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HomeMy WebLinkAboutSP25-001PERMIT # zII :w�� DAT SECTION Q % BL( TYPE OF WORK 40az.)/7/, JOB LOCATION lelWf iP OWNER 0/c,{� 0 T. COST Co IIIIIII�C(' TV O it LOT � c ✓ i.4, o %`//JS /)) Y3830011 FEE � FEE - INSPECTION RECORD I DATE INSP FOOTING FOUNDATION FRAMING - - RGH FRAMING INSULATION PLUMBING RGH PLUMBING GAS 0 - SPRINKLER ELECTRIC CJ LOW -VOLT O ALARM AS BUILT FINAL RA OVALS l9 BOT PS ZBA OTHI=R (-�yE BR t C QLl.`y�o�uY; �. t9t1 J•�� 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 July 17,2025 Win Ridge Realty LLC c/o Alena Hakanj n 24 Rye Ridge Plaza Rye Brook,New York 10573 Re: 14B Rye Ridge Plaza, Rye Brook,New York 10573 Parcel ID#: 141.27-1-7 Sign Permit#25-001 issued on 4/1/2025 for a New Awnings This certifies that the new awnings;"AAA",installed under the above captioned permit have been satisfactorily completed. Sincerely, Z,-� Steven E. Fews Building&Fire Inspector /to JUL6 2�25 For office use onl,.: BUILDING DEPARTMENT PERMIT id L (3C�! VILLAGE OF RYE BROOK VILLAGE OF RYE BROOK ISSUED: :�Y—/— S' BUILDING DEPARTMENT 938 KING STREET,RYE BROOK,NEW PORK 10573 DATE: :Z--/(c _+�S:_ - (914)939-0668 FEE: u ti�w.rvehrvvl:nv.eo� 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 .................................................. .................................................................... .... Address: 14 Rye Ridge Plaza Occupancy/Use: Business Parcel ID k:141.27-1-7 Zone: B Owner: _ VVfn Ridge Realty LLC Address: it 1 L P.E./R.A.or Contractor: Signs Ink Ltd. Address: 3255 Crompond Road,Yorktown NY 10598 "(ly__?_39_ycS9 Person in responsible charge: James Polinsky Address: 3255 Crompond Road, Yorktown NY 10598 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: James Polinsky beingdul)swom,deposes and saysthatheshe resides at 3255 Crompond Road _ plic.. (No any;nccl, in Yorktown in the County of Westchester in the State of NY ,that 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.vas:., 3000 for the construction or alteration of: AAA office A,',i�u i ((i;!1'!�?q 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-W.A.of the Code of the Village of Rye Brook. Swom to before me this /'-✓' I ST- Sworn to before me this day of ITV LLA .20 Z day of Y .20 as Signatur f Pr pen) "�--�/ S)jki �I App is nt Pri CPropcm r jt/.,�-j I'rinrNamc of applicant Notati Public Notary Public AL 5A WARROAN FAUSTO ESTEBAN BAQUENRO NoTmMiNX,STA?EOi11EMVM to ,a Notary Public-State of New York Ra0tatratlen140.01NA001�tIS x No 01BA6437403 avowed InaEteahaala�'eM20QT Quaiilied in Westchester County ` My Comm.Expires Aug 1.2026 -BUILD-UNG I)EIPARIMENT 11 JUMPING MWAMWAMERNmommoom SSINIWNV 01JILMIM4 INSPECTOR VILLAGE OF RYF, MtoOK D Coint Olvilicam 938 KING STREETo Ity-li BROOK,NY 10573 (914) 939-0668 II&N (914) 939-5801 -WWW-L.rys'.)0-tPj L.