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HomeMy WebLinkAboutBP25-074OWNER / iri -'o - /?/J v � �� e ova &7) 7757& CONTRACTOR P �du pr -v4e ,B �QJgSC,y�.�9a-�9/9 T. COST O, o0n FEE & 0 # '-� FEE` © �/ `'%f� DATE - J� TCO # FEE DATE DATE FOOTING FOUNDATION FRAMING RGH FRAMING INSULATION PLUMBING 0 RGH PLUMBING GAS SPRINKLER ELECTRIC LOW -VOLT I� ALARM G�J AS BUILT O FINAL INSP OTHEf2 APPROVALS ARB • VILLAGE OF RTE BROOK WESTCHESTER COUNTY, NEW YORK No: 25-070 Certificate of ®ccupaucp This is to certify that r J9ojoc�oj6 e- -va of, 1'(�V L j /V 7 having duly filed an application on rn/� � , 20 cQ5 requesting a Certificate of Occupancy for the premises known as, rVe e /U O Oli SCC f 7'T , Rye Brook,NY, located in a PW Zoning District and shown on the most current Tax Map as Section: 26) Block: / Lot: and having fully complied with the requirements of the Builddiinng-Code and the Zoning Ordinance under Building Permit No. , issued 20 �l,J, 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: / Construction: for the following purposes: / X CA Ve re-plctcejx2enY- 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 the building or in the exit facilities shall be made, and no enlargement, whether by extending on any side or by increasing in hei all be made,nor sh buildin ved from one location to another until a permit to accomplish such change has een btained the B 'Idi g 1 ctor. JUN 0 3 2025 Building Inspector,Village of Rye Brook: Date: For office u§Lanill.BUILD d EkTMENT PERMrr# aO74 VILLAGE OF RYE$ROOK ISSUED: FMAY 21 2025 ' KING SIRE RYE BR(x)K,NEW YORK 10573 DATE: _ 14)9 O�c FEE: PAID■ VILLAGE OF RYE BROOK ! 0V APPLICATION FOR CERTIFICATE OF OCCUPANCY, CERTIFICATE OF COMPLIANCE, AND CERTIFICATION OF FINAL COSTS TO BE SUBMITTED 21EY UPON COMPLETION OF ALL WMK, AND PRIOR TO THE FINAL INSPECTION -e.■rssssrrsasssssssssttrstsrstrsssrssrsrrssssasssatttsttstr+ss+ssssrrrsrssrsrsssts+strssrr►♦ssssssssssssrsssssrsssrrssssss Address: C—r-e 5 cz--N� Occupancy/Use: � �� �' ��,I Parcel ID#: /-c�q� P Ye �+ 7� '�—�o Zone:�— Owner: tD rz t }vi Ct.l�h11�, �n'ti, S 1,c 1,.e K6 Address: 4— P.E./R.A.or Contractor: Address: G rskA ( o-yp Person in responsible charge: ev�- /--t— Address: Di 1-( Y5,zS 69\9 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: being duly sworn,deposes and says that he/she resides at (Print Name of Applicant) (No.and Str t) y� in &:-1 �o b .in the County of �� 4c�S`Q V in the State of � I ,that 1-4 (Cityrfown/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 for the construction or alteration of: 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 \0� , 20� day of , Signnatiae of Property,Owner Signature of Applicant �'`� ame of Property Owner Print Name of Applicant Notary PubliQSHARI MEULLO Notary Public Notary Public,State of New York No.01ME6160063 6/t/2024 Qualified in Westchester County2� Commission Expires January 29.20,_,- O�`QyE BRC�jk tim 1. 