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HomeMy WebLinkAboutBP25-061PERMIT #r~ /'QlS'! 0Zo / PATE; j aS psi 'y �(v SECTION Z c� %. 7IIIIIIIIIPBLUK LOT TYPE OF WORK ��7��% C) JOB LOCATION :71111&1 1v0f2Lp7 / � e2 '/ OWNER /1� SS//)q 4 rSS / Q e/ 7 9O-�Sy3 CONTRACT6F'?.10/ice OI %� S LLC - ou 4Q1IIII:fZZQ (9/4)394:)-960(0 T. COST FEE CO #IIIIIIIIIIIIIIIIIN - 10 �IIIIIIIIN FEE Alt If DATE Q TCO # FEE DATE DATE FOOTING FOUNDATION INSP FRAMING RGH FRAMING �✓ c,C.; INSULATION 2 ASK 1 PLUMBING 20 RGH PLUMBING GAS Lmi SPRINKLER _ l , - ELECTRIC LOW -VOLT O �T�o eso(ALARM AS BUILT FINAL NEW OTHER APPROVALS ARB BOT PB ZBA OTHER VILLAGE OF RYE BROOK WESTCHESTER COUNTY, NEW YORK NO: 25-109 Certif irate of ®rrupaurp This is to certify that 'John of, Ay�L —, having duly filed an application on T 20 �requesting a Certificate of Occupancy for the premises known as, l S. e� , Rye Brook,NY, located in a R/5 Zoning District and shown on the most current Tax Map as Section: /0?9 75 Block: / Lot: g , and having fully complied with the requirements/of the Building Code and the Zoning Ordinance under Building Permit No.a5 C./� , issued Y- 20 cV5, such authority and permission is hereby granted to the property owner to lawfully occupy or use said premises or building or part thereof listed under the following New York State Classifications,Use: Q P / Construction: , for the following purposes: Subject to all the privileges, requirements, limitations, and conditions prescribed by law, and subject also to the following: This certificate does not in any way relieve the owners or any person or persons in possession or control of the premises, building,or any part thereof from obtaining such other permits or licenses as may be prescribed by law for the uses or purposes for which the building or premises is designed or intended. Furthermore, it does not relieve such owners or persons from complying with any lawful order issued with the object of maintaining the premises or building in a safe and lawful condition. No changes or rearrangement in the structural parts of th ]ding or in the exit facilities shall be made, and no enlargement, whether by extending on any side or by increasing in fight all be made,p6rs a he building be moved from one location to another until a permit to accomplish such change h bee tain fr the Bui ' g Inspector. Building Inspector,Village of Rye Brook: Date: AUG 2 5 2025 BUILCYEBRO ENT For office use on1 AUG 18 2025 ---� VIL OK ISSUED:# r �/ 93 KING STRE PORK 10573 DATE: Q�SVILLAGE OF RYE BROOK -c /BUILDING DEPARTMENT O FEE: PAIDQ . ov 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 •wtttsrttsttttstttssswttsswtrw**tstatssssstststssstsssttsssststsssttwwsress•rsw*s*tssttwttwt**+s++++++sss++*++*++++*+++***+++ Address: -17JoU kd e Flf /P J DQ- ,frn��-T' Occupancy/Use: Parcel ID#: /420, 75 /- M Zone: Owner: 41A e l fi �S,S/A/ Address: P.E./R.A.or Contractor: Address: Person in responsible charge:NA12/A HC—J91t/(q Address: *0 NO. R1 (MC St. 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: d—A S'5/,u1q being duly swom,deposes and says that he/she resides at '��t� N�• /� 'd9P t/7 (Print Name of A plicant) (No.and Street) in /��(= Y-OO AL-- ,in the County of WQS4-e/'lx s- in the State ofL,that (C�own/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 000. 06 , for the construction or alteration of: -Ey TL K/O 4- R LZ rx AT 10&) s 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 of l�-"T , 20 day of , 20 Signature o Property Owner Signature of Applicant arc 1 w l� Ll 0-3/vA (-Pr-ftviunne of Property Owner Print Name of Applicant No Public Notary Public SHARI MElILLO Notary Public,State of New York No.OJME6160063 6/l/2024 Qualified In Westchester County Commission Expires Jandary 29,202 ? o -t BUILDING DEPAI ,rMENT ❑ISu ��. IN�I�t� (i�It A�s(�InNt ISun nIN(. INS1�1.( (uu VILLAGE OF IZYG BROOK '❑( (►I►I I•N1(►N► 1 %1I NI (►IIt(:I It 938 DING STRIA • 16-l-, ltltmm, NY 1057.1 (91.1) 939-(Ihhti I-Ax (914) 939-1801 (\Iti rc.1•yt•l►t•(►(►k.prg INS1)FI "I'lON REPORT - - - - -. - _ _ _ - - - - - - - �I►1►Itl ♦ti L10 V IV�Q/T'l l�I V(� J DA'I I ' V wW LV f�IIt,1I � :. � 2S -oCo h �„� � �,: y y-Z�\I , � /Zf- 7.�f;►.(►(:L: ! , (,1 : /9.. (M 4 S �Cn LAW.-) I.u( n. rI(►N: J � Occ;uPnNcr•_—__-_._.___. ❑ VIOLATION NU'I'1•.1► f Illi Width IS... It1 II t;TED/ RVINSPECPION ❑ SI'II IVOPI.0 ION Itt:QuIit1:1► ❑ 1.