-wx - -- - -- - - - - - - - - - - - - -- INSPE-G.F.IONREPORT uum 4=10 L Arsiicr: BLOCK:___/_ [A)CATION: "x. -,-AA,4iL_--- 0CCUPANCY: 11 VIOLXFJON NOTED 'hm wo.1th. is... V*ACCEPT111) ❑ REJEc,rED/REINSPIXTION El -SVIT INSPECTION REQUIRED 1:1 VOWYING Q 1"00-1ING DR.A.I.NAcm Q UoiTNj)A'j-jc)N ON INSPEC'.11TON: 0 Roma] P1,17mitim la Rol-14-in VIUMING n- NxrTjjwA.T.(*A i A/ .S 0 L-R (-o'A,.S FINAL PI.TM)tlN(.. 0 Cuoss Co.Nxvc"I,ToT"q ,K FINAL : _ 9 S s w _ w y a _ fq C) N W I \ \ � W _ \ a V o 'c� � ~ ■ a wx a ] -E ° a ►, C� Li. Fit O Z o W os Z ,v cn C O � = a M� ■ PLO fl Q a �p a � Q x I wz � � a = cn �1 H °; N a, ovba u V C O {] V - pp ■ Q W 1 ���// W h G� 0 O . ' p U �I �+ \ W Z .�—i M M Q U z cr E CA � GAR V W lex � o 0-0 *0 1 A A SAU 4-4 a � a G1 W z p! •�' O � � .a w � � x BUILDING DEPARTMENT VILLAGE OF RYE.]BROOK FEB 2 7 2025 939 KINC STRrtcr Rvr Rnoot:,NV 10973 (914)939-0668 I VILLAGE OF RYE BROOK «�ti\�.nebrtlt�ku�.siu\ BUILDING DEPARTMENT rtrtrrt*rr»rrrrt#rwtsxrrssaw»*ttrtrrrrtrrrrrrrwrwrr rMrtsesrrsrtarrrrrtrrrrrwtsswwrrrr*rrwwrt*rrwrw**r**r**rtr Flit OffIf:i•:US-1:QNI.1_: Approval Vale: MA2 2 6 [ rn:it Application %pprov:tltiifaatarr: ARCHITECTURAL REVIEW BOARD: Disappruved: _ Date: S BOT Approval Date: Case 9 : Chairman PB Approval Date: Case 4 secretary. 61,14 ZBA Approval Date: Case# Other: _ Application Fee. ` D 6 Permit Fees: A rrrrsrt»arttrarsWrtattaa*##t#trrtr»»r»meetsarrwrrttraa#»»ttt#t#rW#l+r#rtrrtttrrtrt#tWxxrtwtrrrtrtrWrtxx»xrrttsrtrtr#rtrrt SIGN PERMIT APPLICATION Application dated: is hereby made to the Building Inspector of the Village of Rye Brook.NY,for the issuance ofa Permit for the constructiciVinstallation f a 4ign in accordance with Village Code b350.35 as per detailed statement described below.1, Address: 14B Rye Ridge Plaza SBL:�� �c�� --7-7 zone: C—P 2. Property Use or Business Name: AAA 3 Proposed Sign(s)ll)c%crihc in del of including nwnh,r ofsigw..t.l+t.,..i:t..CXact incaliolum.at:d illunlin.11i.wm m.tht,tir:i it t \a�r.erttt i-Marital P r:nit will th_re litirtd ton sin a.> �iai:d eleari�.d nr,rk.: : Reskin 2 existing awnings. Install window vinyl 4. Height from grade to highest pJJolI i t of sign, 12811 to lowest of t�of si n; 92° 5. Property vrner: 'I t b� Y. Address: \. Phone# � t Cell# email: 6. Applicant: Signs Ink Ltd. --- James PolinskY Address: 3255 Crompond Road, Yorktown NY 105 13 Phone"914-739-9059 Cell ii 914-438-3004 email: Jp@signsink.com 7. Arch iteet)Fngineer: Address: Phone R Cell 7 email: S. Sign Contractor: Same as applicant Address: Phone 9 Cell email: 611/2024 9. Will the proposed sign require a Site Plan Review by the Village Planning Board as per§209 of Village Code? Yes. No: i(�,;.butt,cna>uhtnii a�ilc I'1:u1.':pl hcairnr..c tern id4 dctailc.l.L:netts_>I 10. Does the proposed sign involve a Home-Occupation as per§250-38 of Village Code? Yes: No: 1f yes,indicate: TICK i:_T IEK II:-TIEK III:� ill cc..,:I lnm:(1.culx7tia:1 t'rnvit A11111iiatl.al is rcy:iirrtl) 11. If building,is located on a comer lot,which street does it front on: 12. Property frontage: Store Frontage 23'-8" 13. Properv�size:Sq. Ft.: Acres: 14. What is the total estimated