TOWN OF RAMAPO 237 Route 59 Su ffern, New York 10901 (845) 357-5100 Fax: (845) 369-6945 Christopher P. St. Lawrence Supervisor Scott J. Shedler, IAO June 17, 2015 Assessor Honorable David S.Carlucci i New York State Senate Re: Retroactive Legislation Approval Legislative Of?ce Building Assessment Rolls: 2013 2014 - Room 3] Applicant/Homeowner: Congregation Divret Chaim Albany, NY 12247 I Premises: 61 Carlton Rd, Monsey, NY 10952 Mailing Address: 49 S. Main St, Spring Valley, NY 10977 Dear Senator Carlucci: Enclosed please ?nd the following documents as outlined by the New York State Senate for Retroactive Legislation approval. 1. Copy of the approved application for exemption which the organization has ?led with the assessor for the current year?s assessment roll Copy of notice ??om the Assessor granting the exemption; Town of Ramapo resolution stating no objection to the passing of legislation; and A statement from the local Assessor acknowledging the accuracy of the proposed legislation. New Please consider this letter as the Statement by the Assessor as to the accuracy of the proposed legislation. Therefore, this of?ce requests that you please present the appropriate bills to the Senate in order to pass legislation for a Retroactive Exemption for this property. Finally, I respectfully request that once you have introduced said bill, please have your of?ce forward a copy of same to us. This would help us expedite the process so that we can issue the exemption expeditiously. Please feel free to return a copy of this letter with the appropriate information. Thank you for your anticipated cooperation. . hedler, 1A0 Assessor SJ S:j Enclosure ACT MAIN FILE - FORMS SENATE - RETRO LEG -Cong Divrei Chaim.doc6ll7!15 Town Board Meeting WIOIIS 03:00 PM 237 Rt 59 DOC ID: 2340 Suffem, NY 10901 ADOPTED RESOLUTION 2015-296 Retroactive Tax Exemption - Congregation Divrei Chaim WHEREAS, legislation will be introduced in the New York State Legislature that would grant authority for the Town to accept retroactive application by Congregation Divrei Chaim for real property tax exemption as follows: CON GRE GA TION DI WEI CHAIM 61 CARLTON ROAD MONSEY, NEW YORK 10952 61 Carlton Road, Monsey - SBL: 49-18-2-32.1 2014/15 Tax and Assessment Roll, and. WHEREAS, the State Legislature requires the Town Board to state that it will grant retroactive tax exemption once appropriate State authority is granted, NOW, THEREFORE, BE IT RESOLVED by the Town Board of the Town of Ramapo that it has no objection to the passage of the above legislation and it hereby agrees that it will grant tax exemption for the above properties for the tax year in question if legislation is passed and signed by the Governor. RESULT: ADOPTED I MOVER: Yitzchok Ullman, Councilman I SECONDER: Patrick J. Withers, Councilman A YES: Christopher St Lawrence, Daniel Friedman, Yitzchok Ullman, Patrick J. Withers ABSENT: Brendel Charles TOWN OF RAMAPO 237 ROUTE 59 SUFFERN, NY 