HomeMy WebLinkAboutRP25-009PERMIT # C') " �9
SECTION 5, 6
TYPE OF WORK _Z2 —i
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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
June 3,2025
Omar Jimenez& Kathy Natal
5 Valley Terrace
Rye Brook,New York 10573
Re: 5 Valley Terrace, Rye Brook,New York 10573
Parcel ID#: 135.67-2-38
Roof Permit#25-009 issued on 1/31/2025 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
R
V BUILDING DEPARTNIE\T For office use oil
PERNIIT# a s 009
[E DD VILLAGE OF RYE BROOK ISSUED: /-3/-as
MAY 16 2025 938 KEG STREET,RYE BROOK,NEW YORK 10573 DATE: 5-/!o-aS
(914)939-0668 FEE: �4 /5CU— PAID$.
VILLAGE OF RYE BROOK mww.ryebrook.ori!
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
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Address: 5 Valley Terr Rye Brook NY 10573
Occupancy/Use: / /�� Parcel ID#: 3 �5,& 7 — — Zone: R-7
Owner: Omar Jimenez Address: 5 Valley Terr Rye Brook NY 10573
P.E./R.A.or Contractor: Gunner LLC Address: 78 Halloween Blvd Stamford, CT 06902
Person in responsible charge: Andrew Prchal Address:78 Halloween Blvd Stamford, CT 06902
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 stnlcttire/constntction/alteration herein mentioned in accordance
with law:
STATE OF NEW YORK.COUNTY OF WESTCHESTER as:
Andrew Prchal being duly sworn.deposes mid says that heisheresidesat 5 Valley Terr
(Print Name of Applicant) (No.and Street)
in Rye Brook inntheCounlyof Westchester intheStateof NY that
(City./Town/Village)
heishe 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 12,690.00
for the construction or alteration of: Roof Replacement, GAF Asphalt Roof Sr Gutters
Deponent fiurther states that lie/she has examined the approved plans of the structure/work herein referred to for which a Certificate of
Occupancy i Compliance is sought,and that to the best of hisiher 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/connpleted complies with the laws governing building construction.Deponent fiurther understands that it shall be unlawful for an
owner to use or permit the use of any building or premises or pail 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 l (V M Sworn to before me this
► lfd�
day of 1, 20 02� day of 20 P",-)
Signature of petty Owner Signature of Applicant
Omar Jimenez Andrew Prchal
Print Name of Property Owner Print Name of Applicant
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1982 BUILDING DEPARTMENT
V
ILDING INSPECTOR
SISTANT BUILDING INSPECTOR VILLAGE OF RYE BROOK
❑CODE ENFORCEMENT OFFICER 938 KING STREET - RYE BROOK,NY 10573
(914) 939-0668 FAX (914) 939-5801
www ryebrook.org
- - - - - - - - - - - - - - - - - - - - INSPECTION REPORT - - - - - - - - - - - - - - - - - - - -
ADDRESS : V A DATE: & a O 02.7"
PERMIT# 1 y �5 -op 9 ISSUED: 1-11 - 2--�i SECT: /3-f-' 62 BLOCK:_LOT: $
LOCATION: iz a)`t OCCUPANCY:
❑ VIOLATION NOTED THE WORK IS... D ACCEPTED ❑ REJECTED/ REINSPECTION
❑ SITE INSPECTION REQUIRED
❑ 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
❑ CROSS CONNECTION
FINAL
❑ OTHER OTHER (�
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BUIL MENT JAN 2 9 2025
V E OF RYE OK
938 KING ET RYE SR NY 10573
t VILLAGE OF RYE BROOK
BUILDING DEPARTMENT
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FOR OFFICE USE ONLY:
Approval Date: P �r0�b
Application#
Approval Signature: ARCHITECTURAL. REVIEW BOARD:
Disapproved: Date:
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BOT Approval Date: Case# Chairman:
PB Approval Date: Case# Secretary:
ZBA Approval Date: Case#
Other:
Application Fee Permit Fees:
1 1 p \ ROOF PERMIT APPLICATION
Application dated: is hereby made to the Building Inspector of the Village of Rye Brook.NY,for the issuance of a Permit to
Re-Roof an Existing Building,as per detailed statement described below.
