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HomeMy WebLinkAboutBP25-068PERMIT # An L �vz SECTION 4 , ' `- TYPE OF WORK JOB LOCkTION _ �L OWNER,ZJ2 /Q CONTRACTOR �PsT. COST � V(co #e�L-P �� DATE /s aSs�rn: 1 BLOCK LOTS- ✓Ll //1 `% V e ot�lalrye*4eqove,-Ico Mier/PZ/�i-ia�y 3 FEE WL( FEE DES DqT i TCO ; FEE DATE FOOTING FOUNDATION FRAMING RGH FRAMING INSULATION PLUMBING RGH PLUMBING GAS El SPRINKLER ELECTRIC M LOW4OLT O ALARM C� AS BUILT FINAL DATE INSP �J . � -• 24L SSe OTHER APPROVALS aR k, 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 November 13,2025 Daniel Debari&Catherine Debari 11 Elm Hill Drive Rye Brook,New York 10573 Re: 11 Elm Hill Drive, Rye Brook,New York 10573 Parcel ID#: 135.50-1-46 Building Permit#25-068 issued on 4/15/2025 for Front Door Replacement This certifies that the new front door,installed under the above captioned permit has been satisfactorily completed. Sincerely, Steven E. Fews Building&Fire Inspector /to For office use only: B U I L D I MENT PERMrr# -D(tS VILI,V►IE OF RYE U40OK ISSUED: — S- Nnv 0 5 ?n?5 938 KING STREET' !k*YE BROOK�N. VW YORK 10573 DATE: 9 9 A668 FEE: -$I ) OU PAID APPLICATION FOR CERTIFICATE OF OCCUPANCY, CERTIFICATE OF COMPLIANCE, AND CERTIFICATION OF FINAL COSTS TO BE SUBMITTED ONLY UPON COMPLETION OF ALL WORK, AND PRIOR TO THE r 1NA-L INSPECTION sssrsrrrrsrerrsssrrrsss►•srsssssssrssrrsrsrrssss»rs»ssrssrssrrrrrss»ssrsrrrsrrr»rs»srsrrrsrsrrsssress»ssssr►ss»rss»ssss»r►srs Address: �l CZM f tiLL 7y ✓� �`j E^ /� Q o Q �- v`i o J-�7 Occupancy/Use:QES1�, es!F cC Parcel ID#: Zone:� 42 Owner: b Aw/EZ Qt C A-7W(- -,-NF b t�S g4/ Address: /i C Llt1 P.E./R.A. or Contractor: Address: Person in responsible charge: Address: Application is hereby made and submitted to the Building Inspector of the Village of Rye Brook for the issuance of a Certificate of Occupancy/Certificate of Compliance for the structure/construction/alteration herein mentioned in accordance with law: STATE OF NEW YORK. COUNTY OF WESTCHESTER as: 7S F64-;kJ being duly swom,deposes and says that he/she resides at (Print Name of Applicant) (No.and Street) in A'IC a Q o O < ,in the County of iVis$Z H E S 7 f in the State of that (City/Mown/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� G 341 . �� , for the construction or alteration of: ;moo--/7— D c c)2 P.F7'4- lq-'C&M CG 1 7- 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 1:; Sworn to before me this day of (��V e.M� C, 20� day of , 20 Signature ktllfoorty Owner Signature of Applicant X:M�� Print Name of Applicant Noffly Public 5HAKI MtULLU Notary Public Notary Public,State of New York No.01ME6160063 Qualified In Westchester County-,---) e 1 'W ,a Commission Expires January 29,20 ( QyE DRnv�• w � 1982 BUILDING DEPARTMENT ❑BUILDING INSPECTOR �SSISTANT BUILDING INSPECTOR VILLAGE OF RYE BROOK ❑CODE ENFORCEMENT OFFICER 938 King Street • Rye Brook,NY 10573 (914)939-0668 FAx (914) 939-5801 www.ryebrook.org - - - - - - - - - - - - - - - - - - - - INSPECTION REPORT - - - - - - - - - - - - - - - - - - - - ADDRESS : 1. E L r " / r/ [. �L ��. _ DATE: L 7 2 tO2-5'-- PERMIT# 2J _ p.j ISSUED: �1�SECT:�J V BLOCK: LOT: LOCATION:} `�I��Q/ OCCUPANCY: ❑ Violation Noted THE WORK IS... PASSED ❑ FAILED REINSPECTION ❑ SITE INSPECTION REQUIRED ❑ FOOTING ❑ FOOTING DRAINAGE ❑ FOUNDATION ❑ UNDERGROUND PLUMBING NOTES ON INSPECTION: ❑ ROUGH PLUMBING ❑ ROUGH FRAMING ❑ INSULATION ❑ Natural Gas -oi ❑ L.P.Gas ❑ FUEL TANK ❑ FIRE SPRINKLER Yv OQ�� 0 , ❑ FINAL PLUMBING ❑ C OSS CONNECTION <./�� Up NAL ❑ OTHER 00 . Lin N w O O .a N N \ LC) 72 v a a v a x air� 1©,vW� as W = a M V. � � ■ ♦ O Utj .0 6 ` O Q Lo ~ _ � a = a U w C)u a'a00 �► z A U Lo A v i--1 M a W n c7 v 'd Q v %10 a - a Z H O W v 00 CN rrT�„i k3 04 0.