HomeMy WebLinkAboutBP25-214SECTION % BLOCK LOT
TYPE OF WORK J l� a� ll;"v `I Jn/�*t 19 ;_i
JOB LOCATION
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DATE
FOOTING
FOUNDATION
FRAMING
INSP
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INSULATION ,L
PLUMBING
RGH PLUMBING
GAS 0 -
SPRINKLER
ELECTRIC
LOW -VOLT C�
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AS BUILT C�
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VILLAGE OF RYE BROOK
WESTCHESTER COUNTY, NEW YORK
NO: 26-010
Certif icate of (9ccupaucp
This is to certify that (Jt)W/7D Mu flona Faze k s
of, )et j e )3Y(� L� N Y having duly filed an application on
'= 20,22�O requesting a Certificate of Occupancy for the premises known as,
5 �CjL,-Y-)3 If 1 PQaV , Rye Brook,NY, located in a K-�V Zoning
District and shown on the most current Tax Map as Section: J • / 3 Block: / Lot: 0 ,
and having fully complied with the requirements of the Building Code and the Zoning Ordinance under Building
Permit No.� "ys'�� , issued 20 g5, such authority and permission is hereby granted
to the property owner to lawfully occupy or use said premises or building or part thereof listed under the following
New York State Classifications, Use: /l Construction: V ,
for the following purposes: L oa I/z-'e 1,{b� y i o y- (2 1,4 '—a e� 5�
rP 1060k b4M Pam, 69ad JZ Q IaOdr4::!Ilk" S fa
Y
Subject to all the privileges, requirements, limitations, and conditions prescribed by law, and subject also to the
following:
This certificate does not in any way relieve the owners or any person or persons in possession or control of the premises,
building,or any part thereof from obtaining such other permits or licenses as may be prescribed by law for the uses or purposes
for which the building or premises is designed or intended. Furthermore, it does not relieve such owners or persons from
complying with any lawful order issued with the object of maintaining the premises or building in a safe and lawful condition.
No changes or rearrangement in the structural parts of the building or in the exit facilities shall be made,and no enlargement,
whether by extending on any side or by increasing in he' sha(bbe ade,nor s ll the building be moved from one location
to another until a permit to accomplish such changehe ob m e Bu ding Inspector.
Building Inspector,Village of Rye Brook: A Date: BAN 2 2 2026
QyE DR
C4 is U+'�� -Y
6 tCC4'V�J J
Cti tcJ �.
190
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
January 22,2026
Albano Ruka&Ilona Fazekas
5 Sunset Road
Rye Brook,New York 10573
Re: 5 Sunset Road, Rye Brook,New York 10573
Parcel ID#: 135.73-1-22
This document certifies that the work done under Mechanical Permit #26-001 issued on 1/6/2026 for the
installation of a mini split HVAC system has been satisfactorily completed.
Sincerely,
Steven E. Fews
Building&Fire Inspector
/to
11:17 5G
z
F FC-_ IW
J A IN - 2 2026 IDO
All I n boxes 5 Sunset... /�
VILLAGE OF RY_ BROOK
V111d(y. a UI Mye DFUUK BUILDING DEPARTMENT
Ph: ,(914) 939-0668
BI.ILDING DFPARTMENT
Pr kin l N
Vwi,Ata.OF R%a BROOK Isst l u
938 KING STREET,RVE BR(X)K.NEw YORK I0573 DA-11: /
- 668 FEE: PAID 6000
v
a.
APPLICATION FOR CERTIFICATE OF OCCUPANCY,CERTIFICATE OF COMPLIANCE,
AND CERTIFICATION OF FINAL.COSTS
TO DR SUMUTTED ONLY UPON COMPLETION OF ALL WORK, AND PRIOR TO THE FINAL INSPECTION
Address, C, r
Occupancy Use: Parcel IDN: Zone:
Owner: �— i4 Lv` �— Address: -__7 S 0 0 �-'&
P.E.M.A.or Colntraclor. L �5_4Addr ss: t?9t
Person in responsible charge_ --- -- - -- - Address:
Application is hereby made and subiniticd to the Building Inspector of the Village of Rye Brook for the issuance of a
Certificate of Occupancy/Certificate of Compll.utcc for the struclurc'construciionialtaation heroin mentioned in accordance
with law:
STATE OF NEW YORK.COUNTY OF WESTCHESTER as
1"L�N 0 9-V \ - betllg dui+sworn deposes and Ny s dial he.she rcrttlra Y `' S tJ dJ S t� A
Mesas fiat orAWkwill ( il"W$awl
is_ tF- 1_MCC>K• �m the Cnouy of-- e- in the State of that
Wily'rarn V11wo
helshe has supervised the work aA she location indacated also%c.and that the actual total cast of tht work.U►cbadnsg all silt improvcnn�la.
labor,materials.scaffolding.fixed equipment,professional fees,and including the nwncuary value of any nuu nab and lat%-r sv Itivh stay
have been dtxtated gratis was:S 0
for the construction s r aNaation of.
Deparsent fwdler states that he'sk has examined the approved plans of the structure,'wak harem ick.rod to for which a Ccntflcasc of
Occupancy/Compliance is caught,and that so the best of his.*r►rsowtedge and beliet the structure work has hecn erected completed in
accordance with the approved plans and any amatdmems thereto except in so far as variations therefore have tkcn legally authorized.and
as erected complcud complies with the taws.go%cming building corlSWcnOrt.Deponent futiht7 urnlctstands thin it shall be unlawful for an
owner to use or pennn the use of any building or picmiscs or pan thereof hereafter createc&ervtied_changed.con%erted of cularged.wholly
tic partly,in its use or structure until a C'erttficate of Mcupancy or Cvvufcateof Comp hanre shall has a been duh issued by the Hui Wolg
Inspcaor as per§250.10.A.of the Code ol'the Village of Rye Brook.