10901 (845)357-5100 Date: 5/1/2015 CONG DIVREI CW 61 CARLTON ROAD MONSEY, NY 10952 RE: 89149.18-2-32J NON-PROF 0 (25120) RE: EA420 Exemption Application Dear Property Owner: This is to con?rm that the exemption on the above property has been approved for the 2015 Assessment Roll. This property is 100% exempt. This exemption will apply to: January 2016 County and Town Tax September 2015-2016 School Except special districts. where applicable. Very Truly Yours, aim/4 Scott J. Shedler Assessor (was) NEW YORK STATE DEPARTMENT OF TAXATION FINANCE OFFICE OF REAL PROPERTY TAX SERVICES APPLICATION FOR REAL PROPERTY TAX EXEMPTION FOR NONPROFIT ORGANIZATIONS II PROPERTY USE Conawaqqtio? Di'qrei 374750727 I a. Name ?cyganiza?on 2. loyal-1D? . r1 NM 3 3a. Nmafcontactperson WS - 35'3" auilbl b- Mailing?ddress b. Dayta honenomfcontactperson (nl Cu?t?oh Rental 9113225 MOI-H Evm?ngtelephomno. NW below @bobov'rwonseu my}: c. Addres??ofproperty c. 0 d- "lq- 5:1- 1 4a. '2 DYes IZNO b. DYes igiNo c. No d. 5. Name 1. 6. Dateofacquisi?on: Deedremraingmma?on-Bookomeeds: Page: (1an 7. director, employee, member, etc)? No s. Is?lepmperlymortgaged? a 8- organiza?on? El Yes No b. (attach addilicml sheets if many) FOR USE Assessing unit County City/T own Village School District (9/08) 9. Yes N0 3. Sake] m? and ahnm? IF THE ORGANIZATION SEEKING WON HAS INDICATED ONE OF ITS CORPORATE PURPOSES IS HOSPITAL 1N QUESTION 28. ON FORM RP?420?a-Org, ANSWER QUESTION 1 1 . IFNOTSKIPTOIZ. 11. EINO Hyamswera?noughc. - a. The (2) b. (I) (2) formeprivatepm?oeome sta?'munbars (3) El aomnbina?onofland'z c. pmc?ceof?wsta?'? - 12. DY I a. Name of Wallis) 13. Use by cums) (also indicate speci?c por?on of property so occupied): c. Tenn(s) of occupancy one-year lease, momh-to-mon?: mummy): d. Amountofranmlpaidbyoommamis) 13. cont-?au?onsrecaived?aruse: ?amtheapplicant?? l4. dYes Ifyes,skipques?onsalhmughe. Humanswa-eandskipqms?ons 15-16. a. b. $40 Ifyas, details includingproposequs): c. improvements? [:IYes No It'yes, amoh a copy of resohl?ds). d. e. Whmw?lconstructionbegin? . 15. @?ldi??j u?kk :50 OFQCW a. I). Use orusesoflandre?medtoin 153. ifnotdesm'bed inqu?ion 10. I c. DYes El?n d. hnprovemm?s? Yes 0 Ifyes, attacheopyofresolu??s) e. DY a. b. VERIFICATION State of New York as: Countyof . ,beingdulyswormsaysm_heisme $607,, Subscribedandsworntobeforeme 1:11 of "was: or mtho?zed representame' Commission? eyot' . . mic, Stale ewYork tie. O1K16096406 'fiernn Rockland County ..on Expires July 28. 2013 RP-420-alb-Use (woe) GENERAL INFORMATION AND FIIJNG REQUIREMENTS medical - .- 2. APPLICATION FunnRP-420?b?Org?- Want andRP?4203lb-Rnw-llmn?be?lcd. youarerasponding. ?Iheasses'aormay Intha W?lemmaymhn?tpmofofm 3. Plaeeof?lingapplication BoardofAssessm-s. haTom?cins . 4. Timeof?lingapplicatinn tanblest?hJSdate. Marchl. may SPACE BELOW FOR USE Parcel iden??ca?on no.