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HomeMy WebLinkAboutRB25-0065 C O o = L cu 4"'� O N n 'a �. L C y C n O 0) LL + C) A 1 E o � C ^�N nab '0 a� %n m v a« C. _ a� n n. w `m `i' E ii O X F- v > v > LLi LIJ N L �O a OL c > v � coC v F-- cu LJ s Ln w t Y 7 0 W O N 0 F- z H 3 m L o O m > c 3 a' } 00 N Q 0 s o ai a Z L c-I pp d o >,y u o �� o ao wY � � `-i Ww a oy o ,c � O o0 O p = NY o o o c E Q` 0 w :o -o > 3 E 'ot Z m v o ^ a m o 3 ° L -0 v c CX 0 }L.LJL U Cl) N � O Q m a E o 3 O u O a u Cc > o m 3 _ u O 00 C L C Q > o W Yw — p C i- z > Ow00 � Q) � Q �E 0 � 'o Q �c ° c/ N (A 0J aomEc „ uu �ul � � } Zc7 L o 0 p LA � W � � o 3 N L v O LN � u > � ` E '; �' v Z v c '� .o E cu w0 cou° v > CU LL O M O� •L J w N *�' u m ° w E U �^ � Ln a te Q -�-j a) D w u° } ° o 0 aci a E J X O 3 � � � � � tiocEo w = y c =3 � > _ M Z � mn 0 o O LCNra � asr' CILm ° o o o o o � v E2 m r- a� � ) 0 a, \ 3m O u ' Z (U N o H Q w N o > N aQ CO o N o aallo t ai -°o m L - 0 � � EL° � f0 ° V O M° � E i H N t%i a a > E tko .9 pl �co 2 W W O Q Q a N CCi Y \ w Q Z Q ~ V a) E 0 Ln a � Exterior Building Permit Application � Village of Rye Brook 938 King St Rye Brook, NY 10573 Phone: (914)939-0668 1 www.ryebrook.gov Building Department Property Information Property Address: Property Owner Name: 114 Brush Hollow In Joseph Waine Exterior Building Permit Application,page 1/3 Project Information Zone N.Y. State Construction Classification N.Y. State Use Classification Occupancy Pre-Construction PUD VB R-3 Occupancy Post-Construction 1 family Proposed Improvement Area of lot Windows/door Replacement Lot Square Feet 1850.0 sq.ft. Acres Dimensions from proposed building or structure to lot lines Is building located on corner lot? YES © NO Front Yard Rear Yard Right Side Yard Left Side Yard Other Area of Total Square Footage of the For additions, Total Square Footage of the proposed proposed new construction: total square proposed renovation to the building in 0.0 sq.ft. footage added existing structure: square feet(0 if (0 if N/A) N/A) 0.0 Basement 0.0 Basement sq.ft. sq.ft. 0.0 1st Floor 0.0 1st Floor sq.ft. sq.ft. 0.0 2nd Floor 0.0 2nd Floor sq.ft. sq.ft. 0.0 3rd Floor 0.0 3rd Floor sq.ft. sq.ft. Construction Type Located Number of stories Overall Height Median Height Basement Basement Full ❑ Partial 0 N/A Finished Unfinished W N/A What material is the exterior finish? Roof style Roofing material What system of heating Exterior Building Permit Application,page 2/3 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 ❑ No Will the proposed project disturb 400 sq.ft. or more of land, or create 400 sq. ft. or more of impervious coverage requiring a Stormwater Management Control Permit as per§217 of Village Code? ❑ Yes 0 No Will the proposed project require a Site Plan Review by the Village Planning Board as per§209 of Village Code? ❑ Yes 0 No Will the proposed project require a Steep Slopes Permit as per§213 of Village Code? ❑ Yes W No Is the lot located within 100 ft. of a Wetland as per§245 of Village Code? ❑ Yes 0 No Is the lot or any portion thereof located in a Flood Plane as per the FIRM Map dated 9/28/07? ❑ Yes W No . Will the proposed project require a Tree Removal Permit as per§235 of Village Code? ❑ Yes 0 No Does the