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LU 0 0ff ] ; % g8 = CD .2 E ¥ � D " i > E2g _ k / LLJ 0 � k \ «\ \ » Cm Et u w c « « = � � t .tJ } ƒ u Bulk Regulations in Residential Districts Village of Rye Brook 938 King St Rye Brook, NY 10573 Phone: (914)939-0668 1 www.ryebrook.gov Building Department MAXIMUM GROSS FLOOR AREA USE FORMULA: Maximum Gross Floor Area=4,000+[(Lot Area-21,780)x 0.11478421]: a.Allowed 6567.8 sq.ft. b. Existing 3167.44 sq.ft. c. Proposed 3167.44 sq.ft. Bulk Regulations in Residential Districts,page 1/2 HEIGHT/SETBACK RATIOS FOR RESIDENTIAL DISTRICTS DEFINITION: A standard designed to regulate the height of a building in relation to the average grade of the corresponding portion of the lot line from which it is set back. The ratio modifies the maximum permitted Height of Building by forming an inclined plane beginning at the average grade along the portion of the lot line from which the setback is measured and rising toward the building at the specified ratio above which no part of any building, other than minor architectural features such as chimneys, skylights and dormer windows not covering more than 10% of the entire roof area, shall be permitted to extend. Height and Setback shall be calculated using the formula; Height/Setback= X,where X is the required side or front yard ratio for the zoning district in which a property is located as specified in Article VIII of Chapter 250.A complete elevation view for the proposed improvement must be included on the drawings. EXISTING RATIOS Front Side PROPOSED RATIOS Front Side ZONE REQUIRED FRONT REQUIRED SIDE R-35 .44 1.20 R-25 .48 1.30 R-20 .60 1.60 R-15 .60 1.60 R-15A .80 2.40 R-12 .69 1.60 R-10 .80 2.40 R-7 .96 3.00 R-5 1.20 4.00 R-2F 1.20 4.00 Please confirm: © I attest to the best of my knowledge and belief,the above information is correct. Bulk Regulations in Residential Districts,page 2/2 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: 4 Jacqueline Lane Gaines Exterior Building Permit Application,page 1/3 Project Information Zone rNY. State Construction Classification N.Y. State Use Classification Occupancy Pre-Construction R-10 R-3 1-Family Residential Occupancy Post-Construction 1-Family Residential Proposed Improvement Remodel existing screen porch to repair and/or replace existing decayed elements with new similar materials to match existing appearance. Area of lot Dimensions from proposed building or structure to lot lines Lot Square Feet 22371.18 sq.ft. Front Yard 51.9 FT Acres 0.51357 Rear Yard 109.8 FT Right Side Yard 22.4 FT Left Side Yard 19.6 FT Other Is building located on corner lot? YES 0 NO 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 footage added existing structure: square feet(0 if (0 if N/A) 192.85 sq.ft. 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 Typical Western Lumber Frame Floor& Roof Framing Number of stories Overall Height Median Height 1 47.0 ft 34.9 ft Basement Basement 7 Full ❑ Partial 0 N/A Finished Unfinished W N/A What material is the exterior finish? Roof style White Azak&Charcoal screen Shed Exterior Building Permit Application,page 2/3 Roofing material What system of heating Existing asphalt shingles None 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 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 0 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 0 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, 39000 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 06/01/2026 Exterior Building Permit Application,page 3/3 �y BRnv� VILLAGE OF RYE BROOK o`` y 938 King St Rye Brook,NY 10573 W � Q Y Phone:(914)939-0668 1 www.ryebrook.gov ��• b2•`� Building Department Residential/(Deck)Permit Permit Set 4 JACQUELINE LN P#RB25-0085 R#135.35-1-59 PERMIT INFORMATION Address Permit number Date issued 4 JACQUELINE LN RB25-0085 12/04/2025 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 Photograph 4-7 Contractor's Liability Insurance 8 Application