� H �+ ee et v � Q v � Aa a Q i--� H O F� z z c c ci G A d V S o � � w C7 A z z 0 �-4.q .` �a � .. 0 aG o ,y a� a °' '4 w w �1. BUILD7jRY �iOMENT V IL E EOOK p f � -.938 KING ETR ,NY 10573 Lov MAR 2 8 2025 Ww41r. k _ VILLAGE OF RYE BROOK ALP 3T FOR OFFICE USE ONLY: Approval Date: ' rmi Application# Approval Signature: ARCHITECTURAL REVIEW BOARD: Disapproved: Date: r BOT Approval Date: Case# Chairman: PB Approval Date: Case# Secretary: ZBA Approval Date: Case# Other: ,¢ « Application Fee: 1CJ0 Permit Fees: EXTERIOR BUILDING PERMIT APPLICATION Application dated: is hereby made to the Building Inspector of the Village of Rye Brook,NY,for the issuance of a Permit for the construction of buildings,structures,additions,alterations or for a change in use,as per detailed statement described below. I. JobAddress: I UM `I �� IT015 2. Parcel ID#: f 6-1 -15-0 —/ —q Zone: - 3. Proposed Improvement(Describe in detail): ` 4. Property Owner: 60e, h� f f fi,Nil r,, Address: M `I (%\t f� Nil o_Jlb Phone# Cell#�y�17 Jx-1or7)`•1 e-mail t K►S�Ofs�S 6 nnll�Dyq List All Other Properties Owned in Rye Brook: Applicant: (, Al /Al E b Address: i 1 EUK *1 r'L- b a l Jai ►Q-`I C_ lgam k, N7. 1 o - Phone# Cell# e-mail lu kIS7WJ'GS 'IMAfL Architect: Address: Phone# Cell# e-mail Engineer: Address: Phone# Cell# n^ e-mail General Contractor: M 00 1 CO! Address: 2 w a�ft11 yy+ y Phone# Cell# - ICA e-mail Ck �MUV Mux (1) 6/t/2024 5. Occupancy;(1-Fam.,2-Fam.,Commercial.,etc...)Pre-construction: 1. Post-construction: 1- 6. Area of lot: Square feet: 3{ r g Acres: 0 . 3o 7. Dimensions from proposed building or structure to lot lines: front yard: rear yard: right side yard: left side yard: other: No Ct- 4-^I Cq C 8. If building is located on a comer lot,which street does it front on: 4 L:;I 1 tt I t-t- b Q►V C` 9. Area of proposed building in square feet: Basement: 10 fl: 2'fl: 3'd fl: 10, Total Square Footage of the proposed new construction: la F=P-c.--r h n o e 1'o t2-Tl C p l 1. For additions,total square footage added:Basement: fl: 2nd fl: 3'a fl: 12. Total Square Footage of the proposed renovation to the existing structure: r4 A- Pr-QN r ap o ieLa If--n C G 13. N.Y.State Construction Classification: N.Y.State Use Classification: 14. Number of stories: L Overall Height: Median tHeiA: r,,� 15. Basement to be full,or partial: CU1( V 1 , finished or unfinished: Up 1 (1��1 l� 16. What material is the exterior finish: 17. Roof style;peaked,hip,mansard,shed,etc: Iri 1D Roofing material: 1 18. What system of heating: CQC y Q1 19. If private sewage disposal is necessary,approval by the Westchester County Health Department must be submitted with this application. 20. Will the proposed project require the installation of a new,or an extension/modification to an existing automatic sre suppression system?(Fire Sprinkler,ANSL System,FM-200 System,Type I Hood,etc...) Yes: No: (ifyes,applicant must submit a separate Automatic Fire Suppression System Permit application&2 sets of detailed engineered plans) 21. Will the proposed project disturb 400 sq.ft.or more of land,or create 400 sq.ft.or more of:*mper}�ious coverage requiring a Stormwater Management Control Permit as per§217 of Village Code? Yes: N �/�Area: 22. Will the proposed project require a Site Plan Review by the Village Planning Board as per§209 of Village Code? Yes: No: (if yes,applicant must submit a Site Plan Application,&provide detailed drawings) / 23. 