1. Job Address: 5 Valley Terr Rye Brook NY 10573 SBL: 135.67-2-38 Zone: R-7
Property Owner: Omar Jimenez Address: 5 Valley Terr Rye Brook NY 10573
Phone#: (347) 242-4391 Cell#: email: oj336@yahoo.com
3iyahoo.eom
z Applicant: Andrew Prchal Address: 78 Halloween Blvd Stamford, CT 06902
phone#: 203 388 5555 Cell#: email: kauanny.zanetti@gunnerroofing.com
3. Roofing Contractor: Gunner LLC Address: 78 Halloween Blvd Stamford, CT 06902
Phone#: 203 388 5555 Cell#: email: kauanny.zanetti@gunnerroofing.com
4. Job Description,list all Methods&Materials: Remove&replace existing roof. Inspect roof deck to verify that all all sheathing is
suitable Install seam tape per CT Code Install water and Ice barrier,underlayment asphalt shingles,and proper ventilation.
Install new white aluminum 6" K-Style Gutters using hidden fasteners elbows and downspouts.
5. Estimated Cost of Job: $ 12,690,00 (NOTE:The estimated cost shall include all site
improvements,labor,material,scaffolding.fixed equipment,professional lees.and material and labor which may be donated gratis.)
6. If corner property,indicate street frontage: interior property
7. Construction Type: Roof Replacement, GAF Asphalt Roof& Gutters NYS Construction Class:
8. Number of stories: 2 stories Height:
9. Is garage being re-roofed:No:( )•Yes:(Attached No: O•Yes:VNitmber of Cars:
10. Is roof peaked,hip,mansard,flat,etc: Pitched
11, Estimated date of completion: March/April
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1060023
Please note that this application must include the notarized signature(s) of the
legal owner(s) of the above-mentioned property, in the space provided below.
Any application not bearing the legal property owner's notarized signature(s)
shall be deemed null and void, and will be returned to the applicant.
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STATE OF NEW YORK,COUNTY OF WESTCHESTER ) as:
Andrew Prchal ,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
contractor for the legal owner and is duly authorized to make and file this application.
(indicate architect,contractor,agent attorney,etc.)
That all statements contained herein are true to the best of his/her knowledge and belief,and that any work performed,or use
conducted at the above captioned property will be in conformance with the details as set forth and contained in this application
and in any accompanying approved plans and specifications,as well as in accordance with the New York State Uniform Fire
Prevention&Building Code,the Code of the Village of Rye Brook and all other applicable laws,ordinances and regulations,
Sworn to bef e me this q�
Sworn to be re me this
day of 20p day of 20 OG
VI
Signature of Prop rty Owner Signature of Applicant
Omar Jimenez Andrew Prchal
Print Name of Property Owner Print Name of Applicant
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10/30/2023
Docusian Envelope ID:8683F05A-C8D uuiNi nk iNi LL%-/ uuNNER NY LLC/GUNNER LLC
' V. National Headquarters: 78 Halloween Boulevard, Stamford, Connecticut 06902
Phone: 866-262-6005
License No.: CT-0653672 NY- WC3218OH19
Yonkers,NY License No.- 7592 Rockland County,NY License No. 20118
NJ HIC- 13VH10245900 RI HIC-GC-44886
Gunner NY LLC Federal EIN No. 92-3168370. RRP License-R-1-18342-21-00015
www.jzunnerroofing.com
PROPOSAL/ CONTRACT
This construction agreement(the"Agreement")is made and entered into this 220LDay of November,2024 by and between(a)if the Project
is located in New York,Gunner NY LLC,(b)if the Project is located in New Jersey, Gunner NJ LLC,and(c)if the Project is located in
Connecticut,Gunner LLC(hereinafter referred to as "Gunner Roofing" or"Contractor")and Omar Jimenez(hereinafter the"Owner"or
"Customer")whose address is 5 Valley Terrace,Rye Brook,NY, 10573 (the"Project").Contractor and Owner hereby agree as follows:
Contract Documents:The contract documents consist of this Agreement,and any exhibits attached hereto,Terms and Conditions,Notice
of Cancellation, Statutory Warnings, and limited workmanship warranty (if any) and all modifications and change orders issued after
execution of the Agreement(the"Contract Documents").Owner represents that it has read,reviewed,analyzed and become familiar with
all of the Contract Documents and the identified and included costs in the Contract Price(as defined below),subject to any manifest errors,
inconsistencies,omissions,or discrepancies.These contract documents represent the entire agreement of both parties and supersede any
prior oral or written agreement.
