Loading...
HomeMy WebLinkAboutRP25-0010 c O CN � . N oY L I-- . L 00 a,04 +� crE � n v v c v aj ii a, cw v c aQ :3 v aj E LEIcl c m 1 cn -an v d w a; a, U- X N N a s uj c 4-j LU m C c .� >O v L a�>i a, H -n W u v t `n Z u.lF- t Y = o L N H N 3 Z5 O Ln HZ m > c3 Q } °�� N QD u u -C a C ~ ° >'o DY CCN 0 � w a -E 0, ° •E Y c L O ` O aZ Ow `O oo 03EZ uvm + oc nO oiW N � } � U 3Y NZ) $ aao m O 3 v O �a) 0 2 " m >'C YW — LLJ0 LU co �� m DQZ } u � �� o o � N � ccn � dJ a o o f0 v a mNO N a 0` NCL W u m � v 'a � •— O Z p LLJ - LLJ � `cLU w z r uwYa U > oai LL ooa >Ow a)Mff � O ' o - a ELL O. Z a v LUi � oa o O U � Q � 0 wU 0 Qo tc � cy Q Q) ( N Zocn °� � w � _ > ° m0 N L L � O a a) 00 O w N � �cu4* c as }cu o LU ,tO � > N C N Q Z Z u v 3 m N a NN Q W u F- � > p c c'M .-1 a CL � dJ � N 0 + 0 u p, c 0 a� r 00 a� W Doa V � � � oM0 � � C oo :2cEv NEWYO� 0 boa > -5 a a,0 N c ' E � c%1 a - c G N00 JLLj W O p } a y d ol C U C Cl E u v Yd �r W Q Q z0 :E' a ai u y� �9d1� a Q a a my - vy CP Yi i f Roofing 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: Construction Type: NYS Construction Class: PUD VB VB If corner property, indicate street frontage no Job Description, list all Methods& Materials: Roof Removal and Replacement Number of stories Height Roof Type Peaked Is garage being re-roofed: attached? 0 Yes ❑ No ❑ Yes ❑ No Number of Cars: Estimated Cost of Job: (NOTE: The estimated cost shall include all site improvements, 7200 abor, material, scaffolding,fixed equipment, professional fees, nd material and labor which may be donated gratis.) Estimated date of completion: 11/20/2025 Roofing Permit Application,page 1/1 BR VILLAGE OF RYE BROOK O� 7' 938 King St Rye Brook,NY 10573 � W .� Phone:(914)939-0668 1 www.ryebrook.gov ��• b2• i Building Department Residential/(Roofing) Permit Permit Set 35 GREENWAY LN P#RP 25-0010 R#129.84-2-24 PERMIT INFORMATION Address Permit number Date issued 35 GREENWAY LN RP 25-0010 10/28/2025 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 Roof Work Proposal 4-9 Roofing Permit Application 10 Building Department.938 King St Rye Brook,NY 10573/Phone:(914)939-0668 ey BR�� VILLAGE OF RYE BROOK 938 King St Rye Brook,NY 10573 W Q Phone:(914)939-0668 1 www.ryebrook.gov O >��• 19p2 • i� 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 r � 3fi I . REQUIRED INSPECTIONS Name Description Certificate of Occupancy Completion of ALL Work,All fees Paid and Final Survey in if required) ZV* PERRY'S ROOFING EXTERIOR SIDING I GUTTERS 12 Center Street Pleasantville, NY 10S70 info@perryverroneroofing.com Office: (914)747-7663 Fax: (914)747-7665 License WC 21701 H09 10/6/2025 Prepared by Perry Mary McCabe 35 Greenway Lane Rye Brook NY 10573 (914) 217-0032 nestfinder4u@gmail.com PROPOSAL ROOF REMOVAL AND REPLACEMENT • All landscaping and exterior belongings to be protected as best as possible,before the start of work • All existing asphalt roofing removed and carted from job site • All rotted plywood replaced at$90.00 per sheet • GAF Weather Watch Ice and Snow barrier installed on all gutter edges,valleys and around skylights (6 feet up) • GAF TIGER PAW paper installed on the entire field of roof • GAF LIFETIME Timberline Architectural HDZ shingles installed on entire field of roof (SHINGLE COLOR: ) • GAF Cobra Ridge vent installed on all ridges of roof for attic ventilation • GAF TimberTex hip and ridge shingles installed on all ridges • Closed valleys fashioned with shingles • Aluminum vent pipe boots installed over all vent pipes • BROWN Aluminum drip edge flashing installed around entire perimeter of roof • GAF Weather Blocker starters installed on all perimeter edges • GAF Lifetime Material Warranty included • Perry's Roofing"10 Year Workmanship Warranty"included • Rye Brook Building Permit for an additional cost TBD The price for the aforementioned work,which includes labor and material (excluding any additional plywood),totals to the sum of: $7,200.00 Page 1 of 6 M.M. 10/20WIrrDate: ADDITIONAL WORK OPTIONS Please check appropriate box for desired extra work Copper chimney flashing fabricated and installed for an additional $1,275.00 Aluminum Seamless Gutters and Leaders fabricated and installed 0 6-inch gutters and 3x4 leaders (brown) for an additional $1,800.00 o Gutter screens installed for an additional $375.00 Timberline UHDZ (Ultra High Definition) shingles installed for an additional $28.00 per square -1 Perry's Roofing is a GAF Master Elite Installer which allows us to offer you top of the line warranties directly from GAF for a minor additional one-time cost: ■ GAF Golden Pledge Warranty (50 Years Materials & 25 Years Workmanship) for an additional$ ADDITIONAL WORK NOTIFICATIONS Work that may be performed if needed to complete scope of work listed in proposal Carpentry/handyman work calculated on a time and material basis,said work performed at$120.00 per man hour plus material, if necessary Step and/or Wall flashing fabricated and installed to meet current building code standards (aluminum or copper) for an additional cost TBD, if needed M.M. Page 2 of 6 10/20/?A?