 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: William Libardi (Print name of authorized representative or licensed agent of insurance carrier) Approved by: _�,tJ�ff��yjr ,����' 08/26/2019 (Signature) (Date) Title: President Telephone Number of authorized representative or licensed agent of insurance carrier: (516)333-3611 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