Materials 9-15 Architectural drawing 16-17 Application Materials 18-24 Building Inspector Stamped&Signed Set of Plans 25-26 Contractor's Workers Compensation Insurance(Showing Rye Brook Cert Holder 27 Survey(Required Recent Survey) 28 Westchester Home Improvement License 29 Bulk Regulations in Residential Districts 30-31 Exterior Building Permit Application 32-34 Building Department.938 King St Rye Brook,NY 10573/Phone:(914)939-0668 BRnuk VILLAGE OF RYE BROOK 938 King St Rye Brook,NY 10573 W � Q O� Phone:(914)939-0668 1 www.ryebrook.gov ��• t 02•`f Building Department INSTRUCTIONS THE PERMIT HOLDERAND/OR PROPERTY OWNER IS RESPONSIBLE FOR ENSURING THATALL REQUIRED/APPLICABLE INSPECTIONS ARE SCHEDULED ANDTHAT 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. Certificate of Occupancy Completion of ALL Work,All fees Paid and Final Survey in if required) BUILD� MENT VIL ' E OF RY OOK 938 KING ET RYE BR ,NY 10573 (914) 9-066j w ARCHITECTURAL REVIEW BOARD CHECK LIST FOR APPLICANTS This form must be completed and signed by the applicant of record and a copy shall be submitted to the Building Department prior to attending the ARB meeting. Applicants failing to submit a copy of this check list will be removed from the ARB agenda. Job Address: 4 Jacqueline Lane Date of Submission: Parcel ID#: 135.35-1-59 Zone: R-10 10/29/25 Proposed Improvement(Describe in detail): Remodel existing screen porch to repair and/or APPLICANT CHECK LIST: replace existing decayed elements with new MUST BE COMPLETED BY THE APPLICANT The following items must be submitted to the Building similar materials to match existing appearance Department by the applicant-no exceptions. Property Owner: Stephen Gaines &Teri Friedman 1. (X)Completed Application 2. (X)Two(2)sets of sealed plans. (one full size {maximum Address: 4 Jacqueline Lane, Rye Brook allowable plan size=36"x 42"} and one 11"x17") 3. ( )Two(2)copies of the property survey. Phone# 914-584-2461 4. ( )0 Two(2)copies of the proposed site plan. Applicant appearing before the Board: 5. ( ))One electronic/disc copy of the complete Jonathan Metz application materials. 6. ( X)Filing Fee. Address: 64 Windsor Road, Rye Brook, NY 7. (X)Any supporting documentation. Phone# 914-645-6451 8. ( )HOA approval letter. (if'applicable) 9. (X)Photographs. Architect/Engineer: Jonathan Metz 10.( X) Samples of finishes/color chart. (a sample board or Phone# 914-645-6451 model may be presented the night of the meeting) By signature below, the owner/applicant acknowledges that he/she has read the complete Building Permit Instructions& Procedures, and that their application is complete in all respects. The Board of Review reserves the right to refuse to hear any application not meeting the requirements contained herein. Sworn to before me this Sworn to before me this day of , 20 day of , 20 Signature of Property Owner Signature of Applicant Print Name of Property Owner Print Name of Applicant Notary Public Notary Public III 8/12/2021 BUILDING DEPARTMENT VILLAGE OF RYE BROOK 938 KING STREET RYE BROOK,NY 10573 (914)939-0668 www.ryebrook.ori! FOR OFFICE USE ONLY: Approval Date: Permit# Application# Approval Signature: ARCHITECTURAL REVIEW BOARD: Disapproved: : Date: BOT Approval Date: Case# Chairman: PB Approval Date: Case# Secretary: ZBA Approval Date: Case# Other: Application Fee: Permit Fees: EXTERIOR BUILDING PERMIT APPLICATION Application dated: 1OZ29/25 is hereby made to the Building Inspector of the Village of Rye Brook,NY,for the issuance of a Permit for the construction of buildings,structures,additions,alterations or for a change in use,as per detailed statement described below. 