Loading...
HomeMy WebLinkAboutBP19-095EKP; PER �3MEM 1t+ E , Kf+X0/ TYPE OF WORK r,icse JOB LOCATION CONTRACTOR SI �A W(Im so/ _, _ FOOTING FOUNDATION FRAMING RGH FRAMING INSULATION PLUMBING ❑ RGH PLUMBING GAS Cl SPRINKLER ELECTRIC ❑ LOW -VOLT O ALARM AS BUILT FINAL mmmm� IN IN INSPECTION RECORD DATE iiiiiii, ORION MINIMUM INSP CC C IT �a �tCCcti uJJJ G CCU SCa Q JI.C�t,`vJu 198 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 Gellin Murguia 21 Ridge Boulevard Rye Brook,New York 10573 Re: 21 Ridge Boulevard, Rye Brook,New York 10573 Parcel ID#: 135.60-1-21 Building Permit#19-095 issued on 5/23/2019 for a New Fence This certifies that the new four foot high cedar privacy fence,installed under the above captioned permit has been satisfactorily completed. Sincerely, Steven E. Fews Building&Fire Inspector /to (� (� (� BUILDING DEPARTMENT FOr office use onl - /�, D V� E� 1l��J E VILLAGE OF RYE BROOK PERMIT# "D`�S ISSUED: � — 8 KING STREET,RYE BROOK,NEW YORK 10573 DATE: p"Z ' L/ 3D4, LEB2 6 20 (914)939-0668 FEE: /d PAID www.rvebrook.orL 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 #ititffffti##i#i##i#i�f7iiiif#fk##tittftk####fktkf#####ftfif#f##ifftnn#fktitf#i#t#####t##ttiii####k#iiitiiii#####iitiiii##ii##### Address: 2-1K 1(j e Siva Q z DV'-.) U 0C Njy- o Occupancy/Use: Parcel ID#:, J35"00 Zone: — 7 Owner: �—yP '. 1\ (./YS .� Address: P.E./R.A. or Contractor: tV tCq 1GC (x{1U I nC Address: -7 0 h Gt S L-jh 1 r lc.., 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:G C o 1 ' (A)V 1 V 1 being duly swom,deposes and says that he/she resides at 2 1 1 C J l J �1I in �not Name of pplicant) -I_ (No.and Street) \' \.Ac ryQ�� ,in the County of ; �ZY�-.� in the State of 7 ,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:$ 1 7 O O c� for the construction or alteration of. T::: ' 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 pat tly,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 day of , 20,2 day of , 20 Sign t re Property Owner Signature of Applicant N �V� v-, PMamc of Property Owner Print Name of Applicant , \--,, a '�� Notary Public SHARI MELILLO Notary Public Notary Public,State of New York No.01ME6160063 8/1 2/_02 1 Qualified In Westchester County)--, Commission Expires January 29,20�4_ 1 �E BRC��• ZI 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: ` ' l V 8 DATE: PERMIT# I Q 9 5' ISSUED:j"Z / SECT: U BLOCK: LOT: ZI LOCATION: � � �-P %t�� I( U ' eIVF OCCUPANCY: / ❑ Violation Noted THE WORK IS... b PASSED ❑ FAILED REINSPECTION ❑ SITE INSPECTION REQUIRED ❑ FOOTING ❑ FOOTING DRAINAGE ❑ FOUNDATION ❑ UNDERGROUND PLUMBING NOTES ON INSPECTION: ❑ ROUGH PLUMBING ❑ ROUGH FRAMING ❑ INSULATION ❑ Natural Gas l� ❑ L.P.Gas ❑ FUEL TANK N ❑ FIRE SPRINKLER ❑ FINAL PLUMBING ❑ CROSS CONNECTION 24INAL ❑ OTHER QyE BRC�k. '9a2 BUILDING DEPARTMENT ❑BUILDING INSPECTOR 0 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: 2/ R / F / DATE: PERMIT# 13 P i 9 0 ,-r ISSUED: SECT:/a' (�U BLOCK: � LOT: G I LOCATION: / ���G� �/4- N(%P /ti • OCCUPANCY: ❑ Violation Noted THE WORK IS... ❑ PASSED fr- FAILED REINSPECTION Er-SITE INSPECTION REQUIRED ❑ FOOTING ❑ FOOTING DRAINAGE ❑ FOUNDATION ❑ UNDERGROUND PLUMBING NOTES ON INSPECTION: ❑ ROUGH PLUMBING ❑ ROUGH FRAMING ❑ INSULATION // ❑ Natural