cost of construction: s$3000. iIhccbtinlaicillco'1.hahilic'milaAh( iteilapro%cw#aii .IaKir.rinalcrirllo�aiti,Lolls.;i�cicy(ri,mclat.pn3c.,.i,an:,llce:ittar•.hn_ammatc.j:d and lalLir%thich nlat N:Jonaled trati..I 15. Estimated date of completion: This application must Include the notarizes;; 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 krrill be returned to the applicatt. Please Dote that application bees are noll-refundable.. STATE CW7NE YO CO N'Y OF WESTCHESTER ) as: �` being duly sworn.deposes and states that he/she is the applicant above named, (print name of rndwidual signing nthe 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,controator.agent,atiomcy.etc.) That all statements contained herein are true to the best of his/her knowledge and belief, and that any work perfomled, 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 R Building Code, the Code of the Village of Rye Brook and all other applicable laws, ordinances and regulations. +Z. Sworn to before me this �rf Sworn to before me this 0 day of ) /1 20 day of_ �.b(ocrj 20 oZ on re ol-Pru crty Qu.+wF— Signal l"Applicant Pr' i C of Prc PC 'ti� Print Name or,lliplicant it r lJ;, d NI Notary Public Notary tic ALENA 1iAKANJIN NOTARY PUStration STATE ANEW YORX FAUSTO t:STEBAN BAOU@N0 ----- Registration No.OtHA0013643 to OusHOed in Westchester county Notary Public-State of New York My Commission Espies 91191202T No 01BA6437403 ' Qualified in wesictiesier County My Comm Expires Aug t,2026 6/1 r202•t Building Permit Check List & Zoning Analysis OB & C ONLY Address: SBL N kA - 2 Zone v' Use Const.Type: Other. Submittal Date: 2 Z� Revisions Submittal Dates: Applicant: Nature of Work: t0 o-u-) k C_ A Reviews:ZBA: MAR 0 6 2025 PB: BP: Other. NEED OK ( ( ) :Filing. ��� C/O: Legalization: ( ) ( APP.: Date Stamped Properly Signed: SBL Verified: Cross Connection: F.O.G.: ( ) ( ) 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. ( ) ( ) XVEY:Dated Current: Archival• Sealed Unacceptable: ( ) ( LANS:Date Stamped Sealed Copies: Electronic Other. (� ( ) License: Workers Comp: Liability Comp.Waiver. Other. ( ) ( ) Code 753#: Dated N/A: ( ) ( ) HIGH-VOLTAGE ELECTRICAL:Plans: Permit: N/A Other. ( ) ( ) LOW-VOLTAGE ELECTRICAL:Plans: Permit: N/A Other. ( ) ( ) FIRE ALARM/SMOKE DETECTORS:Plans: Permit: H.W.I.C.:_Battery:_Other. ( ) ( ) PLUMBING:Plans: Permit: Nat.Gas: LP Gas: Grease Trap: 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. (�4fi mtg.date: \N\2-15 approval• 3 notes: ( )ZBA mtg.date: approval notes: ( )PB mtg. date: approval _notes: REQUIRED EXISTING PROPOSED NOTES APPRON'f r.) Area: 15,_ MAR i a 2025 Circle: -. Frorr�tatag _ Front: Front: Sides: Rear. F.A.R.: en Space: Height- Stories: notes: BUILDING DEPARTMENT D 3D VILLAGE OF RYE BROOK FEB 2 7 2025 938 KING STREET R,%,m BROOK,NY 10573 (914)939-0668 VILLAGE OF RYE BROOK ���+,w.nrettrotil:n�.