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HomeMy WebLinkAboutBP25-047PERMIT #60,s 7 / pAT�; 3 c�lo S 3 b, SECTION IQ 9,* % BLOCK TYPE OF WORK /q C e-*nerI ok),S � q7p Co r JOB LOCATION S v I// OWNER Q elJ LS ;% 4 41uS 2 a,SP/7 9Y % J�/-9492P CONTRACTOR j/1 ou�S F3 U� - pV//) 77 aj) 943 T. COST _ FEE VCO #L FEE DATE TCO # FEE DATE DATE INSP FOOTING FOUNDATION FRAMING RGH FRAMING INSULATION PLUMBING I� RGH PLUMBING GAS SPRINKLER ELECTRIC 0 LOW -VOLT O ALARM AS BUILT C� FINAL OTHER APPROVALS ARB BOT v ZBA OTHER tyywJJv Vj CC�CLC � V`C�y y yy BR JJJ V W V 19 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.uov TRUSTEES BUILDING&FIRE INSPECTOR Susan R. Epstein Steven E. Fews David M. Heiser Donald T. Krom,Jr. Salvatore W. Morhno CERTIFICATE OF COMPLIANCE May 14,2025 Matthew Rosen&Alyse Rosen 175 Ivy Hill Crescent Rye Brook,New York 10573 Re: 175 Ivy Hill Crescent, Rye Brook,New York 10573 Parcel ID#: 129.76-1-38 Building Permit#25-047 issued on 3/26/2025 for Replacement Windows& Door This certifies that the eight new windows and one patio door,installed under the above captioned permit has been satisfactorily completed. Sincerely, Steven E. Fews Building&Fire Inspector /to D E C E 0 " E ��33 For office use only: BUILDIN I3E "i'MENT PERMIT# 1 7 MAY — 8 2025 VILLAGE OF RYE BROOK ISSUED: VPAID 9 8 KING STREET,RYE BROOK,NEW YORK 10573 DAVILLAGE OF RYE BROOK (914)939-0668 FEE: BUILDING DEPARTMENT www,ryebrookuv,gov 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 #ki}#i##ti it##tkkif#itttikii}#####i#I##)#iiitikfititkiiit#ikfifi}i}}##ii}}#tint/ikt,#�t/ifkiffftf#tffiitii}ii#k##}}}}i#k#t#tiitktk Address: 17 T✓Y ��I /l CleSCP e rook, /- L),/ 105 7 5 Occupancy/Use: — Parcel ID#: I.Qq. '7 (Q /' 3 $ Zone: Owner: At'I'6') Address: P.E./R.A. or Contractor: WI/✓5w> I Address: ?-Lb QG S , r, t C) 06q0 Z Person in responsible charge: b (f') 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 Y((ORK, COUNTY OF WESTCHESTER as: )l A�ej,) IL yen being duly sworn,deposes and says that he/she resides at 17 S Lam/ I I/�►�°�'�i�� (P 'nt Name Applicant) (No.and Street) in 'ao kr ,in the County of ""P L S in the State of ,that (City/Town/Village) he/she has supervised the work at the location indicated above,and that the actual total cost of the work,including all site improvements, labor,materials,scaffolding,fixed equipment,professional fees,and including the monetary value of any materials and labor which may have been donated gratis was:$ /Z y75,O J for the construction or alteration of: W U vd 5 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 day o , 20 ZS day of , 20 Signature of Property Owner Signature of Applicant Print Name of Propertyl,7er Print Name of Applicant N blic Notary Public Zulma Teveras Notary Public-State of New York 6/1/202d y_ C. Igo.01TA6171376 OUBlifibd in Bronx Coun :�: My Expires 0712312a' QyE BRC�v�. . 1932 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 - - - - - - - - -- - - - - - - - - - - 1 / `1 ADDRESS : ' ' V 7 L DATE: PERMIT# U1 c 7 2 ISSUED?" SECT: BLOCK:_LOT'3(9 LOCATION: 1 �'�� SV C G-4--' f tZl OCCUPANCY: ❑ VIOLATION NOTED THE WORK IS... E ACCEPTED ❑ REJECTED/ REINSPECTION ❑ SITE INSPECTION REQUIRED ❑ FOOTING ❑ FOOTING DRAINAGE ❑ FOUNDATION ❑ UNDERGROUND PLUMBING NOTES ON INSPECTION: ❑ ROUGH PLUMBING ❑ ROUGH FRAMING ❑ INSULATION ( l ❑ NATURAL GAS ❑ L.P. GAS ' Aj t') NIA1 J-L ❑ FUEL TANK ❑ FIRE SPRINKLER ❑ FINAL PLUMBING ❑ CROSS CONNECTION ❑ FINAL ❑ OTHER Ili A(7LA) G> ,,TL : : O ° a 00 a � � Q � W vll h O {V J H 00 w 3 0 0, � o � '`Ov n � z � 00 (In P3 v z r" Z v y N W o o U 000 W ono z CVO : � � -a \ N '� W V z 's b a o - O r�TT V) � v� G ;aCa v °a'` u Q '' Z 0.0 N W --a a E u W o ° C � V Imo+ a� W Z a z CA O CAa� V " V -Nd� dtov -di° w� � � � � � � M1 a a z o v � c - OD u U O F- I CG O U U v z a � a O p��( CO:.B � A W z 4 dj U . V � a.?