Scone of Work:The scope of work is contained and limited to the work contained on Exhibit"A"—Scope of Work.The scope of work
does not include any engineering or design professional work,which engineering or design professional work shall be engaged and/or paid
for separately by the Owner. All work shall be performed by Contractor in a workmanlike manner and shall meet or exceed all state and
local building codes.Contractor shall obtain all permits necessary for the work to be completed. Contractor shall remove all construction
debris and leave the project in a broom clean condition.
Contract Price:The labor and materials required for this job will be furnished by Gunner Roofing or its subcontractors,including necessary
equipment, and the services performed for a total of$12,690 (the "Contract Price"). Owner shall pay Contractor the Contract Price in
accordance with Exhibit"B"-Schedule of Progress Payments.Each progress payment of the Contract Price shall be paid by Owner to
Contractor within seven(7)days of receipt of Contractor's invoice. If Owner disputes any portion of an invoice for the Contract Price,then
(a)Contractor shall be entitled to stop work on the Project without penalty or liability until payment in full is received or such dispute is
settled to the mutual satisfaction of the parties and(b)Owner shall pay the undisputed portion of any such invoice, such payment to be
made without prejudice to Owner's position. If Owner cancels this Agreement other than pursuant to a Notice of Cancellation validly and
timely delivered within three(3)business days after the date hereof,then Owner shall pay Contractor each of the following:(a) an amount
equal to twenty percent(20%)of the Contract Price(including any Change Orders thereto)plus the full amount of any Permit Costs; and
(b)for any special orders or non-returnable materials(including,without limitation,synthetics,cedar,slate,metal roofing,custom-colored
items,windows,etc.),an amount equal to the cost thereof plus twenty percent(20%). In the event of cancellation by Owner,Owner shall
have the option to either surrender any materials to Gunner Roofing or to take delivery thereof. (In Rockland County,New York: any
deposit charged hereunder shall be the lesser of$1,000.00 or 15%of the Contract Price.Upon satisfactory payment being made for
any portion of the work performed,the contractor shall,prior to any further payment being made,furnish to the person contracting
for the work a full and unconditional release from any claim of a mechanic's lien by the contractor or by a person entitled to enforce
a mechanic's lien for that portion of the work for which payment has been made.)
Estimated Date of Commencement/Completion:The estimated start date of the Work is March 241,2025 and the estimated completion
date is March 281,2025,these dates are subject to change due to delays caused by weather,shortage of materials or labor,Acts of God,
riots,revolutions,strikes,pandemics,medical emergencies that have resulted in a local,state,or federal state of emergency,COVID-19 or
viruses/illnesses requiring quarantine,or other causes or factors beyond Gunner Roofing's reasonable control.Time is not of the essence
for all purposes of this Agreement unless expressly provided to the contrary. Unless otherwise specified,there is no specific completion
date for Contractor's work.Contractor shall use good faith,diligent efforts to complete all work in a reasonable amount of time. If Owner
fails to timely pay the deposit due hereunder,then the foregoing estimated start date and completion date for the Work may be delayed until
such time as such deposit is paid to Contractor and taking into account Contractor's schedule for other projects and work.
Change Orders: All changes to the plans, specifications or selection of finished materials which may be requested in writing
by Owner("Change Orders"), shall be submitted to Contractor using Exhibit "C" — Change Order and are subject to Contractor's
approval.A Change Order is any change in work from the original,permit set,plans and specifications.Each Change Order shall only be
incorporated into the Agreement if signed by both Owner and Contractor prior to the commencement of any work covered by said Change
Order.In the absence of an express lump sum agreement with respect to any Change Order,any work covered by such Change Order shall
be billed to the Owner at the direct cost to the Contractor plus twenty percent(20%). Additional time needed to complete change orders
shall increase the time needed for Project completion.
