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HomeMy WebLinkAboutBP25-203PERMIT # C& SECTION TYPE OF WORK JAB LOCATION I ' - W4 Im`/ I„ «. w:�i►�/lamA M�lig /I�►� SATE FOOTING F*UNDATION FRAMING RGH FRAMING INSULATION PLUMBING 0 RGH PLUMBING GAS a SPRIN ER E RI ' LOW -VOLT ALARM AS BUILT ❑ � ,Z „ /O . Z o 2s _ �t FINAL INSP e -• ZBA OTFi�R (�yE.DR 4- tc4 typo��v C�ti��Vy� 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 December 15, 2025 Win Ridge Realty LLC c/o Alena Hakanjin 24 Rye Ridge Plaza Rye Brook,New York 10573 Re: 204 South Ridge Street, Rye Brook,New York 10573 Parcel ID#: 141.35-2-36 Building Permit#25-203 issued on 8/27/2025 to Relocate Front Entry Door;"KidStrong" This certifies that the new front entry door,installed under the above captioned permit,has been satisfactorily completed. Sincerely, Steven E.Fews Building&Fire Inspector /to DEC - 5 2025 $UILD '. � E `T N'T For office use only: PERMIT# 3 VILLAGE OF RYE BROOK VIL'�' OF:RY& OK ISSUED: — - 5 BUILDING r)FPARTMENT 938 KING STREnt�, YE BROOK, RW YORK 10573 DATE: � 9•T4j 9 -06 8"_ FEE: (y-7,'S _PAID tv'f X. w �4 -o kin ov APPLICATION FOR CERTIFICATE OF OCCUPANCY,CERTIFICATE OF COMPLIANCE, AND CERTIFICATION OF FINAL COSTS TO BE SUBMITTED ONLY UPON COMPLETION OF ALL WORK, AND PRIOR TO THE FINAL INSPECTION /tlltt/t/))tttt/tt//tttf/tt//it/ttlttttt tttltl ttttt►tlltttttlt/t111 Ytt/tttlttl/tttitltttttttl ttltttttttitttl•ittttilttttlttllttt Address: �JC (��1-� !( - �' - U f• 7. i Occupancy/Use: K Parcel ID#: 3 — Zone: Owner: .�,1c �' 'I- LLr A,,ddress L }. C, Ty P.E./R.A.or Contractor:�` Cti r 1 ►t'1C� ��t;v 151�u.I°t6ess: I "Lowe- Ko { irk Person in responsible charge: tT 1 ,� Ct 1 Address:`')[.~) ��,Ci�bU�• , t t�d� � R5�j .� Application is hereby made and submitted to the Building Inspector of the Village of Rye Brook for the issuance of a Certificate of Occupancy/Certificate of Compliance for the structure/construction/alteration herein mentioned in accordance with law: STATE OF NEW YORK,COUNTY OF WESTCHESTER as: toI � l�(Y being duly swom,deposes and says that he/she resides at U 1,C)e V - nnf Namc of Applic�n) n (No.and Street) in" 1(/l� CI f c, P I(l in the County of_ !i- ' l .0 Q0 1 V in the State of that Cit frowtd vi age) he/she has supervised the work at the location indicated above,and that the actual total cost of the work,including all site improvements, labor,materials,scaffolding,fixed equipment,professional fees,and including the monetary value of any materials and labor which may have been donated gratis was:$ � t > 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. Swornto before me this Zro Sworn to before me this t 2-02- 25 day of D 20�_ day of 20_Z 5 L �h ignattu of Prope Owner A(It N) Sill pp Print Name of Property 0%-nTT lotoall Pri N of App oe t o ry P tc gotiVy Public `. Notary Put l.c v Yorke 024 0!-Tl:c; I,_.IOin l^ l �ratNa icit W011N1 "' ::•,.r •'c,:)nty %t�MMtlK11MMIG11 Gainmission I_xp;,,-;s i�iarc:i� 4, �o'A� �E BRC��. 1982 BUILDING DEPARTMENT ❑B IWING INSPECTOR ASSISTAN'r BUILDING INSPECTOR VILLAGE OF RYE BROOK ❑CODE ENFORCEMENT OFFICER 938 KING STREET. RYE BROOK,NY 10573 (914)939-0668 FAx (914)939-5801 www.rygbrook.or8 - - - - - - - - - - - - - - - - - - - - INSPECTION REPORT - --- -- - - - - - -- -- ----- ADDRESS : sr-me.L. DATE: PERMIT,: ISSUED 9-Z7-7 SECT: /91•. BLOCK: Z LOT:,C LOCATION: ms raoti(a, OCCUPANCY: ❑ VIOLATION NOTED THE WORK IS... tu�CCL'PTED ❑ REJECTED/ REINSPFCTION ❑ SITE INSPECTION IZLQUIRED ❑ FOOTING ❑ FOOTING DRAINAGE ❑ FOUNDATION ❑ UNDERGROUND PLUMBING NOTES ON INSPECTION: ❑ ROUGH PLUMBING ❑ ROUGH FRAMING ❑ INSULATION ❑ NATURAL GAS I �v O� ❑ L.P. GAS t' a ❑ FUEL TANK —In - 2 ❑ FIRE SPRINKLER ❑ FINAL PLUMBING yL'^ [I_.CROSS CONNECTION ALL 1- CovyN FINAL ` akQ ❑ OTHER ^ a a s M wLin o s Ln h+l 00 00 ' u �+ x a ti H N W a x _ W A v w ►. 