§ & Date: PRICE EXPIRES 30 DAYS AFTER ESTIMATE DATE Payment schedule is as follows: 50% Deposit Due with Signed Contract and No Later Than 3 Days Prior to Start 50% Due the Day of Substantial Completion Payment is accepted via: i) ACH /wire transfer and ii) personal and certified bank checks (made payable to Perry Verrone LLC or Perry's Roofing). Payment by credit or debit card (MasterCard,Visa,American Express,and Discover) may be made upon request and subject to a 3.0% service charge. Any balances outstanding 30 days after the final invoice is delivered will begin to accrue interest at a rate of 1.5% per month, or 18% per annum. All material is guaranteed to be as specified above. All work to be completed in a workmanlike manner according to the standard practices.Any alteration or deviation from the above specification involving extra costs will be executed upon a written change order and will become an extra charge over and above the proposal.All agreements are contingent upon strikes, accidents, or delays beyond our control. All work will be performed with the expectation that the existing structure meets all building code requirements, and Perry's Roofing will not be liable for any damage occurring due to deviations of current building code in the structure. Commercial magnets to be used for nail removal at all surrounding work areas and driveway, post completion of work. Perry Verrone, LLC will respect and implement all required NYS &OSHA safety protocols. Perry Verrone, LLC is fully insured and carries NYS Labor Law Coverage (Scaffolding law). Page 3 of 6 M.M. 10/20 AWS Date: INSTRUCTIONS FOR HOMEOWNER INSIDE THE HOME: 1. Any precious items in the attic can be either moved to a secure place within the attic or covered and secured to protect from the vibration of the roof removal process. 2. Dust and/or sawdust may be generated in the attic due to the roof removal process, securely covering belongings is advised. Clean- up of debris in the attic is outside the purview of this contract. 3. If your home has high hat lights located in the cathedral ceiling,you may want to tape the fixture to the ceiling(construction activity on the roof may cause these to come loose). 4. If you have cathedral ceilings, although it is not common, on occasion, some nails may be prone to "pop"-thus exposing the head of the nail through the sheetrock. This is unfortunate but is not the responsibility of Perry's Roofing. 5. Perry's Roofing is not responsible for any necessary electrical work required for powered products installed,a licensed electrician must be consulted. SKYLIGHTS: 1. If you have opted for a skylight replacement, please consider that the skylight manufacturer's dimensions have changed over the course of the years,which may alter the interior placement of your new skylight. There may be interior trim work required to remedy this condition. This is not part of the roofing contract. 2. Items below the area of skylight replacement should be moved or covered during this work. 3. Please be aware that Perry's Roofing does not guarantee skylights against leaks that we have not installed new and hence they will not be covered by any warranty issued from us. MULTIPLE LAYER OF ROOFING REMOVAL: 1. Upon removal of multiple layers (2-3),there maybe a space between the new roof and the sidewall of your home (siding,stucco, stone,brick). This area may need attention post roof replacement and is not included in the work,unless otherwise specified. Please consult your estimator to inquire if this may be the case for your home. OUTSIDE OF THE HOME: 1. Outside your home we make every attempt to ensure that we protect your shrubs and belongings. It is the homeowner's responsibility to help us by removing smaller objects, lawn ornaments, outside furniture, etc.,that you can handle, or that may be valuable, to a secure place. Larger items,such as picnic tables, please notify our company before the start of work and we can arrange for our workers to move to a secure location and replace them upon completion if time is allotted. Please notify us if the moved items are not replaced and we will schedule a time for them to be returned at your convenience. 