1982 BUILDING DEPARTMENT ❑BBUILDING INSPECTOR 'ASSISTANT BUILDING INSPECTOR VILLAGE OF RYE BROOK ❑CODE ENFORCEMENT OFFICER 938 KING STREET • RYE BROOK,NY 10573 (914) 939-0668 FAx (914) 939-5801 www.ryebrook.org - - - - - - - - - - - --- - - - - - - INSPECTION REPORT - - - - - - - - - - - - - - - - - - - - ADDRESS : 2Z O �/��� f /LQb_, DATE: J -�O - �C7L� PERMIT# 1.� r7IJ �� �� ISSUED:) - 2 1-7 SECT: /?l 7L BLOCK: LOT: LOCATION: 1�Q_li�.+ \ rl. Tl J OCCUPANCY: ❑ VIOLATION NOTED THE WORK IS... ©1 ACCEPTED ❑ REJECTED/ REINSPECTION ❑ SITE INSPECTION REQUIRED ❑ FOOTING ❑ FOOTING DRAINAGE ❑ FOUNDATION ❑ UNDERGROUND PLUMBING NOTES ON INSPECTION: ❑ ROUGH PLUMBING ❑ ROUGH FRAMING ❑ INSULATION ❑ NATURAL GAS ❑ L.P. GAS ❑ FUEL TANK ❑ FIRE SPRINKLER ❑ FINAL PLUMBING ❑ CROSS CONNECTION FINAL ❑ OTHER e 0 N : ¢ � N Cc,- a H W Z m � 4� i--� � ■ c O � © � cis �� w � v � Q ■ (il n o , o cn as = o Lif)00 14 0 _ Q W � -o C+ L1 x rr��ii 1- }■:■E uw .� WM�r � O _W W cpvq o r. z ■ � � a = ~ � " _ a (� W oC) z O V c A O w v A � �] w �+ 0 � .• A U Q atV , U ON X MM G� r�l U O Pa � p ° LO � � o C) Z z � � � z o o0 4 H O N z PLO m5 C 6J U _ N A W 03. b � -Ccb _ BUILD TMENT D E C EN IE VIL938 KING ET RYE IBR NY 10573 AQR y 2025 14)939- ,' VILLAGE OF RYE BROOK ov BUILDING DEPARTMENT ADMINISTRATIVE EXTERIOR BUILDING PERMIT APPLICATION FoR EX'17?RIOR WORK Wilk ii Doh;s Nor W.QuIRE VILLAGE ARc'HITM'Tt icki, RL,;vIh:W BOARD API'ROVAI, FOR OFFICE USE ONLY: APR �_j�,—7 2/ APPROVAL DATE: APRAP5_�RMIT#: � i✓ / ! APPLICATION FEE: 4 \ 1 00 r APPROVAL SIGNATURE: PERMIT FEES:&/(��0 H.O.A.APPROVAL: DATE: DISAPPROVED: OTHER: #fff##ffff#####,#!f####f############################################################f#f#fff###f####f########## Application dated: /`1r0 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. 1. Job Address: 220 Tree �Tot)Crescent Rye Brook NY (� 2. Parcel ID#: /e I r 7(P /_ �` Zone: ) 3. Proposed Improvement(Describe in detail): _ Patio paver replacement(no changes to existing patio's size, dimensions or layout) S 4. Property owner:Dmitriy Golodnikov and Anna Oshche kova Address: 220 Tree Top Crescent, Rye Brook, NY Phone# Cell# 917-685-7756 e-mail dmitriygolodnikov@gmall.com List All Other Properties Owned in Rye Brook: Applicant: Address: Phone# Cell# e-mail Architect: Address: Phone# Cell# e-mail Engineer: Address: Phone# Cell# e-mail General / General Contractor: 6 i' ! _ l C, 67 y y/I c ,� O�A Address: r �r V G Phone it g Y `f 0 " 6% Z2 Cell# e-mail . (I) 611/2024 5. Occupancy; -F 2-Fam.,Commercial.,etc...)Pre-construction: Post-construction: 6. Area of lot: Square feet: 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: 1"fl: 2°d fl: 3'd fl: 10. Total Square Footage of the proposed new construction: It. For additions,total square footage added:Basement: 1'fl: 2'fl: 31 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:()Typical Western Lumber Frame;()Timber Frame [TC];()Wood Truss[TT]; ()Pre-engineered wood[PW];Located;()Floor Framing[F];()Roof Framing[R];()Floor&Roof Framing[FRI�ther / pavers replacement on existing patio 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: $eacon Hill pavers for patio 18. Roof style:peaked,hip,mansard,shed,etc: Roofing material: 19. What system of heating: 20. If private sewage disposal is necessary,approval by the Westchester County Health Department must be submitted with this application. 