Gas `' 1--2 CP Q ❑ L.P. Gas �p �(/ !t/A S COS' ❑ FUEL TANK ❑ FIRE SPRINKLER ❑ FINAL PLUMBING ❑ CROSS CONNECTION ❑ FINAL ❑ OTHER v A Lj • ♦ • O O 9°2 P2,. qy O ♦ �Sr dG�, S9 ya7 r/e c�6 la � °9 r c/ ♦ ab emf•, a� z� �' � �g a� Q� n • • • 49 ■ Complete items 1,2,and 3. Z •ter. ❑Agent ■ Print your name and address on the reverse so that we can return the card to you. ❑Addressee ■ Attach this card to the back of the mailpiece, Q�'•, C. Date of Delivery or on the front if space permits. v�' 1. Article Addressed to: D. Is from item 1? ❑Yes If YE .tress below: ❑No e11tN a 2 l ��st, go�, 1 e Vaal Py e rJ200 k. Iv-y- 105�.3 I I I III II I II II I I I I I I II I I 3. ig Type ❑Priority Mail Express ❑Adultdult Signature ❑Registered MaiIT" ❑Adult Signature Restricted Delivery ❑Registered Mail Restricted ❑Certified Mail® Delivery 9590 9402 2662 6336 3886 72 ❑Certified Mail Restricted Delivery ❑Return Receipt for ❑Collect on Delivery Merchandise 2. Article Number(Transfer from service lahel) ❑Collect on Delivery Restricted Delivery ❑Signature Confirmation- Mail ❑Signature Confirmation 7018 1830 0001 1821 5349 Mail Restricted Delivery Restricted Delivery 00) PS Form 3811.July 2015 PSN 7530-02-000-9053 Domestic Return Receipt (-Q�C DR ,C C��t uJJ . 198 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 250-1OB 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. Steven E. Fews Building&Fire Inspector Steve fewsaryebrook.org cc:Alfredo DiVitto,Assistant Building&Fire Inspector Tara A.Orlando,Planning&Zoning Secretary Laura Petersen,Office Assistant /to Building Permit Check List&Zoning Analysis Address: Z l ���--yD SBL: 3 9- 'Zone: '_�i - Use: -1 o Const.Type: S Other. Submittal Date: 5d 2_ t'7' Revisions Submittal Dates: Applicant Nature of Work- Reviews:ZBA: 019 PB: BOT: Other. NEED OK ( ( ) FEES:Filing. S- BP: C/O: Legalization: ( ) (-'APP: 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 P otection: S/W Mgmt.: Tree Plan: Other. SURVEY:Dated: 1 I� I 'L__- Current: ✓ Archival: Sealed. --' Unacceptable: ( ) , ( ) ,PLANS:Date tamped: Comp: Copies' Electronic: Other. a/ uj/License Workers Co j�L;b_l Con Waiver. Other. (� ( ) CODE 753#. Dated: N/A: ( ) ( ) HIGH-VOLTAGE ELECTRICAL:Plans: Permit: N/A: Other. ( ) ( ) LOW-VOLTAGE ELECTRICAL:Plans: Perot N/A Other. ( ) ( ) FIRE ALARM/SMOKE DETECTORS:Plans: Permit: I-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: Perot: N/A Other. ( ) ( ) FUEL TANK:Plans: Permit: Fuel Type: Other. O O 20I6 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. (Lj'1(RB mtg.date: approval• S I notes: ( )ZBA mtg.date: approval:- notes: cn ( )PB mtg.date: approval:- notes: PROVED REQUIRED EXISTING PROPOSED NOTES Area: MAY 1 7 2019 Circle: Fie Front: Front: Sides: Rear. Main Cov Accs.Cor. Ft.H Sb: Sd.H Sb: GFA: Tot.Im : Ft.Im P� Height/Stories: notes: BUILDING DEPARTMENT R (L�E C IE ��/7 VILLAGE OF RYE BROOK L� V 938 KING STREET RYE BROOK,NY 10573 (914)939-0668 (914)939-5801 MAY -2 20�9 www.ryrl¢ rook,orQ VILLAGE OF RYE BROOK ARCHITECTURAL REVIEW BOARD CHECK LIST FOR APPLICANTS This form must be completed and signed by the applicant of record and a copy shall be submitted to the Building Department prior to attending the ARB meeting. Applicants failing to submit a copy of this check list will be removed from �the GARB agenda. Job Address: 21 Uk C 61 U Date of Submission: Parcel ID#: T�Er one: Proposed Improvement(Describe in detail): APPLICANT CHECK LIST: MUST BE COMPLETED BY THE APPLICANT The following items must be submitted to the Building Department by the applicant-no exceptions. 