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HomeMy WebLinkAboutRB25-0006 14C) c 0 ❑' O f° lu ,• y � N o L 0 O `- � u> a, 'QED a c v c -I cu cc 0D ` ca a 1) v 11 GJ -0 E O> jw, C. CL L4, � N m 7 y O E 7 L m 1 ' �U/ M C T Li 4/ CL 91 In Q N �a W •m y y LL X ~ N o a o c W N L O O rl m > - y O v .O+ Q) O) In LJ L L a+ Z u� F' r Y 7 0 W 3 L a .-, Y � N F=- N Y 3 � w `0 O �, voo d' } Q� CN Q Q o L L aZ ) a a ,,y U .� DLL, Y p O � w oa 0 0 E C7 O `� V) Y v 0 c `o Z = d LLI m o v $ v -0 a) c a W L Vi Z) Co Q `6 TEa O 3 Q , .>_ o a Yw — \ W � � � : Z '^ u N ^ > OwoO (n D QUO UQ Qa E m O � N � `� CL poo aCUa mNp to 0 t>`a } Na w u 'm 'A C -0 CO - Q W LLL 00 ��-I U a m O m o p 0 L O wZ v, 0 ` L W � v N Nn. i ,s, .0 a° Ln Q _ 2 Z ? Q y LZ v —Cu m to Q L W } cvi 3 -icy c O u � Y a s Q - o >.� O O < N 2 cn >- 0 N Q a0 v E 3 m CD a �n M = m E 2 U Q� X � •v v N CIOa U p CO L U �— Q w ,n o � d L C� Y C I C Q N � M Q -� r-I (y o +� o L $ C11 :� E -o 'U; o -a m uo-0Q'' °13�. ry 9 0 CL v �W ca 00n > 3 U ra a � v, V o � o � vc L o �- oa� �° E v SEW yO,Qk m c v v 'r cii L > E -o ,C N W J In a} y ay w b W W O oa € — .- �:; co U F- 0 u V �r W O Q Q 0D ^ U 'a, F- v Y co �y 13Rnv� VILLAGE OF RYE BROOK �<11 938 King St Rye Brook,NY 10573 7 3► Q Phone:(914)939-06681 www.ryebrook.gov ��• t 42 • j Building Department Other Structures/(Remodel)Permit Permit Set 12 PADDOCK RD P#RB25-0006 R#135.26-1-42.1 PERMIT INFORMATION Address Permit number Date issued 12 PADDOCK RD RB25-0006 11/05/2025 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 Architectural drawing 4 Building Inspector Stamped&Signed Set of Plans 5-12 Architectural drawing 13-20 Contractor's Workers Compensation Insurance(Showing Rye Brook Cert Holder 21 Architectural drawing 22-29 Survey(Required Recent Survey) 30 Administrative Exterior Building Permit Application 31-33 Demolition Permit Application 34 Exterior Building Permit Application 35-37 Building Department.938 King St Rye Brook,NY 10573/Phone:(914)939-0668 �yE BRn2 VILLAGE OF RYE BROOK W 938 King St Rye Brook,NY 10573 � Q Phone:(914)939-06681 www.ryebrook.gov . 1 b2• 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 • REQUIRED INSPECTIONS Name Description Administrative 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 Administrative Exterior Building Permit Application,page 1/3 Project Information Parcel ID# Zone N.Y. State Construction Classification N.Y. State Use Classification 12 Paddock Rd. Residential R-15 V R-2 Occupancy Pre-Construction Occupancy Post-Construction 1 Family 1 Family Proposed Improvement Dimensions from If building is located on a corner lot, Renovation of one story house. Rear proposed building or which street does it front on: addtion to master bedroom with new structure to lot lines roof line over rear flat roof. Addtion to side of garage to make it wider to fit Front Yard 35.32 cars better. new front portico. new rear roof over part of patio. new gas fireplace bumped out of nonconfomring Rear Yard 54 wall. New look for house. Some varainces are needed,front yard set Right Side Yard 18.43 back for garage addtion posible side yard set back for new roof over flat roof, Left Side Yard 7.44 building coverage for main building. existing deck. Other 0 Area of proposed Total Square Footage of the proposed Total Square Footage of the proposed building in square feet new construction: renovation to the existing