HomeMy WebLinkAboutRB25-0012PERMIT# ^(J� J wvl DATE: 2' EXP: I l�
PARCEL ID: S 5 • 5 / -
TYPE OF
10B LOC
OWNER:
CONTRACTOR:
COST: $ _ FEE: $ , - + PAID ,
�! f
V/Ico* FEE:S _ � ❑PAID DATE: /
TCOtf:_
FOOTING
FOUNDATION
FRAMING
ROUGH FRAMING
FEES ❑PAID DATE:
INSPECTION
QATE
PERMiT �:
INSULATION /► ,, Q
PLUMBING 1 8 4e5
-tam 7ass� ay� a �Ir1"��lt 1�
qe
ROUGH PLUMBING
GAS
SPRINKLER
ELECTRIC
LOW VOLTAGE 13 ,
ALARM Lmi -
AS BUILT 0 - -.
FINAL
VILLAGE OF RYE BROOK
WESTCHESTER COUNTY, NEW YORK
Certificate of (orcupaurp
Ehis is to certify that I. Y1 �1V J�(�S s 85zt-ros
of, Rine f )"Oc I NY , having duly filed an application on
A�hi7. at-L4 / J. 20 9 requesting a Certificate of Occupancy for the premises known as,
��Xr Rye Brook,NY, located in a )Q—/() Zoning
District and shown on the most current Tax Map as Section: 5 .50 Block: _] Lot:
and having fully complied with the requirements of the Building Code and the Zoning Ordinance under Building
Permit No.c:�5" , issued V 20 25, such authority and permission is hereby granted
to the property owner to lawfully occupy
or use said premises or building or part thereof listed under the following
New York State Classifications, Use: / Construction: ,
1� a
for the following purposes: ) l )l1f oo i- Y—; 1 o /1" 1 !
Subject to all the privileges, requirements, limitations, and conditions prescribed by law, and subject also to the
following:
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 ex facilities shall be made,and no enlargement,
whether by extending on any side or by increasing in hei t sh a de,no shall the building be moved from one location
to another until a permit to accomplish such change h e n tained o e Building Inspector.
FEB 19 2026
Building Inspector,Village of Rye Brook: Date:
RECEIVED
BUILDING DEPAUTMENT For office use only:
PERMIT 1l BP RB25-0012
VII,LAt)� OF RYF-. OK ISSUED: 10/21/2025
VILLAGE OF RYE: BROOK 9.. 8 KING STRFbijRVKBROOK% YORK 10573 DATE: 2-11-26
BUILDING DEPARTMENT r�1d)9 �o FEE: $150.00 pd. PAID m
'A O V
APPLICATION FOR CF,RTIFICATF.OF OCCUPANCY,CERTIFICATE OF COMPLIANCE,
AND CERTIFICATION OF FINAL COSTS
TO BE SUBMITTED ONLY UPON COMPLETION Or ALL WORK, AND PRIOR TO TRZ FINAL INSPLCTION
.............................................................................................................................
Address: 123 N Ridge St
Occupancy/Use: House parcel ID h:135.59-1-34 Zone:
Owner: Leandro J Diaz Address: 24 Sand Drive
P.E./R.A.or Contractor: My Neighbour heating and cooling Address: Lagrangeville
Person in responsible charge- Leandro J Diaz Address: NY 12540
Application is hereby made and submitted to the Building Inspector of the Village of Rye Brook for the issuance of a
Certificate of Occupancy/Certificate of Compliance for the structure/construction/alteration herein mentioned in accordance
with law:
STATE OF NEW YORK,COUNTY OF WESTCHESTER as:
Edison Barros being duly sworn,deposes and says that he!she resides at 123 N Ridge Street
Pnni Name of Applicant) (\, and Street)
in Rye Brook in the County of Westchester in the State of NY that
iCm crown!village)
he she has supervised the work at the location indicated above,and that the actual total cost of the work,including all site improvements,
labor,materials,scaffolding,fixed equipment,professional fees,and including the monetary value of any materials and labor which may
have been donated gratis was:5 6,500
for the construction or alteration of: { ct ;ny S;K K l� basen,c v!— i„��alli�� ..ew f-�P ►�-0hn�rfi w� fo
c?XiS�.+'�1 d✓4 n iv. +ll f�.,A fo Sivie< Gonntr—cA- 4- G ,r,4-t 4 cs_`,. "OAd k2a1Gy
�uH nQ� W Ire �or rcB �l1AKC1 re K5+"11 a.ad SEMI/ 4Jh p of-•
Deponent further states that he/she has examined the approved pans of the structure/work herein reterredsto for which a Certificate of
Occupancy/Compliance is sought,and that to the best of hWher knowledge and belief,the structure/work has been erected/completed in
accordance with the approved plans and any amendments thereto except in so far as variations therefore have been legally authorized,and
as erected/completed complies with the laws governing building construction.Deponent further understands that it shall be unlawful for an
owner to use or permit the use of any building or premises or part thereof hereafter created,erected,changed,converted or enlarged,wholly
or partly,in its use or structure until a Certificate of Occupancy or Certificate of Compliance shall have been duty issued by the Building
Inspector as per§250-I O.A.of the Code of the Village of Rye Brook.