Sworn to bc(orc the this�. Sworn it,before me thn
day of day of 2U
M{nNurt w Asem.a.I
L-3 KOO P-ldK -
'one d►qeq Uwxt Puai Nam M A.W.nt - - --
NOT IC,STATE OF YORIC -
-101 ME6160063
QUALIFIED IN WESTCHESTER COUN7
,�OMNAISSION E)PRES JANUARY 29,20`7
BRC�jk
O Zm
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1932 BUILDING DEPARTMENT
❑BUILDING INSPECTOR VILLAGE OF RYE BROOK
0 VILLAGE ENGINEER 938 KING STREET RYE BROOK,NY 10573
❑ASSISTANT BUILDING INSPECTOR (914)939-0668 FAx(914) 939-5801
- - - - - - - - - - - ------ - - - - INSPECTION REPORT - - - - - - - - -- - - - - - ------
ADDRESS: `~ DATE:
PERMIT# ' ISSUED: r k SECT ` - BLOCK: LOT: '?2
LOCATION: �•+� 'e ` ' ' OCCUPANCY:
1HE1 G C}CEP
❑ VIOLATION NOTED W��••• �ACCEPTE REJECTED/REINSPECTION
REQUIRED
0 SITE INSPECTION
0 FOOTING
0 FOOTING DRAINAGE
❑ FOUNDATION
❑ UNDERGROUND PLUMBING NOTES ON INSPECTION:
❑ ROUGH PLUMBING �"
❑ ROUGH FRAMING
❑ INSULATION
❑ NATURAL GAS
❑ L.P. GAS
❑ FUEL TANK
0 FmE SPRINKLER
❑ FINAL PLUMBING
❑ FINAL
❑ OTHER
E DR(�uk
�c
319132 •
BUILDING DEPARTMENT
❑ BUILDING INSPECTOR VILLAGE OF RYE BROOK
❑ VILLAGE ENGINEER 938 KING STREET RYE BROOK,NY 10573
❑ CODE ENFORCEMENT OFFICER (914) 939-0668 FAX(914) 939-5801
- - - - - - - - - - - - - - - - - - - - - INSPECTION REPORT - - - - - - - - - - - - - - - - - - - - -
ADDRESS: `�r� DATE:
1�
PERMIT# ` ISSUED: SECT: BLOCK: LOT:
LOCATION: I ` ` ( , ,x- OCCUPANCY:
❑ VIOLATION NOTED THE WORK IS... Q.E4 ' ED ❑ REJECTED/ REINSPECTION
❑ SITE INSPECTION REQUIRED
❑ FOOTING
❑ FOOTING DRAINAGE
❑ FOUNDATION
❑ UNDERGROUND PLUMBING NOTES ON INSPECTION:
•€3" ROUGH PLUMBING
❑ ROUGH FRAMING
❑ INSULATION
❑ NATURAL GAS
❑ L.P.GAS
❑ FUEL TANK
❑ FIRE SPRINKLER _
❑ FINAL PLUMBLING -
❑ FINAL
❑ OTHER
oe Bkjk
c
1982•'i�O
BUILDING DEPARTMENT
❑BUILDING INSPECTOR
❑ASSISTANT BUILDING INSPECTOR VILLAGE OF RYE BROOK
❑CODE ENFORCEMENT OFFICER 938-King Street• Rye Brook,NY 10573
(914) 939-0668 FAx (914) 939-5801
www ryebrook.org
- - - - - - - - - - - - - - - - - - - - INSPECTION REPORT - - - - - - - - - - - - - - - - - - - -
ADDRESS : /� J- � u�—� / DATE:
PERMIT# N ISSUED: SECT: BLOCK: LOT:
LOCATION: OCCUPANCY: I `
❑ Violation Noted THE WORK IS... ❑ PASSED FAILED REINSPECTION
❑ SITE INSPECTION REQUIRED
❑ FOOTING
❑ FOOTING DRAINAGE
❑ FOUNDATION
❑ UNDERGROUND PLUMBING NOTES ON INSPECTION:
❑ ROUGH PLUMBING
❑ ROUGH FRAMING
❑ INSULATION
❑ Natural Gas
❑ L.P. Gas
❑ FUEL TANK
❑ FIRE SPRINKLER
❑ FINAL PLUMBING
❑ CROSS CONNECTION ti
FINAL
❑ OTHER
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BUTTMENT Q E C E 0 " E
ROOK JUN - 3 2025
938 KING6 Q,NY 10573
I VILLAGE OF RYE BROOK
. ov I BUILDING DEPARTMENT
INTERIOR BUILDING PERMIT APPLICATION
FOR OFFICE USE ONLY:
Approval Date: AUG 12 2425 Per # Application Fee:$
Approval Signature: Permit Fees:$
Disapproved: Other: `— D
rl� 2
Application dated: C o—3—c) is hereby made to the Building Inspector of the Village of Rye Brook,NY,fr* e of f
interior alteration of an existing building,or for a change in use,as per detailed statement described below. �C``�
1. Job Address: 5 SUNSET RD I RYE BROOK, NY 10572 SBL: 135.73-1-22 Zone: R-10
2. Proposed Improvement.(Describe in detail): 1 ^� '
LEGALIZATION OF THE EXISTING CO DITIO OF THE HOUSE \ w v-G,, _CLn Wi VJ_
0A� rn �rGcl�rS
3. Does the proposed improvemilat involve a Home-Occupation as r§250-38 of the Code of the Village of Rye Brooms? ,�
No: C(U
V* Yes: If yes,indicate: TIER I: TIER II: 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 I Hood,etc...) :No:_,!�LYes:
(If yes,please submit a separate Automatic Fire Suppression System Permit application&2 sets of detailed enLineered plans)
