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HomeMy WebLinkAboutBP25-130�wcRsFrTION RECORD DATE INSP PERMIT * AD�- SECTION - TYPE OF WORK )OR LOCATIoN -�� Q DATE; . e+cP: BLOC LOT 3 e G(1t'S 1 'hriS7'�4r� �/6i��Qncz S7) 380-®783 V t 5 \t2`� I�1Q TCO !f FEE DATE O FOOTING FOUNDATION FRAMING RGH FRAMING INSULATION PLUMBING CI RGH PLUMBING GAS 0 SPRINKLER ELECTRIC O LOW -VOLT L7 0 AS QUILT FINAL OTHER APPROVALS OTHER 13R1 t� 19 4 ��•��W v Y 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 September 5,2025 Yuri Bogdanov&Ekaterina Bogdanov 27 Doral Greens Drive West Rye Brook,New York 10573 Re: 27 Doral Greens Drive West, Rye Brook,New York 10573 Parcel ID#: 129.26-1-36 Building Permit#25-130 issued on 6/6/2025 for Interior Truss Repairs This certifies that the interior truss repairs,under the above captioned permit have been satisfactorily completed. Sincerely, Steven E. Fews Building&Fire Inspector /to D ECM V/ E BUILDING DEPARTMENT For office use onh: AUG 2 9 225 VILLAGE OF RYE BROOK ISSUED# 0 938 KING STREET,RYE BROOK,NEW PORK 10573 DATE: VILLr,, (914)9 0668CY FEE: PAID F " wwa r t o4kUV.Eov 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 sitittsst/sst►444tt4•►itsstsRRi►itttiilitii44t►444ti4tiR►tttstt•stR►tt44sts►R4ii4i tstttttiti►it►it14/♦///t/t4titi4►iii►►4►tii Address: 27 Doral Greens Dr, West, Rye Brook 10573 NY r Occupancy/Use: I Parcel ID#: IoQq CO" /— Zone: /` y> 1 0 Owner. L Kg-7ef,hq �Ogcl�ll�t�L� Address: ,Z D,� t' ,2hf O�, V 7_S P.E./R.A.or Contractor: STRLICTLIRECON INC. Address: Peekskill Hollow Rd.984, Putnam Valley NY 10579 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: Ekaterina Bogdanov being duly swom,deposes and says that he/she resides at 27 Doral Greens Dr, West (Print Name of Applicant) (No.and Street) in Rve Brook in the county of Westchester in the State of NY ,that (City/To%%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:$ $65.000.00 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 thi t2 T Sworn to before me this 4LC day of .S7 , 20 2 2 day of 2 7;a e Signature of le roperty ner Signature of Applicant f/ s� ��hO Marty Vuksani Print Name of Property Owner Print Name of Applicant 464 Ob Lo2S tary Pu lic Notary Public MARK DORENBOSCH Notary Public,State of Connet;W My Commission Expres Cu3t ow BRC>v� O �m w � �7 1932 BUILDING DEPARTMENT ❑BUILDING INSPECTOR VILLAGE OF RYE BROOK 0 VMLAGE ENGINEER 938 KING STREET RYE BROOK,NY 10573 ❑ASSISTANT BUILDING INSPECTOR (914) 939-0668 FAx(914) 939-5801 - - - - - - - - - - - - - --- - - - - - INSPECTION REPORT - - - - - - - - - - - - - - - - - - - -- ADDRESS: " ` C DATE: l PERMIT# ISSUED: V 1 1 G> Wr. 1 BLOCK: LOT: LOCATION: QCS `- ` `� C `� OCCUPANCY: Z �1 ❑ VIOLATION NOTED THE WORK IS... Jp ACCEPTED ❑ REJECTED/REINSPECTION ❑ SITE INSPECTION 1 / REQUIRED ❑ FOOTING 0 FOOTING DRAINAGE 0 FOUNDATION ❑ UNDERGROUND PLUMING NOTES ON INSPECTION: ❑ ROUGH PLUMING fir- � � 0 ROUGH FRAMING ,&S :S ❑ INSULATION ❑ NATURAL GAS ❑ L.P. GAS 0 FUEL TANK ❑ FIRE SPRINKLER 0 FINAL PLUMBING ❑ FINAL ❑ OTHER a s • s O w y N o N b NPO \ N W y x � W W O W �© W v C7 w " c Wao W o � aa o O w > O z -s: p M ~' w � a� "o ff = v4 lu � � w A � M 00 z �z ov 0 V 'V M � W Q y � �° c ~ : a Ooo z o z - a o O Q wa z v v V W _ v v � rn O zZ -avow V W p H O � - 2 . Q 1--1 z ZO c/a Lin o o v -y 2 - t > a ^1--I 0 Z z � c - v v W 0 � v V? U 0.0 e a,�S O Ed E! 