()O11"(. ❑ 1•001I\(. I)ItAINA(.i. ❑ UNDERGROUND I►I.UNIIII\(, 'VO'I'FIS ON INSI)I:("1'I()N: ❑ R(►u(Ji I►LUMISM. ❑ ItOtl(;Ii FRAMING 0 1NSIII n VION LI NA'1'('It 11 (iAti �1N�— V g�� 1 0-) ❑ I'iltl til'Itl\1�1.1 It T � M ❑ FINA1. PI I'MItIN — Cj I i N n 1. ALL 0 02`c- Co r✓� ---� D- bvm, BUILDING Di'll-A z'i-NIFI T Li lst. niti► INtir►► folk ���►�rnnr 14111- tNG INWI.C101; W1L1,AG1: O1-, IZYG BitOOI% ❑t 0M. IAl0M I NII.NI (>PPIt:►It 918 DING STRIT-1 RI-Ie BItook, NY 1057; (9111) 939-0608 FAX (914) 939-5801 INSPECTION REPORT - - - - - - - - - - - - - - - AI)Il rs- : OQ 02��"� A� 1C1 S _.._ I),�1I C7—L•� �Z� PI::RM1 1:- PP 2-5-- LOCATION: t• 4 S� " ¢ �,v &0^% OCCUPANC]': ❑ VIOLATION Nauuj) Wulm is... Ild l\CC:I?P'1'1:.1► ❑ REJECTED/ RIANSPECTION ❑ SITli INSI'I:(:'I ION 1U.'Qulla-1) ❑ I'(►o ING I] TOOTING I)RAINAGI: ❑ FOUNDATION ❑ UNDERGROUND PLITAIRIM, NOTES ON INtii►FCTION• ❑ R(►mai 1►I•t1MRING ❑ ROUG11 FRAMING ❑ INSULATION L.R GAS ❑ V(11-,I 'IAN1: -- Q -- — ❑ 1'lla.SPRINKI.F..11 ?loco /M1 .&�-'INAL PLUMBING MOD ❑ �.Itl►Sti(�(INN1:("1'lI1N ------ ❑ FINAI. ❑ O'I'll I:It O Ln N w N w ��a 04 7 N M N aq v � N o oz � w a o � � •� c!� " n Q � � rT o. � � _ •� � � r- v 0 61 �O O o v vz .� b v � � cn ° W W � W 00 N Z " . D zoo0. � w � $ � � � v 1-1 O F O 0 p U p W V U zg � 9 ° . 00 t7 A z 0o v � � o BUILDING.DEPARTMENT VILLAGE OF RYE',$fZOOK MAR - 7 2025 ju 938 KING STREET RYE BROOX,NY 10573 (944) 066$ VILLAGE OF RYE BROOK www, a kn . ov BUILDING DEPARTMENT --`� INTERIOR BUILDING PERMIT APPLICATION FOR OFFICE USE ONLY: Approval Date: APR 20 Pe t#: � 'Application Fee:$ / OO �j—'Lj Approval Signature: yz Permit Fees: $ Disapproved: Other: �7 Application dated: 3 / is hereby made to the Building Inspector of the Village of Rye Brook,NY,for the issuance of a Permit for the interior alteration of an existing building,or for a change in use,as per detailed statement described below.1. Job Address: 1Ia8 1JAer4 RI DEC 5rX(_1eT SBL: IA 7_S--- q�—� / Zone: "n�� Proposed Improvement.(Describe in detail):*Red-hled r rep l4eed ylun kim r�I Ayr r to A 14frM T R191y • 1ZemoM4 014 UN►r t&#T K in 4' ftny =M • d d /L bi, w/ sanitlow pump I- rani in Ov ief a QhIOC c 6101t 01fil�zd Pins wrlsw Pvc_ 3. Does the proposed improvement involve a Home-Occupation as per§250-38 of the Code of the Village of Rye Brook? No: Yes: If yes,indicate: TIER I: TIER II: TIER III: 4. Will the proposed project require the installation of a new,or an extension/modification to an existing automatic fire suppression system(Fire Sprinkler,ANSL System,FM-200 System,Type I Hood,etc...) :No: Yes: (If yes,please submit a separate Automatic Fire Suppression System Permit application&2 sets of detailed engineered plans) 5. Occupancy;(I fam.,2 fam.,comm.,etc...)Prior to Construction: After Construction: 6. MY State Constrncti n Classification: N.Y.State Use Classification: t7,I Property Owner:1'!A21 A �GSSJ tJA Address:#of uD lery Zle* 5r. ha)�^ �� osv Phone# Q/�-� 10. KJ y.3 Cell# '&1f1 e33 n email: r I a mBS S Am&C Cam 8. Applicant: 9 Address:g Phone# Cell# email: 9. Architect: Address: Phone# Cell# email: 10. Engineer: Address: Phone# Cell# / email:.. _ 11. General Contractoi.,Aa�J// ?y y�GLo��Address.�as S / P.-J S - PC A!y �3 v Phone 1 Cell# email: Q12. Estimated cost of construction S yi�a� � 1 ( �—}- C(� �C •l�l� p O (r� -STE:The estimated cost shall include all labor,material,scaffolding,fixed uipment,professional fees,and material and labor which maybe donated gratis.) 13. Job Timetable: Start: Finish: (1) 6/1/2024 R ECrEO W E BUILDING DEPARTMENT _U VILLAGE OF RYE 4R,OOK MAR - 7 2025 938 KING SmET RYE BRom,NY 10573 1 (014).9 70668 ' VILLAGE OF RYE BROOK ry� .Qov BUILDING DEPARTMENT AFFIDAVIT OF COMPLIANCE VILLAGE CODE §216 • STORM SEWERS AND SANITARY SEWERS THIS AFFIDAVIT MUST BEAR THE NOTARIZED SIGNATURE OF THE LEGAL PROPERTY OWNER AND BE SUBMITTED ALONG WITH ANY BUILDING OR PLUMBING PERMIT APPLICATION. ANY BUILDING OR PLUMBING PERMIT APPLICATION SUBMITTED WITHOUT THIS COMPLETED AND NOTARIZED FORM WILL BE RETURNED TO THE APPLICANT. STATE /Q�OF NEW YORK, COUNTY OF WESTCHESTER } as:,, ff I, t /hA1 M o!'SS!na-• ,residing at, �a g NI fnp 1�iC�'!P ��'• -► t P �J V (Print name) (Address wheW you live) being duly sworn,deposes and states that(s)he is the applicant above named, and further states that(s)he is the legal owner of the property to which this Affidavit of Compliance pertains at; ,(TJd NOt n tL(I-d , Rye Brook,NY. (Job Address) Further that all statements contained herein are true, and that to the best of his/her knowledge and belief, that 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. t (Signature of Property Owner(s)) I #-/-Io /wesS/AA (Print Name of Property Owner(s)) Sworn to before me this (Notary Public) SHARI MEULLo Notary Public,State of New York No.01ME6160()63 Qualifled In Westchester County (2) Commission Expires Je ntlary 29,2622 6/1✓2024 This application must be properly completed in its entirety and must 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 the applicant. Please note that application fees are non-refundable. STATE OF NEW YORK,COUNTY OF'WESTCHESTER ) as: ,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 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. By signing this application,the property owner further declares that he/she has inspected the