1. ,(�Completed Application 2. )Two(2)sets of sealed plans. (one full size{maximum Property Owner: C—ril I (I ' ' I U'CW C1 allowable plan size=36"x 42")and one 1 Vx17") Address: 2 I ��Z' b�l �d 3. (K)Two(2)copies of the property survey. 4. (�)Two(2)copies of the proposed site plan. Phone# G I q y 2 5. (°q One electronic/disc copy of the complete application materials. Applicant appearing before the Board: 6. ( )Filing Fee. Ci ► 1 I U( "` 7. ( )Any supporting documentation. Address: 2 I (a,e ( . J 8. ( )HOA approval letter. (ifapplicable) 9. (�Photographs. Phone# 04 4 L -2 j 10.( )Samples of finishes/color chart. (a sample board or Architect/Engineer: model may be presented the night of the meeting) Phone# By signature below, the owner/applicant acknowledges that he/she has read the complete Building Permit Instructions&Procedures,and that their application is complete in all respects.The Board of Review reserves the right to refuse to hear any application not meeting the requirements contained herein. Sworn to before me this h` Sworn to before me this day of A1't 120 day of , 20 Signatu o operty er Signature of Applicant Cad v COl,✓ Print Name of Property Owner c, Print Name of Applicant Notary Public Notary Public ALEXANDRA H.FRANK <M w*Gll�j Notary Public,state of New York No.01FR6363711 Qualified In Westchester County Commission Expires August 28,2i�4 3/21/19 VILLAGE OF RYE BROOK BUILDING DEPARTMENT 938 KING STREET, RYE BROOK,NY 10573 (T) 939-0668 (F)939-5801 ARCHITECTURAL REVIEW BOARD Wednesday, May 15, 2019 NAME&LOCATION TYPE OF APPLICATION MOTION SECOND APPROVED REJECTED APPL.# 2 Wyman St(Kukaj) Roof Top Solar Array Consent 4714 Agenda 11 Jennifer Lane Expand Existing Patio & Consent 4715 (Bergman) Install (2) 6ft Fence Agenda Extensions 213 Country Ridge New 4ft High Swimming Consent 4716 Dr(Beatty) Pool Fence Agenda 41 Ridge Blvd 2 Partial 4ft Cedar Consent (Murguia) Fences/Gates Agenda 69 Rock Rodge Dr Replace Rear Wood Fence Consent 4718 (Berger) W/6ft black Aluminum Agenda 94 Valley Terrace Legalize 6 Ft PVC Privacy Consent 4719 (Colucci) Fence Agenda 313 Besty Brown Rd Legalize Rear Stone Wall, 4720 (McEvoy) Patio, Fire pit. Build Waterfall Feature w/Steps &Wall 23 Latonia Rd New Rear Deck and Patio 4721 (Montone) Expansion 5 Horshoe Lane New Rood Structure Over 4722 (Sassawer) Existing Patio w/Patio Extension) 6 Loch lane(Orselli) Legalize&Reconfigure 4723 Existing Deck 253 S. Ridge St- Update Signs For CVS) 4724 (Washington Pk Plz) 3 Winding Wood Rd Replace Garage Door With 4725 (Pohlman) Window, New Front Door, Windows,&Resurface ML NM MR SE JM v SF AC MI JB Existing Walkway 71 Winding Wood Amendment To Prior 4726 Rd(Nierenberg) Approval (siding design change) 275 South Ridge Replace Decking&Railings 4727 Street(Washington on Existing Deck- Park Plaza Assoc) Westchester Burger ML NM MR SE JM SF AC MI JB r✓k�Y RUBEN F COLONIA .