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HomeMy WebLinkAboutRB25-0028 w J VILLAGE OF RYE BROOK w �LA3 �a Building Department-Inspections 938 King St Rye Brook,NY 10573 1 Phone:(914)939-0668 Fax:(914)939-5801 1902 ' CERTIFICATE OF OCCUPANCY Occupancy granted date: 12/01/2025 Permit Number: R1325-0028,Issued on 10/10/2025 Visit result:Granted and fully completed Date of inspection: 12/01/2025 Parcel number: 129.76-1-46 Municipal Address: 233 TREE TOP CRES Legal Description: 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 height shall be made, nor shall the building be moved from one location to another until a permit to accomplish such change has been obtained from the Building Inspector. Additional information Occupancy permit description: ALL WORK COMPLETED FOR SECOND FLOOR HALL BATHROOM. Outstanding matters: • Jeannette Boccini Jeannette Boccini 233 Tree Top Cr,Rye Brook 233 tre top cr,rye brook +1914-419-5999 +1914-419-5999 jboccini@gmail.com jeannette.boccini@cbreaIty.com Inspected By: Alfredo(Freddy)DiVitto Building Inspector,Village of Rye Brook +19149390668 C O C `•+ O f9 a) L; N `O Y L Qj C 0 f• T R ❑ ❑ O \ Q/ QED a cu c v c e-1 M ` m ago Qo• ^ ra a'� Ln v -0 LL clS O O E O cu _c v Y a a L � O m E 7 w 'C L m F- n U L cl °1 E m U Z ui E °v L y LL a` a F- °' > a > Ld � ° O O m j �o +L' > Co ++ L O CU F- a � M � uj u L6 v y in o v M O LLJ I- r �c = o LLJa` � N = N 3 0 CIO z aZ Lo O \ O 0 ~ `o 5 :E N O w Y Y ry \ Y W w a o co: a c 0 0 O } � Y g v O N `p OL c Ow � � > 3E � Zm v � v am ° 3 ° �, cQ T�O W L v 0� O Z J V) E O o OHS N � 8 < c >M,.o" m 3 3 0 0 co > o a a Q o v o O Yw 3 W y aHm � Z � u u=� c o 0 = = a M CO v U Q a c o o E a �N/ o C") � J a z L s O � s o ° M � Y O �`) � u, O aoU 0 -a � ° y > LL 00r-i Q� `ni o w v yEO Ln C, Z : O N Ul) 'o Ln � W EJ U Q E to E J a � � - � [_-- M-J 0 -0 a > = 0 --- = a O .o a� > 3 - � a > 1: �6 w \ E— mo cr N � Z E � O � zvU- voo w r+ p = � c a s ° >— C? 00 Y ' E - Co Ln >COO4 -C c U F- LU v � s (+) N L a c4 r-I O Q c Ln N e1 Q N J 1-4 N O o L ° N �'� E °c '- ° v m Oppa-0 t O a2 -2 , E WO O a v> m E ° i `° v ry V ° -O � g _ s � � a � 0 � v >-LA > S LJJ W 92 0 Q `- a U H e E rd w 0 Q Q z D .T � °s Q a a = vai ►�- v K Interior Building 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 Address Line 2 233 Tree Top CR Proposed Improvement Bathroom renovation-Remove tile and fixtures and replace same location. Does the proposed project involve a Home-Occupation as per§250-38 of Village Code? ❑ Yes 0 No Will the proposed project require the installation of a new, or an extension/modification to an existing automatic fire suppression system? (Fire Sprinkler, ANSL System, FM-200 System,Type I Hood, etc...) ❑ Yes 0 No N.Y. State Construction Classification N.Y. State Use Classification Occupancy Pre-Construction 1 family Occupancy Post-Construction (1 fam., 2 fam.,comm.,etc...) What is the total estimated cost of construction: (NOTE: The estimated cost shall include all labor, material, 17000 USD scaffolding,fixed equipment, professional fees, and material and labor which may be donated gratis.) Interior Building Permit Application,page 1/1 �y BRnv� VILLAGE OF RYE BROOK O� � 938 King St Rye Brook,NY 30573 .