subject property, and that to the best of his/her knowledge there are no roof drains, sump pumps or other prohibited stormwater or groundwater connections or sources of infiltration into the sanitary sewer system on or from the subject property. Sworn to before me this 2 Sworn to before me this day of , 20 Z S day of , 20 Signature of Property Owner Signature of Applicant 141114 ff (_fin Name of Property Owner Print Name of Applicant Notary Public Notary Public sKAju MEULLO Notary Public,State of New York No.OIME6160063 Quailfled in Westchester County Z Commission Expires January 29,202—7 (4) 6/112024 • ''����1���ii��l��i��ii��i��+�1�1��1���il�i �1��1����i ���` �' �' �I�����I�i M �i Ln N N W + N u WLU i U bt xcs z c cc a Lei Z N r Z d F lw w z O U O g ' � 0 Ln ON CA ^ z z � O o � oc In oc ►-� a a z F ZZ V w c c F+ � N Ln o0 a � • yF `� BUIL DER ME D [E C E � \J VIL E OF RYE OK i 938 KiN , ET RYE B ,NY 10573 MAY 2 3 2025 ov VILLAGM OF RYA-` BROOK ELECTRICAL PERMIT APPLICATIO BUILDING Dcr%y�T�/ENT Westchester County Master /Electricians License Required FOR OFFICE USE ONLY BP#: S�CP� EP#: � / 37 Approval Date: -6-' Z e zo L.5' Permit Fee: $ T Approval Signature: Other: DO NOT START WORK or CONSTRUCTION UNTIL A PERMIT HAS BEEN ISSUED BY THE BUILDING INSPECTOR. THE ADMINISTRATIVE FEE FOR WORK PROGRESSED OR COMPLETED WITHOUT A PERMIT IS 12%OF THE TOTAL COST OF CONSTRUCTION WITH A MINIMUM FEE OF$750.00 J� is hereby made to the Building Inspector of the Village of Rye Brook NY,for the issuance of Application dated a Permit to install and/or remove electrical equipment, wiring, fixtures, or to perform other high or low voltage electrical work as per the detailed statement described below. By signing this document, the applicant & property owner agree that all electrical work performed will be in conformance with all applicable Federal,State,County and Local Codes. 1.Address: NO9h1�Pz jb(,.B ST SBL:IQ 9i 7S- 9 Zone: 2.Property Owner: IA AQ1 A "4;SS t t-A Address: Phone#: �J 1 LI 410 45q� Cell#: email: bJ t tt.�avow QrPa��� 3.Master Electrician/Licensed Installer: E�C,-MAC, U—C - Address:_Ti3mb"1'J RMllyAX, Qj Lic.#: ll &3 Phone#: Cell#: et i q bit 160 email:I yJC tjr-,j�l LS 1&6PLIal Company Name:SDW U C_ Address: Do 50% 61.3 VIVAVLO t LAL P Ib S'O 4.Proposed Electrical Work/Fixture Count: ,1 Lj to t n)&- nF �c�D�Q_ �xzt,� � M WS�� 13 ft h Q-uC)tom. LmQg14 5.31 Party Electrical Inspection Agency: STATE OF NEW YORK,COUNTY OF WESTCHESTER ) as: MAX IA MCS51614 ,being duly swom,deposes and states that he/she is the applicant above named,and does further (print name of individualA gning as the applicant) state that(s)he is the JPAMQ LLC— for the legal owner and is duly authorized to make and file this application. (Master Electrician/Licensed Installer) The undersigned further states 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 before me this I 11_1� Sworn to before me this 3 d=of _ ,20 a G day�of 20 Signature of Property Owner plicant MARYANN NI Notary Public,State of New York l LL/f90u' Print Name of P ope Ow r No.01 N1603004t Name I'cant Qualified in Westchester Cour#H Commission Expires Se I St Yor o ryVubl E6160063 Quali led In Westchester County Commission Expires JanUary 29,X� 2e24 STATE WIDE INSPECTION SERVICES,, INC. :0 • • SWIS JOB APPLICATION tel 845.202.7224 1 fax 914.219.1062 1 SWISNYcoml SWISTRAINING.COM Office Use Elect. Permit# Date Bldg Permit# j v Sq Ft Plumbing Permit# Final Certificate# ` Zip Building Dept. County City/Village q'?U.— ;�:; : - p 9 P • � Address Cross Street Section Block Lot Owner Name/Address(If different than above) Contact Number ❑Basement ❑1st FI. ❑ 2nd FI. ❑3rd FI. ❑More Than 3 FI. ❑Garage ❑Attic ❑Outside ❑Residential ❑Commercial Receptacles Special Recept GFCI AFCI Switches Dimmers Smoke Alarms C/0 Detector Hood Trash Compact Amt Amps Range(s) Cooktop(s) Oven(s) Dishwashers Refrigerator Disposal Microwave Luminaires Generator Transfer Switch SERVICE Amperage #Panels 1P 3P # Meters # Disconnect ❑Underground ❑ New ❑ Reconnect ❑ Repair ❑Overhead ❑ Upgrade ❑ Disconnect Utility ID# ❑Con Ed ❑ NYSEG ❑Central Hudson ❑ Orange/Rockland PHOTOVOLTAIC SYSTEM PV Modules Inverters AC Disconnect Junction Box Combiner Box Load Center PV Monitor Energy Storage System DC Disconnect ❑Legalization ❑ Safety Inspection ❑Consultation J� %L 1 rJ(-- v+= �Vw�> vz VUvr-A hl1ASte.z D FCEE MAY 2 3 2025 ID VILLAGE OF RYE BiZOOK BUILDING DEPARTMENT This application is valid for one(1)year from the date received by SWIS.This application is intended to cover the above listed items to be inspected,if at any time of inspection additional items have been installed,you are authorized to make the inspection and adjust the fee for the additional items inspected.The applicant declares that there is no open applications for the above address with any other inspection company.The