Loading...
HomeMy WebLinkAboutBP25-077PERMIT # ) SECTION TYPE OF WORK -L JOB LOCATION OWN ER/) CONTRACTOR_ .� EST. COST ,CO # DA BLOCK LOT 4c r C4m �lqrlCk 1j)ajk1&_)670 S 0 TCO # FEE DATE FOOTING FOUNDATION FRAMING RGH FRAMING INSULATION PLUMBING RGH PLUMBING GAS CJ SPRINKLER ELECTRIC LOW -VOLT 0 ALARM AS BUILT O FINAL �yee /8-sw OTHER APPROVALS yE D i VILLAGE OF RYE BROOK MAYOR 938 King Street, Rye Brook,N.Y. 10573 ADMINISTRATOR Jason A. Klein (914)939-0668 Christopher J. Bradbury ,,,-ww.ryebrookny.Qov TRUSTEES BUILDING& FIRE INSPECTOR Susan R. Epstein Steven E. Fews David M. Heiser Donald T. Krom,Jr. Salvatore W. Morlino CERTIFICATE OF COMPLIANCE June 16,2025 The Marilyn Tokayer Living Trust Marilyn Tokayer,Trustees 3 James Way Rye Brook,New York 10573 Re: 3 James Way, Rye Brook,New York 10573 Parcel ID#: 135.43-1-22.2 Building Permit#25-077 issued on 4/22/2025 to Repair Brick Walkway This certifies that the brick walkway,repaired under the above captioned permit has been satisfactorily completed. Sincerely, Steven E. Fews Building&Fire Inspector /to D I E W, 1 E CYEBROO For office use onl BUILMENT PERMIT# --0 77 JUN - 4 2025 VILtOOK ISSUED: 38 KING STRE1�T�uV PORK 10573 DATE:VILLAGB OF RYt i3P.00K FEE: /'�l� PAIDW BUILDING DFr-' PTP;j=Nl 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 iiii iiii#iirt##rt#i#####rtrti#i}4#i###t##itR#t#4####i#ti}##t######i##rti rti4t i#rti##t#i#i#iiiii#it4#i#####iiiit4i#ii titiii##iiiiiii■ Address: C Occupancy/Use: Q Parcel ID#: 3��r — I r3"") Q�- Zone: D Owner: _1 L l Address: P.E./R.A. or Contractor: V 1 Address: S Person in responsible charge: .1 U 7 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: being duly sworn,deposes and says that he/she resides at Print eofA plicant (No.andSTreetT—k in ,in the County of e7� �- in the State of that (Ciq frown/vil1,ge) 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 c�,00 , 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 1 Sworn to before me this day of e 20�� day of , 20 i tgn re of Pro Owner Signature of Applicant Prt ame of Property Owner Print Name of Applicant Notary Public Notary Public SHARI MEULLO Notary Public,State of New York No.01ME616W63 Gil i202a Qualified in Westchester County Commission Expires JenUary 29.202? Ik r lJJ)lNG .1V VA.s sR;'rAMV BV ILMNIN NSPE(Viro u 0.1"L.A.C.".E 017 0 CoMi FMORCEAXIINT OFFICUR 938 RING' SlIMET- R-Y'L? Blllzooxi:,NY-10573 (914) 939-066-3.1.1-Ax (91.4) 939-584H -- - - - -- - - - - -- - - - - - - - - - - - Aiximmss .............. Xp - OcCUPANCY: 1-1 VIOCATION 0 F001ING.D.�t.&IN IJ PA'Jt-GJt-0'W.)'N 1) PLUM: UM3 x A'NFls.P'Tl'( Ilo N. 0 Ro a.1(:,:A.t El Iw:,u P'.A:.v.U.q ON 0 NNruRAY., 0 Llt GOB xA, El .1luirm T.A.M.C. FJ '1""TNAX. El Cuoss COINNUCTION l."ANA L _ ■ Mn'I � � �T � iNi � w rn aG � v � v � V z ro bD 60 W C) 0. a+ C ° � a N z 00 +Uz °q ° Q �W "� b d JW v z _ 'v Q � wCNa� z W Q z o 1c, Q v. � b ICI '" v a W Fri cn W E- p Zf W z v ° g q a N ., hil V O U V 0 u _ BUILOUW&PARTMENT VIL E OF RYE OK 938 KING ET RYE BR ,NY 10573 EPR 2025 -0 k ov --- VILLAGE OF RYE BROOK BUILDING DEPARTMENT FOR OFFICE USE ONLY: ,Q �J�7 Approval Date: APR 2 P # / 10 i / : Application# Approval Signature: ARCHITECTURAL REVIEW BOARD: Disapproved: Date: BOT Approval Date: Case# : Chairman: PB Approval Date: Case# Secretary: ZBA Approval