1. JobAddress: 4 Jacqueline Lane 2. ParcellD#: 135.60-1-24 Zone: R-10 3. Proposed Improvement(Describe in detail): Remodel existing screen porch to repair and/or replace existing decayed elements with new similar materials to match existing appearance 4. Property Owner: Stephen Gaines &Teri Friedman Address: 4 Jacqueline Lane, Rye Brook, NY 10573 Phone# Cell# 914-584-2461 e-mail j.metz@perkinseastman.com List All Other Properties Owned in Rye Brook: none Applicant: Jonathan Metz Address: 64 Windsor Road, Rye Brook Phone# Cell# 914-645-6451 e-mail j.metz@perkinseastman.com Architect: Jonathan Metz Address: 64 Windsor Road, Rye Brook Phone# Cell# 914-645-6451 e-mail j.metz@perkinseastman.com Engineer: Address: Phone# Cell# e-mail General Contractor: GC Contracting, Inc. Address: 326 Shear Hill Rd, Mahopac, ny 10541 Phone# 914-447-9610 Cell# e-mail jcapsl2@aol.com ll> 8/12/2021 5. Occupancy;(1-Fam.,2-Fam.,Commercial.,etc...)Pre-construction: 1-Fam Post-construction: 1-Fam 6. Area of lot: Square feet: 22,371.18 Acres: 0.51357 7. Dimensions from proposed building or structure to lot lines: front yard: 51.9 ft rear yard: 109.8 FT right side yard: 22.4 FT left side yard: 19.6 FT other: 8. If building is located on a comer lot,which street does it front on: 9. Area of proposed building in square feet: Basement: 1"fl: 2°d fl: 31d fl: 10. Total Square Footage of the proposed new construction: 11. For additions,total square footage added:Basement: 11 fl: 21 fl: Yd fl: 12. Total Square Footage of the proposed renovation to the existing structure: 192.85 13. N.Y.State Construction Classification: VB N.Y.State Use Classification: R-3 1-story over open 14. Number of stories: area Overall Height: 23'-6" Median Height: 17'-6" 15. Basement to be full,or partial: None fmished or unfinished: 16. What material is the exterior fmish:White Azak trim and charcoal screening 17. Roof style;peaked,hip,mansard,shed,etc: Shed Roof(existing) Roofing material: Exisitng asphalt shingle 18. What system of heating: None 19. If private sewage disposal is necessary,approval by the Westchester County Health Department must be submitted with this application. 20. 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: X (if yes,applicant must submit a separate Automatic Fire Suppression System Permit application&2 sets of detailed engineered plans) 21. 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: No: X Area: 22. Will the proposed project require a Site Plan Review by the Village Planning Board as per§209 of Village Code? Yes: No: X (if yes,applicant must submit a Site Plan Application,&provide detailed drawings) 23. Will the proposed project require a Steep Slopes Permit as per§213 of Village Code Yes: No: X (f yes,you must submit a Site Plan Application,&provide a detailed topographical survey) 24. Is the lot located within 100 ft.of a Wetland as per§245 of Village Code? Yes: No: X (if yes,the area of wetland and the wetland buffer zone must be properly depicted on the survey&site plan) 25. Is the lot or any portion thereof located in a Flood Plane as per the FIRM Map dated 9/28/07? Yes: No: X (if yes,the area and elevations of the flood plane must be properly depicted on the survey&site plan) 26. Will the proposed project require a Tree Removal Permit as per§235 of Village Code? Yes: No: X (f yes,applicant must submit a Tree Removal Permit Application) 27. Does the proposed project involve a Home-Occupation as per§250-38 of Village Code? Yes: No: X Indicate: TIER I: TIER II: TIER III: (f yes,a Home Occupation Permit Application is required) 28. List all zoning variances granted or denied for the subject property: 29. What is the total estimated cost of construction: s 39,000 Note.The estimated costhall include all site improvements,labor,material,scaffolding,fixed equipment,professional fees, including any material and labor whiohay be donated gratis.If the final cost exceeds the estimated cost,an additional fee will be required prior to issuance of the CIO. 30. Estimated date of completion: December 31, 2025 (2) 8/12/2021 BUILDING DEPARTMENT VILLAGE OF RYE BROOK 938 KING STREET RYE BROOK,NY 10573 (914)939-0668 RESIDENTIAL LOT AREA COVERAGE Address: 4 Jacqueline Lane Section: 135.35 Block: 1 Lot:59 PERMITTED COVERAGE RATIOS IN RESIDENTIAL