0 � O O aid y '"•5 s w ti a I..i A o 4 o O �Tz� w Iz 0 y a W a V w N can bo cj L" 064 a Ir--il U yy ca 5 n ..yy a > O � O cn FQ a O bA V I i—i P-1 0 O O s C p o x N a Q o a �T A w - hei"1 I" Q y V- -o 04 W U «. Q .. p F-1 V O Uz '� 'ti W ICI �i I O z N W c 5. o R °° a°+" Ln ` A Mcn OC cl, 00 5 y o �, to tA E oZ � vo � 00 u w ~ z r v W U O O g U Q g U tt o N a w Fy O V w O O v U .a � x U V � av' � aLAU v o o .ti �I P* W x �w 14 o o BUILDING DEPARTMENT VIL *E OF RYE: OK JUL 2 3 2025 938 KING STREET RYE eNY 10573 VILLAGE OF RYE BROOK BUILDING DEPAf1�'MENTv *************************************************** ******************************************************* FOR OFFICE USE ONLI,. Approval Date: AW 2 er Application # AR1 '15-/U 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: EXTERIOR BUILDING PERMIT APPLICATION Application dated: � Z� 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,structLres,additions,alterations or for a change in use,as per detailed statement described below. 1. 1obAddress:,7 o U S •,K I_dqf S� -Wy£ Y OCR � NTT 1 0`> 2. ParcelID#: Zone: I 3. Proposed Improvement(Describe in detail): Ce�G �C �; le Ccq�t r--�A­f oo\r 4. Property Owner: al `, L Address: 1 6 r I Phone# 4V v.7 Cell# e-mail List All Other Properties Owned in Rye Brook: Applicant: L u t Address: 1 4— �&t . Q Phone# Cell 020. 0 a-mail ` _j,C_ Architect:p6 t i p fl ! �C_<Y�O f Address: zl- r, 4re,4 Ra r��d, c T O6z y Phone# 2,03^e�-2pj/,W,' Cell# e-mail Engineer: Address: Phone# Cell#_ —e-mail General Contractor. 7 � �n� con 4 ti Gyp Address:S.L� Lowk Q Vt. _tj S ,.Lr• Phone#,0I' 21_o O�UO Cell 4 e-mail LJJAQCA)(.. Cpyl3 !{ 7�Or C 9 C�5 � 6/1/2024 BUILD .DEPARTMENT VI E OF RYE OK JUL 2 3 2025 938 KING T RYE BRooi NY 10573 - -0 VILLAGE OF RYE BROOK BUILDING DEPARTMENT ov 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: w f::SUS�I ,residing at, 2_4 P—t (Print name) (Address where you live) 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; ZV A_ J` f 1' J `' �_ , Rye Brook,NY. (Job Address) Further that all statements contained herein are true, and that to the best of his/her knowledge and belief,that there are no known illegal cross-connections concerning either the storm sewer or sanitary sewer, and further that there are no roof drains, sump pumps, or other prohibited stormwater or groundwater connections or sources of inflow or infiltration of any kind into the sanitary sewer from the subject property in accordance with all State, County and Village Codes. 1 'igna ut Prope 44~+91) 1 VAU(0 (Print Name of Property Q�� - Sworn to before me thhhii'fs(_ day of �1�1..� 20 (Notar) Public ffAL:EU MIIKAMMC,STATE OF NEW VMMn No.01NA0013643 (b) Wostchester COYMybn Eapins 111t/20i1 6/1/2024 This application must be properly completed in its entirety by a N.Y. State Registered Architect or N.Y. State Licensed Professional Engineer& signed by those professionals where indicated. It must also include the notarized signature(s) of the legal owner(s) of the subject property, and the applicant of record in the spaces provided. Any application not properly completed in its entirety and/or not properly signed shall be deemed null and void, and will be returned to the applicant. Please note that application fees are non-refundable. STATE OF NEW YORK,COUNTY OF WESTCHESTER ) as: L.1),S Cluc being duly sworn, deposes and states that he/she is the applicant above named, (print name of individual signing as the applicant) andr�further��states that (s)he is the legal owner of the property to which this application pertains, or that (s)he is the l7`c odw 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 03 Sworn to before me this ' .