'o � N A w z oA _ a a 6 x N eq C 'd v f N s N eq WN a 04 r M N p a p s Z o O 3 cy0i Q © x � d r�!/A LO 91. F O O u .g� E >1 bA Vf'iIJ H C) _ O E C O U `n w' .-• rn d o O RCS. mo 0 y PSI 00 � A • W1 � 0 ig O W C) Z ono i d� z ° Q -� `= � Uz rf) C� oo �' w v Q Z 00 19 cy e O 5 ,0 Q. M+w Oz r', d U y3y v A w z z 4 O � o � f f BUILDING DgARfMENT VILLAGE OF%RO E OOK MAY 2 8 2025 938 KING STREET Rv `l NY 10573 4�� -O, VILLAGE OF RYE BROOK w ov BUILDING DEPARTMENT INTERIOR BUILDING PERMIT APPLICATION FOR OFFICE USE ONLY: Approval Date: n ( I r t c� J/ � plication Fee:$ /00 Approval Signature: Permit Fees:$ Disapproved: Other: Application dated: S712,112A is hereby made to the Building Inspectorof the Village of Rye Brook,NY,for the issuance of Permit forthe interior alteration of a t exi ting building,or for a��change in use,as per detailed statement described below. 1. Job Address: 21 Dcoa o - 2y2.,ze 5 AL VJ&C! SBL: /c�9+ D6 I-J36Zone: 2. Proposed Improvement.(Describe in detail):_T/2,,SS D "+/L +y,r r ,s`nn� x1P+� 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 11: 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 1 Hood,etc...) :No: /Yes: (If yes,please submit a separate Automatic Fire Suppression System Permit application&2 sets of detailed engineered plans) 5. Occupancy•(1 f—)2 fan.,comm.,etc...)Prior to Construction: / 6%-, After Construction: ' "�- 6. N.Y State Construction Classification: / N.Y.State Use Classification: -Q: - 7. Property Owner: ,1/IfQ� `Z • L Address: '2� D!Djaj ��f OX uVef-' Phone# ! Cell# /5/- _6Z -3 oS0 email: 8. Applicant: 6kle1-N Address: Phone# E ;3&_dM Cell# email: &�� - 9. Architect: Address: Phone# Cell# email: 10. Engineer: Address: ,% §V&A0(bm2 N.11 PA �p, g �e cl, Phone# 'l N- "�F - y I q_'S Cell# n—email: �� �/ I1. General Contractor. -S Ct1J �C- Address: gi/ ilzeAsk,if ��wA.'A. ULJ/ m Phone# Cell# —email: � u/C�T c���//f71C� Sit A11 C'.-1 12. Estimated cost of construction $ (NOTE:I'he estimated cost shall include all labor,materia(,scatfolding.fixer[equipment,professional tees.and material and labor which maybe donated gratis.) 13. Job Timetable: Start: Finish: (I) \ v 6/1=4 D W1-L� BUiLDjNCi DEPARTMENT � MAY Z 8 DD 2Q2� VILLAGE,OF RYE BROOK 938 KING STREET RVE BRt)oIC,NY 10573 VILLAGE OF RYE BROOK (914)939-0668 BUILDING DEPARTMENT ww�ur.rvrilit>rc3.e[t� •ii#iiiii*iiiii i*i*#A****Ai ii AA*iii*iiii*i**iAii##*i#*iii A#iii iiikA*#**ii kt iAiii*iii#*4#ii iii liii*ii*iA AFFIDAVIT OF COMPLIANCE VILLAGE CODE §216 • STORM SEWERS AND SANITARY SEWERS THIS AIFIDAVIT WJ9T BE" THE l"ARIitli SICHATLIR.[ :F' THE LEGAL PWPERTY Cr MF( AI'C BT SUMITTtII AL,UMG WITH ANY BUILDING GR PIAMING PIMIT APPL CA;ION. ANY BUILDIWC Cm ;1LUl0INC F134MIT APPLICATION SUBMITTID WTTHOUT THIS C011PUCTXU AND WJTAXIZ[X• r-,"j WILL at RX1111 ttD TM THE APPL.'C_WT - STATE OF NEW YORK,COUNTY OF WESTCHESTER ) as: 1, hrj111yWVb 8. djt1`rC LL- ,residing at, S 1)(2"466 �� d N /3r 0XU"'5 W IPrim r.u::.. Tv1dr.:+•nh:rr}nu Inc 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;7 fir: WC5t" Rye Brook. NY. IL11,Addlc—1 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. f ISifn.ntor ul I'n�pavty Oerlerhll TA1CCIZ 1�4-4Ac.,J6 �f. r�lc�vlFl�y �xecv 1�,� i(•-n,\a+n:nl t`n ry+rn� rh�rK•n11 Sworn to before me this y / day of 20(f4 S 1',olan Leanne M.Freda NOTARY