applicant, owner or authorized agent agrees to all the above terms and conditions as set forth for the application. Email Address Name �v License# Date j 3 Z`7 Signature Address City/State �1 Zip Code —L Company Phone# ' :� D nD C� LO�/� State Wide Inspection Services JUN - 9 2025 1080 Main street Fishkill, NY 12524 I 845 202-7224 Phone L�-- STATE WIDE INSPECTION SERVICES VILLAGE OF RYE BROOK 914-219-1062 Fax BUILDING DEPARTMENT Email: office@swisny.com Website: www.swisny.com Service With Integrity BY THIS CERTIFICATE OF COMPLIANCE STATE WIDE INSPECTION SERVICES CERTIFIES THAT: Upon the application of: Upon Premises Owned by: Spano Electric LLC John & Maria Messina William Spano 408 North Ridge Street PO Box 673 Rye Brook, NY 10573 Amawalk, NY 10501 Located at:408 North Ridge Street, Rye Brook, NY 10573 Section: Block: Lot: Electrical Permit Number: EP25-137 129.75 1 19 Certificate Number: 2025-3823 Building Permit Number: BP25-061 A visual inspection of the electrical system was conducted at the Residential occupancy described below.The electrical system consisting of electrical devices and wiring is located in/on the premises at: 408 North Ridge Street, Rye Brook, NY 10573 The First Floor : 1 Bathroom(s), Laundry Room, and Master Bathroom were inspected in accordance with the NYS and NFPA 70-2017 and the detail of the installation,as set forth below,was found to be in compliance on the 6th day of June 2025. Name Quantity Rating Circuit Type GFCI 04 Switches 04 Luminaires 05 Officer: Frank J. Farina This certificate may not be altered in any way and is validated only by the presence of a seal at the location indicated.This certificate is valid for work performed on the date of inspection only. £ a £ £I s al l N N N = N N i, a Ln x N o ON W ■ 0-4 s � W ~L' A O U C O ■ * k r7 x �+ a, ur) � F O W z > * w A z z W U ►-• a w H w o V W / C /► M N Az � MCI vows*cnW Q Ln � it O W w < 00 CZ o Z a w o V S ►-+ Z U O a afN x G 2 H A C7 � Oa � � ■ £ Aa a £ ■ jVn D �C�L�� EBUILMENT AUG - 1 20250 VIL OK938 KIN ,NY 10573 VILLAGE OF RYE BROOKBUILDING DEPARTMENTov PLUMBING PERMIT APPLICATION ��FOR OFFICE USE ONLY BP PP • c� —0 6/ PP#: — /C-�- Approval Date: 'J\�\ Permit Fee: $— cw_)af AApproval Signature: Disapproved: (fees are non-refundable) DO NOT START WORK or CONSTRUCTION UNTIL A PERMIT HAS BEEN ISSUED BV THE BUILDING INSPECTOR.THE ADMINISTRATIVE FEE FOR WORK PROGRESSED OR COMPLETED WITHOUT A PERMIT IS 12%OF THE TOTAL COST OF CONSTRUCTION WITH A MINIMUM FEE OF$750.00 p Application dated, 0---/—aJr is hereby made to the Building Inspector of the Village of Rye Brook NY,for the issuance of a Permit to install and/or remove Plumbing as per detailed statement described below.The applicant&property owner,by signing this document agree that said plumbing work will be in conformance with all applicable Federal,State,County and Local Codes. 1.Address: 40 Wor`In ;d,(S& S • SBL:-ja 9, 75- Zone: -�r 2.Proposed Work: (Alt w b'LG f x" .. S 1x,,1-i., 1,J 10'�QAC"_Sn _ ct Fv ,A5 io(¢_ rcr vvl c,., �w Lt*+ s C­ Pu 3.Property Owner: H4"I A MR'Z"S+rut Address: 1408 Wo,r-H-i Rig-� 3�-. Phone#: Cell#: NIL() 4C10- L(SL13 email: L i �! � 4.Master Plumber: Sot CO� Address: �q fi n 4-/y) , Aw t f o' 4. 5 ojy Lic.#: o Phone#: Cq/q� g3q-A&I Cell#: (9/4/� email: Jam- coSetI'..- _q✓Y►o��7• Ct�rvt Company Name: ZC- 6DS--� 211461b1 II+Kl� tUddress: c3;V PL44YIcAm Aokeq LOX(A -,S'�-,,oV J INDICATE FIXTURES& LINES TO BE INSTALLED AS PER THE FOLLOWING SCHEDULE: Location Water Urinals Drinking Sinks Showers Bath Laundry Domestic Fire Sanitary Natural/ Other* Total Closets Fountains Tubs Tubs Service Service Sewer LP Gas Basement I st Floor 2nd Floor 31 Floor 4a'Floor 5t°Floor Exterior 5.*List Other Equipment/Provide Details: (Notarized Signatures Required Next 2 Pages) - - 6/1/2024 STATE OF NEW YORK,COUNTY OF WESTCHESTER ) as: MOO 1n i--`5sW4 ,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 Master Plumber for the legal owner and is duly authorized to make and file this application. 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 before me this �� Sworn to before me this day of ,20 4S day of ,20 2 Signature of Property Owner Signa a of Applicant Print Name of Property Owner Print Name of Applicant N aryNOSFfA�t�c1MIEULLO Notary Public,State 0f New York No.01ME6160063 Notary Public,State of New York Qualified In Westchester County No.01ME61fi0063 Qualified in Westchester County Commission Expires January 29,20� Commission Expires January 29,20 L� This application must be properly completed in its entirety and must include the notarized signature(s) of the legal owner(s) of the subject property, and the applicant of record in the spaces provided. Applications not properly completed in its entirety and/or not properly signed shall be deemed null and void and will be returned to the applicant. -2- 6/l/2024 BUILD & MENT