structure: 171.0 sq.ft. 2341.0 sq.ft. Basement 0.0 sq.ft. 1st Floor 2521.0 sq.ft. 2nd Floor 0.0 sq.ft. 3rd Floor 0.0 sq.ft. Construction Type Located Pre-engineered wood Roof Framing Number of stories Overall Height Median Height 1 18.0 ft 12.0 ft Basement Basement ❑ Full ❑ Partial ❑ Finished ❑ Unfinished What material is the exterior finish? Roof style Hardie Clapboard and shingle 5 inche Peaked weahter Roofing material What system of heating Timberline shingle Hot air gas 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 Administrative Exterior Building Permit Application,page 2/3 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, 350000 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 03/02/2026 Administrative Exterior Building Permit Application,page 3/3 Demolition 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 Type of Construction Proposed Demolition Wood Frame Deck demolition and Interior demoltion for renovation and addtion to house. Estimated cost of construction 20000 (NOTE:The estimated cost shall include all labor, material, scaffolding,fixed equipment, professional fees,and material and labor which may be donated gratis.) Method(s) of Demolition By hand Number& Location of Fuel Oil Tanks to be Removed Number of Stories 0 1 Height to Highest Ridge To Highest Chimney 18feet 21feet Estimated Date of Completion 11/07/2025 Demolition Permit Application,page 1/1 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: 12 Paddock Road Barbara Rios Contract vendee Exterior Building Permit Application,page 1/3 Project Information Zone N.Y. State Construction Classification N.Y. State Use Classification Occupancy Pre-Construction Residential R-15 V R-2 1 Family Occupancy Post-Construction 1 Family Proposed Improvement Renovation of one story house. Rear addtion to master bedroom with new roof line over rear flat roof. Addtion to side of garage to make it wider to fit cars better. new front portico. new rear roof over part of patio. new gas fireplace bumped out of nonconfomring wall. New look for house. Some varainces are needed, front yard set back for garage addtion posible side yard set back for new roof over flat roof, building coverage for main building. existing deck. Area of lot Dimensions from proposed building or structure to lot lines Lot Square Feet 14912.0 sq.ft. Front Yard 35.32 Acres 0.34 Rear Yard 54 Right Side Yard 18.43 Left Side Yard 7.44 Other 0 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 171.0 sq.ft. footage added existing structure: square feet(0 (0 if N/A) 2341.0 sq.ft. if N/A) 0.0 Basement 0.0 Basement sq.ft. sq.ft. 1st Floor 171.0 1st Floor 2521.0 sq.ft. sq.ft. 00 2nd Floor 0.0 . 2nd Floor q sq.ft. 0.0 3rd Floor O.Oft 3rd Floor q' sq.ft. Construction Type Located Pre-engineered wood Roof Framing Number of stories Overall Height Median Height 1 18.0 ft 12.0 ft Basement Basement ❑ Full ❑ Partial 0 N/A ❑ Finished ❑ Unfinished © N/A Exterior Building Permit Application,page 2 13 What material is the exterior finish? Roof style Hardie Clapboard and shingle 5 inche Peaked wea hter Roofing material What system of heating Timberline shingle Hot air gas 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 © 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 © No Is the lot or any portion thereof located in a Flood Plane as per the FIRM Map dated 9/28/07? ❑ Yes © No . Will the proposed project