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) 24. Is the lot located within 100 ft.of a Wetland as per§245 of Village Code? Yes: No: 1/ (if yes, the area of wetland and the wetland buffer zone must be properly depicted on the survey&site plan) 25. Is the lot or any portion thereof located in a Flood Plane as per the FIRM Map dated 9/28/07? Yes: No: ✓ (ifyes,the area and elevations ofthe foodplane must be properly depicted on the survey&site plan) 26. Will the proposed project require a Tree Removal Permit as per§235 of Village Code? Yes: No: (if yes,applicant must submit a Tree Removal Permit Application) 27. Does the proposed project involve a Home-Occupation as per§250-38 of Village Code? Yes: No: Indicate: TIER I: TEER II: TIER III: (if yes,a Home Occupation Permit Application is required) 28. List all zoning variances granted or denied for the subject property:_ At-L O V �- 29. What is the total estimated cost of construction: S 3 Q t_ Cs� Note.The estimated cost shall include all site improvements, labor,material,scafJolding!1 fixed 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 CIO. 30. Estimated date of completion: d"b (2) 611/2024 BUILD MENT / I U\1 -, I VIL E OF IZ OOK 938 KING f ET RYE BR NY 10573 MAR 2 8 2025 4 -c wNVw - ov VILLAGE OF RYE t ROOK s } BUILDING rrrlanRTr.1PNT 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: I,eAlinit� a�� � _,residingat, (Print name) — — (Address\here sou Ii'cl 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; /t e—L M LL ' / ✓C , Rye Brook, NY. Ooh 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. (Signuhircol-PropertN Owicr(s)) C' Nf 2�C-f3 � (Print Nami ON%ner(s)) Sworn to before me this day of 20 (Nolur, Pubiic� SHAR1 NIELILLO Notary Public,State of New York No.01ME6160063 Qualified In Westchester County Commisslon Expires 1enUary 29,20 i_� (2) 6r1 r2024 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 the applicant. Please note that application fees are non-refundable. STATE OF NEW YORK,COUNTY OF WESTCHESTER ) as: C��4inr1F_ Dfssj" f 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 C)1� Sworn to before me this day of Y� , 20 =� day of , 20 Signature o Owner Signature of Applicant C � ,NF b,--_4,4-P- o Print Name of Property Owner Print Name of Applicant Notary Public Notary Public SHARI MEULLO Notary Public,State of New York No.O1ME6160063 Qualified In Westchester County Commission Expires landM 29,20D (8) 6/1/2024 TO Catherine Stones 11 Elm Hill Drive Rye Brook, NY O +18485527050 DESCRIPTION RATE QTY AMOUNT Work tobe done on front door $2.800.00 1 $2.800.00 Remove trims from inside and outside of the door Remove door Installation of new door Spray foam between door and opening Installation of finger joint pine inside and azakoutside Labor and material included �����'�����������������������������������������������_��_���������������������������� 8U8ToTxL $2.800.00 TAXES (8.38%) $234.84 TOTAL U8O $3,O34.G4 --------------------------------------------------'- ---------'--------- --- — Nn job too big or small!!!! Contractor License# Westchester County VVC-32183-H1S Putnam Coutny 32585 t — o aa, a � 0 z LL Y U Y � D .