proposed project involve a Home-Occupation as per§250-38 of Village Code? ❑ Yes 0 No What is the total estimated cost of construction: Note: estimated cost shall include all site improvements, labor, 10000 USD material, scaffolding,fixed equipment, professional fees, including any material and labor which may be donated gratis. If the final cost exceeds the estimated cost, an additional fee will be required prior to issuance of the C/O. Estimated date of completion 11/19/2025 Exterior Building Permit Application,page 3/3 �y BRc�t VILLAGE OF RYE BROOK O� 938 King St Rye Brook,NY 10573 W Q Phone:(914)939-06681 www.ryebrook.gov ��• 19b2• Building Department Residential/Exterior(Remodel/Renovation) Permit Permit Set 114 BRUSH HOLLOW LN P#RB25-0065 R#129.76-1-146 PERMIT INFORMATION Address Permit number Date issued 114 BRUSH HOLLOW LN RB25-0065 10/31/2025 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 General Contractor's Home Improvement License-Westchester 4 Contractor's Liability Insurance 5 Contract Proposal for work 6 Details drawing 7 Details drawing 8 Contractor's Workers Compensation Insurance(Showing Rye Brook Cert Holder 9 Details drawing 10 Exterior Building Permit Application 11-13 Building Department.938 King St Rye Brook,NY 10573/Phone:(914)939-0668 BR(�uk VILLAGE OF RYE BROOK O 938 King St Rye Brook,NY 10573 W Q Phone:(914)939-06681 www.ryebrook.gov ��. p2• 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 REQUIRED INSPECTIONS Name Description Certificate of Occupancy Completion of ALL Work,All fees Paid and Final Survey in if required) WIN I) Owe by CT Lt.,11f6.oea0477 Ho,eowne.n,n,a edrlP.. TOLL Wwdelre+stwr Uc+WC•307 Joseph Watn _ 114 Brush HJIIGMy LAM Artartm Ril*Brock NY IOSTJ Scope of Work Windows by Toll vvmld like you to be a saNsHed ruatomer from start to flnlsh.Our goal is to establish char corrtmu licatfon and rvpedatfona throughout your lob p*OOLrCT OPTIONS Jt)QUANTITY Homeowner mr firms exactly how many windows and doors will be installed 6 %mod<wt Bev w�Ck indows _ Bow windows 1 Paho doors Frilly door Storm dories New Rtvlgen figs Direct Set Glass J 21 GLASS OPTIONS Homeowner has been informed of all glass options and their performance values 1 t rem r obscure other I 2 units Child Lock S99 ea Glass Selection tow-E(standard) M'er1 ----------- %t 11 GLASS AREA;THRESHOLD: Homeowner understands that with insert wirdows the visible glass$tze may be smaller than the existing wntdrwt glass area Wrth replacement doors the threshold may be higher than the original J 41 GRILLE OPTIONS:Homeowner has been informed of all available grille styles patterns and loce'wns of grille installation Honeowner has RISC been informed that with the Interior Wood Grille and the Full Drvided Late with Removable ime,Or Gr'fle notions their mai be a slight gap tisibie between the grille and the sash frame and that clips may be visible from the exterior of the horse Gone Selection: GBG(gNies behoren glass) _INTW(removable interior wood grille) —FDLP(full divided lite) Othe'-- J S)Product: Andersen I ProVia i Marvin/Arcadia i Direct Set Models Andersen 100 series Hardware(color) Bronze ExV White InV White HW INSTALLATION brie)INSERT FRAME I FULL FRAME INSTALLATION:Homeowner understands how the