#,1-,3(0 COLONY FENCE COMPANY INC. g$Hc .►^.�.d�'�Road Wh4s Porn NY 10607 --•--------•- Phone: (914)497-3442 Fax (914)4".1229 ems11 coionyferAmftmall.com o+►TE ��b y, y,,!g uw s W.r-oao"jo A b w w~on"W p"wto a c-,- irw in aaoraw cw rw+MNu►me 4WOMO +e Wfta eoftft •.00Rfst I i�be 11 _ u s7�, E0. It W•� s. �� atr T c4fd7r.`- nonmom m4 tt /Sf' ��•�e �� zr wa+ctu mimm ' 'sM C eti41T om of _ Te .. X 'sr KS ir,a E 00 1 " 1, 7 0 0• INC"lolftmwlOifi. p w Dwye a aN a^+a�a a M h NN�w+�..•a,,.�..o,�eae�d ew r.n vov.nrr suryr.w..s owK+M flw frw.cfto ftr omp6w%~�t San ar Mse~,o. r A M owr0"+w bay*"ow cummor•wyareM to*GSM pmywto Mw tMs*AIMon 6", M"ft IN News-3 rooe a"WANsm n'w rrw rvM a ate."WWIM s**a wwp&MO iw W*lK Wreos+s go r w,...• fr 0,~and rrw A wo to"4v ow a w wNMr Mrrt a eu+ArCfew�we�!► -- 1N/TO4fK COIOMr iENt[ C •A- -<1 . �/� '/�p D TOTK hr 7 00�1/�AYYLM ...,..,.w cto"No ti caws~w..u�..r ! ' r IL $ S' r. �FY - l ,-1 , �1 '' -`• •f �� L r ri►� 'Y! . l i�li ���5•t-y i - � e �'•�• '" K h Y R �1 T I': 1 ��1 �I y AF M L V1 `i f- 7y. 1 Y ••• ,. ti �� � ,� _ � � •ir ..:�, . • 1;i � ._' :� � ` •�, .;�1.� E a �� �' ' . �� .. '� Z . .� a i � _�� ., � sr a 4, �� i �'.�� �/l/l.1 f� � .� �� � , . � Check List For Release of Building Permits Address: Ane-- &3ulevarl Al R , Owner/Applicant: Phone Ws: 9[+ Dates Attempted To Contact Owner / Applicant: Comments: etna,i��- h omeoWneX� Comments: Comments: NEED: (\ uilding Permit Fee $ IGO" PO # ( ) Fire Sprinkler Plans (2) ( ) Fire Sprinkler Application ( ) Fire Sprinkler Permit Fee ( ) Estimated Cost $ ( ) SWO Fee $ ( ) Legalization Fee $ ( ) Other Liz Caruso From: Liz Caruso Sent: Monday, May 20, 2019 11:27 AM To: 'Gellin Murguia' Subject: Building Permit Application for 21 Ridge Boulevard Importance: High Good Morning, The building permit application for 21 Ridge Boulevard has been approved by the Building Inspector. Before we can issue the permit, the following items must be submitted to our office: 1. General contractor's contact name & phone number 2. General contractor's valid Westchester County Home Improvement license 3. General contractor's valid liability insurance (Village of Rye Brook must be the certificate holder) 4. General contractor's valid workers' compensation on a NY State Board form (C105.2 or U26.3) 5. Contractor must call Dig Safe NY to get a 10 digit ticket number 6. Building permit fee of$100 (due at the time of permit pickup) Thank you. Liz CARUSO OFFICE ASSISTANT BUILDING DEPARTMENT VILLAGE OF RYE BROOK 938 KING STREET RYE BROOK, NEW YORK 10573 OFFICE (91 4) 939-0668 FAX (914) 939-5801 t. L R' iffy' _ CD N cc 06. CD Q � f_ C) r .. :. 1••� J Q p j p } j `oluect�on �N _ �,,� G� U W Zrid Q Z = m o > W LL WCL LU wuedaG CIO A J � s OL v t O v O v f 4„ - A }.�ti,�t� .� �`✓".. � � F`�'y' j!