PLBLIC.STATE OF NEW PORK (2) Registration No.02FR4M6796 Qualified in Westchester County 6'IR02A Commission Expires Fcbruarn 1?.:027 1 This application must be properly completed In its entirety and must include the notarized signature(s) of the legal owners) of the subject property, and the applicant of record in the spaces provided. Any application not properly completed in its entirety andfor not properly signed shall tx! deemed null and void and will be returned to the applicant. Please note that application fees are non-rofundahle. STATE OF NE W YORK.C'OWFY OF WLSTCHESTER f as: 96y �_M_ JDL 4t~0— being dul) s%�orn.deposes and states that he she is the applicant above named. (prim name of indmdwel%igning a%the apphcantI and further states that (s)hc is the legal owner of the properiy to %%hich this application pertains. or that (s)he is the _9XCC4TU R. _ —_ for the legal owner and is duly authorized to make and file this application. 111'4 ,:tc atchttcct.amnactw,agcnl,allulnev eu I That all statements contained herein are true to the best of his her knowledge and belief.and that any a ork performed, or use conducted at the above captioned property u ill be in conformance with the details as set forth and contained in this application and in am accompanying approved plans and specifications,as.veil as in accordance tiff ith the Ne%% York State Uniform Fire Pre.ention a& Building Code,the Code of die Village of Rye Brook and ail other applicable la►s-s,ordinances and regulations, By signing this application,the property owner further declares that he she has inspected the subject property,and that it) the best of his:her knot%ledge there are no roof drains,sump pumps or other prohibited stormwater or groundwater connections or sources of infiltration into the sanitary w%ker system on or from the subject property. Swom to before me this d 7 Sworn to before me this day of r '' 24 5 day of 2 StgrwRur u(Prt�pertx fMncr \� : Wit E-•i' TE OF FAA14C-IAI L,il'iAXC:r ttMi7 t�lyMar4b M • I--1LA lEL,!r. EXEC. ( Pr�ta IN'atne n, Pcrtfi thtiner lameui.\t pl. .u.711 Mxan Public do 3 4 Nhhc Leanne M.Freda NOTARY PUBLIC,STATE OF NEWYORK Valerie N Ferrara Registrntioa No.02FR4$85796 (l-hfied in WestchesterCounry Notary Public, State of New York Commission Expires February17.2027 Reg, No. 01FE6366324 Qualified in Dutchess County Commission Expires 12/0412025 GMCE PC GROSSFTELD MACRI CONSULTING ENGINEERS, PC 34 SxrwsLow Hai ROAD,RIDGEnELD,CT 06877 914.747.4145 www.GMCEPC.com 25 August 2025 Doral Greens HOA c/o Katonah Management Services, LLC D rc-- � V E 334 Underhill Avenue, Suite 5DID Yorktown Heights, NY 10598 AUG 2 7 2025 VILLAGE OF RYE BROOK Attn: Michael Menewitch, Senior Property Manager BUILDING DEPARTMENT Re: Floor Framing Evaluation 27 Doral Greens Dr. West, Rye Brook, NY 10573 Greetings: In accordance with your request, we visited the site referenced above on 8/21/2025 to assess the construction for remediation of the structure as per our drawings S-1, S-2 dated 4/21/25. The structure we observed is a single-family unit attached to one other unit. Our observations were confined to unit#27. The dwelling unit structure is wood framed, the floors and roof are constructed with open web wood trusses and the walls are conventional framing,the foundation is constructed with concrete walls and there