21. Will the proposed project require the installation of a new,or an extension/modification to an exist' auto atic fire suppression system?(Fire Sprinkler,ANSI,System,FM-200 System,Type I Hood,etc...)Yes: o: (if yes,applicant must submit a separate Automatic Fire Suppression System Permit application&2 sets of detar gineered plans) 22. Will the proposed project disturb 400 sq.ft.or more of land,or create 400 sq.ft.or��of impervious coverage requiring a Stormwater Management Control Permit as per§217 of Village Code? Yes:_jNo: ma: 23. Will the pro ject require a Site Plan Review by the Village Planning Board as per§209 of Village Code? Yes: o: (rf 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: (if yes,the area of wetland and the wetland buffer zone must be properly depicted on the su rte plan) 26. Is the lot or any portion thereof located in a Flood Plane as per the FIRM Map dated 9/28/07? Yes: o: (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: (if yes,applicant must submit a Tree Removal Permit Application) 28. Does the proposed project involve a Home-Occupation as per§250-38 of Village Code? Yes: No: Indicate:TIER I: TIER II: TIER III: (if yes,a Home Occupation Permit Application is 29. What is the total estimated cost of construction: $ 10,000 Note:estimated cost shall include all site improvements,labor,material,scaffolding,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: April 20th, 2025 (2) 6/1/2024 BUILD -RTMENT v VILL.� E OF RY OOK APR ' 4 2025 938 K[NG ��' ET RYE BRI NY 10573 0641 VILLAGE OF RYE BROOK wrv�i ov BUILDING DEPARTMENT AFFIDAVIT OF COMPLIANCE VILLAGE CODE §21 G - 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, Dmitriy Golodnikov ,residing at, 220 Tree Top Crescent, Rye Brook, NY, 10573 (Tint narnel (Address%%here NOni li-10 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; 220 Tree Top Crescent, Rye Brook, NY, 10573 , Rye Brook,NY. (i„b`V1dT_C.N) 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 Propert} (hsnerl.sll DmNy Golodnikov (Print Naive of Property Owner(s)) Sworn to before me this `-) /day of 100Y)/0 20 'T- (Notary Public) (3) 6/1/2A24 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. t5p T ,OF NEW YQR,COUNTY OF WESTCHEST ER ) 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 Sworn to before me this 2"0 �`"day of r) , 20 day of/ ,20 �� Signature of Property Owner Signature of Applicant f),M, '�' Cow AN"C- 0.4 c r , � Print Name ofVroperty Owner Print Name of Applicant Notary Public Notary Public (4) 611/2024 The Arbors Homeowners' Association 173 '/2 Ivy Hill Crescent Rye Brook, NY 10573 p �r L� D U[� i Dj APR 2 1 2025 April 18, 2025 VILLAGE OF RYE BROOK BUILDING DEPARTMENT Dmitriy Golodnikov Anna Oshchepkova 220 Treetop Crescent Rye Brook, NY 10573 Re: Unilock Pavers — Color Almond Grove Dmithy and Anna, 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 -7-7,ee -73�) ,D,;�CD y i as--se,-- Pja ��,��� 1xw- sP aPP r Hill "" Smooth a .r y t.