� IT BUILDING DEPARTMENT Fi i; CENED VILLA(;E OF RY1 BROOKS 938 KING S'I[ti L;T RYE BR04h,NY 10573 MAR 17 2025 .., tn-s n r.b .��$j 1Jt-�UUJ rrt F.'4��?ifrrt,t �� VILLAGE OF RYE BROOK BUILDING DEPARTMENT ADMINISTRATIVE EXTERIOR BUILDING PERMIT APPLICATION FOR EXTERIOR WORT: Wince DOES NOT REQUIRE ViI.I.A(,E ARCIII"Ci:CTUR V.:REY-ILN' BOA u)APPROVAL FOR OFFIiCE USE QNLY: APPROVAL DATE: �} PI00 ?K #: AFPLIC`A�TTON FEE: � ) APPRt1VAT. STl^,NATT_TRF.' MA 2 1 02 PFRmrr FFF.s. H.O.A.APPROVAL: DATE: DISAPPROVED: OTHER: Application dated: 3 is hereby m e to the Building inspector of the Village of Rye Brook,NY,for the issuance of a Permit forthe construction of buildings.stmetures.additions.alterations or for a chanac in use_as per detailed statement described below. 1. Jolt Address: 11S 1 J �r / /� agaoK 2. Parcel IN: ! /r 7/ (o r3 ----- Zone: Pu 3. Proposed Improvement(Describe in detail): 9WzW L L W I AJ 2 5 AN"> I*no Dom_ fjl IdS 4. Property Owner: M Arl- W IS lZO S eA � 1 ySQ oselq Address:- -- l 7'5_ W1r/ / Phone# Cell# I 7 57 4 e-mail A40_- /aJP,J -70 List All Other Properties Owned in Rye Brook: 'f�Q��'�Af Applicant: Address: Phone# Cell# e-mail Architect Address: Phone# Cell# e-mail Engineer: Address: Phone A Cell# v-in;4il General Contractor: ��� S r .� ✓ � /� Address: rr�,�a L�Q���� �! C�P7'L r e-/T D 0c4- Phone#p�lJ3 9 7`�r 7­3 Cell# e-mail (I) 611120-14 5. Occupancy;(1-Fam..2-Fam.,Commercial.,etc...)Pre-construction: Post-construction: 6. Area of lot: Square feet: V 1 30) Acres: 7. Dimensions from proposed building or structure to lot lines: front yard: rear yard: right side yard:_ left side yard: other: _ 8. If building is located on a corner lot,which street does it front on: 9. Area of proposed-building in square feet: Basement: i"fl: ""tl: 3'" 10. Total Square Footage of the proposed new construction: 11. For additions,total square footage added:Basement: I"fl: 2nd fl: 3"fl: 12. Total Square Footage of the proposed renovation to the existing structure: 13. N.Y.State Construction Classification: N.Y. State Use Classification: 14. Construction Type&Location:O Typical Western Lumber Frame;()Timber Frame[TC];O Wood Truss[TT]; f 1 Pre-engineered wood rPWI:Located:(1 Floor Framing fFl:t i Roof Framing rRl:()Floor&Roof Framing[FRI:tither: 15. Number of stories: Overall Height: Median Height: 16. Basement to be full,or partial: finished or unfinished: 17. What material is the exterior finish: (A)JJ 19. Roof style:peaked.hip;mansard. shed.etc: Roofing material: 19. What system of heating: Qt I 20. If private sewage disposal is necessary,approval by the Westchester County Ilealth Department must be submitted with this application. 21. Will the proposed project require the installation of a new.or an cxtension/modification to an existing automatic fire suppression system?(Fire Sprinkler,ANSI.System,FM-200 System,Type I Hood,etc...)Yes: No: _ (ij)'es, applicant must submit a separate Automatic Fire Suppression Svstem Permit application&2 sets ojdetaited engineered plans) 22. Will the nrnnneerl nrniert dicfiirh d110 cn_f nr more of lane) nr rreate A0(1 en ft nr inner of imnPr�ii_nnc rnveraae rPrntirina a Stormwater Management Control Permit as per§217 of Village Code? Yes:—No:—Area: 23. Will the proposed project require a Site Plan Review by the Village Planning Board as per§209 of Village Code? Yes: No: (tf yes,applicant must submit a Site Plan Application,&provide detailed drawings) 24. 