is a low basement with a concrete slab floor. We observed the work that was done in connection to our drawings for the first-floor framing. It is our opinion that the work done for the first-floor structure has been done in accordance with our drawings and the New York State Building Code. The opinions and judgments presented herein are based on a visual inspection and our experience with similar projects. No attempt was made during this inspection to open probe holes to examine concealed structural elements. In addition, no testing of the elements was performed. If you have any further questions or concerns, please feel free to contact us. For: GROSSFIELD MACRI CONSULTING ENGINEERS,PC OF NEyI, Y By: 5���Pr`L A Mq�'9•j- wtzc e A Michael A. Macri, P.E. cr MM/sp r 24036 02 �' 2 064200 �FESSIONP 12 ,� Building Permit Check List&Zoning Analysisn , 1 n Address: `QD SBL - 1 L— /�(D Zone • 0se: ��C� Const.Type: l Other. Submittal Date: --JRevisions Submittal Dates: Applicant: (_'0 Nature of Work �-(�6 -F-� C- C V C_�V 2� l Reviews:2BA: PB: BOT: Other. NEE � ( (�EES:Filing. C/O: Flood Plane: Legalization: ( ) (�A P: 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. ( ) ( ) RVEY:Dated: Current: Archival: Sealed Unacceptable: ( ) ( LANS:Date Stamped Sealed Copies: Electronic Other. (�( ) License Workers Comp: Liability Comp.Waiver: Other. ( C 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 FLW.I.C.:_Batter)r_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 Area: Date' Circle: Em�n� Front Front Sides: Rear. Main Cov: Accs.Cov: Ft.H Sb: Sd.H Sb: GFA: Tot : Ft.Im : PgLdw. Height/Stories notes: Laura Petersen From: Josh Rogull <josh@rogullrealty.com> Sent: Friday, June 6, 2025 11:45 AM To: Laura Petersen Subject: 27 Doral Greens Dr W - General Contractor Hi Laura, As requested, the GC for Structure Con managing the the structural work at 27 Doral Greens Dr W, will be Christian Vuksanaj . Please let me know if you need anything else. I can pick up the documents, if needed when ready. Best regards, Josh Joshua M. Rogull Licensed R.E. Broker ROGULL REALTY, LLC. m. 917.975.9732 josh@rogullrealty.com • #1 Agent in Blind Brook School District Sales Volume 2023($40M+), 2022($50M+), 2021($52M+) • Top 50 Westchester County Agent 2023 (Per Sales Volume) • Top 25 Westchester County Agent 2022 (Per Sales Volume) • Top 30 Westchester County Agent 2021 (Per Sales Volume) • Top 50 Westchester County Agent 2020 (Per Sales Volume) • Westchester Magazine "Best Real Estate Agents'' 2023, 2022, 2021 1 } ll`.A/J•. AqA` _ _ IAY �,i �y /� J�T. �' At'� _ i A �— k rA i �^V ,�.��.�.. ` �,:.. �� �''►;11�1►;1 �� �j1!►�Ii' � ��v��� �VI%i'iil,.., � ,;�'4►i�►Ii'�'-.:� ��-''i4111i�1'_ ` 4h��i��:;;a.� �ihlliS�' , <co» / z p sue' Mee - 0. W Cr. 8 g O •� z 03� ) [E y O 'b %r�'• ci ej Q y _ r �.. • V O LOCD ectio O w LU ico)►^"� O F- Y 3 c N �Ga Iry lco» Y C cj� w z �: w e • r 1- w I- O F. IL 00 o 79 MS73 i A • = y fV •O_—_ c0 _cC r^ N LO : ti J o» P Z 00 olio»I; ,c i0_ I O •r y U U U • ,� L y 1''. --��- i� - 1► 1 �1 ��. ' , ,co) /III►INjI -x , ill►IIhj4, rlj►� Ills F 5 'i111►►►III I��h11►jr '_ - .