�• O m V a z Y C O. m o U cmas m E C� U d Q D > 7 G a t .. m Y co 1 D J Y U 0 C U O f0 D 'UO I .N ca E a) a 0 0 0 in a E (M t nu�puvklkaffd��67CeGv7R3ii2bxR+d�YFdcv.a+,.::°asr.;.;.,,. ,.. ::sk;,a.:_ �sl�Bn�v•. ..+iawu, ,,.. .ew�wn .. . ...rai. - u / FM CN � a d 'V v cam` � CY) e o w Q \ L v C i.+ C LU h a:Y a a N � � � +i Ei g � section Co 0 y cn 4 W N o : E co a R R \ a l co cr) Z&Ar : C o co Ch U O N CA rj i o W u rj U ul ap u o 0 } � � t "�fA`/t ► _ � . . .' th ,;� Tex,�� t� �•'-�`�`� i"/Pt. . .� �' �r+'z' t t� t�(\{ Aco" CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDD/YYYY) 11%� 1 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 endorsements). PRODUCER Sharp Insurance Services Inc DBE: T Moises Rosales 120 N Main St, 2nd Floor PHONEVC.N 2032479524 aC ,:20366382.00 Port Chester NY 10573 ADDRESS: mrosaies@sharpsvcs.com INSURE_S AFFORDING COVERAGE--_____ NAIC It ---------- -------- INSURER A:Third Coast Insurance Company 10713 INSURED G4 HOME RENOVATIONS CORP INSURER B: 21 SEDGEWICK ROAD INSURER_C:_ CARMEL HAMLET NY 10512 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 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 ADDL SUBR, POLICY EFF POLICY EXP LTR TYPE OF INSURANCE WVD POLICY NUMBER (MMID IMMIDDIYYMTg COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $1,000,000 ✓ CLAIMS-MADE1:1 OCCUR PREDAMAGE T RENTED 000 PREMISES Ea occurrence S r A GLSISTC006903424 08/09/2024 08IM025 MEDEXP Any one person) s 5,000 PERSONAL 3 ADV INJURY $1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER. GENERAL AGGREGATE s 2.000,000 ✓ POLICY F JECT PRO- ❑ LOC PRODUCTS-COMP/OPAGG $1,000,000 OTHER s AUTOMOBILE LIABILITYLi COMBINED SINGLE LIMIT $ Ea accident) ANY AUTO BODILY INJURY(Per person) S OWNED SCHEDULED BODILY INJURY(Per aotirleM) S AUTOS ONLY AUTOS HIRED NON-OWNED I PROPERTY DAMAGE S AUTOS ONLY AUTOS ONLY Per acddent $ UMBRELLA LIMB OCCUR Li EACH OCCURRENCE $ EXCESS LIAR HCLAIMS-MADE AGGREGATE S DED F RETENTIONS f WORKERS COMPENSATION PER OTH- IAND EMPLOYERS'LIABILITY STATUTE_ Y/N E-L EACH ACCIDENT ANYPROPRIETOR/PARTNER/EXECUTIVE OFFICERWEMBER EXCLUDED? N/A - -- (Mandatory in NH) EL.DISEASE-EA EMPLOYE S �fl yes descnbe under - -- DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT S I Q0, LIEi DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) ADDITIONAL INSURED:VILLAGE OF RYE BROOK,938 KING STREET,RYE BROOK,NY 10573 CERTIFICATE HOLDER CANCELLATION VILLAGE OF RYE BROOK 938 KING STREET SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF. NOTICE WILL BE DELIVERED IN RYE BROOK,NY 10573 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE Moises Rosales Producer ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD rc Workers' Certificate of Attestation of Exemption STATE Co nsaUon from New York State Workers' Compensation and/or Disability and Paid Family Leave Benefits Insurance Coverage **This form cannot be used to waive the workers'compensation rights or obligations of any party.