�o� BUILDING DEPAR T MENT +ssr*ssr*r**sss*s*s*ss*ssssss*s+ssssses*****sss*ssrsrr�ssssssssrssssssrssss*rrrsssssss**srssswssss*ssrr*** ARCHITECTURAL REVIEW BOARD CHECK LIST FOR APPLICANTS This form must be completed and signed by the applicant of record and a copy shall be submitted to the Building Department prior to attending the ARB meeting. Applicants failing to submit a copy of this check list will be removed from the ARB agenda. Job Address: 14B Rye Ridge Plaza Date of S missi n: _ Parcel ID 4: /' b -) 2-1— 7 zone:o—L Z D-7 Proposed Improvement(Describe in detail): Reskin 2 existing awnings. APPLICANT CHECK LIST: this"t' Br COAII'I_I;"I r:i3 ffi� Trip;AI'PLICA:NT Install window vinyl The following items must be submitted to the Building Department by the applicant-no exceptions. Property Owner: �� a � �N �. 1• )completed Application �f 2. ( )Two(2)sets of sealed plans. (unr titll siyv;inaximtan Address: �"l •� (� —I fJli ly 1(i a J i t .�Ir;l: ,.;in_ + :u J un. I I ti I t 3. ( )Two(2)copies of the property survey. Phone# �� 7 4. (,-Y"rxvo(2)copies of the proposed site plan. Applicant appearing before the Board: 5. -One electronic/disc copy of the complete Signs Ink Ltd. --- James Polinsky a lication materials. 6. Fling Fee. Address: 3255 Crompond Road, Yorktown NY 10598 7. ( ny supporting documentation. Phone 4 914-438-3004 8. ( )HOA approval letter. (ifapplicable) 9. (,-TPhotographs. Architect/Engineer: 10.(,-�'Samples of finishes/color chart. o sample•board or Phone 4 model nr )p be presented the night of the meeting) By signature below, the owner/applicant acknowledges that he/she has read the complete Building Permit Instructions&Procedures, and that their application is complete in all respects. The Board of Review reserves the right to refuse to hear any application not meeting the requirements contained herein. Sworn to before me this Swom to before the U1is day of LI. , 20 day of fypfu._r)/ 20 9 S LA ignutwc of Pro,crt 0"Ver Si_&ikirc of APpLcant pakLy_k 6 �InS1G CVK'�S Print N e of PrI4,Qvmtr f ' amc f\pp ican \ rl l✓t 1 , r� r 1 �./ -Notary Public N an Public ALEN, HAKANJIN NOTARY PUBLI .STATE OFONOEWGaOSRK FAUSTO ESTEBAN BAOUI!RO Registration No.6'• IA ausiiried in Westchester County Notary Public-Slate o1 New York My COMMIS ion Expires 911912027 No 018A6437403 Quatdieo in Westcho,ter County s� ' f My Comm Expires Aug 1,2026' t2024 r y () Village of Rye Brook ML MR V. Ott yiq enda FB SE Architectural Review Board Meeting AC AD Wednesday,March 19,2025 at 7:30 PM Village Hall,938 King Street JM SF 1. ITEMS: 1.1. ARB25-015 (Consent Agenda) Max Woltshock&Amanda Chiu 67 Rock Ridge Drive 5'high aluminum and chain link fences&gates. 1.2. ARB25-016 (Consent Agenda) Frank Gabriel&Danna Gabriel 432 North Ridge Street Rooftop solar array. 1.3. ARB25-017 (Consent Agenda) Janine Hannon 20 Country Ridge Circle 5'high white vinyl fence and gate. 1.4. ARB25-018 (Consent Agenda) Mark Bronzo&Meredith Bronzo 8 BelleFair Road 5'high cedar fence with black welded wire and gates. 