5. Occupancy;((fam.,2 fam.,comm.,etc...)Prior to Construction: 1 FA M. After Construction: 1 FA M.
6. N.Y State Construction Classification: V N.Y.State Use Classification: R-3
7. Property OwnerALBANO RUKAAND ILONA FAZEKA Address: 5 SUNSET RD I RYE BROOK, NY 10572
Phone# 914-433-0 20 Cell# email: ALBANORUKA@GMAIL.COM
8. Applicant: Address:
Phone# Cell # email:
9. Architect: TOMASZ MLYNARSKI ARCHITECT Address: 41 BARKER ST I MOUNT KISCO, NY 10549
Phone# 845-849-5051 Cell # email: tomasz@narska.com
10. Engineer: Address:
Phone# Cell# email:
11. General Contractor: Address:
Phone# {C�elll## email:
12. Estimated cost of construction $ �-e�� 49 00
(NOTE:The estimated cost shall include all labor,material,scallolding,fired eyuipmcnt.prolcssiunal tees,and material and labor which may he donated
gratis.)
13. Job Timetable:Start: Finish:
6/l/2024
BUILD MENT D E C 1�f, W IE
VILLAGE OF RY OOK
938 KING STREET RYE BR NY 10573 JUN - 3 2025
(914 _
www ov VILLAGE OF RYE BROOK
pl IiI nl�lr., nEr)i\P I IFN IT
xxxxxr>xx>xxxxnxxxxrxxxxnxxx*xxx*******�****,�xxxx*x,�****xxxxxxx�,�xxxxxxxxxxx�xxxxxx>x,:xxxxxxrxxxxxxxxx�
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 WESTCI4ESTER ) as:
I, ALBANO RUKAAND ILONA FAZEKA , residing at, 5 SUNSET RD I RYE BROOK, NY 10572
(Print name) (Address where you lire)
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;
5 SUNSET RD , 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.
(Signature of P perty Owner(s))
ALBANO RUKAAND ILONA FAZEKA
(Print Name of Property Owner(s))
Sworn to before me this 3
day of SON e , 20
(Notary Public)
SHARI MEULLO
Notary Public,State of New York
No.OIME6160063
Qualified In Westchester County
Commission Expires January 29,20 ZJ (2)
6/1/2024
This application must be properly completed in its entirety and must 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:
, being duly sworn, deposes and states that he/she is the applicant above named.
(print name of individual signing as the applicant)
and further states that (s)he is the legal owner of the property to which this application pertains, or that (s)he is the
for the legal owner and is duly authorized to make and file this application.
(indicate architect,contractor,agent,attorney.etc.)
That all statements contained herein are true to the best of his/her knowledge and belief, and that any work performed. or use
conducted at the above captioned property will be in conformance with the details as set forth and contained in this application
and in any accompanying approved plans and specifications, as well as in accordance with the New York State Uniform Fire
Prevention & Building Code, the Code of the Village of Rye Brook and all other applicable laws, ordinances and regulations.
By signing this application, the property owner further declares that he/she has inspected the subject property, and that to
the best of his/her knowledge there are no roof drains, sump pumps or other prohibited stormwater or groundwater
connections or sources of infiltration into the sanitary sewer system on or from the subject property.
Sworn to before me this Sworn to before me this
day of e , 20 day of , 20
Signatur ro Signature of Applicant
v R-U k4l,A-
rty Owner Print Name of Applicant
Notary Public Notary Public
SHARI MEULLO
Notary Public,State of New York
No.OIME6160063
Qualified In Westchester County
Commission Expires Jandary 29,20fl
(4)
6/l/2024
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N) iriir; SEP 3 0 2025
VILLAGE OF RYE BROOK
ELECTRICAL PERMIT APPLICATION BUILDING DEPARTMENT
APPLICATION
W estchester C ourth Ma-aster FlectriciYns License Required
TOR OFF RI t',F ()%I1 ,�itl' ?:: ��Jri�__I
Approval Date. _____a� Permit Fee:S ._...
,approval Signature: _ Othcr:
,ti!!Z*#=itt;its#�xfs#i 40si>ti*si ##t'/;##sa+ii##se*Ytt+RtXi+/ts#s#iM#3'#s#zss#i#iF#.#Rlsi##YR+R1t il t/l/la aA>Y♦
t)i)%0T%,T%1AT NNORK or C t)N.STR1 C.TION t lTII A 11117 14MIT 1I Vti off L (Ntit f D H% THE- III ILDING I;NNI'E:t_i_Uk._
I HF. AntllNihT(4 grit( FrT FOR %N()Rk T X f'f RMIT 1s 1:"_,l!t'_THE
T )Fht.Ctltil'ttf ('t►\�TRt ('TN)`�_1tlTti i 41t!�!\it'�I�t:f. t3f':+';t1.tN►
Application datedr l _ ,_k herrh., made to tint Building(tts(teCtor of the%illage tit Rye Brtxtk NY for tltc 6,-;Lu rtL ul
a Pemtit to in"I and or remove alecrrical equipment.wtring.fixtures,or to perforttt other hiith tx ILK% volme elei:Zical work as per
the dcuiled ctatemcnt described below. B) &telling this Jocuinent, the ttprlit:ani K rr►tpurt4 owtutr at_rrt:c that all ;IeCtric$1 %ork
performed K ill be in con i'ormancx with all aMlicable I cderal.State.CountL and Lmat Crudes.