$ W Q Phone:(914)939-0668 1 www.ryebrook.gov ��• b2• i Building Department Residential/Interior(Remodel/Renovation) Permit Permit Set 233 TREE TOP CRES P#RB25-0028 R#129.76-1-46 PERMIT INFORMATION Address Permit number Date issued 233 TREE TOP CRES RB25-0028 10/10/2025 REVIEWED BY If you have any questions regarding the review of these drawings please contact: Application in general Alfredo(Freddy)DiVitto adivitto@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 General Contractor's Home Improvement License-Westchester 4 Property Owner/Homeowner Government ID,and/or Proof of Ownership 5 Contractor's Liability Insurance 6 Application Materials 7 Application Materials 8 Interior Building Permit Application 9 Building Department.938 King St Rye Brook,NY 10573/Phone:(914)939-0668 �y BRO VILLAGE OF RYE BROOK 04 �' 938 King St Rye Brook,NY 10573 W Q Phone:(914)939-0668 I www.ryebrook.gov > �O 1 02 Building Department INSTRUCTIONS THE PERMIT HOLDER AND/OR PROPERTY OWNER IS RESPONSIBLE FOR ENSURING THAT ALL REQU IRED/APPLICABLE INSPECTIONS ARE SCHEDULED AND THAT THE PERMIT IS COMPLETE REQUIRED INSPECTIONS Name Description Final Inspection Completion of all required items under the permit including the site grading and the surveyor's final grading certificate. BUILD NT V E OF R OOK 938 lutvG ET RYE NY 10573 ov ###s#ss####ss#*#�tsssss####s#ss###s###s#ss#sst#ss#######s###ssk#s#ss#s##s##ss#s#,t###sssss,k#sswssssssssss 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 WILDING 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: I. s CAEA A/t� VOCCIAP ,residing at, SAf (Print name) (Address where you li,,e) ;Ly /ps73 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; ,Z�i �P �L/7/ ,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 roperty Owner(s)) L jffl-��cJ t�/1/�• �Cx'ci�� (Print Name of Property Owner(s)) Sworn to before me this day of V� 20 XS (Notary Public) SHARI MELILLO Notary Public,State of New York No.OiME6160063 Qualified In Westchester Count (2) Commission Expires January 29,20Li C O �$ra• N c a N ova 00 v c `o ❑ ❑� O L ? > U •� \ C E a C a) C L a ova, cz E to a a Ln v Z � � — W o H ( Ln w �n „ a v W L E 'o LL X LA a o w LJJ c m `° a > - � H O LLI u ^ mo t y Z W H s �c c o W Ln = N Y N Z F- 3 E `O 0 � � � } N QO s >O M a, Q Z L H 0 > r o a L LV Y Y • W w G p Y C , _ O Z •� 0 a m W 0 y N r a � }LLIL N NZ r < ra rl- 'o ULn g > m C (A 0 2 06 turn o a a 0LLLJ � Q ? 0 flZ OZQ QQ � 2 o OC �O m J p c o ro E a � Ln V) ( c NJ-,0 Ul) Y Y .0-+ 3 v 0 Z 0 W -M. 0 0 W �� 0 C L O O w 3 t o a } p� H m c 3 °cYv 2 � M �, w0 oos 0 -0 aci LL 0M � �J a � Co d Z kn � L WO� v N CMS � d ai s x co 0 (� • W E v � Ln NQ Cy c c y g LL m NNN UJ uQEOpa, J V — L >i L fC J O f0 CL 0 Z E 0 _ > u m 0 Z w O C w � ul } o �, c Ln H C , th cn 0 a 0 v 3 m' C') (N oaf (") > ,V H Q Wy O yam+ Ln N .� Q V N J r4 o � y o N N acc 0 ° v .V m ` .D E -2 ,t' ❑. +j W u° s a0) a) V ° � °' � oo -0 _ E NSW YaP — 0 � O; 7m -0 a, a L i > E -b c LLj W J W O Q } a a�i ao as v) o DC u ° � v Y a' a L y �d �r w 0 Q Q 00y aw u y0 39`�1� a Q a a x H � Q) P fir. Electrical 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 Proposed Electrical Work/Fixture Count 3rd Party Electrical Inspection Agency New York Electrical Inspection Services Master Electrician/Licensed Installer Information Name Lic# Address email Phone# Cell# Christopher 1255 26 Heath Road Tmcelectric22@gmail.com 9144474203 Company Name Company Address TMC