** The applicant may use this Certificate of Attestation of Exemption ONLY to show a government entity that New York State specific workers'compensation and/or disability and paid family leave benefits insurance is not required. The applicant may NOT use this form to show another business or that business's insurance carrier that such insurance is not required. Please provide this form to the government entity from which you are requesting a permit,license or contract. This Certificate will not be accepted by government officials one year after the date printed on the form. In the Application of Business Applying For: (Legal Entity Name and Address)' OTHER:Workers Compensation Waiver G4 Home Renovations Corp 21 Sedgewkk Rd From:Village of Rye Brook Carmel,NY 10512 PHONE:9145654264 FEIN:XXXXX1372 Workers'Compensation Exemption Statement: The above named business is certifying that it is NOT REQUIRED TO OBTAIN NEW YORK STATE SPECIFIC WORKERS'COMPENSATION INSURANCE COVERAGE for the following reason: The business is a two person owned corporation,with those individuals owning all of the stock and holding all offices of the corporation (each individual must hold an office and own at least one share of stock). Other than the two corporate officers/owners,there are no employees,day labor, leased employees,borrowed employer;,part-time employees,other stockholders,unpaid volunteers(including family members)or subcontractors. Corporate Officers: Gerico Gutierrez-Coronel President,Andrea Gutierrez Vice President Disability and Paid Family Leave Benefits Exemption Statement: The above named business is certifying that it is NOT REQUIRED TO OBTAIN NEW YORK STATE STATUTORY DISABILITY AND PAID FAMILY LEAVE BENEFITS INSURANCE COVERAGE for the following reason: The business MUST be either. 1) owned by one individual; OR 2) is a partnership(including LLC,LLP,PLLP,RLLP,or LP)under the laws of New York State and is not a corporation; OR 3) is a one or two person owned corporation,with those individuals owning all of the stock and holding all offices of the corporation(in a two person owned corporation each individual must be an officer and own at least one share of stock); OR 4) is a business with no NYS location. In addition,the business does not require disability and paid family leave benefits coverage at this time since it has not employed one or more individuals on at least 30 days in any calendar year in New York State. (Independent contractors are not considered to be employees under the Disability and Paid Family Leave Benefits Law.) 1,Andrea Gutierrez,am the Vice President with the above-named legal entity. I affirm that due to my position with the above-named business I have the knowledge,information and authority to make this Certificate of Attestation of Exemption. I hereby affirm that the statements made herein are true,that I have not made any materially false statements and I make this Certificate of Attestation of Exemption under the penalties of perjury. I further affum that I understand that any false statement,representation or concealment will subject me to felony criminal prosecution,including jail and civil liability in accordance with the Workers'Compensation Law and all other New York State laws. By submitting this Certificate of Attestation of Exemption to the government entity listed above I also hereby affirm that if circumstances change so that workers'compensation insurance and/or disability and paid family leave benefits coverage is required,�j'id ove-named legal entity will immediately acquire appropriate New York State specific workers' compensation insurance and/or disabili a family leave benefits coverage and also immediately fumish proof of that coverage on forms approved by the Chair of the Workers'Compensa nd tothe vernment entity listed above. SIGN HERE Signature: Date: Exemption Certifi to mber Received 2025-02 523 March 24, 2025 NYS Workers'Compensation Board CE-200 01/2018