L Address; ) ' SILL_ / —�- Zone:
2.1'tt pxm t nt r Addreis: -w — _
Phone st: - Celt Z;. - vrmail:
!.ht:utcr i tt ctri4itut't ittmetf iastalkr. ` `, Ad*fSS'
Ltr. Erne?:QI �,� ��' •(,1 yell i,tl l`0 _ entait: 100 0 {�
CcxnpaR} !�atnt. _ :�
4.Proposed Fletuital Work t ixtum Cou
5.1"1 farm Electrkial inNpection Agency
6tRwwtfftaf+tr.a♦ws•xk,Ei<3sas+-wf tsw�i}fwt�f i:rr+.,r►.F�'�i♦w♦w wwf Fww*rYwsft#wtw•tMstfifw twtM tr#w,.wwsafwsfKaswtti
MATT- )l:`FW YOKJt _COCN—TIr OF WLSICIti_STER
C tag awt, and etc s Thal lit: jkc c Utr altpacmu gxwr :nW,,X*d .wd a{t.,e.(urth;r
-Ki!,t s,Z1t"I d .:_ss.L A!If. •.,; At
,rate taut o-khe i,are ± _ :;tr the tc :,xu:ter•uri t,Jula twit-onud it,teak aral tik sin,-witcxnon.
,'%%,qc:f:ci'.sl.t F< i:.'St•at!'t•.i.aL.
I he taideragncd lual(s a ttic,.th u Ail uttttietted lwrrLl or trio:to tits Ht.t os !rt:twf atxl that my.�fwk
per94VW4L of u.e c,.r:darta'tl At the atvtt a C.gttatA,:d rralvna tc r11 he in c.mtexmsne.-A nIt tiw dcr ih-s,+c!torti,And ctxttat,1Kit in
lgy+ln yttaw!dial ra an) sulwlpuming a.,prtl1,:,l pf tr.,tred?plli�C 12Srttti iY M�'It iri.tvwrdzk-x%�iih the,ieu N'orl Staw l mif r9n t s,e
t'1'etL",th1i1;itW61i4au t•stC,!ttC.i_o&Of tn;Vill.t}.e 44 R%:c HUNIk at:.t ttr.3 ars.,uaJ trirruiaior_+.
Sum to twrim.Inc thic _ r2 6Aki t be rt M this
dM, of �- �P— Yu-- 1. dati t
�+. glia o •rty t�ii t; 'Lit a,Rpi nt
L D A- 0 L > .v t-, A-- -
Print Nantc of Vim,t_h,-nt-r_ to N, e App t it
hw►�i
�'rgt3t'� hlit: MubmanadRA111116
C mMi3*0 olUAOOM73 MARLENE R VARBEROh Ett a
Nobtty;Ptffil10SMaalfNowYork Notary Public State of New�mit
NO.OIVA0027388
My Commission.E)G Iratian:01/17/2029 Qualified in Westchester County
My Commission Expires Jul 31, 2028
STATE WIDE INSPECTION SERVICES, IN7
service I'lit
0•0 Main Street, Fishkill, NY.125241 Email:OFFICE@SWISNY.COM,
SWIS JOB APPLICATION tel 845.202.7224 1 fax 0.
Office Use Elect. Pei nit .� �' Date
Bldq Permit A .a
Su Ft
Plumbing Permit At
Final Certificate a
City/Village Zip Building Dept, Count4�,Vh",r
Address nir \, �-8 Cross Street J Section �1 Block Lot
Owner Name/Address of different than above) ��tE Contact Number l _ ,_O5
❑Basement ❑1st FI. ❑2nd FI. ❑3rd FI. ❑More Than 3 Fl. [:]Garage ❑Attic ❑Outside esidenhal ❑Commercial
Receptacles Special Recept GFCI AFCI Switches Dimmers Smoke Alarms C/0 Detector Hood Trash Compact
Amt Amps
Range(s) Cooktop(s) Oven(s) Dishwashers Refrigerator Disposal Microwave Luminaires Generator Transfer Switch
SERVICE
Amperage #Panels 11P 3P 4 Meters a Disconnect [—]Underground ❑ New ❑ Reconnect ❑Repair
❑Overhead ❑ Upgrade ❑ Disconnect
Utility iDtt []Con Ed ❑NYSEG ❑Central Hudson ❑Orange/Rockland I
PHOTOVOLTAIC SYSTEM 1
PV Modules Inverters AC Disconnect ]unction Box Combiner Box Load Center PV Monitor Energy Storage System DC Disconnect
)!-"-2 ah7ation ❑Safety Inspection ❑Consultation
ScApe of work
JD;
I,
I sEP 3 0 2025 L�.