-L day of `. , 2025- day of �l ` , 20 p.' t t natur f Prope 9 vnm S' ature of Appli t 019 WMA&W /U— Print Name of Property Owner Print Name of Applicant Notary Public Not y ublic A VALERIYA PAK IOIMr1111M 1W it VW Notary Public-State of New Jersey �• NAND! My Commission Expires Apr 14, 2026 NM�«CNq (8) 6/I/2024 Bung Permit Check List&Zoning Anal sis Address: 6 SBL Zone: G (� Use; Const.Type: Other. Submittal Date: Revisions Submittal Dates: Applicant n i qc, 1 C \ _ Y U Nature of Work: e \S 1 Reviews:ZBA: AUG PB: BOT: Other. NEED OK (1�(� FEES:Filing._j!; —BP: C/O: Flood Plane: Legalization: ( ) (y APP: 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. ( ) ( ) SURVEY:Dated Current: Archival;- Sealed Unacceptable: ( ) ( ) PLANS: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: 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. ( ) ( ) 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 (J�ARB mtg.date approval• "Z notes: —1( ( )ZBA mtg.date: approval;- notes: ( )PB mtg.date: approval;- notes: REQLMtED EXISTING PROPOSED NOTES APPROVED Area: Cirde: Dgt�: Fie: Front Front Sides: Rear. Main Cov- Accs.Cov: Ft.H Sb: Sd.H Sb: GFA: Tot : Ft Im : Pad6w. Hecht/Stories: notes: [ECEWED BUILDING DEPARTMENT ��� 2 3 1025 VILLAGE OF RYE BROOK 938 KING STREET RVE BROOK,NY 10573 914 939-0668 VILLAGE OF RYE BROOK BUILDING DEPARTMENT www,rvel k , ,.Eov *********************************************************************************************************** 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:2 0�-1 S .TI A :C 431 Date of ubmissi n: Parcel ID#: Zone: Proposed Improvement(Describe in detail): APPLICANT CHECK LIST: �V��1I� QU i�n�er�d� MUST BE COMPLETED BY THE APPLICANT MoVc S6,-r_ Eft r\� 0 0r3�c- The following items must be submitted to the Building Department by the applicant-no exceptions. Property Owner: l. ( )Completed Application D 2. ( )Two(2)sets of sealed plans. (one full size ;maximum Address: 1 allowable plan size=36"x 42'; and one 11"x 1T') i — 3. ( )Two(2)copies of the property survey. Phone# 4. ( )Two(2)copies of the proposed site plan. Applicant appearing before the Board: 5. ( )One electronic/disc copy of the complete �.�an 0 application materials. LJ L.:�CJC� 6. ( ) Filing Fee. Address: OLve C',It t. i iN�( nj 7. ( )Any supporting documentation. 8. ( ) HOA approval letter. (;fapplicable) Phone#1n- ?OL— Q to Z Q 9. ( ) Photographs. Arch itect/Engineer: I Lip Cc.ryo ni_ 10.( )Samples of finishes/color chart. (a sample board or c a 7? 5 g model may be presented the night of the meeting) Phone# Z 0�j — �2 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 Sworn to before me this day of VC , 20 Z 5— day of ` , 20 2 Signature f Property er• Si ppli ant Pri t Nam f Property 04VRW - Print Name of Ap otary Public No P is III � VALERIYA PAK IkR IN.h� ENotar�yublic-State of New Jersey Ncow MI ission Expires Apr 14, 2026 6/l/2024 Village of Rye Brook NIL MR •tiAgends FB SE Architectural Review Board Meeting Wednesday,August 20,2025 at 7:30 PM Ivi SF Village Hall,938 King Street J 1. ITEMS: 1.1. ARB25-094(Consent Agenda) Bradley Emott&Emily Bien 57 Country Ridge Circle 6'high white vinyl fence and gate. 1.2. ARB25-095 (Consent Agenda) Klaus Tanner&Brigitte Tanner(Contract Vendee) 17 Wilton Road 6'high white pvc fence. 