T P,
Sworn to before me this Sworn to bdtirre me this U
r
day of fie crv��� , 20 ),C, day of <Lr exv 20 Zoo
$ignattue of Properry Owner *ofApphcan,
Edison Barros Print Nam ofProp wncrhe
7CESAR J COLON CESAR J COLON
NOTSTATE OF NEW YORK NOTARY PUBLIC,STATE OF NEW YORK
Ro.01C00042651 Registration No. 01C00042651
Qestchester County Qualified in Westchester County
Cxpires 10/10/2029 Commission Expires 10/10/2029
E BRCZj�
• +9�2 BUILDING DEPARTMENT
UILDING INSPECTOR
ASSISTANT BUILDING INSPECTOR VILLAGE OF RYE BROOK
❑CODE ENFORCEMENT OFFICER 938 KING STREET • RYE BROOK,NY 10573
(914) 939-0668 FAX (914) 939-5801
www ryebrook.or¢
- - - - - - - - - - - - - - - - - - - - INSPECTION REPORT - - - - - - - - - - - - - - - - - - - -
ADDRESS: ( —� N I� C j I l Jt DATE: �—
PERMIT# ISSUED: -SECT: % 1 BLOCK: LOT:
LOCATION: -, kU Irk J \L OCCUPANCY:
❑ VIOLATION NOTED THE WORK IS... Ltd' ACCEPTED ❑ REJECTED/REINSPECTION
❑ SITE INSPECTION REQUIRED
❑ FOOTING
❑ FOOTING DRAINAGE
❑ FOUNDATION
❑ UNDERGROUND PLUMBING NOTES ON INSPECTION:
❑ ROUGH PLUMBING
❑ ROUGH FRAMING
❑ INSULATION r
❑ NATURAL GAS
❑ L.P. GAS
❑ FUEL TANK
❑ FIRE SPRINKLER L LJ 1C j
❑ FINAL PLUMBING
❑ CROSS CONNECTION ���e' �" �l
FINAL
❑ OTHER
Syr✓BRC�k.
0 tim
�' �9r32•�,�0
BUILDING DEPARTMENT
,❑ UILDING INSPECTOR
�Q ASSISTANT BUILDING INSPECTOR VILLAGE OF RYE BROOK
❑CODE ENFORCEMENT OFFICER 938 KING STREET . RYE BROOK,NY 10573
(914) 939-0668 FAX (914) 939-5801
www ryebrook.org
- - - - - - - - - - - - - - - - - - - - INSPECTIONREPORT - - - - - - - - - - - - - - - - - - - -
_
ADDRESS : CZ J " • t-) , �� O r l (lipI DATE: 7-
(�
PERMIT# \US `� ( Z `1 ISSUED: SECT:BLOCK: LOT:
LOCATION: L �,, k A L ( r,A L� ly��� p_ OCCUPANCY:
❑ VIOLATION NOTED THE WORK IS... M ACCEPTED ❑ REJECTED/ REINSPECTION
❑ SITE INSPECTION REQUIRED
❑ FOOTING
❑ FOOTING DRAINAGE
❑ FOUNDATION
❑ UNDERGROUND PLUMBING NOTES ON INSPECTION:
❑ ROUGH PLUMBING
❑ ROUGH FRAMING
❑ INSULATION f
❑ NATURAL GAS U / J
❑ L.P. GAS Ra (o co l
❑ FUEL TANK , n
❑ FIRE SPRINKLER
0 FINAL PLUMBING
❑ CROSS CONNECTION
❑ FINAL
❑ OTHER
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E 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
Barros Project R-7 123 N Ridge St
Proposed Improvement
Legalize Kitchen renovation that includes kitchen cabinets, countertops and backsplash
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
VB R-3 1 Family
Occupancy Post-Construction 0 fam., 2 fam.,comm.,etc...)