2. If our company is not notified of larger items that should be moved, Perry Verrone LLC will not be held responsible and any damage that occurred will be held to the homeowner's responsibility to rectify. 3. Let us know if there is a power source outside that we can use. 4. Let us know if there are any special precautions regarding any item, or situation,that we should be aware of outside,prior to starting. DUMPSTER: 1. If a dumpster is necessary, it will be placed in your driveway the day before or the morning of the scheduled work. Please be sure to move any vehicles out of the garage and driveway to avoid being blocked in. The dumpster may not be removed the same day of completion. Page 4 of 6 M.M. 10/20/262k-1;31&Date: NOTICES TO HOMEOWNER Right to stop work: If any payment under this agreement is not made when due, Perry Verrone, LLC may suspend work on the job until such time as all payments due have been made. Notice of Lien: The contractor or subcontractor who performs on the contract and is not paid may have a claim against the owner which may be enforced against the property in accordance with the applicable Lien Laws. Cancellation: The owner has an unconditional right to cancel the contract without penalty until midnight of the third business day after he/she signs the contract. Cancellation must be done by giving Perry Verrone, LLC, a written notice indicating the owner's intention not to be bound by this agreement. Upon cancellation, any property traded in,or payments made under this contract will be returned within 10 business days following the receipt of the cancellation notice by Perry Verrone, LLC. If a scheduled job is cancelled,the deposit will be returned net of a scheduling and material restocking fee equal to 7.5% of the contract value. Acceptance of Proposal: I have read the introductory packet along with this document and accept the specified conditions as stated,and the prices associated with such. I understand that upon signing this proposal, all documents presented become a binding contract. You are authorized to do the work as outlined. Payment will be made as indicated above. e-Signed by Mary McCabe 10/20/2025 Signature Date M.M. Page 5 of 6 10/2WA Date: GAF � � �• � . - GAF LAYERLOCK - � TECHNOLOGY 21 at e T 1 �. •�- �,s r ..� � cam'' "rt,-a�•,�r. � ,! • • • • •• 00 • • 2 tia Timberline® HDZ'm Shingles Benefits: Product details: Is LayerLock"Technology—Proprietary durability, strength, and exceptional Product/System Specifics technology mechanically fuses the wind uplift performance. ■ Fiberglass asphalt construction ■ Dimensions(approx.):13 Y<'x 39 V common bond between overlapping is StainGuard®Algae Protection— (337 x 1,000 mm) shingle layers. Helps protect the beauty of your ■ Exposure:5 5/e(143 mm) ■ Bundles/Square:3 ■ Up to 99.9%nailing accuracy— roof against unsightly blue-green ■ Pieces/Square:64 The StrikeZone'"nailing area is so algae discoloration' ■ StainGuardOO Algae Protection easy to hit that a roofer placed 999 ■ Hip/Ridge:Ti m berTex@';TimberCrest'"; ■ High Performance—Designed Seal-A-Ridge ,ZORidge;Ridglass out of 1,000 nails correctly in our test. ■ Starter:Pro-Start3:QuickStarte: with Advanced Protection®Shingle WeatherBlocker" • WindProven' Limited Wind Technology. Warranty—When installed with Applicable Standards&Protocols: ■ Seamless compatibility—The new ■ UL Listed to ANSI/UL 790 Class A the required combination of GAF ■ State of Florida approved Accessories,Timberline"HDZ'" Timberline HDZ' Shingles are com ■ Classified by UL in accordance with Shingles are eligible for an industry patible with traditional Timberline HDI ICC-ES AC438 Shingles for the same look and feel ■ Meets ASTM D7158,Class H first:a wind warranty with no ■ Meets ASTM D3161,Class F 2 homeowners and contractors rely Meets ASTM D3018,Type 1 maximum wind speed limitation. on for beauty and endurance." Meets ASTM D34625 ■ Our legendary Dura Grip'sealant ■ ICC-ES Evaluation Reports ■ Perfect Finishing Touch—For the ESR-1475 and ESP-3267 pairs with the smooth microgranule best look, use TimberTex,'Premium Meets Texas Department of Insurance surface of the StrikeZone"nailing Ridge Cap Shingles or TimberCrest" Requirements area for fast tack.Then,an asphalt-to- ■ ENERGY STAR Certified(White Only) Premium SBS-Modified Ridge (U.S.Only);Rated by the CRRC;Can asphalt monolithic bond cures for be used to comply with Title 24 cool Cap Shingles. roof requirements Colors & Availability: Results based on study conducted by Home Innovation Research Labs, an independent research lab,comparing installation of Timberline HD" .