DISTRICTS (Local Law 3-88) YOUR ZONE AREA IN MAIN ACCESS. DECK ZONE DISTRICT SQ. FEET BLDG. BLDG. MAX. CHECK MAX. R-35 35,000 14% 4% 5% R-25 25,000 14% 3.5% 4% R-20 20,000 14% 3.5% 4% R-15 15,000 16% 3.5% 4% R-15A 15,000 12% 3.5% 4% R-12 12,500 17% 4% 4% R-10 10,000 20% 4.5% 3.5% R-7 7,500 23% 4.5% 3.5% R-5 5,000 30% 5% 3.5% R-21F 5,000 30% 5% 3.5% Existing: Proposed: 1.AREA OF LOT 22,371.18 Sq. Ft. 22,371.18 Sq. Ft. 2. AREA OF HOUSE a. Coverage of Main Building (Including Attached Garage or Accessory Building) 1,588.22 Sq. Ft. 1,588.22 Sq. Ft. b. Area of 1 sc Floor Divided By Area of Lot x 100 7 % 7 % 3. AREA OF ACCESSORY BUILDING (Includes Detached Garages,Tool Shed, Playhouses) Sq. Ft. Sq. Ft. a. Coverage of Accessory Building Area of Accessory Building Divided By Area of Lot x 100 % % 4. AREA OF DECK 192.85 Sq. Ft. 192.85 Sq. Ft. a. Coverage of Deck Area of Deck Divided By Area of Lot x 100 0.86 % 0.86 % I attest to the best of my knowledge and belief,the above information is correct. chitect's Signature (3) 8/12/2021 BUILDING DEPARTMENT VILLAGE OF RYE BROOK 938 KING STREET RYE BROOK,NY 10573 (914) 939-0668 IMPERVIOUS COVERAGE RATIOS RESIDENTIAL DISTRICTS Address: 4 Jacqueline Lane Section: 135.35 Block: 1 Lot: 59 Zone: R-10 IMPERVIOUS SURFACES (Definition): All buildings, as defined herein, and all areas on the ground or elevated above the ground which are comprised of materials through which water cannot readily flow, including, but not limited to asphalt, concrete, masonry, wood, gravel and clay, and which consist of elements including, but not limited to, court yards,sports courts,swimming pools,patios,sidewalks,ramps,terraces and driveways. TOTAL MAXIMUM PERMITTED MAX. PERMITTED COVERAGE Zoning IMPERVIOUS LOT AREA BY IMPERVIOUS SURFACES District COVERAGE IN FRONT (sq.ft.) For Base Lot For Lot Area YARD(%) Area(sq.ft.)* Over Base R-35 15 Lot Area %) R-25 20 0 to 4,000 0 55 R-20 30 4,001 to 6,000 2,200 35 6,001 to 12,000 2,900 27 R-15 35 12,001 to 16,000 4,520 26 R-15A 35 16,001 to 20,000 5,560 25 R-12 40 20,001 to 30,000 6,560 24 30,001 to 40,000 8,960 23 R-10 45 40,001 &larger 11,260 22 R-7 40 R-5 30 *"Base Lot Area"is the minimum end of the lot size R2-F 30 range in the"Lot Area"column Area of lot: 22 371.18 sq.ft. Existing Allowed Proposed Total impervious coverage = 3,084 S .ft. 7,128 S . ft. 3,084 S .ft. Front impervious coverage = 13.7 % 45 % 13.7 % I attest to the best of my knowledge and belief,the above information is correct. O�L(/ Architect's Signature (4) 8/12/2021 This application must be properly completed in its entirety by a N.Y. State Registered Architect or N.Y. State Licensed Professional Engineer & signed by those professionals where indicated. It must also 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: Jonathan Metz ,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 Architect 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 , 20 day of , 20 Signature of Property Owner Signature of Applicant Print Name of Property Owner Print Name of Applicant Notary Public Notary Public (8) 8/12/2021 -dY* s< - i r FRONT OF HOUSE r: t � REAR OF HOUSE .. z0. 1 ► F 1� EXISTING PORCH STAIR .d r oq` i :W6.h ve S RIDE SIDE OF HOUSE • y t, •Gr Affiftl rY ti k- - LEFT SIDE ME �Y ~ I I Eft �I�tG INTE 10R VIEW oft gbar,�02W ws �i ► •-_�3�`_1� �`.-tip�� s_._ _ !J�d i,t,_'_ _�... is _yd_s �'=Uft._._s:'tt1r �u '"'„�, 'fih1E/%A '� F b Ister . � George Latimer unty James Maisano \'estebester<'ounty kaeculise Director,Consumer Protection '-, > I Department of Consumer Protection Home Improvement License � ► GC CONTRACTING INC. 326 SHEAR HILL ROAD MAHOPAC,NY-10541 This license is issued in accordance ith Article XV I 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. as►a� NOT FOR FEDERAL PURPOSES `ot GonsuhP i Lcense Number 6� ^°^ a � � � Date of Expiration VKW WC-28363-H16 p ;f 01/05/2026 P�QhesterC0 ts... �i�y1y -..�_. 1 `"- r 5�r -*- ��j� 111-, . ?;TAij'-7. +tea r1��y��a��� 1cx���I� v�'���x � �t �rp ;.iStk� ��Qtins Ott/► a>rr,. au�5 ' '"A .