`�1',P a/v���, r ATE(MMI AC" DD/YYYY) CERTIFICATE OF LIABILITY INSURANCE E(MM/019 DfY 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 The Hamilton Group, LLC NAME:PHONE 973-292-2292 FAX 3 Wing Drive A/C No:973292-2443 AIL Cedar Knolls NJ 07927 ADDRESS: INSURERS AFFORDING COVERAGE NAIC N INSURER A:Ohio Casualty Insurance Co. 24074 INSURED COLON05 INSURER 8: NICO Fence Company Inc.744 W Hartsdale Rd INSURERC: White Plains NY 10607 INSURERD: INSURER E INSURER F: COVERAGES CERTIFICATE NUMBER:586010534 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 ADDL SUBR POLICY EFF POLICY EXP LTR POLICY NUMBER MM/ D/YYYY MWDD LIMITS A x COMMERCIAL GENERAL LIABILITY BK058487307 4/27/2019 4/27/2020 EACH OCCURRENCE $2.000,000 DAMAGE T REN E CLAIMS-MADE X OCCUR PREMISES Ea occurrence $100.000 MED EXP(Any one person) $15,000 PERSONAL 3 ADV INJURY $2.000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERALAGGREGATE $4,000,000 POLICY D JEPROCT F7 LOC PRODUCTS-COMP/OP AGG $4,000,000 OTHER: $ A AUTOMOBILE LIABILITY BA058487307 4/27/2019 4/27/2020 COMBINED SINGLE LIMIT $�,000,000 ANY AUTO (Ea accident BODILY INJURY(Per person) S OWNED X SCHEDULED BODILY INJURY P AUTOS ONLY AUTOS (Per accident) $ X HIRED X NON-OWNED PROPERTY DAMAGE AUTOS ONLY AUTOS ONLY Per acc dent $ I $ UMBRELLALWB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED I ! RETENTION$ $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY YIN STATUTE ER ANYPROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ OFFICERWEMBEREXCLUDED? ❑ N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached If more space Is required) Village of Rye Brook is added as an Additional Insured under the General Liability policy above,with respects to work performed by the Named Insured as required by written contract. 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 ACCORDANCE WITH THE POLICY PROVISIONS. 938 Kings Street 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 NEW Workers' STATE Compensation CERTIFICATE OF Board NYS WORKERS' COMPENSATION INSURANCE COVERAGE 1a. Legal Name and address of Insured(use street address only) 1b. Business Telephone Number of Insured NICO FENCE CO LLC (914)615-9500 744 HARTSDALE RD WHITE PLAINS NY 10607-1814 1c. NYS Unemployment Insurance Employer Registration Number of Insured Work Location of Insured (Only required if coverage is specifically 1d. Federal Employer Identification Number of Insured or limited to certain locations in New York State. i.e. a Wrap-Up Policy) Social Security Number 82-3355523 2. Name and Address of the Entity Requesting Proof of 3a. Name of Insurance Carrier Coverage(Entity Being Listed as the Certificate Holder) Property & Casualty Ins Co. of Hartford The Village of Rye Brook 34690 938 KING ST 31b. Policy Number of Entity Listed in Box '1a": RYE BROOK NY 10573-1226 76 WEG AA9HGC 3c. Policy effective period: 10/30/2018 to 10/30/2019 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 "la" 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 Worker's 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: Danielle Clausen (print name of authorized representative or licensed agent of insurance carrier) Approved by: , \ �ruo��e.Na 4AZU1: 05/21/2019 (Signature) (Date) Title: Operations Manager Telephone Number of authorized representative or licensed agent of insurance carrier: (877) 287-1316 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) Form WC 88 31 21 F Printed in U.S.A. www.wcb.ny.gov Page 1 of 2 9 8 ICU < C r U�U �� rn� N N� Dmcm ICU r�rt O '�Ahalt pa�`enteRO nt ��l _- co (a CD o -� � 1 g "Age" o =:,I N 4, �� � h 83, �.. �i1�. O A A A� `� a Q O �� 'b c,, cc co n Ob O ``� Q � A y a Ile � � O 1100, h A GO O tb A' ►� u, "`� O, 45 A �• O