� �� i3c�3Aq� �►�tS ac^4�' I t�►�I�►x }��i��i ., 11111 3�i'�^F�'� �1l1�1 :��Ay1��,`��♦ A ♦♦ � ,� •• � w �i \ ACo`� CERTIFICATE OF LIABILITY INSURANCE °A0527120 5"/' 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 endoraement(s). PRODUCER 4 NAME CT Daniel McRitchie Pleasant Valle A PHOIA/C.NNE (845 635 8131 FAX (845)635-2385 Y Agency Y I o.Ertl: )_ A/C No): 13 North Avenue,Suite 5 E-MAIL ADDRESS: danmap)easantvalk yagency.tcom PO Box 652 INSURERS)AFFORDING COVERAGE NAIC9 Pleasant Valley NY 12569 INSURER A: American European Insurance 23337 INSURED INSURERB: MAIN STREET AMERICA STRUCTURE-CON INC INSURERC: SHELTERPOINTINS 984 PEEKSKILL HOLLOW ROAD INSURERD: INSURER E: PUTNAM VALLEY NY 10579 INSURER F: COVERAGES CERTIFICATE NUMBER: CL21 8220 1 84 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMEDABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACTOR 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. EXP �� TYPE OF INSURANCE I p POLICY NUMBER MM/DDYfYYY MWDD EFF iibY LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $DAMAGE TO RENTED 1,000,000 CLAIMS-MADE OCCUR PREMIS :aoccurrence: $ 100,000 MED EXP(Any one person) $ 5,000 A CP2013607-03 05/0612025 105/06/2026 PERSONAL&ADV INJURY s 1,000,000 GEN'LAGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE S 2,000,000 JEa LOC PRODUCTS-COMPIOPAGG S 2,00O,Ooo POLICY © OTHER: _ _ S AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT S Ea accident, ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per acciderti) $ AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE S AUTOS ONLY AUTOS ONLY Peraccidem' $ X UMBRELLA LIAR X OCCUR EACH OCCURRENCE S 5,000,000 A EXCESSLUIB CLAIMS-MADE I CUP 1206208 05/06/2025 05/06/2026 AGGREGATE y 5,000,000 DIED 1 I RETENTION S $ WORKERS COMPENSATION PEAR ATUTE ER H AND EMPLOYERS'LIABILITY YIN 1,000,000 ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ B OFFICERIMEMBEREXCLUDEDI N/A WCJ8724U 06/14/2025 08/14/2028 (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE S If yes,describe under 2,000,000 DESCRIPTION OF OPERATIONS below _ _ E.L.DISEASE-POLICY LIMIT $ STATUTORY DISABILITY C DBL637829 i 04/28/2025 04/2ti/2026 1 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,msy be attached U more space Is required) Certificate Holder is named as an Additional Insured. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN BUILDING DEPT VILLAGE OF RYE BROOK ACCORDANCE WITH THE POLICY PROVISIONS. 938 KING STREET AUTHOR DREPRESENTATIVE RYE BROOK NY 10573 -r 4�5 ACORD CORPORATION. All rights reserved. ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD YORK Workers' CERTIFICATE OF STATE Compensation NYS WORKERS' COMPENSATION INSURANCE COVERAGE Board 1 a. Legal Name 8 Address of Insured(use street address only) 1 b.Business Telephone Number of Insured STRUCTURECON INC (845)656-6851 984 PEEKSKILL HOLLOW RD Putnam Valley NY 10579 1c.NYS Unemployment Insurance Employer Registration Number of Insured Work Location of Insured(Only required if coverage is specifically limited to 1d.Federal Employer Identification Number of Insured or Social Security certain locations in New York State,i.e., a Wrap-Up Policy) Number 832852110 2.Name and Address of Entity Requesting Proof of Coverage 3a.Name of Insurance Carrier (Entity Being Listed as the Certificate Holder) MAIN STREET AMERICA BUILDING DEPT VILLAGE OF RYE BROOK,938 KING STREET,RYE BROOK,NY. 10573 3b.Policy Number of Entity Listed in Box"1 a" WK00019861 i 3c.Policy effective period 06/14/2024 to 06/14/2025 3d.The Proprietor,Partners or Executive Officers are ❑ included.