(s) Applicant organim?on Employermno. Data application?led Application Appmved El Disapproved AssessedValua?on .Tmble Exempt Documentaty evidence presented: ASSESSingunit I Assasm?ssignahne Date APPLICATION FOR REAL PROPERTY TAX EXEMPTION PROPERTY USE OCCUPANCY STATEMENT PROPERTYADDRESS LOCATION: bl Carlton Rood Home? NH ld?I?Sa Ccn?mnanblon Chaim ORGANIZATIONS MAIIJNG ADDRESS: 1[?1 South Main Ska-dual: Spw?ng Valle? NH [0977 PARCEL DESCRIPTION AS IT APPEARS ON ASSESSMENT ROLL: 39. .I A. NAME OF OCCUPANTS: 1- Conifecaq-hod Divl?il. Chaim 2. 3. 4. B. SPECIFY THE EXACT USE OF THE PROPERTY BY THE 1 FA umbi'm $6de {Rwsk WW3 Una 304MB 2 WI . 3- 59?3415?09 4. SE ORS I STATUS . CH C. OF OCCUPANCY: 1. 2. 3. 4. D. AMOUNT OIF RENT PAID BY E. IS THIS PROPERTY OR ANY PORTION THEREOF ATANY TIME USED BY 0 RS THAN THE APPLICANT OR THE OCCUPANT NAMED YES NO IF YES. SPECIFICALLY FOR WHAT PURPOSE: 81(3me HII UJQIBIWIM TELEPHONE: PRINT NAME: TITLE: ?d'M I'Str'q I7, EIWmn?on fowl-A1011 mntp?on fuzqu sumac-.- This Page Intentionally Left Blank Rum-3.0mm NYS DEPARTMENT OF TAXATION OFFICE OF REAL PROPERTY TAX SERVICES APPLICATION-FOR REAL TAX WON FOR NONPROFIT ORGANIZATIONS - MANDATORY CLASS I-ORGANIZATION PURPOSE unbackof?xm) Con?reaortwn Dl?uref Chaim ?ri Mq?mm . Ia. Name?0ryniza?on d. Name ofcontantperson 5 8- Mona R'i'mk. SLIS- e. Daytelephonenomfcontactpason WW Io?m qn- (175-4044 b. Mailingaddress Eva?ngtdaphonem. 31 475 01a? 0 Bobowatonsm. at c. Employermno. f. E?mail ErReh'gious B?Edm?oml Charitable El b. 56/100] I c. Sgna?o?k, EchCIxtn'on Huh?Sakai; dew-psi? Laws. (Dad. glcaalms Sh addi?cmal sheets if necessmy) FOR USE City/Town Village School District - 2 3. EYES - kg: a. SO wr?tenrequestorstaiement? DND Ifyes: (1) Was?aeemptiunreeogl?zedbya (checkane) EIGroupemptionle?ar Ummonlmr (2) (3) (Why/Year) ATTACH COPY OF DETERMINATION OR RUIJNG LETTER Ifno: (4) Please explainhowthe m-ganin?onis miditional c. EIY I?o ATTACH COPY OF EACH RETURN FILED FOR THE ORGANIZATIONS LAST FISCAL YEAR d. Forms last?scalyear, did?le organiza?on?le Yes 0 IFYESATTACH COPY OF FORM 990-TANDSKIPTO QUESTIONS 4. Yes a. b. Date ofapplica?on ATTACH COPY OF APPLICATION, REQUEST OR STATEMENT AND ATTACHMENTS IF NO, COWIETE AND ATTACH ULE A (obtain Sch. A from Mar) 5. hmeargm?m?mincarpmd? mes DNO Hyegmswerathroughc. 3 a. Dateimpmated 2-1144 It/dwi??rk ?oat/w c. Underwhiohlaw?Law: masons Article?orsection: AraL ?0 - ATTACH COPY oP INCORPORATION (Note: Ifadissohnitmpm?sionis organizationdissolve.) cap) 949 6c;- Rate of Inwp- frag/IMJ d. Formofm-gsnizs?on eDstefomod . E?s Ifyes? M9?:r Kim!" ff?; (2) UndawhichLav?Im e4:le (org Lad macaw?LL (3)Dstespplieation?led: - ATTACH COPY OF APPLICATION AND CONSENTS REQUIRED WITH APPIJCATION ATTACH COPY OF CURRENT ARTICLES OF ORGANIZATION (Note: Ifadissohnion should the mganiza?m dimolve.) I i??o 6. DY Ifyes,answera?noughc. a. Whichonqs)? Givenamcandaddress b. Does?worganiza?onhavean byapublicregulatorybody? .Y IF YES, ATTACH COPY OF AUTHORIZATION c. mg VERIFICATION State ofNeW York 53: Countyo 1L Se of the applicant organization, ?Jatthe statements contained in this application (including the attached sheets consisting of pages) are true, conect and complete, andthat_he makes this application forreal law. Slgnatme' of miner or amho?zed represemnuv' Notary Public. State 3- - - No. 01K18096- . Quali?ed In Rockland Cu- - Commission Expims July IS RP-420-a-Org (was) GENERAL INFORMATION AND FILING mom 1. 