Docusign Envelope ID:8BB3F05A-C6D5-49C1-97CC-441C6813021`38
I HAVE READ AND UNDERSTAND THIS CONTRACT, THE TERMS AND CONDITIONS, AND ALL
APPLICABLE CONTRACT DOCUMENTS AND AGREE TO BE BOUND BY THEIR TERMS.
ACCEPTANCE OF CONTRACT: The above prices,
specifications and conditions are satisfactory and are As Applicable:Gunner bQ4unner NJ LLC/Gunner LLC
hereby accepted. Contractor is authorized to do the
work as specified. By signing below, Customer M"I,A.
acknowledges that Customer is the owner(or authorized Authorized Signature:
agent of the owner)of the property where the work is to Ni chol l a zanetti
be performed. Contractor will provide Customer with a By:
copy of this Contract after it is signed by both parties.
md by*
sU`-' Its:
Customer Signature: Eaam�.. Date: 11/29/2024
Date: 11/29/2024
CONSUMER'S RIGHT TO CANCELLATION.CUSTOMER MAY CANCEL THIS CONTRACT WITHOUT ANY
PENALTY OR FURTHER OBLIGATION WITHIN THREE(3)DAYS FROM THE DATE OF THIS TRANSACTION.
SEE THE ATTACHED NOTICE OF CANCELLATION FORM FOR AN EXPLANATION OF THIS RIGHT.
Docusign Envelope ID:8BB3F05A-C6D5-49C1-97CC441CB8B02F38
EXHIBIT A-SCOPE OF WORK
DESCRIPTION OF THE WORK TO BE PERFORMED:
ROOFING ASPHALT -$11,383
•Tear off existing shingles (2 asphalt layers included)
• Inspect plywood and replace damaged plywood as needed (3 sheets included, additional sheets of
$110 per sheet or%" plywood $130/sheet or$4/If for batten replacement)
• Install Standard Aluminum Drip Edge F5: White
• Install GAF Weather Watch Ice and Water Shield -6' along eaves, 3' along valleys, and 3'along rake
edges.
• Install GAF Synthetic Tiger Paw Underlayment
• Install underlayment using galvanized T50 Staples
• Install GAF Weather Blocker Starter Strip Shingle
• Install GAF Architectural Timberline HDZ Asphalt Shingle-COLOR: CHARCOAL
• Install Shingles using Galvanized Roofing Coil Nails - 1 1/4"
• install GAF Cobra R-ReWO Country AdvanGed Ridge Vent
• Install GAF Timbertex Hip& Ridge Shingles-COLOR: CHARCOAL
• Install Copper Chimney Flashing and Solder all joints
• Install Aluminum Pipe Flashing Combo 1"-4"
•Valleys will be woven using shingles if applicable
• Use Elastomeric/Caulk(Clear) where applicable
• Use Dynamoic Caulk(Limestone)where applicable
• Gunner will provide job related materials
• Gunner will provide dumpster to clean site and remove job related debris
• Magnetic sweep property for nails
• Crews will maintain safety requirement at all times during the construction process
• Provide GAF Golden Pledge Warranty(50 Years on materials and 25 years on labor) upon completion
and final payment
• Gunner will pull permit for owner(and subsequently close) and save receipt for reimbursement
from customer(if needed) I�;tl,, InMal
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K-STYLE GUTTERS-ALUMINUM-FREE! (BLACK FRIDAY PROMOTION -$1,500 VALUE)
• Remove existing gutters and discard
• Install 6" K-style Gutters using quick screw hidden fasteners-COLOR: WHITE
• Newly installed gutters will match existing gutter layout
• Install new elbows and downspouts using pipe cleats and zip screws -3x4 downspouts COLOR:WHITE
• Downspouts will be connected to existing french drains if applicable using pvc adapter
•All end cap terminations will be caulked and crimped
• Gunner will provide job related materials
• Material: .032 Aluminum (Heavy Guage)
• Install Gutter Guards: Yes -$1,307 Initial ,n;w,
• STYLE: DROP IN O A
Docusip envelope ID:8BB3F05A-C6D5-49C1-97CC-441CB8B02F38
EXHIBIT B—SCHEDULE OF PROGRESS PAYMENTS
Payment shall be made to (a) if the Project is located in New York, Gunner NY LLC, (b) if the Project is located
in New Jersey, Gunner NJ LLC, and (c) if the Project is located in Connecticut, Gunner LLC. Checks are to be
mailed to 78 Halloween Boulevard, Stamford, Connecticut 06902.