require a Tree Removal Permit as per§235 of Village Code? ❑ Yes © No Does the proposed project involve a Home-Occupation as per§250-38 of Village Code? ❑ Yes © No What is the total estimated cost of construction: Note: estimated cost shall include all site improvements, labor, 350000 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 03/02/2026 Exterior Building Permit Application,page 3 13 BUILDING DEPARTMENT VILLAGE OF RYE BROOK 93 8 KING STREET RYE BROOK,NY 10573 (914)939-0668 BULK REGULATIONS IN RESIDENTIAL DISTRICTS Address: l Z t�e0oo t_ )�Io Section: 0S. Z-G Block: I Lot: �Z- MAXIMUM GROSS FLOOR AREA USE FORMULA: Maximum Gross Floor Area = 4,000 + [(Lot Area—21,780) x 0.11478421 ]: a. Allowed = 3Z-I k Sq. Feet , b. Existing = ILI-A t Sq. Feet c. Proposed = Z-S 1 Z- Sq. Feet HEIGHTISETBACK 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. FILL IN YOUR RATIOS: ZONE EX/S71M6 PIPOPOSED IPEOWEED FRONT: FRONT: FRONT: .44 1Pz3N SIDE: SIDE: SIDE: 1.20 FRONT: FRONT: FRONT: .48 RLZN SIDE: SIDE: SIDE: 1.30 FRONT: 45' FRONT: 051 FRONT: .60 AIL" SIDE:y3$�1.1 SIDE:,,3tj,fa SIDE: 1.60 FRONT: FRONT: FRONT: .60 AFLIS SIDE: SIDE: SIDE: 1.60 FRONT: FRONT: FRONT: .80 ANINA SIDE: SIDE: SIDE: 2.40 FRONT: FRONT: FRONT: .69 AP-I2 SIDE: SIDE: SIDE: 1.60 FRONT: FRONT: FRONT: .80 fiL10 SIDE: SIDE: SIDE: 2.40 FRONT: FRONT: FRONT: .96 AF-7 SIDE: SIDE: SIDE: 3.00 FRONT: FRONT: FRONT: 1.20 ALA SIDE: SIDE: SIDE: 4.00 FRONT: FRONT: FRONT: 1.20 "F SIDE: SIDE: SIDE: 4.00 attest to the beset of my knowledge and belief, the above information is correct. rchitect's Signature (5) 6/I/2024 BUILDING DEPARTMENT VILLAGE OF RYE BROOK 938 KfNG STREET RYE BROOK,NY 10573 (914)939-0668 RESIDENTIAL LOT AREA COVERAGE Address: 1 Z f PV0DGQ. , Section: 1 33-. ZG Block: Lot: 4-7- PERMITTED COVERAGE RATIOS IN RESIDENTIAL DISTRICTS YOUR ZONE AREA IN MAIN ACCESS. DECK ZONE DISTRICT SQ. FEET BLDG. BLDG. MAX. CHECK MAX. R-35 35,000 14% 4% 5% R-25 25,000 14% 3.5% 4% R-20 20,000 14% 3.5% 4% R-15 15,000 16% 3.5% 4% R-15A 15,000 12% 3.5% 4% R-12 12,500 17% 4% 4% R-10 10,000 20% 4.5% 3.5% R-7 7,500 23% 4.5% 3.5% R-5 5,000 30% 5% 3.5% R-2F 5,000 1 30% 5% 3.5% Existing: Proposed: 1. AREA OF LOT `� Z Sq. Ft. A-9,kZ Sq. Ft. 2.AREA OF HOUSE a. Coverage of Main Building (Including Attached Garage or Accessory Building) Z�`E� Sq. Ft. Z$Z_ � Sq. Ft. b. Area of 11 Floor Divided By Area of Lot x 100 r S•7 % I d `l % 3.AREA OF ACCESSORY BUILDING (Includes Detached Garages,Tool Shed, Playhouses) Sq. Ft. 7 f Sq. Ft. a. Coverage of Accessory Building _ Area of Accessory Building Divided By Area of Lot x 100 "`� % '3 % 4. AREA OF DECK 081 Sq. Ft, Sq. Ft. a. Coverage of Deck Area of Deck Divided By Area of Lot x 100 I attest to the best of my knowledge and belief,the above information is correct. c&tect's Sigr4f e (3) 6irizaza � i I BUILDING DEPARTMENT VILLAGE OF RYE BROOK 938 KING STREET RYE BROOK,NY 10573 (914) 939-0668 IMPERVIOUS COVERAGE RATIOS RESIDENTIAL DISTRICTS Address: 1 Z etkmaou�- 34P Section: 135• W Block: 1 Lot: Zone: R— S 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 rN 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 ER22-F 40 30 *"Base Lot Area"is the minimum end of the lot size 30 range in the"Lot Area" column Area of lot: )A `WL s .ft. Existing Allowed Proposed Total impervious coverage '7 z4 S .ft. Se-11 S . ft. -141 9 bik, S .ft. 