2. Application eadIassessingunit. 1113mm CountyDiVisionofAssment. 4. . Intuwns be?ledpromp?y. SPACE BELOW FOR USE Applicant organization Employer iden??ca?on number Date applica?on ?led See form RP?420-alb-Use for parcel numhe?s) Documemmy evidance presmted: Assewingunit Assasm?ssignatm'e Dale SCHEDULE A NYS DEPARTMENT OF TAXATION FINANCE RP-420-nIb-Org (1/95) OFFICE OF REAL PROPERTY TAX SERVICES APPLICATION FOR REAL FOR NONPROFIT ORGANIZATIONS i mistcompletertD. RELIGIOUS ORGANIZATIONS . ..Part CHARITABLE ORGANIZATIONS THAT ARE NOT FOUNDATIONS OR TRUSTS . .Part HOSPITAL ORGANIZATIONS . ?Put EDUCATIONAL ORGANIZATIONS . .Part ORGANIZATIONS THAT OPERATE HOMES FOR THE A . ..Part I assessor. . ALL ORGANIZATIONS MUST COMPLETE THE VERIFICATION ON PAM 19 C?mm qt" 133ml 31- 1150131 la. Nme?of?gm:i:im c. Employarano. T'q Hr; d. Nana ofme (aw-{hay Umuuaq RH {(3771 31/5? 353" b. Mai?ngaddicss 0 e. 9/7- ?17_Yes Part AND OPERATIONS l. onand?losewhidlw?lbecar?edm thBGEaniza?on. organim?onal docmnents). aclivi?es arerclated 2aFom1 RP-420-a-OrgorRP?420?b?Org. SCHEDULEA 2 RP-420-alb-Org (1/95) PartB(con?nned) 2. a. Nmaddrmanddu?nsofof?om, b. direcmm, Meta. orpar?cuqum??mhons. Hirsch ?ablho?rh Weave/f Road PMs-e4 AN fo?g'i ?esftfa? OWN, An' (WW mgr/haw gr- IWB Maria . Sprm?? L?s/Asa M977 Mich 16191756; Errz?gg/a (1) Won? (AWWE em?whocmnibnbdorbeqmathedan (2) (3) Apaw?uofma?nnZOmef?wtoml ammuniofme?nn??omif mhamamtismathaanarca?of?m mammal-Man? Yes No (4) ?narganin?minwhioh?nom?bu?onor (Amba'of?wfm?ywith In?aecamofatn?fhe Yes No bequmt). Yes No IF YES ANSWERED TO ANY OF THE ABOVE QUESTIONS, ATTACH FULL EXPLANATION. d. (5) meincdw?ngpowu?? __Ya _No ea Yes __No (2) __Yas (3) w?ngpomofacmpma?m. mapu?BiIItHEtofapmt- (6) Aparmmhipinwhichperm (n42). abowhuldmn?nn? of?m Ma?abma?cialimaesmfatmstor Yes No tolhu orgmimim? Yes No (7) ?rebenn?dal?mt? Yes No (4) i110), . (Z)or(3)above? (Samuel) (8) Ya No madaby hymn- ozgmimim? Ya No IF YES ANSWERED TO ANY OF THE ABOVE QUESTIONS, ATTACH FULL Yes a. SCHEDULE A 33-42mm (1/95) Part (mud) 2f. Isit?g?dpatnd?mtanyummtor Yes No IF YES, FILL EXPLANATION SEPARATE ATTACHA DETAILED STATEMENT EXPLAINING TEE (S). Na 3. Yes OFALL PAPERS WASEFFECIED. ornahum' 'dn mun Eyes, WWI) ofargu?z?i?s) Indmhinmh?mdnp. I Yes A0 Kym, .- /Y:s No b. gamma-FM aw (113901;, 01 (hl'mrgfawl Yes 40 c. SCHEDULEA Pal-thumbing!) 