D �` �/�(� VIL OF RYE OOK �% L� 938 KING ET RYE BRO w� �4 -0466-$a j NY 10573 " AUG 2025 ov VILLAGE OF RYE BROOK �- BUILDING DEPARTMENT AFFIDAVIT OF COMPLIANCE VILLAGE CODE &216 • STORM SEWERS AND SANITARY SEWERS THIS AFFIDAVIT MUST BEAR THE NOTARIZED SIGNATURE OF THE LEGAL PROPERTY OWNER AND BE SUBMITTED ALONG WITH ANY BUILDING OR PLUMBING PERMIT APPLICATION. ANY BUILDING OR PLUMBING PERMIT APPLICATION SUBMITTED WITHOUT THIS COMPLETED AND NOTARIZED FORM WILL BE RETURNED TO THE APPLICANT . STATE OF NEW YORK, COUNTY OF WESTCHESTER ) as: ('/ /1P.SSIA L. , residing at, #D& l�G'1�7�Y l�a>D OJT wl t (Print name) (Address where Au live) being duly sworn, deposes and states that(s)he is the applicant above named,and further states that(s)he is the legal owner of the property to which this Affidavit of Compliance pertains at; C� A101 11 066C 1TlZ Ear , Rye Brook,NY. (.lob Address) Further that all statements contained herein are true, and that to the best of his/her knowledge and belief,that 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. (Signature of'Property Owner(s)) (Print Name of Property Owner(s)) Sworn to before me this of1�U��� 20 ( otary Public) SHARI MEULLO Notary Public,State of New York No.OIME6160063 Qualified In Westcheste►Count" -3- Commisslon Expires January 29,20L_ 6/1/2024 p ECEN JUL 3 0 2025 ID VILLAGE OF RYE BROOK BUILDING DEPARTMENT jdb gr fv� olpd addl, & kf1k e /'n 9 y � _ _ s CN N • � p O Ln 1 \ \ w w °" tj a, Z •� a w x z o H Mil �--i Fri Z LO Qv � z �—, w z PLO ° v� ham) w Z O z 0o z r' z z H o ° • Z z z u cn _ of A w LI) 99 ICI z z O 7 1 L" z a x E-+ u `� W 3 a w M U0-4 o � 4u, BUILDING DEPARTMENT D D VIL' E OF RYE BROOK APR 2 8 2025 � 938 KIN ET RYE B ,NY 10573 _ VILLAGE OF RYE BROOK R BUILDIN RTMENT PLUMBING PERMIT APPLICATION FOR OFFICE USE ONLY BP#: L Approval Date: APR 29 20 Permit Fee: S Approval Signature: Disapproved: (fees are non-refundable) kkkkkkkkkkkkkkkkkkkkkkkkkkkkkkkMkkkkkkkMkkMkM*kkkkkkMk'F�k>FkFkkKkkkkkkkkkkkkkkkkkkk>;c>;c ,x�c;ckkk>kkkk�kM DO NOT START WORK or CONSTRU(`HON LIN I IL A PLRNIC1 HAS BEEN ISSUED BN 1 HF: BUILDING INSPECTOR. Ttil: ADNIINISTRATIVL FF.F: FOR WORK PROGRESSED OR COMPLFTtj) WITHOUT A PERMIT IS 12%, OF THE TO"T.1L COST OF'Cf)NS I'RUC'"I"ION WITH A MINIMUM FFL OF S750.00 Application dated, a 8 a S is hereby made to the Building Inspector of the Village of Rye Brook NY, for the issuance of a Permit to install and/or remove Plumbing as per detailed statement described below.The applicant&property owner,by signing this document agree that said plumbing work will be in conformance with all applicable Federal,Q� S State,County and/Looccal Codes. 1.Address: 08 NORTN /� f J 9 7' SBL: /a/ 7 —J'—( 7 Zone: 2C-1r 2.Proposed Work: A/ -6� e_ ���l 404 d k' & Acy,4 cue r r I �" -•, 3.Property Owner: A91,4 Nlr SS/NA Address: 7t1 APIffH RIIAGF Alee� Phone#: 71:f• ?`70• �fSN3 Cell#: email: 4 Al SS 2 /NQ/l e lm 4.Master Plumber: ��A �ti � p Address: 1 l) ��/Y ^�Q ��,,c� Lic.#: T f 7 Phone#: Cell#: ! I y Yf0 S_S'Vd 1 email: TN v LeW , v /K Company Name: ��� � Address: yy l.(JQJ��, F �l' c INDICATE FIXTURES&LINES TO BE INSTALLED AS PER THE FOLLOWING SCHEDULE: Location Water Urinals Drinking Sinks Showers Bath Laundry Domestic Fire Sanitary Natural/ Other* Total Closets Fountains Tubs "Pubs Service Service Sewer LP Gas Basement 1st Floor 2nd Floor 31d Floor 01 Floor 5'h Floor Exterior 5.*List Other Equipment/Provide Details: (Notarized Signatures Required Next 2 Pages) -1- 6/1/2024 STATE OF NEW YORK,COUNTY OF WESTCHESTER ) as: M)?gj.g m it 55 u q ,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 Master Plumber for the legal owner and is duly authorized to make and file this application. 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 before me this `� Sworn to before me this �?L1?4& day of 20 GIS day of A ,20 QL " Signature of Property Owner nature of Applicant Print Name of Property Owner Print Name of Applicant --� Notary Pu�6RI MEULLO ary ublic, State of New yot Notary Public,State of New York Registration No.01VA6272779 No.0iME6160063 Oualified in Westchester County Qualified In Westchester County Commission E)tpires 11/26/2028 Commission Expires January 29,20-j This application must be properly completed in its entirety and must include the notarized signature(s) of the legal owner(s) of the subject property. and the applicant of record in the spaces provided. Applications not properly completed in its entirety andior not properly signed shall be deemed null and void and will be returned to the applicant. -2- 6/1/2024 BUILD. 'i .