Electric Contracting LLC 26 Heath Road Road Valhalla NY Address of Work? Homeowner Information 233 TREE TOP CRESCENT RYE BROOK NY 10573 Electrical Permit Application,page 1/1 O�iy 4RC�,'. VILLAGE OF RYE BROOK . ■ W P 938 King St Rye Brook,NY 10573 Phone:(914)939-0668 1 www.ryebrook.gov /� 1902 Building Department Electrical/New Fixtures And Wiring(Remodel)Permit Permit Set 233 TREE TOP CRES P#RB25-0054 R#129.76-1-46 PERMIT INFORMATION Address Permit number Date issued 233 TREE TOP CRES RB25-0054 10/09/2025 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 3rd Party Electrical Inspection Form 4 Electrical Permit Application 5 Building Department.938 King St Rye Brook,NY 10573/Phone:(914)939-0668 �y BR(�k VILLAGE OF RYE BROOK O� P 938 King St Rye Brook,NY 10573 W � Phone:(914)939-06681 www.ryebrGok.gov > �O ��• b2•`i Building Department INSTRUCTIONS THE PERMIT HOLDER AND/OR PROPERTY OWNER IS RESPONSIBLE FOR ENSURI NG THAT ALL REQU IRED/APPLICABLE INSPECTIONS ARE SCHEDULED AND THAT THE PERMIT IS COMPLETE o a a REQUIRED INSPECTIONS Name Description Rough Electric Rough Electric Final Electric Final Electric STATE WIDE INSPECTION SERVICES, INC. CA-,�) Serivice 14ith lnlegri�y 0.0 • • swis JOB APPLICATION tel 845.202.7224 1 fax 914,219.1062 1 SWISNY.comi SWISTRAININGCom', Office Use Elect. Permit# Date Bldg Permit# K 13,2.-5 .-0 0 5 Sq Ft Plumbing Permit# Final Certificate# City/Village If YE f��U6 Zip i 0-5 73 Building Dept. ��¢3.000 K County Address -33 1z'36 6111?AScew r ross Street Section Block Lot Owner Name/Address(if different than above) T;FA*1/e71-2F 50,-C/N l Contact Number ❑Basement ❑1st Fi. ❑2nd FI. ❑3rd FI. ❑More Than 3 FI. ❑Garage ❑Attic ❑Outside Residential ❑Commercial Receptacles Special Recept GFCI AFCI Switches Dimmers Smoke Alarms C/0 Detector Hood Trash Compact Amt Amps r A Range(s) Cooktop(s) Oven(s) Dishwashers Refrigerator Disposal Microwave Luminaires Generator Transfer Switch SERVICE Amperage Panels 11P 3P # Meters #Disconnect ❑underground ❑ New ❑ Reconnect ❑ Repair ❑Overhead ❑ Upgrade ❑ Disconnect Utility ID# [-]Con Ed ❑NYSEG [:]Central Hudson ❑Orange/Roddand PHOTOVOLTAIC SYSTEM PV Modules Inverters AC Disconnect Junction Box Combiner Box Load Center PV Monitor Energy Storage System DC Disconnect []Legalization ❑ Safety Inspection ❑Consultation Scope of work Ttds application is valid for one(t)yew from the date received by SMS.This application Is intended to cover the above listed items to be Inspected if at any time of inspection additional items have been instaaed you ate authorised to maYethe irrspectlon and adjust the fee for the additional Items Inspected.The applicant declares that there is no open applications for the above address with any other inspection compary.The appscantmvnec or authorized e•nd aWen to aM the above terms and conditions as set forth for the application. Name Luse#�0'/� fj' Date signature �ldr Address (� /`fail � �� City/State XW1 46VL4.4 1 zip Code �Q l✓—�1� Company 7M4! iLOe770/ L C I Phone# 5/¢ -'s#7 4;2 State Wide Inspection Services NOV , 2 1080 Main Street ``� � Fishkill, NY 12524 845 202 7224 Phone 914-219-1062 Fax STATE wIDE INSFEC110N;f Rvl<f5 Email: office@swisny.com Website: www.swisny.com Service With Integrity BY THIS CERTIFICATE OF COMPLIANCE STATE WIDE INSPECTION SERVICES CERTIFIES THAT: Upon the