- Shingles to Timberline•HDZ"Shingles on a 16-square roof deck using "k standard 4-nail nailing pattern under controlled laboratory conditions. Actual results may vary. 15-year WindProven"limited wind warranty on Timbedlne"HDZ" Shingles requires the use of GAF starter strips,roof deck protection, ' ridge cap shingles,and leak barrier or attic ventilation,See GAF Rooting _ Charcoal System Limited Warranty for complete coverage and restrictions.Visit r...- gof.conVLRS for qualifying GAF products. 'StoinGuord`algae protection is available only on shingles saki in packages bearing the Svered by a"logo.Products with my agai against —�..�:- algae protection are covered by a 10-year limited warranty against { blue-green algae discoloration.See GAF Shingle&Accessory Limited Wormntyfor complete coverage and restrictions. To be mixed on one roof,Timberline'Or Shingles and Timberline HD" c ? Hunter Green Shingles must have matching 6-digit codes found on the end of the bundle. • _ When mixed,always use Timberline HD"installation instructions. °Periodically tested by independent and internal lobs to ensure compliance with ASTM D3462 at time of manufacture. °Lifetime refers to the length of warranty coverage provided and means as long as the original individual owner(s)of a single-family detached residence for eligible second owner(s)]owns the property where the qualifying GAF products are installed.For other owners/structures.Lifetime i Mission Brown Oyster coverage is not applicable.Lifetime coverage on shingles requires use of GAF Lifetime shingles only.See GAF Shingle&Accessory limited Warmnly o ] - for complete coverage and restrictions.Lifetime coverage on shingles and _ occessones requires use of any GAF lifetime Shingle and any 3 qualifying GAF accessories.See GAF Roofing System Limited Warranty for complete z coverage and restrictions.Visit gof.coMLRS for qualifying GAF products. ,r Note:tt is difficult to reproduce the color clarity and actual color blends Slate Sunset Brick Weathered Wood Williamsburg Slatc of these products.Before selecting your color,please ask to see several full-size shingles. 0 a LIFETIME A AMERICAN A 8` www�irrmea � We protect what matters most" .-Again.• ■ Ms k t � Av _ '�'��-''-ems: `��►��� �1 i • �i� risk M d `!�• ..... .......... ...... ...... .... .... .... ..... AAA , t, rr i o Aa1�N1 +Ilril► _ 11'i♦/} ,i���,1 ,,Ii 1 11@.. .hN r..ltl fi.l 11!'t�i CN F::• a �} ',O f� w lf•) L Ir Q711ih� 4_0cn ' a z I` O += w `\ ' +yet+,;: � I Lu LU t1J �yj o U) J ui k / w u o > Of LU < f' t� �•.�,f r d J O .U �G� 0� v •�y t. W = '""' X ooPI eap a 1 II1 11 �; �. .f t*as 1. . . . _ C •) • 111 /� - 1 1'1 A 1••11 .� _`, If ♦ 1 �•♦ +•,e•_ A dflj�l� I,111, in , f 1 1, IIII'ft,l r � /�111111� oft - j, §�Y +ARr� 'hlakt Nul o rj Ov'1 'fr - -v arr t+►�{r. "+$.�-• � 2tis, .. a �y Y c ., t ��® DATE(MM/DD/YYYY) A C" CERTIFICATE OF LIABILITY INSURANCE 8/20/2025 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:__Joe Bruno Levitt Fuirst Associates, Ltd. PHONE 914�57�200 AX No:914-457-4220 520 White Plains Road E-MAIL Tarrytown NY 10591 ADDREss: ibruno@levittfuirst.com INSURERS AFFORDING COVERAGE NAIL 0 INSURER A:Admiral Insurance Company 24856 INSURED PERRVER-01 INSURER B:Selective Insurance Company of 19259 Roofing, LLC 12 Center Street INSURER c:Accident Fund Insurance Com an 10166 12 Center Pleasantville NY 10570 INSURERD:ShefterPoint 81434 INSURER E INSURER F COVERAGES CERTIFICATE NUMBER:1841867477 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. INSR ADDLTYPE OF INSURANCE INSO SUER POLICY NUMBER MM/DDPOLICY EFF PO LICY LTR LIMITS A X COMMERCIALGENERALLIABILITY CA000057681-01 6/1/2025 6/1/2026 EACH OCCURRENCE $1,000,000 -DAMACLAIMS-MADE X OCCUR PREM ET RENTED J PREMISES Ea occurrence $300,000 MED EXP(Any one person) $5,000 PERSONAL&ADV INJURY $1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $2,000,000 POLICY a JECT LOC PRODUCTS-COMP/OP AGG $2,000,000 OTHER: $ B AUTOMOBILELIABIUTY S 2673562 5/15/2025 5/15/2026 CO BINEDISINGLE LIMIT $1,000,000 1X 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 C UMBRELLA LIAB X OCCUR GXL0002617 01 6/1/2025 6/1/2026 EACH OCCURRENCE $5,000,000 X EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY Y/N STATUTE ER ANYPROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ OFFICER/MEMBEREXCLUDED? ❑ NIA (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ H yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ D NYS Disability DBL358637 5/10/2022 5/10/2026 Statutory DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Certificate holder and/or the entities listed below would be covered as an additional insured per attached endorsement,to the extent provided therein if required by written contract,on a primary and non-contributory basis on the General Liability.Waiver of Subrogation applies.Additional insured, primary and non-contributory basis and waiver of subrogation on the Auto.Additional insured,primary and non-contributory basis and Waiver of Subrogation on the Umbrella. Certificate Holder is included as additional insured when required by written contract 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 Street 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 YoeK Workers' CERTIFICATE OF STATE Compensation NYS WORKERS' COMPENSATION INSURANCE COVERAGE Board 1a.Legal Name&Address of Insured(use street address only) 1 b.Business Telephone Number of Insured 914-867-1747 Perry Verrone LLC DBA Perry's Roofing 12 Center Street 1 c.NYS Unemployment Insurance Employer Registration Number of Pleasantville,NY 10570 Insured Work Location of Insured(Only required if coverage is specifically limited to 1d.Federal Employer Identification Number of Insured or Social Security certain locations in New York State,i.e.,a Wrap-Up Policy) Number 26-2754386 2.Name and Address of Entity Requesting Proof of Coverage 3a.Name of Insurance Carrier (Entity Being Listed as the Certificate Holder) Continental Indemnity Village of Rye Brook 3b.Policy Number of Entity Listed in Box"la" 938 King Street 46-884191-0122 Rye Brook,NY 10573 3c.Policy effective period 03/01/2025 to 03/01/2026 3d.The Proprietor,Partners or Executive Officers are ❑ included.(Only check box if all partners/offioers included) Z all excluded or certain partners/officers excluded. This certifies that the insurance carrier indicated above in box"3"insures the business referenced above in box"1 a"for workers' compensation under the New York State Workers'Compensation Law. (To use this form, New York(NY)must be listed under Item 3A on the INFORMATION PAGE of the workers'compensation insurance policy). The Insurance Carrier or its licensed agent will send this Certificate of Insurance to the entity listed above as the certificate holder in box"2". The insurance carrier must notify the above certificate holder and the Workers'Compensation Board within 10 days IF a policy is canceled due to nonpayment of premiums or within 30 days IF there are reasons other than nonpayment of premiums that cancel the policy or eliminate the insured from the coverage indicated on this Certificate. (These notices may be sent by regular mail.)Otherwise,this Certificate is valid for one year after this form is approved by the insurance carrier or its licensed agent,or until the policy expiration date listed in box"3c",whichever is earlier. This certificate is issued as a matter of information only and confers no rights upon the certificate holder.This certificate does not amend, extend or alter the coverage afforded by the policy listed, nor does it confer any rights or responsibilities beyond those contained in the referenced policy. This certificate may be used as evidence of a Workers'Compensation contract of insurance only while the underlying policy is in effect. Please Note: Upon cancellation of the workers'compensation policy indicated on this form,if the business continues to be named on a permit, license or contract issued by a certificate holder,the business must provide that certificate holder with a new Certificate of Workers'Compensation Coverage or other authorized proof that the business is complying with the mandatory coverage requirements of the New York State Workers'Compensation Law. Under penalty of perjury, I certify that I am an authorized representative or licensed agent of the insurance carrier referenced above and that the named insured has the coverage as depicted on this form. Approved by: Steven Diamond(President) (Print name of authorized representative or licensed aqent of insurance carrier) Approved by: 1! ?&6- , Difu"t 2ve 02/28/2025 (Signature) (Date) Title: Licensed Insurance Broker Telephone Number of authorized representative or licensed agent of insurance carrier: 516-488-3040 Please Note:Only insurance carriers and their licensed agents are authorized to issue Form C-105.2.Insurance brokers are NOT authorized to issue it. C-105.2 (9-17) www.wcb.ny.gov