�
� Vlt_I.',Gt. �. � �= BROOK
BUI_.DING t7EPARTNAIENT I
This appkadon is vaNd for one(1)year Rom the date received by WAS.this application is intended to cover the abo-listed stems to be inspected,M at any time of inspection additional items haste been Installed,you are
m authorized toake the inspection an d adjust the fee for the additional items snspected.The app7Kant declares that there is no open applicatsons for the above address with any other inspec tows company.The appikant.owner
or authorized agent agrees to all the above terms and conditions as set forth tor the applicatun
Email Addr 42 I n Nam
License Ar aa. Ddte11 ignature
Address City/Stat �,� Zip Code
Company ✓ �' Phone�F
I `I ! I State Wide Inspection Services
< Do
1080 Main Street
CAC Fishkill, NY 12524
11 U 845 202-7224 Phone
SWUS 914-219-1062 Fax
STATE WIDE INSPECTION SERVICES Email: office(&swisnv.com
VILLAGE OF RYE BROOK Website: www.swisny.com
Service With Integrity P.! III nlr,;r-, nPpn NT
pTIIIE
BY THIS CERTIFICATE OF COMPLIANCE STATE WIDE INSPECTION SERVICES
CERTIFIES THAT:
Upon the application of: Upon Premises Owned by:
Red Star Electric Corp. Albano Ruka
2 Hedge Row 5 Sunset Road
Congers, NY 10920 Rye Brook, NY 10573
Located at: 5 Sunset Road, Rye Brook, NY 10573
Sect-ion: Block: Lot: Electrical Permit Number: 25-240
135.73 1 22
Certificate Number: 2025-7043 Building Permit Number: BP25-214
A visual inspection of the electrical system was conducted at the Residential occupancy described
below.The electrical system consisting of electrical devices and wiring is located in/on the premises
at: 5 Sunset Road, Rye Brook, NY 10573
The Kitchen, Bedrooms, Hallway, Bathroom, Mechanical Room, was inspected in accordance with the
NYS and NFPA 70-2017 and the detail of the installation, as set forth below, was found to be in
compliance on the 10Th day of October 2025.
Name Quantity Rating Circuit Type
Kitchen
Receptacles 07
GFCI Receptacle 01
Oven 01
Stove 01
Dishwasher 01
Bedrooms
Switch 01
Receptacles 08
Smoke Detectors 01
Name Quantity Rating Circuit Type
Hallway
Smoke Detectors 01
Bathrooms
GFCI 02
Switches 06
Recessed Luminaire 02
Vanity 02
Exhaust Fan 01
Mechanical Room
Fan in A Can 01
GFCI O1
Mini Split HVAC System 01
AFCI 12
Officer: Frank J.Farina
This certificate may not be altered in any way and is validated only by the presence of a seal at the location
indicated.This certificate is valid for work performed on the date of inspection only.
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Plumbing Permit Application
Village of Rye Brook
938 King St Rye Brook, NY 10573
Phone: (914)939-0668 1 www.ryebrook.gov
Building Department
Project Information
SBL Zone:
R-10
Proposed Work:
Legalization of kitchen and two bathrooms,three fixtures for each bathrooms total of 6 fixtures for two bathrooms and two
fixtures in the kitchen one sink and gas line, total of 8 fixtures. mini split legalization were included in the previous application.
Indicate Fixtures&Lines to be installed as per the following schedule:
1st 2nd 3rd 4tiht Other gtWipment/Provide Details:
FIXTURES Basement or
Floor Floor Floor P20RWhroo�end one gasrlinne in the kitchen
Water
Closets 1
Urinals
Drinking
Fountains
Sinks 2 1
Showers 1
Bath Tubs 2
Laundry
Tubs
Domestic
Service
Fire
Service
Sanitary
Sewer
Natural/LP 1
Gas
Other* 2
TOTAL 10
Plumbing Permit Application,page 1/1
BR(ly� VILLAGE OF RYE BROOK
938 King St Rye Brook,NY 10573
W �
Q O� Phone:(914)939-06681 www.ryebrook.gov
�982'� Building Department
INSTRUCTIONS
THE PERMIT HOLDER AND/OR PROPERTY OWNER IS RESPONSIBLE FOR ENSURING THAT ALL REQUIRED/APPLICABLE INSPECTIONS ARE SCHEDULED AND THAT
THE PERMIT IS COMPLETE
0
REQUIRED INSPECTIONS
Name Description
Rough plumbing Installation of all plumbing including drains,waste,vents and water supply lines.A test for this portion is
required including a 100 psi test on all water supply lines.
Natural Gas Pressure Test 406.4.1Test pressure.
The test pressure to be used shall be not less than 11/2 times the proposed maximum working pressure,but
not less than 3 psig(20 kPa gauge),irrespective of design pressure.Where the test pressure exceeds 125 psig
(862 kPa gauge),the test pressure shall not exceed a value that produces a hoop stress in the piping greater
than 50 percent of the specified minimum yield strength of the pipe.
406.4.2Test duration.
Test duration shall be not less than 1/2 hour for each 500 cubic feet(14 m3)of pipe volume or fraction
thereof.When testing a system having a volume less than 10 cubic feet(0.28 m3)or a system in a single-family
dwelling,the test duration shall be not less than 10 minutes.The duration of the test shall not be required to
exceed 24 hours.
Plumbing final Installation of all CSA approved plumbing fixtures and hot water tank(water meter must be installed).A test
for this portion of the plumbing system may be required.
�y BRnv� VILLAGE OF RYE BROOK
938 King 5t Rye Brook,NY 105731
Q Phone:(914)939-06681 www.ryebrook.gov
j/ .�� ❑�t 7}'_itirr'
1962 Building Department
Plumbing/Legalization(Remodel) Permit
Permit Set 5 SUNSET RD P#RB25-0067 R#135.73-1-22
PERMIT INFORMATION
Address Permit number Date issued
5 SUNSET RD RB25-0067 10/17/2025
REVIEWED BY
If you have any questions regarding the review of these drawings please contact:
Application in general
Steven Fews
stevefews@ryebrook.org
INSTRUCTION AND ATTENTION
It is the responsibility of the Applicant to print full size the entire approved permit package and provide at the time of inspection.