'Will the proposed project require a Steep Slopes Permit as per§213 of Village Code Yes: No: (if yes, you must submit a Site Plan Application,&provide a detailed topographical survey) 25. Is the lot located within 100 ft.of a Wetland as per§245 of Village Code? Yes: No: (if yes, the area of wetland and the wetland buffer zone must be properly depicted on the survey&site plan) 26. Is the lot or any portion thereof located in a Flood Plane as per the FIRM Map dated 9/28/07? Yes:-No: (if yes, the area and elevations of the flood plane must be properly depicted on the survey&site plan) 27. Will the proposed project require a Tree Removal Permit as per§235 of Village Code?Yes: No: (i yes,applicant must submit a Tree Removal.Permit Apphcariont 2A. 1-)ne.s the nrono.sed nrniert involve a Nome-Orminwion s,ner e)i0-3R of Villao_e Cndr.? Veer No: Indicate:TIER I: TIER II: TIER III: (if yes,a Home Occupation Permit Application is required) 29. What is the total estimated cost of construction: $ /� 7J Note:estimated cost shall include all site improvements,labor, material,scaffolding, fired equipment,professional fees,including any material and labor which may be donated gratis.If the final cost exceeds the estimated cost,an additional fee will be required prior to issuance of the C/O. 30, Estimated date of completion: (2) F11 nm4 BUILD, ARTMENT VIL t`X(YE OF RYE BROOK 938 Knvc�� r ET RYE BR06 ,NY 10573 (%4)9I -046S AFFIDAVIT OF COMPLIANCE VILLAGE CODE §216 • STORM SEWERS AND SANITARY SEWERS '.PHIS AHFIDAVII' MUST BEAR THE NOTARIZED SIGNATURES OF THE LEGAL PROPERTY OWNER AND BE SUBMITTED ALUM; wi= ANY oil WLUIZ+ia_G:10:11::ii Ai"VLI :<i'T.,o" i-.= 1;1JILD,114G OR rL:zmlt2G ruiSiiT APPLICATION SUBMITTED WITHOUT THIS COMPLETED AND NOTARIZED FORM WILL BE RETURNED TO THE APPLICANT. STATE OF NEW YORK. COUNTY OF WESTCHESTER�)7 as: I, mpe ln `L� ec'sE' , residing at, � 15 1�y t �11� ca buing duly bwu111, UCIJUJCS d11U SLdLCb U1t1L[S)11C 1J L11C t11.)pllt.4tu1L t1DUVC 1RU11CU, allu 1urulur bwws Lum kbplc 15 li1C legal owner of the property to which this Affidavit of Compliance pertains at; Rye Brook, NY. 1.,. +1,.,-♦t. r 11 r .�.. r r J 1. A +1,-.:. AI L n. � 1,' /1...1.... 1.4 A 1.. ' � r1..,* 1 Lll LS!�" L1tf1L all JLQ.WmCniS Ll.'11La.111[:U .!L!`-!:i a2L it uf.;', almi L!iat lV L!!� !;GJL V! 111j/11G1 fy11V1N!GUr'L all" Ut11Gi, ulat there are no known illegal cross-connections concerning either the storm sewer or sanitary sewer, and further that there are no roof drains, sump pumps, or other prohibited stormwater or groundwater connections or sources of inflow or infiltration of any kind into the sanitary sewer from the subject property in accordance with all State, County and Village Codes. (Siowil re rat"Propom'Owner(c)) (I'ru�t Nun„of Propern owner s}1 day of . 20 23 fNotar�' 'uhlicl DEBRA L.CASTIGLIONE NOTARY PUBLIC STATE OF NEW YORK Registration No.OICA4808725 Qualified in Westchester Count Commission 'Expires April 02„ ox 6J1/2024 This application must be properly completed in its entirety by a N.Y.. State Registered .Architect or N.Y. State Licensed Professional Engineer & signed by those professionals where indicated. It must also include the notarized signature(s) of the legal owner(s) of the subject property, and the applicant of record in the spaces provided. Any application not properly completed in its entirety and/or not properly signed shall be deemed null and void, and will be returned to ire applicant. Hease note that application tees are non-refunciaple. **9c Erie******k*************;,************************************tk at'k**SFr tt k tt 9t si'it*it tk ek 9t lk tP f49r*74*tit*ir*tk**#eF 1F lF�t tk tkk*ink tl* ST,A F�TE NEW�SORK, 'OUNTY OF WES`1'CHESTER ) as: r lw �_W ,c ,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)o.; -is thc legal owner of the property to which this application pertains, or that (s)hc is the for the legal owner and is duly authorized to make and file this application. !indicate architect cnntractor anent attnmev etc) That all statements contained hereinare true to the best of his/her knowledge and belief, and that any work performed, or use conducted at the above captioned property will be in conformance with the details as set forth and contained in this application and in any accompanying approved plans and specifications,as well as in accordance with the New York State Uniform Fire Prevention&Building Code,the Code of the Village of Rye Brook and all other applicable laws, ordinances and regulations. By signing this application, the property owner further declares that he/she has inspected the subject propCrty, and that to the best of his/her know-lcdgc there arc no roof drains, sunip putnph or otlicr prohibited store-A -Goer or rrrntµndwater connect:cnv nr vni*. "v of i f1:1trwtion into tb: S."