windows will be mstalled Homeowner confirms how they will look on the ntenor and exterior.With an INSERT FRAME installation,windows will be installed within the frame of the existing window With FULL FRAME installation new exterior trim will be needed If the homeowner does not want to remove the interior tnm our installers can in many instances leave it in place.This will be confirmed on your tech measure 7)INTERIOR I EXTERIOR INSTALL EXPLAINED:Exterior install meads we will try to not disturb the interior trmvstops Interior mstall means we wilt try not to disturb the extenor tnm/stops.In both cases.the install crew still needs access to the interior of the budding Final determination will be made by the installation crew based on lob site variables d8)INTERIOR STOPS:New Interior Stops' YE NO Where Necessary C11 W illCiouJ S Homeowner has been given the option to keep or replace the existing ntenor stops WBT will be installing new pnmed interior stops .A)EXTERIOR TRIM.Does this lob requtre ew Exterior Trim/NO NEW PVC Exterior Trim Type Wood I Aluminum I V Painted Trim?YES/NO WELT recommends panting at/ Wood and PVC exterior trim-wood for rot prevention/PVC to keep d loolring fresh Aluminum coil does not need to be painted Windows by Toll does not provide painting-we may recommend someone who can paint -1'0)ROT REPAIR:WBT will replace or repair minor rot found at installation Molar structural damage may be subject to an additional cnarge J11)SHEETROCK I STUCCO:Does the job require additional carpentry,sheetrock or stucco work) YES t NO /✓6T can quote addifronel serm.es that may be associated wrtb a window replacement or renovation protect Would the customer',ke oddrib lnal services mcdodaa ire our quoted price') I've ------ _ (Customer initial J12)WINDOW TREATMENTS:WBT van remove and reinstall interior window treatments including curtains railer shades vertical or inn,bkrds and viteror wood shutters Homeowner understands that WBT may have to adjust IOCattOn or positron of shades and binds in order to accommodate new window installation and that shades and blinds may not fit exactly in the same position as poor to '^stauabrx Bfirvss and shades five m direct sunlight The plastic becomes brittle and tends to break upon removal or installation era we r,arinot guaranteE tries will nut happen and will not take responsibility for(@placement Electric shades have delicate parts are It is rE Ammer✓lbd thyf you(eacti out to your blind of shade company tot advice on removal J13)SECURITY ALARMS:Homeownef undea lar0r,that VVB I is not responsible lot the removal and to vlslallabon of security alarm systems Homeowner m tsponsible for contacting security alarm provider pnuf to installation to coordinate hooking up security system to new wvWuws (Gcswdy w0vide,+Lail a"ar(dnuu lu Le un ado uii ddy of inatallalion of let us know it advance hen to leave wires for fd:ow up wore post,nstaflabo(i) NA J14)CONDOMINIUM BOARD APPROVAL Residerib of Condominium)1-lomeownev Aasociatlons have been informed that we must receive written approvej(ruin the Cuntlorninlunt I I10A Baud prior la ordering windows ui doors NA 015)SLIDING SCREENS and STORM DOORS, Homeowner understands that a sliding scieen or Storm Door is not a preventative