(Only check box if all partners/officers included) FX 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"1 a"for workers' compensation under the New York State Workers'Compensation Law. (To use this form, New York(NY)must be listed under Item 3A on the INFORMATION PAGE of the workers'compensation insurance policy). The Insurance Carrier or its licensed agent will send this Certificate of Insurance to the entity listed above as the certificate holder in box"2". The insurance carrier must notify the above certificate holder and the Workers'Compensation Board within 10 days IF a policy is canceled due to nonpayment of premiums or within 30 days IF there are reasons other than nonpayment of premiums that cancel the policy or eliminate the insured from the coverage indicated on this Certificate. (These notices may be sent by regular mail.)Otherwise,this Certificate is valid for one year after this form is approved by the insurance carrier or its licensed agent,or until the policy expiration date listed in box"3c",whichever is earlier. This certificate is issued as a matter of information only and confers no rights upon the certificate holder. This certificate does not amend, extend or alter the coverage afforded by the policy listed, nor does it confer any rights or responsibilities beyond those contained in the referenced policy. This certificate may be used as evidence of a Workers'Compensation contract of insurance only while the underlying policy is in effect. Please Note: Upon cancellation of the workers'compensation policy indicated on this form, if the business continues to be named on a permit, license or contract issued by a certificate holder,the business must provide that certificate holder with a new Certificate of Workers'Compensation Coverage or other authorized proof that the business is complying with the mandatory coverage requirements of the New York State Workers' Compensation Law. Under penalty of perjury,I certify that I am an authorized representative or licensed agent of the insurance carrier referenced above and that the named insured has the coverage as depicted on this form. Approved by: DANIEL MCRITCHIE (Print name of authorized representative or licensed agent of insurance carrier) Approved by: (Signature) (Date) Title: PRESIDENT Telephone Number of authorized representative or licensed agent of insurance carrier: 845-635-8131 Please Note: Only insurance carriers and their licensed agents are authorized to issue Form C-105.2. Insurance brokers are NOT authorized to issue it. C-105.2 (9-17) www.wcb.ny.gov NEW Workers' CERTIFICATE OF YORK STATE . Compensation NYS WORKERS' COMPENSATION INSURANCE COVERAGE Board 1 a. Legal Name&Address of Insured(use street address only) 1 b.Business Telephone Number of Insured STRUCTURECON INC (845)656-6851 984 PEEKSKILL HOLLOW RD Putnam Valley NY 10579 1c.NYS Unemployment Insurance Employer Registration Number of Insured Work Location of Insured(Only required if coverage is specifically limited to 1 d.Federal Employer Identification Number of Insured or Social Security certain locations in New York State, i.e., a Wrap-Up Policy) Number 832852110 2.Name and Address of Entity Requesting Proof of Coverage 3a. Name of Insurance Carrier (Entity Being Listed as the Certificate Holder) MAIN STREET AMERICA BUILDING DEPT VILLAGE OF RYE BROOK,938 KING STREET.RYE BROOK,NY, 10573 3b. Policy Number of Entity Listed in Box"1a" WK00019861 3c.Policy effective period 06/14/2025 to 06/14/2026 3d.The Proorietor.Partners or Executive Officers are ❑ included.