� t STEEL MOUNTAIN FOSSIL i .. �2 WALNUT . �.� r.)rnF:S-rRIAN ONLY Y ,€1i-L4�'' ;�,F,r,, ����. �+r s�{ v;•;�r� `�1 M x�'; Li 9� ,. r.` �` � ��`ti"'-r > e 4 ram, + i_Y t �F �•J' •'Yr s-� I�1„ � , �' /�. � �' a. 14YI �i4J. � fir; v `��k� ��"•��+ ?�.�j\'d:���i4�ye'Y��.�'�x, §rJ�Vi':' ® t /, �.% f a^ t tir.� S% 1 , r � ` J UnI gm Fia ar y`y Ai !.' 6. .,,� ,s►,, .5 4 MA °i .rr ..• ty �� Mr Y 4 \\ I . I x I ' U i.f y q�ti( n reel;:. �t -40 r CV,I� - ..'.•` ' 1 1 ` j5 ��x,'7 ,Jt�IL.� f,. ,,�� ;�: I � ys•. •� L � 1 9 yw* xfiF1 f� ' ��.J'! Imo. �I .��' "i 5•e�T, +�. � I -w�. � -- sa-- ,• .. ��� �'�� ,� '�, -t ,� .. �, _-fig .. � .Y` • `... - _-- � �`: r'� � 0 f _ � i+� � ' _ -, _ -!" ,� -, '� �' r. ,or' I I� t f - r ��� � ' �� 1t b � ••e rt .� ,� �� • _�� t. _ �r r ..,� E ..- h- CSy ��tii `• A /(rime' n ° sill MA-l +"IM ",�•,•�, 111'ftiil ••+�� ��'°'l�ti1 ++�,�;, ,'yH14m�� +•�,,r;st��otp, ,+,,+�,�,, , �,+,�y ''i'+ l►� �'fi'i'�,�, = «o � ;ssr �.. ti xxxxrc�cx4xxxxxmcxxxscrc,rvs�mrxxxsc�cxncyrmrxxnxrax�-r.�... __ _ ___ ,[,. 'i0�`r < T s I = V cs N O _ r Q t� o =1 W a r.w In wedion W U 0= O LU w N e `' 0� f co E 17; Ca C O F p $ o ,G LL o = ( ° - U �'. � •3 � :' � ^ y-tip as c t, k7 c0 cC N Cc, U i Ems.. lL DATE(MM/DD/YYYY) ACCW?" CERTIFICATE OF LIABILITY INSURANCE 4/7/2025 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: Betty Reyes PHONE (203 570-2689 A/c,No): The Willett Insurance Agency A/C No Ell: ( ) 338 Willet Ave ADDRESS: bettyreyes(a)..the�%illettinsurance.us INSURERS)AFFORDING COVERAGE NAIC# Port Chester NY 10573 INSURER A: lI1XCOX Insurance INSURED INSURER B: Progressive Insurance From The Ground Up 1 Corp INSURER C P.0 Box 1422 INSURER D: INSURER E: Port Chester NY 10573 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. LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYY) LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE I—XI OCCUR PREMISES(Ea occurrence) $ 100,000 MED EXP(Any one person) $ 5,000 A P1004211844 07/28/2024 07/28/2025 PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER. GENERAL AGGREGATE $ 2,000,000 X POLICY ECT LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: $ 300,000 AUTOMOBILE LIABILITY (Ea accident) ANY AUTO BODILY INJURY(Per person) S A OWNED SCHEDULED 02323237-3 0T02/2024 07/02/2025 BODILY INJURY(Per accident) $ AUTOS ONLY I AUTOS HIRED NON-OWNED $ AUTOS ONLY AUTOS ONLY (Per accident) UMBRELLA LIAR OCCUR EACH OCCURRENCE $ EXCESS LIAB HCLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION STATUTE I ER AND EMPLOYERS'LIABILITY Y/N NY PROPRIETOR/PARTNER/EXECUTIVE❑ N/A E.L.EACH ACCIDENT S FFICER/MEMBER EXCLUDED> Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) 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. 