1.5. ARB25-019 (Consent Agenda) Michael Fisher&Jaclyn Fisher 108 Country Ridge Drive 4'high black aluminum fence and gates. Consent Agenda Approvals: Motion Second Abstention Aye; Nay; Adjournment; Notes Page 1 of 4 Architectural Review Board March 19,2025 1.6. ARB25-020 Thomas Tempesta&Jeannine Tempesta 29 Brook Lane 2nd story dormer addition. Approvals: Motion Second Abstention Aye; Nay; Adjournment; Notes 1.7. ARB25-021 (Amendment to Approved Plans) Vivian Nolan&Sonia Patel 4 Maple Court Construct second floor addition and new balcony. Approvals: Motion Second Abstention Aye; Nay; Adjournment; Notes 1.8. ARB25-022 Vivian Nolan&Sonia Patel 4 Maple Court In-ground swimming pool. Approvals: Motion Second Abstention Aye; Nay; Adjournment; Notes 1.9. ARB25-023 (Amendment to Approved Plans) Scott Schwartz&Stacy Schwartz 35 Meadowlark Road Siding,stone and roof material changes. Approvals: Motion Second Abstention Aye; Nay; Adjournment; Notes Page 2of4 Architectural Review Board March 19,2025 1.10. ARB25-024 Washington Park Plaza Associates LLC 259,261,263,265 South Ridge Street New signs,"Rye Brook Wine&Spirit Shop",Villa Rustica Trattoria", "salon la bottega"&"Rye Ridge Cleaners". Approvals: Motion Second Abstention Aye; Nay; Adjournment; Notes 1.11. ARB25-025 Win Ridge Realty LLC 14B Rye Ridge Plaza New awnings,"AAA" Approvals: Motion / " 2 Second_ a Abstention Aye; _ Nay; _ Adjournment; Notes 1.12. ARB25-026 Michael Chiappini&Joanne Chiappini 10 Paddock Road Rear yard paver patio,steps to landing and gas fire pit. Approvals: Motion Second Abstention Aye; Nay; Adjournment; Notes 1.13. ARB25-027 Easwaran Nambudiri&Draupat Nambudiri 9 Castle View Court Window changes. Approvals: Motion Second Abstention Aye; Nay; Adjournment; Notes Page 3 of 4 Architectural Review Board March 19,2025 1.14. ARB25-028 Eric Steinert&Caryn Steinert 24 Meadowlark Road Front porch roof extension,siding and roof changes. Approvals: Motion Second Abstention Aye; Nay; Adjournment; Notes 1.15. ARB25-029 Corey Shulman&Lindsay Shulman 40 Meadowlark Road Facade,windows,siding and roof material changes. Approvals: Motion Second Abstention Aye; Nay; Adjournment; Notes 1.16. ARB25-030 Daniel Fix&Glenna Fix 7 Oriole Place Demo screened porch,construct new deck and interior alterations. Approvals: Motion Second Abstention Aye; Nay; Adjournment; Notes NEXT MEETING: April 16, 2025 Page 4 of 4 ® DATE(MM/DD/YYYY) AC� `� CERTIFICATE OF LIABILITY INSURANCE 12/4/2024 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($), 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 CONTACT Miller& Miller Insurance Agency Inc NAME:PHONE --John-G.Sldway- - FAx 720 Commerce Street rua wo.Wa 914-741-6400 (AIC.Not:914-741-6407 Thornwood NY 10594 ADDRESS: JohnS@miller-ins.com INSURERS AFFORDING COVERAGE NAIC#_ INSURER A:Greenwich Insurance Co. INSURED SIGNS-1 INSURERS:XL Specialty Insurance Co 37885 Signs Ink Ltd dba White Plains Signs Co INSURERC:Twin City Fire Ins Co 29459 3255 Crompond Road Yorktown Heights NY 10598 INSURERD: Hartford Life&Health INSURER E: INSURER F COVERAGES CERTIFICATE NUMBER:237791433 