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Ln 3 oEui o 'k ��EWYp�� cii 0 ° $ > E � .9 W JW o}te 0) Ea V ° ` - vva, . 0c a Q a a i 'n v L Electrical 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 135.26-1-42.1 Proposed Electrical Work/Fixture Count 3rd Party Electrical Inspection Agency WIRE ENTIRE HOUSE NEW, 2 HVAC SYST, 1-20 KW SWIS GENERATOR, 200 AMPS SERVICE Master Electrician/Licensed Installer Information Name Lic# Address email Phone# Cell # Company Name Company Address MYRON PERICH 232 9144902020 MYCO ELECTRIC Address of Work? Homeowner Information 12 PADDOCK Electrical Permit Application,page 1/1 y 4Rnv VILLAGE OF RYE BROOK W 938 King St Rye Brook,NY 10573 � Q Y Phone:(914)939-0668 1 www.ryebrook.gov �• ��O 0 . 198 Building Department Electrical/New Fixtures And Wiring(New) Permit Permit Set 12 PADDOCK RD P#RB25-0128 R#135.26-1-42.1 PERMIT INFORMATION Address Permit number Date issued 12 PADDOCK RD RB25-0128 11/25/2025 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 Electrical License-Photo-Westchester County 4 Application Materials 5 3rd Party Electrical Inspection Form 6 Electrical Permit Application 7 Building Department.938 King St Rye Brook,NY 10573/Phone:(914)939-0668 �y BROVS VILLAGE OF RYE BROOK V 938 King St Rye Brook,NY 10573 W Q Phone:(914)939-0668 1 www.ryebrook.gov -a� ��. B2• i Building Department INSTRUCTIONS THE PERMIT HOLDER AND/OR PROPERTY OWNER IS RESPONSI BLE FOR ENSURING THAT ALL REQUI RED/APPLICABLE INSPECTIONS ARE SCHEDULED AND THAT THE PERMIT IS COMPLETE ❑�E .❑ I• 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,A►I fees Paid and Final Survey in if required) B \\. Bum ENT VIL OK 939 KIN Y{' NY 10.573 (914)9_ t 939-5801 w org ELECTRICAL PERMIT APPLICATION Westchester County Master Electricians License Required FOR OFFICE USE ONLY BP#: R r5 A5- OOaL EP#: Approval Date: Permit Fee: S4.2f. 1pproval Signature: Other: Disapproved: (fees are non-refundable) Application dated, —1� F �� is hereby made to the Building Inspector of the Village of Rye Brook NY, for the issuance of it Permit to install and/or remdve electrical equipment,wiring,fixtures,or to perform other high or I0w voltage electrical work as per the detailed statement described below. The applicant & property owner, by signing this document agree that all electrical work performed wi Il be in conformance with all applicable Federal, State,County and Local Codes. P 1,Address: L BL /.�5. . - -y,�.. 1 Zone: � � ` k� —_ - � — 2.Property Owner A a -2(y1'1 ' Addreaa /4;2 /'n �c�c-K nj Phone#: ran 'Y147 86& amsI.r oS V! 3.Master EI�'cian: ,r'! T 2 o� �►Z I G � /I m 5' dy F, kw f 07 0 1 Lic. a 7S)-)- Phone 91y gb�'?7ti Cell#:Q I4 e�.il: e_ 1, , .0 Company Name: ��,`Cr..� JS�L e--,c T t Z , Ad&etts:S-) V X770I 4.Proposed Electrical Work/Fixture Cant LUG 0 0,42 1' .r f 70 V e,4 c. -huge- 5c-s-1 6-2&e2Z21C, C-'f STATE OF NEW YORK,COUNTY OF WESTCHESTER i as: M 4'.Q Pr./L I G tY being drily sworn,deposes and states that he/she is the applicant above named,and does fu tber (print name orindividual signing as the applicant) state that(s)he is the legal owner of the property to which this application pertains or drat(s)he is the for the legal owner and is duly authorized to make and file this application. (md,catc architect,contractor,agent,attorney,etc The undersigned further state..,that all statements contained herein are true to the best of hislher 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 