application of: Upon Premises Owned by: TMC Electric Contracting, LLC Jeannette Boccini 26 Heath Road 233 Tree Top Crescent Valhalla, NY 10595 Rye Brook, NY 10573 Located at: 233 Tree Top Crescent, Rye Brook, NY 10573 Section: Block: lot: Electrical Permit Number: 129.76 1 46 —_ i Certificate Number: 2025-7973 Building Permit Number:RB25-0054 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:233 Tree Top Crescent, Rye Brook, NY 10573 The Second Floor: Bathroom 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 12"'day of November 2025. Name Quantitv Rating Circuit Type Bathroom Fan 01 Switch 02 GFCI receptacle 01 LED Light 01 26 inch Vanity fixture 01 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. 1.0 c O ❑�P�d` N a O � N N o - CL) ° pl �, O o 0 0 o � � >. u a E a O iCCL c to i ^ v -0 aj ii cz E o to 4-j a Q v `0 E W v � TE c m Q� OC a} `° in E v a a w ; a; v � H N o a o LLi LJJ m v a aci V > O v L a� H- W ua, A 'o w 04 = N 3 o -, ° ,� H O ~ Z Y 3 ~ O ° Q } �/ N QO �' � o � ai d0 \ L U u s Z L Q� H o > �, u +, NYC N LLJ F- LLj a ° ,� 0E O O cn $ ++o } C Ow pa > 3 °0� -m , 3: 0 CC 5.LLJ J � ° a owL N EviO m , U Uc ° a Q co Q Yw — W m pZ OZ � u (A 'n > 0 W � Q) 4. Y u a Q E O 41 Q) O Q 0 � 'oo Q N o Q) 0 da Y .2 y \ ) m N O N y C m N w u m c v W U as (n a � co 0 Z � ' i ce O O P } Za o OM > O ] >� � � y a` � Na' u Ln w0 oo 0 E a, v ,- ti Cp Z O, m W mo o ° E 0 c) o% w d�n 'm Z 4n a wa` " u 0of Hd a, I s 'X 'ow X Ln .� O N vvic C7 w U � w Q o � O � vc ( � V Q E E oo E LL C. p N m 5 ONO O E _ > L Z O O 41 c� d N w C �-vm0wH u f° LU sC� yr o o cu au E avEOoM L- � '3Zuy u >M 0) Cns co N aN WNc c i LN e-I C-4 o oE0 N flo 2 p -0 v .o� ° Q E ooa0m = W g V wmp � ° E p v c # 0 o c tom v NEWyp� 0 ` ° > E - c C W J W O O } Co pp. L w W 0 u H N � gyp�9d��\C a Q a a 'O Q LAv .� x V) �- a� 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: Proposed Work: Replacing fixtures first floor bathroom tub toilet and sink Indicate Fixtures&Lines to be installed as per the following schedule: 1st 2nd 3rd dtifit OthergfWipment/Provide Details: FIXTURES Basement Floor Floor Floor Floor Floor Exterior Water Closets 1 Urinals Drinking Fountains Sinks 1 Showers Bath Tubs 1 Laundry Tubs Domestic Service Fire Service Sanitary Sewer Natural/LP Gas Other* TOTAL Plumbing Permit Application,page 1/1 BR�k VILLAGE OF RYE BROOK 2 938 King St Rye Brook,NY 10573 Phone:(914)939-0668 1 www.ryebrook.gov ��• 02• f Building Department Plumbing/New Fixtures And Lines(Replacement) Permit Permit Set 233 TREETOP CRESCENT P#RB25-0037 R#129.76-1-46 PERMIT INFORMATION Address Permit number Date issued 233 TREETOP CRESCENT RB25-0037 10/09/2025 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 BRnu VILLAGE OF RYE BROOK 938 King St Rye Brook,NY 10573 W Q Phone:(914)939-0668 1 www.ryebrook.gov >>��• t 02 •`i�o Building Department INSTRUCTIONS THE PERM IT HOLDER AND/OR PROPERTY OWNER IS RESPONSI BLE FOR ENSURING THAT ALL REQU IRED/APPLICABLE I NSPECTIONS ARE SCHEDULED AND THAT THE PERMIT IS COMPLETE ❑� R1 L ti REQUIRED INSPECTIONS Name Description Final Inspection Completion of all required items under the permit including the site grading and the surveyor's final grading certificate. 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. � \\��`• A ,;ii� �_ ;._ .1�1' ♦ � IJ�J�����TV '1 I'�I�i� r.e*f�.