Date: Case# Other: Application Fee: �ermit Fees: CERMIT 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 build' s,s tures,additions,alterations or for a change in use,as per detailed statement described below. QJobAddress: —o �/ 2. Parcel ID#: /3 Sr '7 3 a\ Zone: Proposed improvement(Describe in detail): 4/0e �' � J 1 l _ Property Owner: 64 Address: cf Phone# C00'ell# e-mail T--r alazq List All Other Properties Owned in Rye Brook: ��? Applicant:u Address: Phone# Cell# /J L623e-nail Architect: Address: Phone# Cell# e-mail Engineer: Address: Phone#— Cell# e-mail General Contractor: J14 Address: a✓ n Phone# Cell# e-mail J\jAn r (1) 6/1/2024 5. Occupanc ;(1-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: 15,fl: 2nd fl: 31d fl: 10. Total Square Footage of the proposed new construction: 11. For additions,total square footage added:Basement: 11,fl: 2"1 fl: 3.d 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. Number of stories: Overall Height: Median Height: 15. Basement to be full,or partial: finished or unfinished: 16. What material is the exterior finish: 17. Roof style;peaked,hip,mansard,shed,etc: Rooting material: 18. What system of heating: 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 fire 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 impervious coverage requiring a Stormwater Management Control Permit as per§217 of Village Code? Yes: No: 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: (ifyes,you must submit a Site Plan Application,&provide a detailed topographical survey) 24. Is the lot located within 100 fl.of a Wetland as per§245 of Village Code? Yes: No: (if yes,the area of wetland and the wetland buffer zone must be properly depicted on the survey&site plan) 25. Is the lot or any portion thereof located in a Flood Plane as per the FIRM Map dated 9/28/07? Yes: No: (if yes,the area and elevations of theJlood plane 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 1: TIER 11: TIER III: (ifyes,a Home Occupation Permit Application is required) 28. List all zoning variances granted or denied for the subject property: 29. at is the total estimated cost of construction: CP/ ©-_ !Vote:The estimated cost skald include all site improvements,labor,material,scaffoldi►(g,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: (2) 6/1/2024 BUILD DE)f"_ , . MENT VIL E OF RYE'r ©K APR 14 2025 938 KING 4 ET RYE BRI )7€ NY 10573 �_�__ _0 In GE OF fE BROOKM_ X DING DEPARTMIE ww vv 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: residing at, (P nt name) (Address where you live) Wisth being duly sworn, deposes and states that(s)he is the applicant above named, and further states that(s �J legal owner of the property to which this Affidavit of Compliance pertains at;J0 e, /'v� , Rye Brook,NY. (Job A less) 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)) � (� _/_*T . (Print Name of Mperty Owner ) Sworn to before me this day of �A cl\ , 20 (Notary Public) SHARI MEULLO Notary Public,state of New York No.oiME6160063 Qualified In Westchester county. Cammission Expires Jentiaty 29,20Z� (6) 6/1f2024 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 NPW YO K, OUNTY OF WESTCHESTER ) as: being duly sworn, deposes and states that he/she is the applicant above named, '(p nib t n�atne oflfdiv/idual signing as&Ke a I cant) 