NC
What is the total estimated cost of construction: (NOTE: The estimated cost shall include all labor, material,
6500 USD scaffolding,fixed equipment, professional fees, and material
and labor which may be donated gratis.)
Interior Building Permit Application,page 1/1
BROu� VILLAGE OF RYE BROOK
2 938 King St Rye Brook,NY 10573 �
u✓ �
Q Phone:(914)939-0668 i www.ryebrook.gov
O �
��• b2 • i� Building Department
Residential/Interior(Remodel/Renovation) Permit
Permit Set 123 N RIDGE ST P#RB25-0012 R#135.59-1-34
PERMIT INFORMATION
Address Permit number Date issued
123 N RIDGE ST RB25-0012 10/21/2025
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
Interior Building Permit Application 4
Building Department.938 King St Rye Brook,NY 10573/Phone:(914)939-0668
BROv� VILLAGE OF RYE BROOK
O 938 King St Rye Brook,NY 10573
lu :E
Q Y 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
MAIN]
REQUIRED INSPECTIONS
Name Description
Final Electric Final Electric
Plumbing final Installation of ail CSA approved plumbing fixtures and hot water tank(water meter must be installed).A test
for this portion of the plumbing system may be required.
Certificate of Occupancy Completion of ALL Work,All fees Paid and Final Survey in if required)
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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
SBU Zone:
135.59-1-34 1
Proposed Work:
Replace sink in the basement installing new trap reconnecting to existing drain, installing trap for kitchen sink connecting to
existing drain and water lines, ran new water line for ice maker. reinstall and seal Water Closet Replace sink in the basement
installing new trap reconnecting to existing drain, installing trap for kitchen sink connecting to existing drain and water lines, ran
new water line for ice maker. reinstall and seal Water Closet
Plumbing Permit Application,page 1/2
Indicate Fixtures&Lines to be installed as per the following schedule:
1st 2nd 3rd t Other Fgfhjipment/Provide Details:
FIXTURES Basement Floor Floor Floor Face siFloirrthe basement installing new trap reconnecting
or kitchen sink connecting to
Water existin drain and water lines, ran new water line for ice
Closets 1 maker. reinstall and seal Water Closet
Urinals
Drinking
Fountains
Sinks 1 1
Showers
Bath Tubs
Laundry
Tubs
Domestic
Service
Fire
Service
Sanitary
Sewer
Natural/LP
Gas
Other* 1
TOTAL 2 2
Plumbing Permit Application,page 2/2
BRnv VILLAGE OF RYE BROOK ■ ■
938 King St Rye Brook,NY 10573
W �
Q E Phone:(914)939-06681 www.ryebrook.gov
�982' Building Department
Plumbing/Other(Replacement) Permit
Permit Set 123 N RIDGE ST P#RB25-0124 R#135.59-1-34
PERMIT INFORMATION
Address Permit number Date issued
123 N RIDGE ST RB25-0124 11/17/2025
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
Contractor's Liability Insurance 4
Contractor's Workers Compensation Insurance(Showing Rye Brook Cert Holder 5
Copy of Plumbing License 6
Westchester Home Improvement License 7
Plumbing Permit Application 8-9
Building Department.938 King St Rye Brook,NY 10573/Phone:(914)939-0668
�y BRnv� VILLAGE OF RYE BROOK
938 King St Rye Brook,NY 10573
W �
Phone:(914)939-0668 1 www.ryebrook.gov
O
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
& 4
1
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)
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.
Plumbing final Installation of all CSA approved plumbing fixtures and hot water tank(water meter must be installed).A test
for this portion of the plumbing system may be required.
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BUILDING DEPARTMENT D V I
VILL f,E OF RYE BROOK
938 KING ET RYE Bi;UOK,NY 10573 SEP 18 2025
(91� _fl66g..
wwi ,rV66& okny.goy VILLAGE OF RYE BROOK
ELECTRICAL PERMIT APPLICATION BUILDING DEPARTMENT
Westchester County/master Electricians License Required
FOR OFFICE USE ONLY BP#: 'S'r ` EP#: C
Approval Date: Permit Fee: $ FV
Approval Signature: Other:
DO NOT START WORK or CONSTRUCTION UNTIL A PERMIT HAS BEEN ISSUED BY THE BUILDING INSPECTOR.