A 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 -- day of 9�''�r'►nb ' 2 Signature of Property Owner Si at a of Applicant I-K (Z UA) Print Name of Property Owner l Name of Appl;tcan�` „n Notary Public Notary Public SHARI MEULLO •.;:ary Public,State of New York No.OIME6160063 -�ified In Westchester County �:ission Expires January 29,2007 7rl/17 STATE WIDE INSPECTION SERVICES, INC. Service It ilh IntegrilY 0•0 • • SWIS • B APPLICATION tel 845.202.7224 1 fax 914.219.1062 1 SWISNY.coml SWISTRAINING.COM Office Use Elect. Permit u Date Bldg Permit # R� �s-+ — t`/IOO Sq Ft Plumbing Permit n Final Certificate u City/Village • YE fob Zip Building Dept. (.Ounty �Qa� Address • , / O Cross Street Section 6 Block / LotG� / 7 Owner Name/Address(if different than above) Zqrb Contact Number ❑Basement 91st Fl. ❑2nd FL ❑3rd Fl. ❑More Than 3 FL ❑Garage ❑Attic ❑Outside ❑Residential ❑Commercial Receptacles Special Recept GFCI AFCI Switches Dimmers Smoke Alarms C/0 Detector Hood Trash Compact -3 Amt Amps 8 ; o ,y j 2 - Z Range(s) Cooktop(s) Oven (s) Dishwashers Refrigerator Disposal Microwave Luminaires Generator Transfer Switch 2 ! ! SS SERVICE Amperage *Panels 1P 3P Meters g Disconnect Isdunderground ❑New ❑ Reconnect ❑Repair i� Q l / / ❑Overhead Upgrade ❑ Disconnect Utility IDr ❑Con Ed ❑NYSEG ❑Central Hudson ❑ Orange/Rockland PHOTOVOLTAIC SYSTEM PV Modules Inverters AC Disconnect Junction Box Combiner Box Load Center PV Monitor Energy Storage System DC Disconnect ❑Legalization ❑ Safety Inspection ❑Consultation t, v-) This application is valid for one�I)year from the date rece,ved by SWIS.Th s application is intended to cover the above listed items to be inspected,if at anytime of—pect—additional items have been-Called.you are authorized to make the inspection and adjust the fee for the addMonal items inspected The applicant declares that there is no open applications for the above aodress with any other inspection company The applicant owner or authonzed agent sprees to all the above terms and condthom as set forth for the application a Email Address /77j�`vid L ram-f tL,e- 17yI 9 z( . Name /" y I&,I rJ / C J2 f ic,11 License t� Date `y z ' . Signature 12:L Address /M (Jr City/State J7 Zip Code Company CL�i.r �� L �'1.�� # q (y �l U(?C-).4o,,j i 41 'A 74 4Yy l> I' 1�,�►►tJ `lid �, �, . . e r OA rs Y T s`. ! l p b < tyomi. K 1 ' w -.`tom- a+�•,. t a. i fr . F. VA Ski`• f ix ua ,. w "4 •, �4 � � �. Nry y M.. ��ti III r f s 1�a lw i a tit 't �' 4 _''•. � 4��� •,�r PON Arm i, fit I { I Y lY t +,Y t ti, i p� 1�9 f�I'�ioll+Il'iN� I i �p � I r I - •Y . s f��'t , rl.• �. +,(I/ •t x , t.x•�Y .' y� fir¢' 1 NEW YORK Workers' Certificate of Attestation of Exemption STATE Compensation from New York State Workers' Compensation and/or Board Disability and Paid Family Leave Benefits Insurance Coverage **Thu form cannot he used to waive the workers'compensation rights or obligations of any parts:** I he applicant may use this Certificate of Attestation of Exemption ONLY to show a government entity that New York State; .pccific workers'compensation and/or disability and paid family leave benefits insurance is not required. The applicant may NOT use this form to show another business or that business's insurance carrier that such insurance is not required. Please provide this form to the government entity from whicb you are requesting a permit, license or contract. This Certificate will not be accepted by government officials one year after the date printed on the firm. In the Application of Business Applying For: (Legal Entity Name and Address): Building Permit Barbara Rig,. 