-DEPARTMENT VILL' OF RYE OOK ID 938 KING FT RYE ftqq�,NY 10573 APR 2 8 2029 4)939-066 �1� VILLAGE OF RYE BROOK NvNvi4.rN v brot)k n v.uov BUILDING DEPARTMENT AFFIDAVIT OF COMPLIANCE VILLAGE CODE §216 - STORM SEWERS AND SANITARY SEWERS THIS AFFIDAVIT MUST BEAR THE NOTARIZED SIGNATURE OF THE LEGAL PROPERTY OWNER AND BE SUBMITTED ALONG WITH ANY BUILDING OR PLUMBING PERMIT APPLICATION. ANY BUILDING OR PLUMBING PERMIT APPLICATION SUBMITTED WITHOUT THIS COMPLETED AND NOTARIZED FORM WILL BE RETURNED TO THE APPLICANT . STATE OF NEW YORK, COUNTY OF WESTCHESTER ) as: 3, HAR14 NE-ST11J.4 residing at, go PDX 1hF )?119F �&—FT (Print 11�tw I I being duly sworn, deposes and states that (s)he is the applicant above named, and further states that(s)he is the legal owner of the property to which this Affidavit of Compliance pertains at; 6W N011-11 -RID60 ShIEW , Rye Brook,NY. (Jol, V1,11v"I Further that all statements contained herein are true, and that to the best of his/her knowledge and belief,that 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. %" Sworn to before me this da of 20 SHARI MEULLO Notary Public,state of New York No.OIME6160063 Qualified In Westchester County -3- Commission Jandary 29.20 6/1/2024 .Building Permit Check List&Zoning Analysis O Address: _ `� U `�►® � PN t SBL: Zone: �— %5 Use: �Z Const.Type Other. Submittal Date: Revisions Submittal Dates: Applicant 1 Q Nature of Work e o V Cl 0 Reviews:ZBA:APR — 3 2025 PB: BOT: Other. Q NEED K FEES:Filing. \ BP: C/O: Flood Plane: Legalization: ��, •� ( ) ( 0,,�PP: 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 Protection: S/W Mgmt.: Tree Plan: Other. ( ) ( ) SURVEY:Dated: Current: Archival: Sealed: Unacceptable: ( ) ) PLANS:Date Stamped: Sealed Copies: Electronic Other. ) License: Workers Comp: Liability Comp.Waiver. Other: ( ) ( ) CODE 7S3#: Dated: N/A: (�( ) HIGH-VOLTAGE ELECTRICAL:Plans: Permit N/A: Other. ( ) ( ) LOW-VOLTAGE ELECTRICAL:Plans: Permit: N/A Other. ( ) ( ) FIRE ALARM/SMOKE DETECTORS:Plans: Permit: H.W.I.C.:_Battery:_Other. (►�( ) PLUMBING:Plans: Permit: Nat Gas: LP Gas: N/A/: Other. ( ) ( ) FIRE SUPPRESSION:Plans: Permit N/A: Other. (�( ) H.V.A.C.: Plans: Permit N/A: Other. ( ) ( ) FUEL TANK Plans: Permit Fuel Type: Other. O O 2020 NY State ECCC: N/A: Other. ( ) ( ) Final Survey. Final Topo: RA/PE Sign-off Letter. As-Built Plans: Other. ( ) ( ) BP DENIAL LETTER. C/O DENIAL LETTER: Other. ( ) ( ) Other. ( )ARB mtg.date: approval:- notes: ( )ZBA mtg.date: approval:- notes: ( )PB mtg. date: approval: notes: REQUIRED EXISTING PROPOSED NOTES VE D Area: Date: APR — 3 2025 Circle: Fronts e Front Front Sides: Rear. Main Cov: Accs.Cov Ft.H Sb: Sd.H Sb: GFa Tot : Fc I : Height/Stories: notes: �k T r �►�, �.��- � � 4,,�.+��� ter. '` �'�.�;,, 5 r r. yo_1 ! j4 1 rc�' .Vu y - Y ll ke� r" , Y Aoc 740,4 g ..a f Jf ell Y✓: Y *, 1 0 °w o00 Qc 3 � ul ^ i i mp 1 0i V d a n. ` m _� t_ 1 I. z In O LL uj .� '►; j O O 1 I Z E LL Ci w x � COIM .. o � = o O w � W W 3 ~ 0 c J ° `a m z W LLco 910 O �, _ � a A W q a .0 Z to a I o y ncu ri OWQ= Z J d ` � � zc� w QD A d cn W J _ 04 •+-� 1 to i C N 1 LyZ o' ° co .. c ' l°9 y LT I � "r ii�" E O 1 Cftftu l) Q v N G W p �.� ; = W , 0 d CO I Q � � � � O tC C ' pa 1 t W UJ 1 C oNZO ' aWh a �dl? ° w � ► LL I y a o ; \ T e I a c C a ^ eo N o y N p K N I �i a 6 y L17 I� Ev g� �0 cps v 3 u O 0 � A u V O 8 ` ` ,ice+ V1 u c CO)w o w A, a JW o In :7 Q tr u E7p W W cn C v W In uJ o w W aW c� V f O z L) 3 .� up' O c : 0 due ap �0 C ►., n ,n a > c x Z u 8 r � � 41 a .3 = K 1.0 i e rn N CN G = C z Q o = C u u V 1 + Ju C J wI j Vcu I DATE(MM/DD/YYYY) AC")?" CERTIFICATE OF LIABILITY INSURANCE 03/24/2025 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 endorsement(s). PRODUCER NAME: Laurette Rubino Hallahan,McGuinness and Lorys,Ltd PHONE (914)939-8895 AX (914)939-3104 Firti.Ali OnAC No: 553 Westchester Avenue t-MAIL s: laurie@hmlinsurance.com ADDRE INSURERS AFFORDING COVERAGE NAIC a Rye Brook NY 10573 INSURERA: Utica First Insurance Company 15326 INSURED INSURER B Pawling Holdings LLC INSURER C 25 South Regent Street INSURER D: INSURER E: Port Chester NY 10573 INSURER F: COVERAGES CERTIFICATE NUMBER: CL2532108834 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 LTR TYPE OF INSURANCE POLICY NUMBER MM/DD/YYYY MM/OD LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE ®OCCUR 50,000 MED EXP An one person) 5,000 A Y ART3001556510 03/01/2025 03/01/2026 PERSONAL BADVINJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER. GENERAL AGGREGATE 2,000,000 POLICY 0 PRO LOC PRODUCTS-COMP/OPAGG 2,000,000 PRO- Pq OTHER: $ AUTOMOBILE LIABILITY SINGLE LIMIT $ accid nt ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS HIRED NON-OWNED PROPER DAMAGE: $ AUTOS ONLY AUTOS ONLY UMBRELLA LU1B OCCUR EACH OCCURRENCE EXCESS LIAR HCLAIMS-MADE AGGREGATE DED I I RETENTION WORKERS COMPENSATION PER STATUTE OTH- AND EMPLOYERS'LIABILITY Y/N ER ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT OFFICER/MEMBER EXCLUDED? 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 I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Certificate holder is included as additional insured when required by written contract or agreement. 