measure to keep a child from accessing a pool or from getting out of ilia house J16)BUILDING PERMITS and ARCHITECTURAL PLANS:Are at the discretion of and sole responsibility of the homeowner. MEMO 1 AJANDERSEN W I N DO W S & DOG* S SOLD BY: SOLD TO: CREATED DATE �a2z2ms Windows Ev Toll —� '43'Selleck St uTE� ,� Stamtord.CT 06902-6309 tat 2025 OMMER Chrs K: Abbreviated Quote Report QUOTE NAME PROJECT NAME QUOTE NUMBER CUSTOMER PO# 'TRADE 0 :k+c A''ane Rvebmok NY Arbors Unassigned Project 8067591 ORDER NOTES: DELIVERY NOTES: Item Qty Operation Location 100 1 Left-Stationary Patio Door Check operational side f RO Size=60"x 80" Unit Size=59 114"x 79 1/2" 100GD2P5068,Unit, 100 Series Patio Doors Gliding Patio Door,Factory Assembled,1 3/8'Setback,Dark Bronze Exterior Frame,Dark Bronze Exterior Sash/Panel,w/White Interior Frame,w/White Interior Sash/Panel,Left-Stationary Dual Pane Lcw-E Tempered Argon Fill Stainless Glass/Grille Spacer,Tulsa,Dark Bronze,White,Dark Bronze,Full Screen,Fiberglass.Giidi�— g xJnrt# U-Factor SHGC ENERGY STAR A' 0.3 0.32 NO Quote 0: 8067591 Print Date: 10/1/2025 4A 1:18 PM UTC All Images Viewed from Exterior Page 1 of 4 I l ��y It, 10 Ir e6ed JOIJOIXI Ux111 peMOIA se6puil IIV ')I(1 Nd 9L L h 6 91,0l,/l/Ol '9teQ IUIId 1,69L909 'p elonb bn gn Operation Location 200 1 Active/Stationary,(XO) 60*36 size GLIDER iRO Size-60 1/2"x 36 1i2" Unit Size=60"x 36" 1Lk1GX0 5'X3',Unit,100 Series Gliding XO/OX-Insert,No Flange w/Exterior Ar;ressrrry Kerf(Insert),D»rk Bronze Exterior Frame, Dark Bmnze Exterior Sesh/Panel.w,'1Nhite Interior Frame,w/White Interior Sash/Panel,Active/Stationary(XD).Dual Pane Low-E Tempered Argon Fill Stainless Glass/Grille Spacer,Auto Lock,Andersen 100 Series, 1 Sash Locks White,Dark Bronze,Full Screen,Fiberglass Unit# U-Factor SHGC ENERGY STAR Clear Opening/Unit# Width Height Area(Sq.Ft) Al 0.3 0.31 NO At 26.2890 32.5000 5.93330 Item Location 300 1 Active/Stationary(XO) 59"47 size GLIDER RO Size=59 1/2"x 47 1/2" Unit Size=59"x 47" 100GXO 4'11"X3'11",Unit,100 Series Gliding XO/OX-Insert,No Flange w/Exterior Accessory Kerf(Insert),Dark Bronze Extenor 5_ Frame,Dark Bronze Exterior Sash/Panel,w/White Interior Frame,w/White Interior Sash/Panel,Achve/Stationary(XO).Dual Pane Low-E Tempered Argon Fill Stainless Glass/Grille Spacer,Auto Lock,Andersen 100 Series, 1 Sash Locks White,Dark Bronze. R-�. -- Full Screen,Fiberglass Unit# U-Factor SHGC ENERGY STAR Clear Opening/Unit# Width Height Area(Sq.Ft) Al 0.3 0.31 NO Al 25.7890 43.5000 7.79040 Item Ot.Y Operation Location 400 1 Active/Stationary(XO) 59*47 size GLIDER RO Size=59 1/2"x 47 1/2" Unit Size=59"x 47" 100GXO 4'11"X3'11",Unit, 100 Series Gliding XO/OX-Insert,No Flange w/Ederior Accessory Kerf(Insert),Dark Bronze Exterior Frame,Dark Bronze Exterior Sash/Panel,w/White Interior Frame,w/White Interior Sash/Panel,Active/Stationary(XO).Dual Pane Low-E Tempered Argon Fill Stainless Glass/Grille Spacer,Auto Lock,Andersen 100 Series, 1 Sash Locks White,Dark Bronze. Full Screen,Fiberglass Unrf z U-Factor SHGC ENERGY STAR Clear Opening/Unit# Width Height Area(Sq.Ft) A' 0.3 0.31 NO Al 25.7890 43.5000 7.791040 Quote#: 8067591 Print Date: 10/1/2025 4:41:18 PM UTC All Images Viewed from Exterior Page 2 of 4 � yyy - airy tx[)o0 White. ^ � A