..^.;f"nl ;e::7pv QN,vtp^ �r frnm flip --prti, Sworn to before me this f Sworn to before me this day of M d.vu 9202 3 day of ,20 natwc of Vropc—" ....... PP &J Print Name of Property Owne Print Name of Applicant Lb,') �. 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M M LA C W 1 C C (1) Z Cn _ �U Z , AX M w d) WI d O co Li X oN O 5El O (n � C U) El O (n U)o CD 0 cn — Q' � WQ �L cA I c U c U M = i M F l o �`!� � U) 1 0 1 �il rn r- I � I r- ti 0 fi o M i M Co 1 CMci I� U_ , I O utr C I r .fttr C � Q ,ttroa : i Q - srar.oa i Q The Arbors Homeowners' Association 173 '/2 Ivy Hill Crescent Rye Brook, NY 10573 March 7, 2025 Matthew Rosen 175 Ivy Hill Crescent Rye Brook, NY 10573 Re: Replace All Windows and Patio Sliding Door Dear Matt. This letter serves as confirmation that the Architecture & Grounds (A&G) Committee has reviewed and accepted your application for the above-named work. This approval is valid for six (6) months from today's date. If any changes need to be made to the original plans submitted to A&G either before or during construction, the Committee must be notified in writing, and your application must be amended. Work must stop and cannot proceed until you receive written approval for those changes. A permit from the Village of Rye Brook must be presented to the property manager before work begins. You are also required to inform the Property Manager when work begins. When the project is complete, the Property Manager must again be notified so that an inspection may take place. Please include a photograph of the work as well. Failure to comply with these procedures will result in fines and/or work stoppage. If you have any questions, contact me at: Property Manager. Nicholas Salzarulo Property Manager Just checking to see if the permit is ready. Thanks! On Thu, Mar 20, 2025, 2:08 PM Laura Petersen <LPetersen@ryebrookny.gov>wrote: Perfect,thank you! I will let you know as soon as the application is approved and the permit is ready for pick up. Thank you Laura Laura(Petersen Office Assistant Village of Rye Brook 938 King Street Rye Brook, NY 10573 (914)939-0668 From: Matt Rosen<mattrosen70@gmail.com> Sent:Thursday, March 20, 2025 2:00 PM To: Laura Petersen<LPetersen@ryebrookny.gov> Subject: Re: 175 Ivy Hill Crescent- Permit for Windows and Door Kevin Elston, Windows by Toll, 203-942-8428. On Thu, Mar 20, 2025, 1:25 PM Laura Petersen <LPetersen(C0 rye brookny.gov>wrote: Ok great! Do you have the name and phone number of the contractor? 2 Laura(Petersen Office Assistant Village of Rye Brook 938 King Street Rye Brook, NY 10573 (914)939-0668 From: Matt Rosen<mattrosen70@gmail.com> Sent:Thursday, March 20, 2025 12:58 PM To: Laura Petersen<LPetersen@ryebrookny.gov> Subject: Re: 175 Ivy Hill Crescent- Permit for Windows and Door 8 windows. Cost/$12,475 On Thu, Mar 20, 2025, 10:58 AM Matt Rosen <mattrosen70@gmai1.com>wrote: I think we changed it to 8 windows. I will get back to you. On Thu, Mar 20, 2025, 10:54 AM Matt Rosen <mattrosen70@gmail.com>wrote: I attached the specs to the application. I think the estimated cost was around $13,000. 