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 King Street AUTHORIZED REPRESENTATIVE Rye Brook NY 10573 - @ 1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD 17--0;';'k*\- NYSIF New York state Insurance Fund PO Box 66699,Albany,NY 12206 1 nysif.com CERTIFICATE OF WORKERS' COMPENSATION INSURANCE o . .,o n n n n n n 451481271f �v � LEVITT-FUIRST ASSOCIATES LTD }M. 520 WHITE PLAINS ROAD,2ND FL 21 P. TARRYTOWN NY 10591 t SCAN TO VALIDATE AND SUBSCRIBE POLICYHOLDER CERTIFICATE HOLDER PAWLING HOLDINGS LLC VILLAGE OF RYE BROOK 25 South Regent Street(REAR) 938 KINGS STREET PORT CHESTER NY 10573 RYE BROOK NY 10573 POLICY NUMBER CERTIFICATE NUMBER POLICY PERIOD DATE G2146 860-8 241346 06/29/2024 TO 06/29/2025 3/25/2025 THIS IS TO CERTIFY THAT THE POLICYHOLDER NAMED ABOVE IS INSURED WITH THE NEW YORK STATE INSURANCE FUND UNDER POLICY NO. 2146 860-8, 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. 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. 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 7 �V DIRECTOR,INSURANCE FUND UNDERWRITING VALIDATION NUMBER: 612961858 U-26.3 Policy Change Adak Proposal TRAVELERS J Travelers Personal Insurance Company One Tower Square, Hartford, Connecticut 06183 (A Stock Insurance Company) HOMEOWNERS POLICY Named Insured Your Agency's Name and Address JOHN S MESSINA & MARIA MESSINA FRANK H REIS INC 408 NORTH RIDGE ST PO BOX 3967 RYE BROOK NY 10573 KINGSTON, NY 12402 Your Policy Number: 981731632 633 1 For Policy Service Call: (845) 338-4656 Your Account Number: 981731632 For Claim Service Call: 1-800-CLAIM33 Policy Period Location of Residence Premises FROM: 08-22-24 To: 08-22-25 12:01 A.M. 408 NORTH RIDGE ST STANDARD TIME AT THE RESIDENCE PREMISES RYE BROOK NY 10573 Change Effective Date: 03/10/25 No Change in Premium Reason for Change: Change to Insured Name Section I - Property Coverages Limits of Premium Liability A - DWELLING $ 713,000 $ 1,874.00 B - OTHER STRUCTURES 71,300 INCL C - PERSONAL PROPERTY 499,100 INCL D - LOSS OF USE 213,900 INCL Section iI - Liability Coverages E - PERSONAL LIABILITY (BODILY INJURY AND $ 500,000 $ 55.00 PROPERTY DAMAGE) EACH OCCURRENCE F - MEDICAL PAYMENTS TO OTHERS- 5,000 INCL EACH PERSON Policy Forms and Endorsements HO-3 (12-86) Homeowners 3 Special Form HA-300 NY (05-15) Special Provisions - New York HA-390 NY (12-02) Workers Compensation and Employers Liability 58065 NY (05-15) Value Added Package - PLUS New York $ 405.00 58244 (10-10) Identity Fraud Expense Reimbursement Coverage $ 25.00 HA-61-B (06-95) Valuable Items Plus (Coverage G) 35.00 Furs $5,000 Total Premium $ 2,394.00 Continued on next page Agent Copy Page 1 of 3 PL-86561-97 577/OXK597 DEC#:21 Policy Change TRA V E L E R S,w►. 'Proposal HOMEOWNERS POLICY Named Insured: JOHN S MESSINA & MARIA MESSINA Policy Number: 981731632 633 1 Policy Period: 08-22-24 To: 08-22-25 Effective Date: 03-10-25 Your Premium Reflects the Following Credits or State Surcharges Security Credit -70.00 Account Discount -584 .00 Loss Free Credit -324 .00 Policv Deductible: $ 2500.00 All perils insured against In case of loss under section I, only that part of the loss over the stated deductible is covered. Your Insurer: The Charter Oak Fire Insurance Company One of The Travelers Property Casualty Companies One Tower Square, Hartford, CT 06183 For Your Information For information about how Travelers compensates independent agents and brokers, please visit www.Travelers.com or call our toll free telephone number 1-866-904-8348. You may also request a written copy from Marketing at One Tower Square, 2GSA, Hartford, Connecticut 06183. You may be eligible for a policy in a newer product from one of our other Travelers companies. The way we determine the price for a policy is done differently for the newer product. For example, we may use new criteria, such as the building characteristics of your home, or we may use the existing criteria in a different manner. A new product policy might cost you less or more than what you now pay. It may also have different features than your current policy. You may continue with your current policy, or you may request a policy in the new program. We also offer many other ways to save on your premium. Travelers is here to help - so contact your agent or Travelers representative to discuss whether a different Travelers Homeowners insurance policy is right for you. It is important that the information we used to rate your policy is correct. It is your responsibility to make sure that the information on these Declarations is accurate and complete, including checking that you are receiving all the discounts for which you are eligible. To see a full list of discounts offered, including discounts for having multiple policies with us, protecting your home with safety devices and being claim free, go to