THE ADMINISTRATIVE FEE FOR WORK PROGRESSED OR COMPLETED WITHOUT A PERMIT 1S 12%OF THE
T TAL COST OF CONSTRUCTION WITH A MINIMUM FEE OF$750.00
Application dated, 5 is hereby made to the Building Inspector of the Village of Rye Brook NY,for the issuance of
a Permit to install and/or remove electrical equipment,wiring, fixtures,or to perform other high or low voltage electrical work as per
the detailed statement described below. By signing this document, the applicant & property owner agree that all electrical work
performed will be in conformance with all applicable Federal,State,County and Local Codes.
1.Address: 1 a S 0 R,I` t-c- J+ SBL: 115 'S lG
1 3'9 Zone:
2.Property Owner: �`1 SO/� �tflrOS Addresss:l J � A)3 t�
Phone#: Cell#: r.��i �`� 3 C (0 1-1email: a' CX'it 14) F 5biAACD Al
3.Master Electrician/Licensed Installer: & ` 'J ken - G j Address:
Lic.#: 8� : 1_Phone# Cell#:q !6 I �� email: �►►�� �ll �cn��GY» �,�1,►
Company Name: s-+ C�+t�+0��1 �-ls�c-Ir)<— Address: 1)G rYi o 1( M V V er nor)
4.Proposed Electrical Work/Fixture Count: lf'c 4 t Zi, i vti ±(��..
5.3rd Party Electrical Inspection Agency:
**,r,ee**w*w*,r**+r*tr**,r*,t**,r*,r*rtwr+rr,rr►**rr***,t*,r***,t««**r,r,r****+t*,t**,r*******,r**,r**atr***«,t«*,t*+r***,e,r***,r*•,r,r,r«
STATE
�OF NEW YORK,COUNTY OF WESTCHESTER ) as:
(�
i Jao'\C )1,�p
—�2 _,being duly swom,deposes and states that he/she is the applicant above named,and does further
(print name of individual signing as the applicant)
state that(s)he is for the legal owner and is duly authorized to make and file this application.
(Master Electrician)icensed Installer)
The undersigned fu a 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.
Sworn to before me this Sworn to before me this
day of ,20 d
Signature of Property Owner Signature of A p ican
1)GJ"
Print Name of Property Owner "Name of Applic t
(^�MA*QqW 4& —
Notary Public
state of ITew York
No.01ME6160063
Qualified In Westchester County 6/1/2024
Commission Expires January 29,20ZJ
r
STATE WIDE INSPECTION SERVICES, INC.
swisJOB APPLICATION tel 845.202.7224 1 fax 914.219.1062 1 SWISNY.coml SWISTRAINING.COM i
Of+fce Use Elect.Permit# 2,5 Date
Bldg Permit# 2J_ J S VN7 SQ R
Plumbing Permit#
Final Certificate k
City/Village R rC U t"D o I Zip /L ,f Building Dept. County QrSOV-3�„/�
Address , o(� Q" j Cross Street Section I Sy.Sq Block I Lot 3/
Owner Name/Address(If dtrferent man above) ` ;S l Contact Number 1
❑Basement ❑1st FL ❑2nd FL ❑3rd FL ❑More Than 3 R. ❑Garage ❑Attic ❑Outside [:]Residential []Commercial
Receptacles Special Rece GFCI AFCI Switches Dimmers Smoke Alarms C/0 Detector Hood Trash Compact
Amt Amps
Range(s) Cooktop(s) Oven(s) Dishwashers Refrigerator Disposal Microwave Luminaires Generator Transfer Switch
SERVICE
Amperage #Panels 1P 3P #Meters # Disconnect [:]Underground ❑ New ❑ Reconnect ❑ Repair
❑Overhead ❑ Upgrade ❑ Disconnect
Utility ID# ❑Con Ed ❑NYSEG ❑Central Hudson ❑Orange/Rockland
PHOTOVOLTAIC SYSTEM
PV Modules Inverters AC Disconnect )unction Box Combiner Box Load Center PV Monitor Energy Storage System DC Disconnect
❑Legalization ❑ Safety Inspection ❑Consultation
Scope of Work
+
SEP 18 2025 DD
VILLAGE OF RYE BROOK
BUILDIt4G DEPARTMENT
This application is valid for one(t)year from the date received by SWfS This applcaton is intended to cover the above bsteo hems to be inspected,if at any time of inspection additronaf items have been installed,you art
authorized to make the,inspection and adjust the fee for the additional items inspected The applicant declares that there:s no open appl,cations for the above address wito any other inspection company'he applicant,owner