� rl ATE ACORN CERTIFICATE OF LIABILITY INSURANCE (MMIDD/YYYY) 0/25/2025 THIS CERTIFICATE IS ISSUED AS A MATTER UF INFORMATION ONLY AND CONFERS NO RIGHTS UP N THE CERTIFICATE H LDER. THI 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 HISCOX Inc. NAME: 5 Concourse Parkway E-WIL (888)202-3007 ac No: Suite 2150 ADDRESS: contact@hiscox.com Atlanta GA,30328 INSURERS AFFORDING COVERAGE NAIL# INSURER A: Hiscox Insurance Company Inc 10200 INSURED INSURER B: GC Contracting Inc. INSURERC: 326 Shear Hill Rd Mahopac, NY 10541 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. INSR I ADDLISUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE Jusa Wyn POLICY NUMBER MM/DD MM/DD LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE 1$ 1,000,000 DAMAGE To RNTED CLAIMS-MADE r_x1 OCCUR PREMISES E.Eoccurrence $ 100,000 MED EXP(Any one person) $ 5,000 A P 100.644.629.8 10/10/2025 10/10/2026 PERSONAL a ADV INJURY $ 1,000,000 GEN'LAGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 x POLICY PRO LOG JECT PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY Per accident)AUTOS AUTOS ( ) $ HIRED AUTOS NON-OWNED PROPERTYDAMAGE $ AUTOS (Par accident UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB HCLAIMS-MADE AGGREGATE $ DED I I RETENTION$ $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY YIN STATUTE ER ANYPROPRIETO W PARTNER/EXECUTIVE OFFICE R/MEMBER EXCLUDED? ❑ N/A E.L.EACH ACCIDENT $ (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ H 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 938 King Street SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Rye Brook,NY 10573 THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE �-?dB-Tw- ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD NYSIF New York State Insurance Fund PO Box 66699,Albany.NY 12206 1 nysif.com CERTIFICATE OF WORKERS' COMPENSATION INSURANCE (RENEWED) 0 f' �I ^^^A^^ 462336696 �+ GC CONTRACTING INC. 326 SHEAR HILL RD ❑� f MAHOPAC NY 10541 SCAN TO VALIDATE AND SUBSCRIBE POLICYHOLDER CERTIFICATE HOLDER GC CONTRACTING INC. VILLAGE OF RYE BROOK 326 SHEAR HILL RD 938 KING STREET MAHOPAC NY 10541 RYE BROOK NY 10573 POLICY NUMBER CERTIFICATE NUMBER POLICY PERIOD DATE W2545 871-2 69094 04/28/2025 TO 04/28/2026 10/25/2025 THIS IS TO CERTIFY THAT THE POLICYHOLDER NAMED ABOVE IS INSURED WITH THE NEW YORK STATE INSURANCE FUND UNDER POLICY NO. 2545 871-2, COVERING THE ENTIRE OBLIGATION OF THIS POLICYHOLDER FOR WORKERS' COMPENSATION UNDER THE NEW YORK WORKERS' COMPENSATION LAW WITH RESPECT TO ALL OPERATIONS IN THE STATE OF NEW YORK, EXCEPT AS INDICATED BELOW, AND, WITH RESPECT TO OPERATIONS OUTSIDE OF NEW YORK, TO THE POLICYHOLDER'S REGULAR NEW YORK STATE EMPLOYEES ONLY. IF YOU WISH TO RECEIVE NOTIFICATIONS REGARDING SAID POLICY,INCLUDING ANY NOTIFICATION OF CANCELLATIONS, OR TO VALIDATE THIS CERTIFICATE,VISIT OUR WEBSITE AT HTTPS:/MIWW.NYSIF.COM/CERT/CERTVAL.ASP.THE NEW YORK STATE INSURANCE FUND IS NOT LIABLE IN THE EVENT OF FAILURE TO GIVE SUCH NOTIFICATIONS. THIS POLICY DOES NOT COVER CLAIMS OR SUITS THAT ARISE FROM BODILY INJURY SUFFERED BY THE OFFICERS OF THE INSURED CORPORATION. PRESIDENT GIOVANNI CAPOLUPO GC CONTRACTING INC.- 1 OF 1 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS NOR INSURANCE COVERAGE UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICY. NEW YORK STAT SUR NCE FUND TT �/ DIRECTOR,INSURANCE FUND UNDERWRITING VALIDATION NUMBER: 269170356 U-26.3 JZ o O a ui m c I x / LJ N NV ii O` O � � jN Y>Q^COMA N� }TI, �O r Z M M 6>Zq mO�C7ma0Y N3 N �$ a�Nrnm mz z V .W� � ; O�2 i - J z� �_ as8 o U W r�n O S W 1� w zt REP X; pia a=9� o S Ay HIM ;Moil 1 t 41 1 p�' tij I N N HOKS m W3 C y �U�� WO O O / � a Y� m \ o + � o W N N gc�O,y�\ w o d Np y } E: J Z M mod' Jx� o to O a + M / I W w W �yo� 5�0o N Z Za J V O\ N Q= 'cr li w� O ��w Z ~W2 OY� \O O CL WHW X WOr (�cnm Enm� W d C Fe N m W in U m ? 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