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 M Sworn to before me this day of , 20')� day of ,20 Signature Property er Signature of Applicant t e r perty Owner Print Name of Applicant r�J'Lk-z' Notary Public Notary Public SHARI MEULLO Notary Public,State of New York No.01ME6160063 Qualified in Westchester county, commission Expires JanUary 29,20,L (8) 6/I/2024 r r r t I Pt AF or Or r� � " V' • fit' � t .Ax '$ *r'r� � •mil now SOW meow Y - ESTIMATE Jvpainting & Contract DATE :APRIL 15,2024 258 WASHINGTON AVE NEW ROCHELLE NY, 10801 PHONE 914-318-8858 JVPAINTING26@GMAIL.COM TO Marilyn Tokayer 3 James Way Rye Brooke, NY 10573 marilynalana@optonline.net ITEM DESCRIPTION PRICE -Remove all of the old brick then level the ground with sand. After leveling put back same bricks. Sidewalk $6,200.00 -reaper the edge surface with concrete where it's necessary. -Power wash old brick. LABOR&MATERIAL INCLUDED Clean and cart away all debris. Contractor's License#WC-24961-1­112 TOTAL»»»»»»> $6,200.00 PAYMENT SCHEDULE: 1/3 DEPOSIT 1/3 MIDDLE OF JOB 1/3 FINAL PAYMENT UPON DAY OF COMPLETION *THE CONSUMER MAY CANCEL THE CONTRACT AT ANY TIME PRIOR TO MIDNIGHT OF THE THIRD BUSINESS DAY AFTER THE CONTRAACT IS SIGNED. * CONTRACTOR SIGNATURE CUSTOMER SIGNATURE •yr_ J'� r.�. i Y r 1 . �"L��S'���� i'� - , � a..,�• - -i +'� i►-.��,�+ - -,tih�T�,r,ICE�"�ti, � {•� r •.�a �'J ,�; `,ems• - t,• ��� �� All AF -47 ., mot. - ter S ' '• T `771 or _ , i -- y ■T ,.. i 'ti r • F f -ter ,�� w •.�� -• "•1F �,,..` ,., - r ir AA •yr�. It 40 M r�Y of F r• .� r f' 4 r . ' � r e ,�,—off•.'•,�-•,���t •� 1 • y •a. o + .�' Yr art. _ �e� � '� �j�• �^� a �'Af'�.. `R�e•e - ��{i.■ � _ p•1+ "� ., '¢ �-�• a al.. y — •�. Ad 40 V � . .ilia + ' r , r, � JL l+ •'i d, F # r,�.ayy. J up t+ 96 T _ �—^+ • rp7. s is, _ Aft IA `� 'y' �`�� ,tom �`''�' A "',.R.■ -. � :,': .rr.-A J. .e. Loa• � �.++5 * ` Is. ! : 6.1If . r • G• a y_.� �e �• f� } � *ram. 11% x z• t - 0 1 J - Apt. f � Ile a- IF r CK:yt ?; x I-'► � I i t � i lot • t T • '�'-e +• + f, r• • ,1Y. y. . er 17 •• 4 � `�L •rL 4 L f'�y .� fit• �• �. •. ice(- ,,,,.r.r777 � � rr �,� .fl". ��� • "I• OED RETENTION S 3 WORKERS COWENSATION 1.IWYC YT�.I. oTH•'. AND EMPLOYERS'UA9LITY Y 1 N ,kNY PF;QPFIETCFLFART,EFLtXEGUTI'.E EL.LCHACC40ENT S C=FICER VEA9=R EXCLUDEDI N f A - - - IMandY.ory n NNI EL DISEASE-EA EMPLOYEES _____ H rc: We_r.tc vAcr DESCH-IION OF CPERAT 0N5Dc,:I.r c.L 'ISLASE POLICY LIMP S DESCRIPTION OF OPERATIONS I LOCATIONS!VEHICLES IA-tach ACORD 101.AdcM.Ional Rar—Iiis SchadL"-/more soaca is ra Q.drs d) RYE BROOK BUILDING DEPARTMENT, 938 KING STREET, RYE BROOK, NY 10573 IS AN ADDITIONAL INSURED SUBJECT TO THE TERMS, CONDITIONS AND EXCLUSIONS INCLUDED IN THE POLICY ABOVE. CERTIFICATE HOLDER CANCELLATION RYE BROOK BUILDING DEPARTMENT 938 KING STREET SHOULD ANY O F THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE RYE BROOK, NY 1a573 THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHDRIIED REPRESENTATIVE 1988-2010 ACORD CORPORATION. All rights reserved. ACORN 25(2010105) The ACORD name and logo are registered marks of ACORD 1 14 tt Ira �a Latimer V(�,/0► ' �I�����II�L7ll/� J/Iflfl�Ial+/rls ""— %Nc,.Ichr.trr(ouat%V%"utnr otintv Ihrrrtoa('anwmtr I'rorrcLm Department of Consumer Protection Home Improvement License ( a J.V. PAINTING .�. 