(Only check box if all partners/officers included) QX all excluded or certain partners/officers excluded. This certifies that the insurance carrier indicated above in box'Y insures the business referenced above in box"1a'for workers' compensation under the New York State Workers' Compensation Law. (To use this form, New York(NY)must be listed under Item on the INFORMATION PAGE of the workers'compensation insurance policy). The Insurance Carrier or its licensed agent will send this Certificate of Insurance to the entity listed above as the certificate holder in box"2". The insurance carrier must notify the above certificate holder and the Workers'Compensation Board within 10 days IF a policy is canceled due to nonpayment of premiums or within 30 days IF there are reasons other than nonpayment of premiums that cancel the policy or eliminate the insured from the coverage indicated on this Certificate. (These notices may be sent by regular mail.)Otherwise,this Certificate is valid for one year after this form is approved by the insurance carrier or its licensed agent,or until the policy expiration date listed in box"3c",whichever is earlier. This certificate is issued as a matter of information only and confers no rights upon the certificate holder. This certificate does not amend, extend or alter the coverage afforded by the policy listed, nor does it confer any rights or responsibilities beyond those contained in the referenced policy. This certificate may be used as evidence of a Workers' Compensation contract of insurance only while the underlying policy is in effect. Please Note: Upon cancellation of the workers' compensation policy indicated on this form, if the business continues to be named on a permit,license or contract issued by a certificate holder,the business must provide that certificate holder with a new Certificate of Workers'Compensation Coverage or other authorized proof that the business is complying with the mandatory coverage requirements of the New York State Workers' Compensation Law. Under penalty of perjury,I certify that I am an authorized representative or licensed agent of the insurance carrier referenced above and that the named insured has the coverage as depicted on this form. Approved by: DANIEL MCRITCHIE _ jk (Print name of authorized representative or licensed agent of insurance carrier) Approved by I�� (Signature) (Date) Title: PRESIDENT Telephone Number of authorized representative or licensed agent of insurance carrier: 845-635-8131 Please Note: Only insurance carriers and their licensed agents are authorized to issue Form C-105.2. Insurance brokers are NOT authorized to issue it. C-105.2 (9-17) www.wcb.ny.gov -2zyy,.ix.xz�w znO q rwnWq h w � t9 Aw M W I- co E O E -O-r gp�P O W Cn cn ga48[,iy,- K. 0� px A � � w w w U) Q 0 04 w =00 9bI b' LE'b16 LL890 Zo 'Q'I3Idioara 'GVOH'I'IIH 11 OrMICHHS �c o� t,J va v AN NO C7 ❑ 3A❑ •0 F F w h °z � z `� � � U 0 Ep � � °' "' " � Q W � w v) cV LO N m W Od S2i331�IO�t3 OtILL'Il1SN0D I2ID�1111i Q'I3I3SS02I� �� Q 1S3M'a SN33�J ]`d�0a LZ o o q 0 w LY .. 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