12 padork From:Town otRyehrouk Rse hr wk,Nl 10573 PI1r)NF-914-44'1-861a FEIN:XXXXX9141 I he location of ochere work will be vertiormed is 12 Paddock Rd., Rvehrook,NY 10573. Estimated dates necessary to complete work associated with the building permit are from November 4,2025 to November 3,21126. 1 he estimated dollar amount of protect is over$11NI,INN1 Workers'Compensation Exemption Statement: Hie above named business is certifying that it is NOT REQUIRED TO OBTAIN NEW YORK STATE SPECIFIC WORKERS'COMPENSATION INSURANCE COVERAGE for the following Mason: The applicant is a homeowner serving as the general contractor for a primary/secondary owner-occupied residence.The homeowner has ONLY uncompensated friends and family working on his/her residence or is hiring individuals a total of less than 40 aggregate hours per week and has a current homeowners insurance policy that covers the property. Disability and Paid Family Leave Benefits Exemption Statement: 'the above named business is certifying that it is NOT REQUIRED TO OBTAIN NEW YORK STATE STATUTORY DISABILITY AND PAID FAMILY LEAVE BENEFITS INSURANCE COVERAGE for the following reason: I he applicant is a homeowner serving as the general contractor for his/her primary/secondary personal residence. The homeowner has not employed one or more individuals on at least 30 days in any calendar year in New York State. (independoit contractors are not considered to he Lrnployees under the Disability and Paid Family Leave Benefits law.) I.Barbara Rios,am the Homeowner with the above-named legal entity. I affirm that due to my position with the above-named business I have the knowledge,information and authority to make this Certificate of Attestation of Exemption. I hereby affirm that the statements made herein are true,that i have not made any materially false statements and i make this Certificate of Attestation of Exemption under the penalties of perjury. I further affirm that I understand that any false statement.representation or concealment will subject me to felony criminal prosecution,including jail and civil liability in accordance with the Workers'Compensation I.aw and all other New York State laws. By submitting this Certificate of Attestation of Exemption to the government entity listed above 1 also hereby alltrm that if circumstances change so that workers'compensation insurance and/or disability and paid family leave benefits coverage is required,the above-named legal entity will immediately acquire appropriate New York State specific workers' compensation insurance and/or disability and paid family leave benefits coverage and also immediately filmish proof of that coverage on forms approved by the Chair of the Workers'Compensation Board to the government entity listed above. SIGN Signature: i Date: //lf��ZS HERE .J Exemption Certificate Number Received 2025-082810 ` October 23, 2025 JOLANTA SCHMiDT NOTARY PUBLIC,STATE OF NEW YORK N YS Workers' Compensation Board Registration No.01 SC5002401 Qualified in Nassau ty l'1-21K1 012019 My Commission Expires.— T �� s F o E ui to m CV Z € a 8 E 2 EE' f�y m U- E . 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