939 King St AUTHORIZED REPRESENTATIVE (3e*q R"" Rye Brook NY 10573 ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD NEW Workers' Certificate of Attestation of Exemption YORK STATE Compensation from New York State Workers' Compensation and/or Board 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:Landscaping Services From The Ground UP 1 Corp From:Village of Rye Brook 9 Drew St Apt 4 Port Chester,NY 10573-4860 PHONE:914-490-6919 FEIN:XXXXX8220 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 one person owned corporation,with that individual owning all of the stock and holding all offices of the corporation. Other than the corporate owner,there are no employees,day labor,leased employees,borrowed employees,part-time employees,other stockholders,unpaid volunteers(including family members)or subcontractors. 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,Heriberto Barajas,am the 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 affirm 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,the above-named legal entity will immediately acquire appropriate New York State specific workers' compensation insurance and/or disability and paid family leave benefits coverage and also immediately furnish proof of that coverage on forms approved by the Char of the Workers'Compensation Board to the government entity listed above. SIGN Signature: Date: HERE g° �� Exemption Certificate Number Received April 5 2025-025994 , 2025 NYS Workers' Compensation Board >;x CE-200 01/2018 TITLE SURVEY OF AS SWWN ON *< ry\eX\. �� �� \V\s'�ova p $e-r-Co SITUATE IN —T '� © RY C�o, � �o r Y� FILED IN THE COUNTY CLERK'S F10E O et�Yj � \c� PREPARED BY:r EDWARD G.MIHALCZO LAND SURVEYOR LLC 24 BERKSHIRE ROAD YONKERS,NEW YORK 10710 u�NocRTMi`sn`iw'R nn�i[ORVYNegnieilo.T w`Rc sYcvi TY a�cu`[Rn�vitic:invTOYc�:ow°O`e iC (9 476-1453(914)969-2341 FAX ouARANR[s oR CLRTU CAT ORL woT TNMsrte.mc DTw[In awnso A[aRr fT[T R[R[ror Tv ADgilpNAt ulsmvnoaf m suef(anwr wrNus Tws cwv[Y K NaT TD K us[D/.xl+cll LLICt RTICATtJN[Nq(p AR[YAL1DIp1 TNCYM reOY[St1ORA[StpwR,rlpwl.MOrg1V MDCgr,[/TMR[OI dLLTO LID WV pt OOrl[S OWw[Rf QI AMY OfRQ CwnTYs lD D6RiN YMI Fltss[DL[wLA TN[LURvcTDR wNou OR iR[CTLAUCTYN[i tMO[CARwq IRCl4[[ EOWARD 0.N01ALC LAND ND SURVEYOR LLC fOJIAMRENR[A►KMSNq[pl trt[IURi AIryYIOR GD[dwG lgQn OR NEW VORK STA (iC`E�IL,S�E,a 3610 U"-$gIoM ALTiuro/0[TNS DOCY [ORIYO—ctf DATED 'Ot Y 1 9,,01-7 e1 ART WAY co MTn nD SA r-or1 w(W nIc.DACNrun/aoW DAADC AND OR sua uADc YOwR STAR[DUCAttlN UW>.•e1CD IUNR[i V ANT NOT v+ueu AT rua Or LVNv[T ul( TNK 511eK'fKwOT TO/[HDAROOY NOT SNOWN ON MR RA! •v,suu iNsrtCnaw• CO►YRNWT 2C1'']][DWARD2 YDIALTrn LAYD fY[/[w.f YO sl--S(T AS/MT(K TIDE Se R3'CY SVRVCTOR LL[�Al1 RIONff R[f[AV[D DILIUDYlO LVRV[l'CD Yf AIDSS[fYOI[R,ONTS Of R(rp001tCTI0N e GY e a-4 + o YL Se c- YL 00oo11E. 2,oq J V uh °!d ape ti ,". 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