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(NOTE: The estimated cost of construction shall include all site $1,500 improvements, labor, material, scaffolding,fixed equipment, professional fees, and material and labor which may be donated gratis.) Estimate date of completion 10/31/2025 Fence/Wall/Gate Permit Application,page 1/1 I VILLAGE OF RYE BROOK 938 King St Rye Brook,NY 10573 Phone:(914)939-06681 www.ryebrook.gov Building Department Residential/(Fence/Wall/Gate) Permit Permit Set 1 CHURCHILL RD P#RB25-0040 R#135.34-1-18 PERMIT INFORMATION Address Permit number Date issued 1 CHURCHILL RD RB25-0040 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 Building Inspector Stamped&Signed Set of Plans 4-5 Fence/Wall/Gate Permit Application 6 Building Department.938 King St Rye Brook,NY 10573/Phone:(914)939-0668 J y BRC�bVILLAGE OF RYE BROOK Z938 King St Rye Brook,NY 10573 O� Phone:(914)939-0668 1 www.ryebrook.gov 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 ❑ ❑0 REQUIRED INSPECTIONS Name Description Certificate of Occupancy Completion of ALL Work,All fees Paid and Final Survey in if required) BACK TO WORKSPACE Application forms 1 Cht, jlChl NEEDS CHANGES Q 4wage or tiye d;OWN archite77Z, l Lev w Bo ird Appruvai Date' lS7�� -- 10/6/2025, 9:00 AM OK Steven Fews Direct message fa ----- - --- DELETE FORM FENCE/WALL/GATE PERMIT APPLICATION OK All required fields are marked with Project Information Occupancy/Use: 3B- safety railing for back wall All information BACK TO WORKSPACE saved a week ago rt" ba4 1 a �f 1 3r ..' ., fa .•' 1-4 • F x�. • / . d - mt '• . lit t . 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Ac" CERTIFICATE OF LIABILITY INSURANCE FDATE(MM/DD/YYYY) �� 10/20/2025 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 Joanne Sirico NAME: Borrelli Partners Insurance Agency PHONE (914)939-7900 FAX (914)407-5088 A/C No Ext: A/C,No): 287 Bowman Avenue E-MAIL jsirico@borrellipartners.com ADDRESS: Suite 406 INSURER(S)AFFORDING COVERAGE NAIC# Purchase NY 10577 INSURERA: NGM Insurance Company 14788 INSURED INSURER B COPERINE LANDSCAPING INC INSURER C 206 LEICESTER ST INSURER D: INSURER E: Port Chester NY 10573 INSURER F: COVERAGES CERTIFICATE NUMBER: CL2412506490 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 ADDLSUEIR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER MMIDD/YYYY MM/DD/YYYY LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 ENIED CLAIMS-MADE a OCCUR PREMISES Ea occurrence $ 500,000 MED EXP(Any one person) $ 10,000 A Y CP00102899 12/11/2024 12/11/2025 PERSONAL&ADV INJURY $ 1,000,000 GEN'LAGGREGATE LIMITAPPLIES PER: GENERAL AGGREGATE $ 2,000,000 X POLICY ❑ PRO- ❑ 2,000,000 JECT LOC PRODUCTS-COMP/OP AGG $ OTHER $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000 000 Ea accident X ANY AUTO BODILY INJURY(Per person) $ A OWNED SCHEDULED CA00031816 12/11/2024 12/11/2025 BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY Per accident $ UMBRELLA LAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION X PER I STATUTE EORH AND EMPLOYERS'LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE Y/N 100,000 A OFFICER/MEMBER EXCLUDED? Y N/A WK00007622 12/11/2024 12/11/2025 E.L.EACH ACCIDENT $ (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ 100,000 If yes,describe under 500,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) CERTIFICATE HOLDER IS NAMED AS ADDITIONAL INSURED AS PER THE WRITTEN CONTRACT OR AGREEMENT 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. 938 King St AUTHORIZED REPRESENTATIVE 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 YORK Workers' CERTIFICATE OF STATE Compensation Board NYS WORKERS' COMPENSATION INSURANCE COVERAGE 1a.Legal Name&Address of Insured(use street address only) 1b.Business Telephone Number of Insured Coperine Landscaping Inc (914)939-4958 206 Leicester St 1c.NYS Unemployment Insurance Employer Registration Number of Port Chester, NY 10573 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 13-3998910 2.Name and Address of Entity Requesting Proof of Coverage 3a.Name of Insurance Carrier (Entity Being Listed as the Certificate Holder) NGM Insurance Company Village of Rye Brook 3b.Policy Number of Entity Listed in Box"l a" 938 King Street Rye Brook, NY 10573 WK00007622 3c.Policy effective period 12/11/2024 to 12/11/2025 3d.The Proprietor,Partners or Executive Officers are included.(Only check box if all partners/officers included) ® 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". Will the carrier notify the certificate holder within 10 days of a policy being cancelled for non-payment of premium or within 30 days if cancelled for any other reason or if the insured is otherwise eliminated from the coverage indicated on this certificate prior to the end of the policy effective period? YES ®NO 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: Joanne SiriCO (Print name of authorized representative or licensed agent of insurance carrier) Approved by: C�BQiLlL� 74� C 10/20/2025 (Date) Title: ACCt Mgr Telephone Number of authorized representative or licensed agent of insurance carrier: (914)939-7900 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 (9-15) www.wcb.ny.gov i I 9rw Lr's'dy Y� t--"P- Tr cot/e � J Let 16 Lot 1) M AV nw�P.O. 19=7 9, naA `c_ j tee. 5 w� Y q r� f wewc � $trry H aka !berme D"F"g O N Q Q O =f Arie TN g la+e� in = U Y 7dJ•J R.t 279.90' L-106.23' i J i CHURCHILL ROAD 'S�OF NFVY r ._ -1.�. t a ` ♦ Survey of tot 17 os shoes on 'Map or Rkhard A- Sptnmili Section D. Rye Aria, the Property of Rye H50 Hamew Avenue \ Acres Company situated In the Toes of Rye, MoTaramck N. Y. 10543 \ Westchester Co., N. Y.' (914) 591-2J57 l =Q w r'Aed :: Mar. S. 1953 as Moo No. 7951 Lard Surveyor No 42240 UID Scats t'-20' Juwary 27. 2020 (Updated) Nownber 25. 2024 Village of Rye Brook PERMIT# -+rchiteC ural evi w Board Approval Date. _ d SBL# Chafrmarl CATE A PR E� 6 2025 We BUILDING IN �. `Jtl: of Rye Brook. NY