1.3. ARB25-096 (Consent Agenda) Gregory Varone 47 Hawthorne Avenue Rooftop solar array. 1.4. ARB25-097 (Consent Agenda) Scott Plasky&Nicole Plasky 19 Woodland Drive 4'high aluminum fence and gates&4'high welded wire fence. 1.5. ARB25-098 (Consent Agenda) Matthew Proto&Jenny Proto 24 Red Roof Drive Replace and widen bluestone walkway. Consent Agenda Approvals: Motion Second Abstention Aye; Nay; Adjournment; Notes 1.6. ARB25-087 (Re-Appearance) Dylan Fijor 8 Beacon Lane Addition of three dormers. Approvals: Motion Second Abstention Aye; Nay; Adjournment; Notes Page 1 of 4 Architectural Review Board August 20,2025 1.7. ARB25-099 John Capistrano&Maricar Capistrano 300 South Ridge Street Legalize front yard off street parking area and remove 1,445 square feet of impervious coverage by removing additional driveway areas. Approvals: Motion Second Abstention Aye; Nay; Adjournment; Notes 1.8. ARB25-100 Paige Buonocore 12 Talcott Road Replace three windows and add two new windows. Approvals: Motion Second Abstention Aye; Nay; Adjournment; Notes 1.9. ARB25-101 Kevin Branch&Alecia Thompson-Branch 279 Neuton Avenue Construct rear two story addition and interior alterations. Approvals: Motion Second Abstention Aye; Nay; Adjournment; Notes 1.10. ARB25-102 Andrew Frieman&Jody Frieman 1 Little Kings Lane Front elevation changes,new garage door and overhang,new front door with window above and stone veneer. Approvals: Motion Second Abstention Aye; Nay; Adjournment; Notes Page 2 of 4 Architectural Review Board August 20,2025 1.11. ARB25-103 Justin Weiner&Samantha Weiner 282 North Ridge Street Rear deck. Approvals: Motion Second Abstention Aye; Nay; Adjournment; Notes 1.12. ARB25-104 Win Ridge Realty LLC"Kidstrong" 204 South Ridge Street Relocate front entry door. Approvals: Motion Al- Secon Abstention Aye; Nay;'1 Adjournment; Notes S Vo W • A ^ Lo A - Z •a 1.13. ARB25-060 (Amendment to Approved Plans) Kenneth Gerchick&Amy Bernstein-Gerchick 3 Mohegan Lane New bay window. Approvals: Motion Second Abstention Aye; Nay; Adjournment; Notes 1.14. ARB25-105 Benjamin Kushner&Rebecca Kushner 19 Churchill Road 2nd story addition,rear one story addition&interior alterations. Approvals: Motion Second Abstention Aye; Nay; Adjournment; Notes Page 3 of 4 f Architectural Review Board August 20,2025 1.15. ARB25-106 Jose Davila&Maritza Molina 1 Parade Lane Enlarge rear deck. Approvals: Motion Second Abstention Aye; Nay; Adjournment; Notes 1.16. ARB25-107 Win Ridge Realty LLC "Spear" 12A Rye Ridge Plaza New entry door. Approvals: Motion Second Abstention Aye; Nay; Adjournment; Notes NEXT MEETING: September 17,2025 Page 4 of 4 ��rr�Jrn CERTIFICATE OF LIABILITY INSURANCE DATE(YMI)DlYYYY) 106!11!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 NAAMME. )NY VARGAS _ Juny's Professional Services PHONEr Q ,I�L201)624-8010 PAxNot 201 624-8013 8400 Kennedy Blvd E-MAIL ADDRESS: Jvar as Jun PrD-Services.com North Bergen NJ 07047 NsuREgtgtAFFORalNQc RASE wucr INSURER A; CLEAR SPRING PROPERTY&CASUALTY INSURED INSURER 0 m MT.HAWLEY INSURANCE CO. C&C PAINTING AND CONSTRUCTION LLC INSURER C: EMPLOYERS INSURANCE CO. 515 Lowe Avenue INSURER D: Ridgefield NJ 07657 INSURER E INSURER F COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS 10 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 DFSCRIBFD HEREIN IS SUBJECT `0 ALL THE TERMS. EXCLUSIONS AND CONDITIONS OF SUCH 7POLICIES LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS nR TYPE OF INSURANCE IADOL UBRj POLICY EFF POLICY EXP _ ICY NUMBER LIMITS X COMMERCULL GENERAL LIABILITY EACH OCCURRENCE 1 000 000 � ! A I CLAIMSlyWDE LY—1 OCCUR DAMAGE TO RENTED i RFULCFc 100,000 _ X X CB003392202 02/17/2025 02/17/2026 MEDEXP $5,000 PERSONAL a M INJURY .