www.travelers.com/discounts. Once at the website, type in your policy number 9817316326331 and product code HL1 to view the discounts available. If any of the information on the Declarations has changed, appears incorrect, or is missing, please advise your Travelers agent or representative immediately. Your Travelers agent or representative is also available to review the information on the Declarations with you. Continued on next page Agent Copy Page 2 of 3 PL-86561-97 5771QXK597 DEC#1 21 For Your Information (continued) Rating Information Only Dwelling Occupied By 1 FAMILY Territory 00049 Construction FRAME Protection Class 4 Year Built 1958 Rate Tier REG Not More Than 300 Feet from Hydrant, 1 Miles from Fire Dept. Upon request, we will furnish you, or your representative, with a written estimate of damages to real property, specifying all deductions, provided such estimate has been prepared by us or has been prepared on our behalf for our own purposes. This estimate will be provided within thirty days after your request or its preparation, whichever is later. Important Notice: A Loss free credit is applicable to all Homeowner policies if the account has been loss free for three or more years. This credit is applicable for both new and renewal business. The credit is applied at the new business or renewal date and is only removed at the next applicable policy renewal after a qualifying applicable loss. The credit is applied at the time of the fourth policy renewal. Thank you for insuring with Travelers. We appreciate your business. If you have any questions about your insurance, please contact your agent or representative. These declarations with policy provisions HO-3 (12-86) and any attached endorsements form your Homeowners Insurance Policy. Please keep them with your policy for future reference. GENERAL POLICY/RATING INFORMATION: Rate Tier: REG Agt Cd: OXK597 Commissions $ % Terr: 00049 Sub-Agt: Comm-HO: 0.00 .200 Prot Cls: 4 Trans Type: PCDR Comm-Endt: 0.00 .000 #Fam: 1 FAMILY Trans Prem: 0.00 Comm-PLUS: 0.00 .000 #Apts/Unit: SPC Case: Comm-VI: 0.00 .120 Yr Built: 1958 Pay Ind: 95 Comm-HO Bus: Roof Type: ASPH/FIB/CMP Eff Dt: 08/22/24 Constr: Frame BC: 239 ITV%: 1.001 SVC Ind: 577 PSO Ind: A EDI Copy: NO Rate Plan: A FRMPREM $0.00 TRANSID LEADSTG 0.000 TRANTYP YRSPRGM ORGCHG 0.000 TRANSPREM $0.00 Page 3 of 3 PL-8656 1-97 577/OXK597 DEC#:21 Affidavit of Exemption to Show Specific Proof of Workers' Compensation Insurance Coverage for a 1, 2, 3 or 4 Family, Owner-occupied Residence **This form cannot be used to waive the workers'compensation rights or obligations of any party.** Under penalty of perjury, I certify that I am the owner of the 1, 2, 3 or 4 family, owner-occupied residence (including condominiums) listed on the building permit that I am applying for, and I am not required to show specific proof of workers' compensation insurance coverage for such residence because (please check the appropriate box): ❑ I am performing all the work for which the building permit was issued. ❑ I am not hiring,paying or compensating in any way,the individual(s)that is(are)performing all the work for which the building permit was issued or helping me perform such work. I have a homeowners insurance policy that is currently in effect and covers the property listed on the attached building permit AND am hiring or paying individuals a total of less than 40 hours per week (aggregate hours for all paid individuals on the jobsite) for which the building permit was issued. I also agree to either: ♦ acquire appropriate workers' compensation coverage and provide appropriate proof of that coverage on forms approved by the Chair of the NYS Workers' Compensation Board to the government entity issuing the building permit if I need to hire or pay individuals a total of 40 hours or more per week(aggregate hours for all paid individuals on the jobsite) for work indicated on the building permit,or if appropriate, file a CE- 200 exemption form; OR ♦ have the general contractor, performing the work on the 1, 2, 3 or 4 family, owner-occupied residence (including condominiums)listed on the building permit that I am applying for,provide appropriate proof of workers' compensation coverage or proof of exemption from that coverage on forms approved by the Chair of the NYS Workers' Compensation Board to the government entity issuing the building permit if the project takes a total of 40 hours or more per week(aggregate hours for all paid individuals on the jobsite)for work indicated on the building permit. ,, o2lJo2� (Signature of Homeowner) (Date Signed) Mgpg /I'&Tsl y Home Telephone Number ���' 'f 90• �S`f3 (Homeowner's Name Printed) • Sworn to before me this day of Property Address that requires the building permit: �� C N4/ZTiJ i CVA r anryZ` pKE ()rryirblic) 62-o!) 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