P"e „ Item Ope11AU1 Loc ntion 500 1 Activa/Stationary(XO) 59'47 size GLIDER RO Site=59 112"x 47112" Unit Size=59"x 47" 100GXO 4'1 MY 11",Unit, 100 Series Gliding XO/OX-Insert,No Flange w/F_xterkw Ar res v)ry Kerf(Insert),Dark Bronze Exterior T T V Frame,Dark Bronze Exterlor Sash/Panel,w/Whlte Interior F rame,w/1Nhlte Interior Sash/Panel,Active/Stationary(XO),Dual Pane Low-E 1 empered ArWi Fill Stainless Glass/Grille Spacer,Auto Lock,Andersen 100 Series, 1 Sash Locks White,Dark Bronze, Full Screen,Fiberglass Unit# U-f-actor SHGC ENERGY STAR Clear Opening/Unit# Width Height Area(Sq.Ft) Al 0.3 0.31 NO Al 25.7890 43.5000 7,79040 ftm Alt f Operation Location 600 1 Active/Stationary(XO) 47 x 47 Glider RO Size=47 1/2"x 47 1/2" Unit Size=47"x 47" 100GXO 3'11'X3'11",Unit, 100 Senes Gliding XO/OX-Insert,No Flange w/Exterior Accessory Kerf(insert),Dark Brorza Exterior Frame,Dark Bronze Exterior Sash/Panel,w/White Interior Frame,w/White Interior Sash/Panel,Active/Stationary(XO).Dual Pane T T Low-E Tempered Argon Fill Stainless Glass/Grille Spacer,Auto Lock,Andersen 100 Series, 1 Sash Locks White,Dark Bronze. Full Screen,Fiberglass Unit# U-Factor SHGC ENERGY STAR Clear Opening/Unit# Width Height Area(Sq.Ft) Al 0.3 0.31 NO Al 19.7890 43.5000 5.97790 ftem gty Operation Location 700 1 Active/Stationary(XO) 47 x 47 Glider RO Size=47 1/2"x 47 1/2" Unit Size=47"x 47" 100GXO 3'11"X3'11",Unit, 100 Senes Gliding XO/OX-Insert,No Flange w/Exterior Accessory Kerf(Insert),Dark Bronze Exteror Frame,Dark Bronze Exterior Sash/Panel,w/White Interior Frame,w/White Interior Sash/Panel,Active/Stationary(XO). Dual Pane T Low-E Tempered Argon Fill Stainless Glass/Grille Spacer,Auto Lock,Andersen 100 Senes, 1 Sash Locks White,Dark BrOrtze. Full Screen,Fiberglass Unit# U-Factor SHGC ENERGY STAR Clear Opening/Unft# Width Height Area(Sq.Ft) Al 0.3 0.31 NO Al 19.7890 43.5000 5.97790 Quote#. 8067591 Print Date: 10/1/2025 4:41:18 PM UTC All Images Viewed from Exterior Page 3 of b only ,Ir ....,,«.... \\rih.t�l pow"I�14'Rt)as � .0 r Department tof coniumer Protection 1lt)tnV Improvement Liceme AYE!`2'Y A f RYt. L LC YVk1t} vs 9%,Toti. Y, r�Amv 6Rl l,9`.�`rwJ-O2 .��M all 1�YN!�L Vl arl fft�'�a/M*Kf t w�s�t 1.�1AS+�1e1�c�Zrt�1-b4�Mad YM a d1a:.;+r'9 4�t O'N= M:r ® DATE(MM/DDIYYYY) AC� CERTIFICATE OF LIABILITY INSURANCE 10/27/2025 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 Bethel Account NAME: The Insurance Center a°Nr E. Exc: (203)730-0634 aC No): (203)730-0683 6 Stony Hill Rd,Suite 210 ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC# Bethel CT 06801 INSURER A: Midvale Indemnity Company INSURED INSURER B: AmGUARD Avery&Frye LLC,DBA:Windows By Toll INSURER C 226 Selleck Street INSURER D STE B INSURER E Stamford CT 06902 INSURER F COVERAGES CERTIFICATE NUMBER: CL2451513376 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 AUDIL bUtSM POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER MM/DD MMIDD/YYYY LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED CLAIMS-MADE � OCCUR PREMISES Ea occurrence $ 100,000 MED EXP(Any one person) $ 5,000 A CP00061531 05/25/2025 05/25/2026 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE $ 2,000,000 POLICY I—XI PRO ❑LOC PRODUCTS-COMP/OPAGG $ 2,000,000 JECT