or authorzed agent agrees to all the above terms and conditions as set forth for the application
Email Address 0I�-r'VW " ' 54 ( t 1�J �lf Y n I I �L�� Name 0,11 �� I�1C o IY
License# Date Signature t f
Address Qv G%(.) �C 4 City/State�nA Zip Code �S
Company L Gh� 1 Phone# G���
State Wide Inspection Services
1080 Main Street
Fishkill, NY 12524
845 202-7224 Phone
TO Vff U S NOV 14 2,025 914-219-1062 Fax
STATE WIDE INSPECTION SERVICES Email: off iceC�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:
Yost and Campbell Edison Barros
David Kenney 123 North Ridge Street
20 Brookdale Place Rye Brook, NY 10573
Mount Vernon, NY 10550
Located at: 123 North Ridge Street,Rye Brook, NY 10573
Section: Block: Lot: Electrical Permit Number: 25-250
135.59 1 34
Certificate Number:2025-7400 Building Permit Number: RB25-0012-0047
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: 123 North Ridge Street, Rye Brook, NY 10573
The Basement, First Floor and Exterior were 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 23'd day of
October 2025.
Name Quantity Rating Circuit Type
AFCl/GFCI 05
GFCI 01
Air Handler 01
Condenser 01
A Visual Inspection of existing conditions was performed on October 23`d, 2025,of the Basement, First
Floor and Exterior and Conforms to NFPA 70-2017 NEC. No Defects Were Noted.
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.
AC�0 DATEIMM/DDIYYYYI
��. EVIDENCE OF PROPERTY INSURANCE 10/16/2025
THIS EVIDENCE OF PROPERTY INSURANCE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE
ADDITIONAL INTEREST NAMED BELOW. THIS EVIDENCE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE
COVERAGE AFFORDED BY THE POLICIES BELOW. THIS EVIDENCE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE
ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE ADDITIONAL INTEREST.
AGENCY PHONE COMPANY ----- ---
LAIC No Ertl: 800 841-3005
TRAVELERS PERSONAL INSURANCE COMPANY
(GEICO INS AGENCY LLC
IPO BOX 9503 ONE OF THE TRAVELERS PROPERTY CASUALTY COMPANIES
IFREDERICKSBURG, VA 22403 ONE TOWER SQUARE, HARTFORD, CT 06183
FAX E-MAIL --- ----_--
iA/C Nol: _ ADDRE" T -
CODE-0BC461 SUB CODE:
AGENCY
CU$T4MER ID I:
INSURED LOAN NLYiBEIt POLICY NUMBER
EDISON BARROS 1819286096 6_175937_68 633 1
DIANA BARROS EFFECTIVE DATE EXPIRATION DATE
CONTINUED UNTIL
123 N RIDGE ST
07/17/2025 07/17/2026 TERMINATED IF CHECKED
PORT CHESTER, NY 105 73-2145 TiRSREPLACESPRIOR EVIDENCE DATED:
PROPERTY INFORMATION
LOCATI O N/DESC RIPTION
123 N RIDGE ST
PORT CHESTER, NY 10573-2145
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
EVIDENCE OF PROPERTY INSURANCE 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.
COVERAGE INFORMATION PERILS INSURED BASIC BROAD SPECIAL
COVERAGE/PERILS/FORMS _ _ AMOUNT OF INSURANCE DEDUCTIBLE
Coverage A - Dwelling $ 468,000
Coverage B - Other Structures $ 46,800
Coverage C - Personal Property $ 234,000
Coverage D - Loss of Use $ 93,600
Coverage E - Personal Liability - Bodily Injury and $ 300,000
Property Damage(each occurrence)
Coverage F - Medical Payments to Others(each person) $ 2,000
Property Coverage Deductible (All Perils) $ 11000
TOTAL PREMIUM $1,736.00
REMARKS (includingSpecial Conditions)
Make checks payable to: Travelers Indemnity and affiliates
Mail payments to: Travelers Personal Insurance
PO Box 660307
Dallas, TX 75266-0307
SEE ADDITIONAL REMARKS SCHEDULE FOR MORE INFORMATION (ACORD 101)
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.