TABLE OF CONTENTS
Cover page 1
Building Permit 2
Required Inspections 3
Plumbing Permit Application 4
Building Department.938 King St Rye Brook,NY 10573/Phone:(914)939-0668
BUIIla,
NT D I IE 0 V [E
VELOF, K BAN -2 2026
938 KINGY 10573
VILLAGE OF RYF� BROOK
BUILDING DEPAR-rMENT
APPLICATION FOR PERMIT TO INSTALL AND/OR REMOVE
HEATING,VENTILATION AND/OR AIR CONDITIONING EQUIPMENT
FOR OFFICE USE ONLY: PERMIT#:
Approval Date: Permit Fee: $ 200.00 •fb
Approval Signature: Other:
Disapproved:
(fees are non-refundable)
DO NOT START WORK or CONSTRUCTION UNTIL A PERMIT HAS BEEN ISSUED BY THE BUILDING
INSPECTOR.THE ADMINISTRATIVE FEE FOR WORK PROGRESSED OR COMPLETED WITHOUT A PERMIT IS
12%OF THE TOTAL COST OF CONSTRUCTION WITH A MINIMUM FEE OF$750.00
REQUIREMENTS FOR RELEASE OF PERMIT&CERTIFICATE OF COMPLIANCE:
1. Properly completed&Signed Application.
2. Site/Staging Plan if Required by the Building Inspector.
3. Copy of Contractor's Westchester County Home Improvement License,Liability Insurance.(Village of Rye Brook must
be listed as certificate holder)&Workers Compensation Insurance on a NYS Board form(Form#C105.2 or Form#U26.3/or
NY State Workers Compensation Waiver)
4. Payment of Fees/Unit: RESIDENTIAL=$200.00/unit•COMMERCIAL=$450.00/unit.
5. Complete specifications for each unit being installed.
6. Inspection by the Building Department for removal and/or installation.(48 hour notice required)
7. Electrical work requires a separate Electrical Permit&Electrical Inspection.
8. Plumbing/Gas work requires a separate Plumbing Permit&Plumbing Inspection.
Application dated, is hereby made to the Building Inspector of the Village of Rye Brook for a permit for the
installation and or removal of the HVAC equipment as listed below.The applicant and property owner,by signing this document
agrees that said equipment will be installed and/or removed in conformance with all applicable Local,County,State&Federal laws,
codes,rules and regulations.
1. Address: 5 SUNSET ROAD d- Z I Egz-e c SBL. 135.73-1-22 _Zone:
2. Property Owner: ALBANO RUKA Address:
Phone#: Cell#: 9144330520 email: albanoruka@gmail.com
3. Contractor:Mohamad Salameh Address: 134 Tomahawk st yorktown heights 10598
Phone#: Cell#: 9143497740 email: dynamicm005@gmail.com
4. Scope of Work:New Installation( )•Replacement( )•Removal( )•Other( ):
5. List Equipment:
CURRENT CODE
6. Location of Equipment: MECHANICAL ROOM Boiler
7. Method Of Installation/Removal(list all equipment needed to perform job):
1
7/l/2025
STATE OF NEW YORK,COUNTY OF WESTCHESTER ) as:
,being duly sworn,deposes and states that he/she is the applicant above named,
(print name of individual signing as the applicant)
and further states that(s)he is the Heating,Ventilation and/or Air Conditioning Contractor for the legal owner and is duly
authorized to make and file this application.
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.
Sworn to before me this Q Sworn to before me this
day of ,20 day of ,20
Signature of Property wner Signature of Applicant
ame of Property Ovper Print Name of Applicant
� � J
Notary PffiWl MELILLO Notary Public
NOTARY PUBLIC,STATE OF NEW YORK
N0.o1MEB160065
QUALIFIED IN WESTCHESTER COUM
,, tOm v4.SSKA EXPIRES JAW ARY 29,2(1�
This application must be properly completed in its entirety and must 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.
z
7rl i2o2s
ft- 3
9-,XF Alpine Home Air Products
—JHome Air Products`"
Address:1509 Coral Ridge Rd Suite A,Shepherdsville,KY 40165
Phone: (800)865-5931
https://www.alpinehomeair.com/
Date:2023.04.12
Type TC cable
Application
This cable is used for industrial power or control circuits where small diameter,flame retardant
cables are desired.Primary installations include cable trays,raceways,and outdoor locations where is upported by a
messenger wire.Conductors may be used at temperatures not to exceed 167"F in wet locations or 194°F in dry
locations.
Standard
UL 1277
Rated Voltage
600V
Construction
Conductor Stranded or solid copper
Insulation PVC/Nylon d(
Sheath Heat,Moisture and Sunlight resistant PVC
Conductor Insulation Nylon Sheath Overall Approx.
Cross Section of Construction Diameter thickness thickness thickness Diameter Weight
Conductor
(No./in) (in) (in) (in) (in) (in) (lb/FT)
4*14AWG 7/0.024 0.07 0.01 0.003 0.04 0.35 0.09
Feature:
Rated at 194*F dry, 167°F wet. Ripcord applied to all cables with jacket thickness of 60 mils or less.
Provides outstanding sunlight,cold bend and cold impact resistance.Offers the smallest cable O.D.
available for suitable applications. Provides long service life. Provides good oil and chemical resistance.
Meets cold bend test at-13°F.