Work or Services Performed and Materials Amount Due:$12,690
to be Supplied:
** CLIENT FINANCING $12,218 THROUGH WF 68 MONTH TERM AT 5.9%,REMAINING
BALANCE OF$472 TO BE PAID IN CASH**
10% Deposit $1,269
60% On Start $7,614
30% On Completion $3,807
**(Payment terms are not applicable if approved for a financing plan for full project)**
Customer agrees to pay $20 fee for any bounced check for any reason, including Not Sufficient Funds.
If Customer elects to pay by credit card,then the Contract Price will be increased by a three percent(3%)
and will total $13,070.70
GUNNER NJ LLC /GUNNER NY LLC /GUNNER LLC will void the contract if home sale falls through.
Deposit will be refunded to the customer within 10 business days.
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Client#: 1952221 HOMEEN
ACORD CERTIFICATE OF LIABILITY INSURANCE D1/29/2o25YYY
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(les)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 any rights to the certificate holder In lieu of such endorsement(s).
PRODUCER NAME:CONTACT Jennie Foster
USI Insurance Services LLC PHONE 855 874-0123 FAX 203 634-5701
A/C No EM: A/C No
530 Preston Avenue E-MAIL uslctcertlficates@usl.com
Meriden. CT 06450 ADDRESS:
855 874-0123 INSURER(S)AFFORDING COVERAGE NAIC F
INSURER A:Admiral Insurance Company 24856
INSURED
Gunner LLC INSURER B:Liberty Mutual Insurance Company 23043
78 Halloween Blvd INSURER C:Selective Insurance Company of America 12572
Stamford,CT 06902 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 CONTRACTOR 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
TL pR TYPE OF INSURANCE ADDL UBR POLICY EFF POLICY EXP
INSR WVD POLICY NUMBER MM/DD/YYYY MM/D LIMITS
A X COMMERCIAL GENERAL LIABILITY CA00004513602 421/2024 04al/2025 EACH OCCURRENCE $1 00 000
accueCLAIMS-MADE a OCCUR EAMSEorrnce $50 000
MED EXP(Any one person) s5,000
PERSONAL 8 ADV INJURY $1 000 000
GEN'L AGGREGATE LIMIT APPLIES PER. GENERALAGGREGATE $2,000,000
POLICY a JECT LOC PRODUCTS-COMP/OP AGG $1 000 O00
OTHER.
C AUTOMOBILE LIABILITY S2579842 927/2024 0927/202 EO eB�I IN,ED SINGLE LIMIT 1,000,000
X ANY AUTO BODILY INJURY(Per person) $
OWNED SCHEDULED
AUTOS ONLY AUTOS BODILY INJURY(Per accident) $
X AIUTOS ONLY X NON-OWNEDPROPERTY DAMAGE
AUTOS ONLY Per accident $
UMBRELLA LIAB OCCUR EACH OCCURRENCE $
EXCESS LIAR HCLAIMS-MADE AGGREGATE $
F_ T
DED 1 RETENTION$ $
B WORKERS COMPENSATION WC533S381014053 1/19/2025 01/19/202 X PER OTH-
AND EMPLOYERS'LIABILITY
OFFICERIMEMBEER EXCLUDED?PROPRIETOR/PARTNER/EXECUTIVE N/A
E.L.EACH ACCIDENT $1 000 000
Mandatory i If es. E.L.DISEASE-EA EMPLOYEE $1 000 000
ynd
_ DESCRIdescribee a under PTION OF OPERATIONS below E.L.DISEASE-POLICY UMIT $1 000 000
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Rernarks Schedule,may be attached if more space is required)
Village of Rye Brook Is Included as an Additional Insured under the General Liability policy,for
ongoing and completed operations, when required in a written agreement in accordance with policy
terms,conditions,and exclusions regarding services provided by the Named Insured.