7 or 8 windows plus the door. On Thu, Mar 20, 2025, 9:07 AM Laura Petersen <LPetersen_@ryebrookny.gov>wrote: Good morning, I will be working on your permit today for your windows and door. At your earliest convenience, please send to me the following information: 1. Estimated cost of the work 3 7 1 : c y Q r Ni o)s y O •y •� CN r e u W N �"'► ry' ��RII cG ;9r U O - ; ci u En L LI NO } } to S_ J �y LL LU 06 J OQ r w ry / O Lij LL N Q N � as ° Q S _ a O Q CIS I•[EF�1 t• Y MO Cd v 00 �t� )fir•W�. CQ � "� O U Y.. AN W. y ' y 71 n DATE(MMIDD/YYYY) ACORD® CERTIFICATE OF LIABILITY INSURANCE 03/18/2025 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 endomement(s). PRODUCER CONTACT Bethel Account NAME: The Insurance Center PHONE (203)730-0634 FAX (203)730-0683 A/C No Ezt: A/C,No 6 Stony Hill Rd,Suite 210 E-MAIL ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC• Bethel CT 06801 INSURER A: Midvale Indemnity Company INSURED INSURER B: AmGUARD Avery&Frye LLC,DBA:Windows By Toll INSURER C: 226 Selleck Street INSURER D: STE B INSURER E: Stamford CT 06902 INSURER F: COVERAGES CERTIFICATE NUMBER: CL2451513376 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 ADOLSUBR POLICY EFF POLICY EXP L7R TYPE OF INSURANCE INSD WVD POLICY NUMBER MM/DDIYYYY MM/DD/YYYY LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE X OCCUR DAM O N 100,000 PREMISES Ea occurrence $ MED EXP(Any oneperson) $ 5,000 A CP00061531 05/25/2024 05/25/2025 PERSONAL&ADV INJURY $ 1,000.000 GEN'LAGGREGATE LIMITAPPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY [g PRO ❑ 2,000,000 JECT LOC PRODUCTS-COMP/OP AGG $ OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000 IF accident ANYAUTO BODILY INJURY(Per person) $ B X OWNED X SCHEDULED AVAU623494 02/12/2025 02/12/2026 BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY Per accident UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 1,000,000 A X1 EXCESS LIAB rl CLAIMS-MADE 0000003053 05/25/2024 05/25/2025 AGGREGATE $ 1,000,000 DED I I RETENTION$ $ WORKERS COMPENSATION X SPER TATUTE ER AND EMPLOYERS'LIABILITY Y/N 500,000 B ANY PROPRIETOR/PARTNER/EXECUTIVE ❑ NIA AVWC537385 05/11/2024 05/11/2025 E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 500,000 If yes,describe under 500,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ NY Disability B DB15036181.1 05/11/2024 05/11/2025 50,000 DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached If more space is required) 175 Ivy Hill Crescent Road Rosen 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 BLDG Opt. ACCORDANCE WITH THE POLICY PROVISIONS. 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 PORK Workers' CERTIFICATE OF STATE Compensation NYS WORKERS' COMPENSATION INSURANCE COVERAGE Board 1 a. Legal Name&Address of Insured(use street address only) 1 b. Business Telephone Number of Insured Avery &Frye, LLC 646 265 8924 DBA/TA Windows by Toll 700 Forest Ave 1c. NYS Unemployment Insurance Employer Registration Number of Insured Rye, NY 10580-3201 N/A Work Location of Insured(Only required if coverage is specifically limited to 1 d. Federal Employer Identification Number of Insured or Social Security certain locations in New York State,i.e.,a Wrap-Up Policy) Number 82-3674820 2.Name and Address of Entity Requesting Proof of Coverage 3a. Name of Insurance Carrier (Entity Being Listed as the Certificate Holder) AmGUARD Insurance Company Village of Rye Brook BLDG Dept 938 King St. 3b.Policy Number of Entity Listed in Box"1 a" Rye Brook, NY 10573 AVWC537385 3c. Policy effective period 05/11/2024 to 05/11/2025 3d.The Proprietor,Partners or Executive Officers are ❑ included.(Only check box if all partners/officers included) XQ 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 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: Adam Edelstein (Print name of authorized representative or licensed agent of insurance carrier) Approved by: 03/19/2025 (Date) Title President Telephone Number of authorized representative or licensed agent of insurance carrier: 800-673-2465 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