Insulation Color:
4 cores: White/Black/Red/Green
Sheath Color:
4 cores: Black
Cut length and quantity
Wire length(ft) 25 35 50 65 125 250
Cable type 4*14 4*14 4*14 4*14 4*14 4*14
Number of packages 3744 2380 2308 1003 1018 427
Quantity per segment 93600 83300 115400 65195 127250 106750
Total quantity (ft)
4 cores: 591495
Packing
Make rolls according to specified length on the standard wooden pallet
Technical Specifications
Split-type Inverter
Sr No Parameter Unit Value
57 Indoor Unit Model -- BMKH09M-LM
58 Fan Type Cross-flow
59 Fan Diameter Length(DxL) mm m98x633.5
60 Fan Diameter Length(DxL) inch
61 Cooling Speed r/min 1350/1200/1050/750
62 Heating Speed r/min 1300/1150/1000/900
63 Fan Motor Power Output W 20
64 Fan Motor RLA A 0.09
65 Fan Motor Capacitor pF /
66 Heater Power Input W
67 Evaporator Form — Aluminum Fin-copper Tube
68 Evaporator Pipe Diameter mm y7
69 Evaporator Pipe Diameter inch
70 Evaporator Row-fin Gap mm 2-1.4
71 Evaporator Row-fin Gap inch
72 Evaporator Coil Length(LxDxW) mm 635x22.8x306.3
73 Evaporator Coil Length(LxDxW) inch
74 Indoor Unit Swing Motor Model — MP24HF
75 Swing Motor Power Output W 1.5
76 Fuse Current A 3.15
77 Set Temperature Range C 16--30
78 Set Temperature Range 'I' 61--86
79 Sound Pressure Level dB(A) 43/39t35/29
80 Sound Power Level dB(A) 5 3/4 914 513 9
81 Dimension(WxHxD) mm 894x291x211
82 Dimension(WxHxD) inch 35 13/64x11 29/64x8 20/64
83 Dimension of Carton Box(LxWxH) mm 943x349x278
84 Dimension of Carton Box(LxWxH) inch 37 8/64x13 47/64x10 60/64
85 Dimension of Package(LxWxH) mm 948x365x289
86 Dimension of Package(LxWxH) inch 37 21/6404 24/64x11 24/64
87 Stacked Layers - 7
88 Net Weight kg 11
89 Net Weight Ib 24.3
90 Gross Weight kg 13
91 Gross Weight Ib 28.7
Building Permit Check L &Zonin Anal sis
2Z
Address: U ` SBL:
Zone:A^ se: �A \0 Const.Type: V. Other
Submittal Date Z Re ' ions Submittal Dates: ( �7
Applicant O
Nature of Work % O 1 NA nF 1 N e(-) C
cG e V C-e 6 %.�w r t
Reviews:ZBA: AUG 12 25 PB: T: Other.
NEED K V
FEES:Filing: \_1�6 BP: /O: Flood Plane aliza 'on:_ , `
( ) ("P: Dated: Notarize&' SBI_ Truss I.D. Cross Connection: �� . 1- -\Wu
( ) ( ) Scenic Roads: Steep Slopes: Wetlands: Storm Water Review: Street Opening-
) ENVIRO:Long. Shore 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.
( ) ( COerase Workers Comps` Liability. Comp.Waiver. Other.
DE 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.
(yY ( ) 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.
( )ARB mtg. date: approval notes:
( )ZBA mtg.date: approval:- notes:
( )PB mtg.date: approval:- notes:
REQUIRED EXISTING PROPOSED NOTES APPROVF,6
Area 04-air: AUG 1 2' 2025
Circle:
Fronts e
Front:
Front:
Sides:
Rear.
Main Cov:
Accs.Cor.
Ft.H Sb:
Sd.H Sb:
GFA:
Tot :
Ft.Imy:
PA&jW.
Heiiaht/Stories:
no N S S
Z C C� < 7
.j
\,
tc,l �1 er
Neisf► George Latimer James Maisano
bounty
Westchester County Executive Director,Consumer Protection
Department of Consumer Protection
Home Improvement License
r >. NARSKA
41 BARKER STREET
MOUNT KISCO,NY-10549
This license is issued in accordance with Article XVI of the Westchester County Consumer Protection Code and is valid only upon
presence of the official department seal.Proof of citizenship or immigration status is not required for issuance of this license.
NOT FOR FEDERAL PURPOSES 1/I
• `01 Consu�Pe
ec ` A 1
License Number roF �� Date of Expiration '
c
WC-37280-H24 0 01/23/2026 .� ►(/
I hOsterCO I /i
� M
L"M IN U.t.A. -
Westchester
County
George Latimer
County Executive
Department of Consumer Protection
James h1aisano
llirecwr
January 25, 2024
Narska
Attention: Tomasz Mlynarski
License Number: WC-37280-H24
Dear Contractor:
A background investigation that was conducted in relation to your home improvement license
application revealed the following judgment as unsatisfied:
-See Enclosed—
Please respond in writing, to the attention of the individual listed below, as to the current status of this
judgment. The address for the department is listed at the bottom of this letter. If the iudgment is satisfied,
Please provide proof of satisfaction. If the judgment is not satisfied but a payment arrangement is in place with
the Plaintiff(s) please provide the documents substantiating the arrangement and proof of payment(s)
correlating to the agreement.
You must include a copy of this letter with the document(s).
Failure to provide the requested documentation before your next renewal may result in any future
Westchester County Home Improvement License application(s) being denied.
Respectfully.
Investigator Vincent A. Cassels
Senior Inspector— Home Improvement Licensing and Investigations Division
Westchester County Department of Consumer Protection
914-995-2158
Enc. (1)
1.`-�RECYCLE
1,18 Martine Avenue.loom 107
White Plains.New York 10601 Telephone:(914)995.2155 Fax:(91.1)995-5259 Website:consumer.weatchestergov.com
ACO09/08/2025YY)
R" CERTIFICATE OF LIABILITY INSURANCE DATE(M /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 CONTACT NAME: Nikki Blanchard
Blue Line Insurance Agency Inc A ONE x : (518)523 4321 AIC No): (518)636 4200
55 Bam Road E-MAIL nikki@bluelineagency.com
ADDRESS:
STE 204 INSURER(S)AFFORDING COVERAGE NAIC M
Lake Placid NY 12946 INSURER A: Evanston Ins Co
INSURED INSURER B:
Tomasz Mlynarski,DBA:Narska,Narska Build INSURER C:
41 Barker Street INSURER D:
INSURER E:
Mount Kisco NY 10549 INSURER F:
COVERAGES CERTIFICATE NUMBER: CL251806664 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 CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAYBE 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.