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. --- TR - -- ILR TYPE OF INSURANCE ' N DL-SU D POLICY NUMBER MM/DDY/YYYY MM/D /YYYY LIMITS A X COMMERCIAL GENERAL LIABILITY Y NPC-100218005 11/21/2024 11/21/2025 EACH OCCURRENCE $1,000,000 CLAIMS-MADE X OCCUR PR MISEa_CEa occunence $100,000 _ MED EX (Any one arson) $10,0D0 PERSONAL&ADV INJURY $1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $2,000,000 POLICY K JET LOC PRODUCTS-COMP/OP AGG $2,000,000 OTHER: $ B AUTOMOBILE LIABILITY Y NBA100218105 11/21/2024 11/21/2025 MBINED IN L LIMIT $1.000,000 Ea accident X ANY AUTO BODILY INJURY(Per person) S OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTYDAMAGE $ AUTOS ONLY AUTOS ONLY Per accident f UMBRELLA LIAR OCCUR EACH OCCURRENCE $ EXCESS LIAR Id CLAIMS-MADE AGGREGATE f DIED RETENTION $ C WORKERS COMPENSATION 16WECDU0437 11/21/2024 11/21/2025 X PER AND EMPLOYERS'LIABILITY ST Y ATUT ER ANYPROPRIETOR/PARTNER/EXECUTIVE N N/A E.L.EACH ACCIDENT $1,000,000 OFFICER/MEMBER EXCLUDED? (Mandatory in NH) E.L.DISEASE-EA EMPLOYEEI$1,000,000 if yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $1,000,000 D Disability LNY647952 1/1/2021 12/31/2026 STATUTORY Statutory DESCRIPTION OF OPERATIONS/LOCATIONS I 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 ACCORDANCE WITH THE POLICY PROVISIONS. Village of Rye Brook 938 King St AUTHORIZED REPRESENTATIVE 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' STATE 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 SIGNS INK LTD (914) 739-9059 3255 CROMPOND RD YORKTOWN HEIGHTS NY 10598-3605 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 13-3841692 2. Name and Address of the Entity Requesting Proof of 3a. Name of Insurance Carrier Coverage(Entity Being Listed as the Certificate Holder) Twin City Fire Insurance Company Village of Rye Brook 29459 938 KING ST, 3b. Policy Number of Entity Listed in Box 1a": PORT CHESTER NY 10573 16 WEC DU0437 3c. Policy effective period: 11/21/2024 to 11/21/2025 3d. The Proprietor, Partners or Executive Officers are XD 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 "T' 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 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: �.¢ 02/24/2025 (Signature) (Date) Title: Operations Manager Telephone Number of authorized representative or licensed agent of insurance carrier: (866)467-8730 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) Form WC 88 31 21 F Printed in U.S.A. www.wcb.ny.gov Page 1 of 2 I --I in' O cu co .D 0 CD 0 a .� 0 _. O Z 00 0 0 X )IN N• D r CL D o 00 01 z ch V) CD o s0000t'! 00 CCn;.TI Z c o Z 0 0 - ma C7 -, � oor,.�n 0 omQ to m 0 -4QC cn cn CD C Z 03 ��� CO) Z =r CO) 00D� � oo== c� y W�� = m l,JM z; V V V Z > o M Z t�i Z O —� Z O ? Z �' r+ r C z 0 .< 7� > m 73 O CSC n C710 = CSC ? G� Z > >70 U3 mr-7Q T� Z M Q ram,_ n Z --AZ Ch N G) > � < o -� C r r� Z i-- > [t (t�t ._... 7� C) Z r- mQ) V• -'1 > ((1 O n ..� Z V• • w CU .... 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