- i.1e0001090-- N L AGGRE('aaAATE LIMIT APPLES PER GENERAL AGGREGATE S2,000,000 POLICY u PROOTWrR - U LOC PRODUCTS-COMP/OP 2 000 OOO S —_ AUTOYOSU LJAMIJTY I COhBNED SWGLE LIMIT $ ANY AUTO BODILY INJURY(Par person) _ OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY(Per eccid") i HIRFO NON-OWNED PROPERTY DAMAGE AUTOS CN�V F AUTOS ONLY i I f X UMBRELLA LIAR I X OCCUR EACH OCCURRENCE $6,000,000 R EXCESS LIAR I_ CwrS-MADE GXS0019214 09/17/2024 09/17/2025 AGGREGATE $5,000,000 DE �— WORKERS COMPENSATION X PER OTFI- AND EMPLOYERS'LIABILITY _ ANY PROPRIETOR/PARTNER/EXECUTNEY�N E. EACHACCIDENT 1000000 C IOFFICER/MEMBEREXCLUDED7 �N L. IN/AI EIG5755471-00 11/1212024 11/12/2025 (Mandatory in NH)if yes �1BscliCR�rWer E.L.DISEASE-EA EMPLOYEE 1 000 000 RIPTI N or oPERATioNsbeiow E.L.DISEASE-POLICYLaMT $1,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101.Additional Hemarks Schedule,may be attached it more apace is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN RYE BROOK BUILDING DEPARTMENT ACCORDANCE WITH THE POLICY PROVISIONS. 938 King St Rye Brook.NY 10573 AUTHORIZED REPRESENTATIVE ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD YORIc Workers' CERTIFICATE OF STATE Compensation Board NYS WORKERS' COMPENSATION INSURANCE COVERAGE 1a.Legal Name&Address of Insured(use street address only) 1b.Business Telephone Number of Insured j C&C PAINTING AND CONSTRUCTION 20 1-9 0 6-04 20 1204 S RIDGE ST RYE BROOK,NY 10573 1 c.NYS Unemployment Insurance Employer Registration Number of Insured Work Location of Insured(Only required it coverage is specifically limited to certain locations In New York State,i.e.,a Wrap-Up Policy) 1d.Federal Employer Identification Number of Insured or Social Security Number 384010085 2.Name and Address of Entity Requesting Proof of Coverage 3a.Name of Insurance Carrier (Entity Being Listed as the Certificate Holder) EMPLOYERS PREFERRED INSURANCE COMPANY Village Of Rye Brook 93B King Street 3b.Policy Number of Entity Listed In Box"'a" Rye Brook,NY 10573 EIG5755471-00 3c.Policy effective period t 9/19/9n?A to m qr?n-2 3d.The Proprietor,Partners or Executive Officers are included.;Onty check tux If all partners/offloers Included) all excluded or certain partners/officers excluded. This certifies that the insurance carrier indicated above!n box"3"insures the ousiness referenced above it box-1a"for workers' compensation under the New YorK State Workers'Compensation Law. (To use this form,New York(NY)must be listed under)tem_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 listec above as the certificate holder in box"21. 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. Apprcved by: _Matthew Batton (PInt name of authorized representattve or licensed agent of insurance carrier) Approved by: ijaAtowl 07/10/2025 (Signature) (Date) Title: Document Services Telephone Nu nber of authorized representative or licenses agent of insurance carrier: 800-700-91 13 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.wr-b.ny.gov