1LTR E TYPE OF INSURANCE INSD WVD POLICY NUMBER MMIDD/YYYY MM/DD/YYYY LIMITS
X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000
CLAIMS-MADE Fx_]OCCUR PREMISES Ea occurrence $ 50,000
MED EXP(Any one person) $ 10,000
A 3AA741798 01/03/2025 01/03/2026 PERSONAL BADVINJURY $ 1,000,000
GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000O-
POLICY JECT PRO ❑LOC PRODUCTS-COMP/OPAGG $ 2,000,000
OTHER: $
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $
Ea accident
ANY AUTO BODILY INJURY(Per person) $
OWNED SCHEDULED BODILY INJURY(Per accident) $
AUTOS ONLY AUTOS
HIRED NON-OWNED PROPERTY DAMAGE $
AUTOS ONLY AUTOS ONLY Per accident
UMBRELLA LIAR OCCUR EACH OCCURRENCE $
EXCESS LIAB HCLAIMS-MADE AGGREGATE $
DED I I RETENTION$ $
WORKERS COMPENSATION PER OTH-
AND EMPLOYERS'LIABILITY YIN STATUTE ER
ANY PROPRIETOR/PARTNER/EXECUTIVE ❑ N I A E.L.EACH ACCIDENT $
OFFICER/MEMBER EXCLUDED?
(Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $
If yes,describe under
DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached If more space Is required)
Certificate issued as proof of General Liability Insurance with respects to General Contracting services rendered.
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN
Village of Rye Brook ACCORDANCE WITH THE POLICY PROVISIONS.
5 Sunset Road
AUTHORIZED REPRESENTATIVE j--
Rye Brook NY 10573
@ 1988-2015 ACORD CORPORATION. All rights reserved.
ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD
NEW Workers' Certificate of Attestation of Exemption
STATE Compensation from New York State Workers' Compensation and/or
Board Disability and Paid Family Leave Benefits Insurance Coverage
"This form cannot be used to waive the workers'compensation rights or obligations of any party.**
The applicant may use this Certificate of Attestation of Exemption ONLY to show a government entity that New York State
specific workers'compensation and/or disability and paid family leave benefits insurance is not required. The applicant
may NOT use this form to show another business or that business's insurance carrier that such insurance is not required.
Please provide this form to the government entity from which you are requesting a permit,license or contract. This Certificate will
not be accepted by government officials one year after the date printed on the form.
In the Application of Business Applying For:
(Legal Entity Name and Address): Contractors License
Tomasz Mlynarski From:Westchester County
DBA:Narska
41 Barker St
Mount Kisco,NY 10549-1601
PHONE:845-249-5051 FEIN:XXXXX7634
Workers'Compensation Exemption Statement:
The above named business is certifying that it is NOT REQUIRED TO OBTAIN NEW YORK STATE SPECIFIC
WORKERS'COMPENSATION INSURANCE COVERAGE for the following reason:
The business is owned by one individual and is not a corporation. Other than the owner,there are no employees,day labor,leased
employees,borrowed employees,part-time employees,unpaid volunteers(including family members)or subcontractors.
Disability and Paid Family Leave Benefits Exemption Statement:
The above named business is certifying that it is NOT REQUIRED TO OBTAIN NEW YORK STATE STATUTORY
DISABILITY AND PAID FAMILY LEAVE BENEFITS INSURANCE COVERAGE for the following reason:
The business MUST be either. 1) owned by one individual; OR 2) is a partnership(including LLC,LLP,PLLP,RLLP,or LP)under
the laws of New York State and is not a corporation; OR 3) is a one or two person owned corporation,with those individuals owning
all of the stock and holding all offices of the corporation(in a two person owned corporation each individual must be an officer and own
at least one share of stock); OR 4) is a business with no NYS location. In addition,the business does not require disability and paid
family leave benefits coverage at this time since it has not employed one or more individuals on at least 30 days in any calendar year in
New York State. (Independent contractors are not considered to be employees under the Disability and Paid Family Leave Benefits Law.)
1,Tomasz Mlynarski,am the Sole Proprietor with the above-named legal entity. I affirm that due to my position with the above-named business I have the
knowledge,information and authority to make this Certificate of Attestation of Exemption. I hereby affirm that the statements made herein are true,that I
have not made any materially false statements and I make this Certificate of Attestation of Exemption under the penalties of perjury. I further affirm that
I understand that any false statement,representation or concealment will subject me to felony criminal prosecution,including jail and civil liability in
accordance with the Workers'Compensation Law and all other New York State laws. By submitting this Certificate of Attestation of Exemption to the
government entity listed above I also hereby affirm that if circumstances change so that workers'compensation insurance and/or disability and paid
family leave benefits coverage is required,the above-named legal entity will immediately acquire appropriate New York State specific workers'
compensation insurance and/or disability and paid family leave benefits coverage and also immediately furnish proof of that coverage on forms approved
by the Chair of the Workers'Compensation Board to the government entity listed above.
HEI EE Signature: " Date: l�
Exemption Certificate tuber Received
2024-004388 January 22, 2024
NYS Workers'Compensation Board
CE-200 01/2018