OTHER. $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000 Ea accident ANY AUTO BODILY INJURY(Per person) $ B X OWNED �/ SCHEDULED AVAU623494 02/12/2025 02/12/2026 BODILY INJURY(Per accident) $ AUTOS ONLY /� AUTOS HIRED �/ NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY /� AUTOS ONLY Per accident UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 1,000,000 A X EXCESS LIAB CLAIMS-MADE 0000003053 05/25/2025 05/25/2026 AGGREGATE $ 1,000,000 DED I I RETENTION$ $ WORKERS COMPENSATION X1 STATUTE ORH AND EMPLOYERS'LIABILITY YIN SOO,000 B ANY PROPRIETOR/PARTNER/EXECUTIVE ❑ N/A AVWC672603 05/11/2025 OS/11/2026 E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 500,000 it yes,describe under 500,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ NY Disability B DB15036181.1 05/11/2025 05/11/2026 50.000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Project:114 Brush Hollow Lane,Rye Brook CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN The Village of Rye Brook BLDG Dpt. ACCORDANCE WITH THE POLICY PROVISIONS. 983 King Street AUTHORIZED REPRESENTATIVE Rye Brook NY 10573 A ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD etc Workers' CERTIFICATE OF STATE Compensation NYS WORKERS' COMPENSATION INSURANCE COVERAGE Board 1a.Legal Name&Address of Insured(use etrost addinva„nlyl 1h.nueinfins Tnleplxnxr Number rf Inowred Avery&Frye,LLC 646-265-8924 DBA/TA windows by Toll 1c.NY9 Unempinymani Inerxanoe F mrMiyer Replotration Number of 226 Selleck St Ste 8 Insured Stamford,CT 06902-6420 N/A Work LOW-on of lnsured(Onfp rppulmdIt cr+rrrtgfo is rtpedBceffy kmrNd fo 1d.Federal Employnr Identification Numtrn ,f inarrrn 1 r Bode)3ecurky ctW*rr McMrons in New York SSMe,IA,a Wnrp-UP liwicy) Number 82-3674820 2 Name and Address of Entity Requesting Proof of Coverage 3a.Name of Insurance Carrier (Entity Beft Listed as the Certificate Holder) NorGUARD Insurance Company The Vitlage of Rye Brook BLDG Dept. 983 king Street 3b Policy Number of Entity Listed in Box"I a" Rye Brook,NY 10573 AVWC672603 3c.Policy effective period 05/11/2025 to 05/11/2026 3d.The Propr ,etor.Partners or Exeartive Officers are Included.(Only Cheri box it ail partners(orFcers inciudedi ® all excluded or certain partners(offlcers 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 seed this Certificate of Insurance to the entity listed above as the certificate holder in box"2'. Tt a insurance carrier must notify the above certificate holder and the Workers'Compensation Board within 10 days IF a policy a 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 r 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, ex-.end or alter the coverage afforded by the policy listed,nor does it confer any rights or responsibilities beyond those contained in the referenced policy. T'nis 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. Adam Edelstein !Pant name of auf torized representative or licensed agent of insuraime carrier) Approved by: 05/28/2025 (Date) Tale. President Telephone Number of authorized representative or licensed agent of insurance carrier: 800-673-2465 Please Note:Only Insurance carriers and their licensed agents are authorized to Issue Form C-105.2.htsurance brokers are hW authorized to issue it. C-105.2(9-17) www.wcb.ny.g0v