258 WASHINGTON AVENUE-#3 �sn NEW ROCHELLE,NY-10801 Y r This hcerw is issued in accoldance uich Articic K VI of the Westchester County Con%umcr Pro4cclion Ca,.re anJ is♦alid only upon pfe+clue of 11x official dcP: MCvI seal.Proof of cltiienship of inunipation status is not require"t for isvlhlnCt of Uii.licra.. NOT FOR FEDERAL PURPOSES 6 Q r o DatcO'E-piraflan Liccnsc\unttxr C • + � � r ti � 07110/2025 as VX-36695-H23 0 ;� �jar, t �a aZ Ff, �chPtlerCo`yP� {2i a �' • [./nslr�'E tir,�-��� tr---,,:rr � M+--•ryT- / n•--arr.-,��-��1tir--'Yr r M.•-'�nt.,-� 1 Z^- , ,. •-71r.. 1"�_•�# 1 ;(tr'' �% aJL���,a1�`r�,lf��, W. :, �Ar my side now. Have a good night . nco�D CERTIFICATE OF LIABILITY INSURANCE DATEIMM�U7YYYY) 03/2812025 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 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 CONT914 337-6353 914 337-6245 MEAT MUNOZ AND MUNO_Z lN_S_U_R_ANCE CO_N_S_ULTANTS____ MUNOZ AND MUNOZ INSURANCE CONSULTANTS PHo-NE 914 337-6353 F"c.Nnh 914 337-6245 236 WESTCHESTER AVENUE EMAIL PMUNOZCMADVISORYGROUP.COM INSURER,SI AFFORDING COVERAGE NAIC R MOUNT VERNON, NY 10552 INSURERA: INSURED INSURER B. JOSE VILLA DBA JV PAINTING INSURERC: 258 WASHINGTON AVENUE. APT 3 INSURER D: INSURERE- NEW ROCHELLE NY 10801 INSURER COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS 15 10 CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOIN HAVE 13EEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED NOTWITHSTANDING ANY REOUIREMENT, 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 SHOViN 1.,AY HAVE BEEN REDUCED BY PAID CLAIMS. INSR tTIR TYPE OF NSVRANCE ADOL SUER POLICY NUMBER r POLICY EFF POLXY EXP I LIMITS GENERAL LIABILITY ✓ EACNOCCLKRLNCk -�,000,000 A 1Ck TOFTENM0 ✓ Core,LRufL GEhbIu,L LIPd t-I� t,5E5 cLa 5xLrrcnccl_-a 50,fl00 jCLAWSL,ACE ✓ OCCUR ART3000904800 04.18,2024 04iT8l2025 ►fDFJc'-;Any ono penonl ls$,000 -- PERSONAL&ADVNJURV 11,000,000 GENERALAGGREGATE 51�00 fl�04 GENi AGGREGATE LIMIT APPLE_ $PER PFOMMTS-C:HUP-IDPAGG S2,a0O,000 ✓ PODGY FRO- LOc 5 AYTt>rOBILE LUIBAJTY GMUNED SINGLE LIMI r ----,ANY NJ t O BODILY HAIRY IPcr po sen I -S ALL MIMED _1 SCHEDI-LD --- A'JTOS —�AUTOS BODILY NJJRY IPr:r axganl) 1 `!D^I OI,'NEO PROPERTY DAMAGE S HIRED F.JTOS AUTOS -iP�r accdcrxl. -._ f VMBRELLA L:AB OCCUR EACH OCCURRENCE EXCESS LIAJ3 ::LAIMS [89%9FqA E ti BED RETENTION I Is WORKERS C UWE N SATION � YNC STATU- I IOT1'r-I AND EMiPLO YE R S'UABIIJTY _OR�MI75 ER ANY FRO F'F.IET CR.t AR PEFLEXEG UTIVE Y� NIA EL EACH ACC DENT ti C,tFICER VEMSSR EXCLUDED? IMwcW,ory rl NHI EL 7ISLASE.EA EMR__ n ve.dc.cntc unWr D(=GCRFTION OF OPERA CYS bean EL 'DISEASE-POLICY LIMIT 1 DESCRIPTION OF OPERATIONS(LOCATIONS!VFW LES IAT,xn ACORD 101_AdW.Ic"l Rerr r*z Schrdu:e_A mors space Is roWlre d) RYE BROOK BUILDING DEPARTMENT, 938 KING STREET, RYE BROOK, NY 10573 IS AN ADDITIONAL INSURED SUBJECT TO THE TERMS, CONDITIONS AND EXCLUSIONS INCLUDED IN THE POLICY ABOVE. CERTIFICATE HOLDER CANCELLATION RYE BROOK BUILDING DEPARTMENT 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 New Workers' STA E Compensation CERTIFICATE OF Board NYS WORKERS' COMPENSATION INSURANCE COVERAGE 1a. Legal Name and address of Insured (use street address only) 1b. Business Telephone Number of Insured JV PAINTING (914) 738-0631 258 WASHINGTON AVE NEW ROCHELLE NY 10801 1c. NYS Unemployment Insurance Employer Registration