�j•`1'•��'�n �' po�'� "^".0���/�Yr'• � II� r � ��� II�'II _•$ ..Y�., Ili.I�6Gt> -� -� � �µ�, ��/� T � � tA �► O �• +•+ CNI I ,,• •71c c, - C14 Cl y 4.1 �yyy� )>/ y !1 � � III ��.•p�q'� . Oe y ❑ on CO •PWui Z M U n •� ; " Z tie n .. U W �1 W N O E PdoG •� •cr i�l N X Z � � •�, Y cvtl � � � I y�i .� LB ty. •� O � c— 1.," / co Ib IJ / �IIA�f 4, i1kTl11 N 1 '( ^II�''. 1�1 11 zs aC i• T�t.�, , •� �}k, l 1 � RVEig 1Iggtrsi•s� ootAt "v'.'Ali:'�6Yk<atlHi".i:d.'f.•Yi' 'w, ,•4..'Y � :Y_.. ♦h 4�;.tOw: �' "aU �:, 1.�lD�:i ` p �.A.. �(�''.(�:i 1 ® DATE(MM/DD/YYYY) ACORN CERTIFICATE OF LIABILITY INSURANCE 09/16/2025 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: Progressive Advantage Agency PHONE FAx (A/C.No.Ext):1-888-302-8533 lac Not 300 N Commons Blvd E-MAIL Box W9G ADDRESS: INSURERS AFFORDING COVERAGE NAIL# Mayfield Village,OH 44143 INSURER A: Utica First 15326 INSURED INSURER B. Kozee Contracting Inc INSURER C: 214 Etville Ave Yonkers,NY 10703 INSURERD: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 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. ILTR TYPE OF INSURANCE ADDL SUER POLICY NUMBER MM/DDPOLICY EFF MWDD POLICY EXP LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1 non non CLAIMS-MADEX OCCUR PREMISES Ea occurrence $ A MED EXP(Any one person) $ 5000 N N ART3001682720 07/08/2025 07/08/2026 PERSONAL 8 ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY JECTPRO LOC PRODUCTS-COMP/OP AGG $ X OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY(Per accident) $ HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY Per accident UMBRELLA LiAB OCCUR EACH OCCURRENCE $ EXCESS LIAB Id CLAIMS-MADE AGGREGATE $ DED 1 1 RETENTION$ $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY Y/N STATUTE ER ANYPROPRIETOR/PARTNER/EXECUTNE E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? ❑ N/A (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 I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) CERTIFICATE HOLDER CANCELLATION Village Of Rye brook Building Department 938 King St SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Rye Brook,NY 10573 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE S,g—d by. uilf• ©19 -'W3EAd5RD CORPORATION. All rights reserved. ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD E 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): Building Permit Kozee Contracting Ina 214 Etville Ave From:Village of Rye Brook Yonkers,NY 10703-1042 PHONE:914-3764164 FEIN:XXXXX2625 The location of where work will be performed is 233 tree Top Cresent,rye Brook,NY 10573. Estimated dates necessary to complete work associated with the building permit are trom October 14,2025 to May 4,2026. The estimated dollar amount of project is $10,001-$25,000 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 a one person owned corporation,with that individual owning all of the stock and holding all offices of the corporation. Other than the corporate owner,there are no employees,day labor,leased employees,borrowed employees,part-time employees,other stockholders,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.) I,James R.Kozee,am the President 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. SIGN Signature: Date: HERE Exemption Certificate Number Received 2025-078124 October 6, 2025 NYS Workers'Compensation Board CE-200 01/2018