ADDITIONAL INTEREST
NAME AND ADDRESS ADDI I IONAL INSURED LENDER'S LOSS PAYABLE LOSS PAYEE
JPMORGAN CHASE BANK N.A. X MORTGAGEE _
ISAOA/ATIMA LOAN
PO BOX 4465 1819286096
SPRINGFIELD, OH 45501 AUTHORIZED REPRESENTATIVE
ACORD 27 (2016103) 1993-2015 ACORD CORPORATION.All rights reserved.
The ACORD name and logo are registered marks of ACORD
AGENCY CUSTOMER ID:
LOC It: - - --
ACO® ADDITIONAL REMARKS SCHEDULE Page 1 of 1
AGENCY NAMED INSURED
GEICO INS AGENCY LLC EDISON BARROS
-- ---- DIANA BARROS
POUCY NUMBER 123 N RIDGE ST
617593768 633 1 PORT CHESTER, NY 10573-2145
CARRIER NAIC CODE
TRAVELERS PERSONAL INSURANCE COMPANY 3 8130 EFFECTIVE GATE: 0 7/17/2 02 5
ADDITIONAL REMARKS
THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM,
FORM NUMBER:ACORD 27 FORM TITLE: EVIDENCE OF PROPERTY INSURANCE
Coverage Level: Travelers Protect®
Policy Type - Homeowners
Optional Coverages
Optional Coverages Endorsement Limit
Water Back Up and Sump Discharge or Overflow HQ-208 NY (08-20) $5,000
Coverage
Personal Property Replacement Cost Loss Settlement HQ-290 CW (02-21)
Additional Replacement Cost Protection Coverage HQ-420 CW (11-18) $117,000
25% of Coverage A - Dwelling Limit
*Note: The additional cost or premium reduction for any optional coverage or package shown as
"Included" is contained in the Total Policy Premium Amount.
ACORD 101 (20081011 ®2008 ACORD CORPORATION. All rights reserved.
The ACORD name and logo are registered marks of ACORD
i
Affidavit of Exemption to Show Specific Proof of Workers' Compensation Insurance
Coverage for a 1, 2, 3 or 4 Family, Owner-occupied Residence
"Tkis form cannot be used to waive the workers'coarpensotioe rights or obt4stions of any party."
I
Under penalty of perjury, I certify that I am the owner of the 1. 2, 3 or 4 family, owner-occupied residence
(including condominiums) listed on the building permit that I am applying for, and I am not required to show i
specific proof of workers' compensation insurance coverage for such residence because (please check the 1
appropriate box).
I am performing all the work for which the building permit was issued.
❑ I am not hiring,paying or compensating in any way,the individual(s)that is(are)performing all the work
for which the building permit was issued or helping me perform such work.
❑ I have a homeowners insurance policy that is currently in effect and covers the property listed on the
attached building permit AND am hiring or paying individuals a total of less than 40 hours per week
(aggregate hours for all paid individuals on the jobsite) for which the building permit was issued. '
I also agree to either:
acquire appropriate workers' compensation coverage and provide appropriate proof of that coverage on
forms approved by the Chair of the NYS Workers' Compensation Board to the government entity issuing �
the building permit if l need to hire or pay individuals a total of 40 hours or more per week(aggregate hours
for all paid individuals on the jobsite)for work indicated on the building permit,or if appropriate,file a CE-
200 exemption form;OR i
a have the general contractor, performing the work on the 1, 2, 3 or 4 family, owner-occupied residence j
(including condominiums)listed on the building permit that I am applying for,provide appropriate proof of
workers'compensation coverage or proof of exemption from that coverage on forms approved by the Chair
of the NYS Workers' Compensation Board to the government entity issuing the building permit if the
project takes a total of 40 hours or more per week(aggregate hours for all paid individuals on the jobsite)for
work indicated on the building permit.
� 'icinU �I A;s 101�
(Signa tore of Homeowner) (�._)a4 Signed) -
,y a �
-- �- L ��G _ _ _ _ Home Telephone Number lP 05-3�l y i
'(Homeowner's Name -- —(H Printed)
Sworn to b0 ore woo Ibis _ I(0� day t,l ..
(
Property Address that requires the building permit'.
rr r ( nr sr nr Pab!!c!
Joni Lama)
—1 Commission#01 LA0025681
j Notary Public,State of New York
N1y(-onimisston Expires June 07,2029 t
Once notarized,this BP-1 form serves as an exemption for both%orkers'compensation and disability benefits insurance coverage.
BP-1 (12/08) NY-WCB