CERTIFICATE HOLDER CANCELLATION
Village of Rye Brook SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
938 King St ACCORDANCE WITH THE POLICY PROVISIONS.
Rye Brook, NY 10573
AUTHORIZED REPRESENTATIVE
(c 1988-2015 ACORD CORPORATION.All rights reserved.
ACORD 25(2016/03) 1 of 1 The ACORD name and logo are registered marks of ACORD
#S43188187/M42873328 SZBZP
NYSI F
New York State Insurance Fund PO Box 66699,Albany, NY 12206
1 nysif.com
CERTIFICATE OF WORKERS' COMPENSATION INSURANCE
^^^^A A 832024199
GUNNER LLC
78 HALLOWEEN BLVD
STAMFORD,CT 06902
SCAN TO VALIDATE
AND SUBSCRIBE
POLICYHOLDER CERTIFICATE HOLDER
GUNNER LLC VILLAGE OF RYE BROOK
78 HALLOWEEN BLVD 938 KING STREET
STAMFORD,CT 06902 RYE BROOK NY 10573
POLICY NUMBER CERTIFICATE NUMBER POLICY PERIOD DATE
W2485 011-7 336017 09/12/2024 TO 09/12/2025 1/29/2025
THIS IS TO CERTIFY THAT THE POLICYHOLDER NAMED ABOVE IS INSURED WITH THE NEW YORK STATE INSURANCE
FUND UNDER POLICY NO. 2485011-7, COVERING THE ENTIRE OBLIGATION OF THIS POLICYHOLDER FOR
WORKERS' COMPENSATION UNDER THE NEW YORK WORKERS' COMPENSATION LAW WITH RESPECT TO ALL
OPERATIONS IN THE STATE OF NEW YORK, EXCEPT AS INDICATED BELOW, AND, WITH RESPECT TO OPERATIONS
OUTSIDE OF NEW YORK, TO THE POLICYHOLDER'S REGULAR NEW YORK STATE EMPLOYEES ONLY.
IF YOU WISH TO RECEIVE NOTIFICATIONS REGARDING SAID POLICY,INCLUDING ANY NOTIFICATION OF CANCELLATIONS,
OR TO VALIDATE THIS CERTIFICATE,VISIT OUR WEBSITE AT HTTPS://WWW.NYSIF.COM/CERT/CERTVAL.ASP.THE NEW
YORK STATE INSURANCE FUND IS NOT LIABLE IN THE EVENT OF FAILURE TO GIVE SUCH NOTIFICATIONS.
THIS POLICY DOES NOT COVER THE SOLE PROPRIETOR, PARTNERS AND/OR MEMBERS OF A LIMITED LIABILITY COMPANY.
THE POLICY INCLUDES A WAIVER OF SUBROGATION ENDORSEMENT UNDER WHICH NYSIF AGREES TO WAIVE ITS RIGHT
OF SUBROGATION TO BRING AN ACTION AGAINST THE CERTIFICATE HOLDER TO RECOVER AMOUNTS WE PAID IN
WORKERS'COMPENSATION AND/OR MEDICAL BENEFITS TO OR ON BEHALF OF AN EMPLOYEE OF OUR INSURED IN THE
EVENT THAT, PRIOR TO THE DATE OF THE ACCIDENT, THE CERTIFICATE HOLDER HAS ENTERED INTO A WRITTEN
CONTRACT WITH OUR INSURED THAT REQUIRES THAT SUCH RIGHT OF SUBROGATION BE WAIVED.
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS NOR INSURANCE
COVERAGE UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER
THE COVERAGE AFFORDED BY THE POLICY.
NEW YORK STAT SUR NCE FUND
TT �/
DIRECTOR,INSURANCE FUND UNDERWRITING
VALIDATION NUMBER: 898437915
U-26.3