Number of Insured Work Location of Insured (Only required if coverage is specifically 1d. Federal Employer Identification Number of Insured or limited to certain locations in New York State, i.e. a Wrap-Up Policy) Social Security Number 45-5138018 2. Name and Address of the Entity Requesting Proof of 3a. Name of Insurance Carrier Coverage(Entity Being Listed as the Certificate Holder) Property and Casualty Insurance Company of THE RYE BROOK BUILDING DEPARTMENT Hartford 938 KING ST 34690 RYE BROOK NY 10573-1226 3b. Policy Number of Entity Listed in Box"1 a": 76 WEG AF1VS6 3c. Policy effective period: 02/22/2025 to 02/22/2026 3d. The Proprietor, Partners or Executive Officers are XO Included. (Only check box if all partners/officers included) all excluded or certain partners/officers excluded. This certifies that the insurance carrier indicated above in box "3" insures the business referenced above in box "la" for workers' compensation under the New York State Workers' Compensation Law. (To use this form, New York (NY) must be listed under Item 3A on the INFORMATION PAGE of the workers' compensation insurance policy). The Insurance Carrier or its licensed agent will send this Certificate of Insurance to the entity listed above as the certificate holder in box "2". The insurance carrier must notify the above certificate holder and the Workers' Compensation Board within 10 days IF a policy is canceled due to nonpayment of premiums or within 30 days IF there are reasons other than nonpayment of premiums that cancel the policy or eliminate the insured from the coverage indicated on this Certificate. (These notices may be sent by regular mail.) Otherwise, this Certificate is valid for one year after this form is approved by the insurance carrier or its licensed agent, or until the policy expiration date listed in box "3c", whichever is earlier. This certificate is issued as a matter of information only and confers no rights upon the certificate holder. This certificate does not amend, extend or alter the coverage afforded by the policy listed, nor does it confer any rights or responsibilities beyond those contained in the referenced policy. This certificate may be used as evidence of a Worker's Compensation contract of insurance only while the underlying policy is in effect. Please Note: Upon cancellation of the workers' compensation policy indicated on this form, if the business continues to be named on a permit, license or contract issued by a certificate holder, the business must provide that certificate holder with a new Certificate of Workers' Compensation Coverage or other authorized proof that the business is complying with the mandatory coverage requirements of the New York State Workers' Compensation Law. Under penalty of perjury, I certify that I am an authorized representative or licensed agent of the insurance carrier referenced above and that the named insured has the coverage as depicted on this form. Approved by: Sara Seier (print name of authorized representative or licensed agent of insurance carrier) Approved by: v � 03/28/2025 (Signature) (Date) Title: Operations Manager Telephone Number of authorized representative or licensed agent of insurance carrier: (866) 467-8730 C-105.2 (9-17) Form WC 88 31 21 F Printed in U.S.A. www.wcb.ny.gov Page 1 of 2