6. Bywambmhipm? Yes -/No - yes: pmilegmmcuived. I I h. c. Yes No. Ifno. phase uplain. . law . See, Note: Ifin 20 I. RECEIVE (1) (2) Mamma? (4) Lessoostofsala (and: soluble) (S has??mhmiwhla) schedule) - (6) c7) Congregation Divrei Chaim BUDGET 14?15 PAYROLL Divrei Chaim School Expenses Gas - Buses-Maintenance Of?ce Equipment Payroll Tax Maintenance Insurance Utilities Taxi for teachers Total School Expenses Total Salary Total School Expenses Total Expenses Income Tuition Fundraising/Dinner Total Income Total Expenses Total Income Yearly income YEARLY 5 164,810.00 20,250.00 4,900.00 12,607.97 14,000.00 16,800.00 28,860.00 5,040.00 102,457.97 164,810.00 102,457.97 267,267.97 min-tn 315,000.00 31,500.00 ill-{? 345,500.00 267,267.97 345,500.00 79,232.04 13,734.17 1,687.50 408.33 1,050.66 1,166.67 1,400.00 2,405.00 420.00 8,538.16 13,734.17 8,538.16 22,272.33 26,250.00 2,625.00 28,875.00 22,272.33 28,875.00 6,602.67 mus-mumm- 7'1 SCHEDULEA 5 (9) Fundraisth (10) Cannibalian gi?s. giants ands?nil?'annunts (11) (12) Compmsa?mofn?cuadimcmH?tmsm (13) (l4) Entrust (15) lint (16) (17) (18) TOTAL EXPENDITURES (19) 1b. I. ASSETS BMW Emu-Dams (mother (2)Amountsrecuivah1e.net (3)1nvenmrins (4) Bundsandmte?athdunhedulc) (5) (G) Mrtgagelnan?mduchedl?c) (3) (9)1111! (10) O?ner assets (MM) (l 1) TOTAL ASSETS (12) Assam Mable (Blm?mmp?wm? (l4) (15) (16) SCHEDULEA 6 Rum-wow (1/95) . PartC-Fmanmtcon?nnad) (l7) (18) 17] (19) Yes No EmmBhadeta?eduplma?nn. 28. Ifmyamelsaranot?l?y?pmi?unal, Dr 00F Car-?tan R004 . ?232) bq Sand 4 b. mm ?sunnpt?ncum? ?f . Does ?win anyparlof?le No Ifyes, explain indan . I Hastheorganizntianmde Yes No EYES. A RF-420-alb-Org (1/95) PartC-Fimncas (W) b. No - Emphadesuibemduplmn' themgumt?sruhufehgih?l?y? . aO?mdirmanduustaes: . Tune Wm Emmud Nannand??e devotedto erm album posi?m (ml) (m1) ?usgh magnum plush-IL FT Dowel (316m Ff "a Hr: waIdi-ham FT - soc/ear} Tim Cmi?m?mtn ExpaMand devotedm PmployaeBme?tlen o?mA?owances Position (ml) (man 160mm FT H.000 mam {mt?LN" Fr 39:030 Me L. PT moon ls?sz Semaraka 434;: FT 11,000 Tomk GelanmEak FT 3e. Thus I Coal?hu?unstn mamas damn EnpbyenBenc?tles o?l?rh?nwmces Nmti?cmdAddressas position (mull) (m1) (m1) Ban-nun I-(musw 15mm: PT ??ee JEsepn Te'dell?um'?m- 9T i133"! Ham 3? ?am- PT "We Elm Raise Hucwr PT $400 SRULQM D-Zut?h PT SCHEDULE A (1195) PartC?Fh?mm(mn?nne?) mm and Name andAddress Type of Time devoted to service o?m??nwances amine (annual) (annual) Yes No 4. Ifya. annual ?nial: . WW theorgmia?nnap?wta?mnda?nn? Ya h. Foundational-trusth 44m. SCHEDULEA c. as d. jam-estIfyas. please uphill. f. Enppanbeadl? g. Funny . I. SCHEJUIEA 10 RP-420-a/b-Org (1195) 3. ?scalyear: . I Ifmcipiu?isauhdivml, - Concisestainnu?ofpmposeof Amman (humourbusim) macrome glantorcm?rilm?nn - . 1 a. Paiddmingm TOTAL h. Approvedformpaymmt TOTAL 4. Yes a. 13. Mostme co school? Yas Na. d. ofapm?u?ar Yes No Iers, ME-R?i?morgu?n?om 1- /Yes No 1 l/G N0 3- kaam??mmM Yes No SCHEDULEA ll RP3420-alb-Org PartE-Wimn No 4. ?I?heologimlminmyar mm Men?s You?igmup Yes /No Jew-5k 7. {Myers 3 am; o/m/si a. Roe?J Qrang? w?c 62' 9. mammalian). .. 3 whs'?e 01:wa /02. Sen}! and 10. ll. 12. (:YeuCSk LN Sdka'M 119*? am {a 50% wk aw ?aim;ch Maw Ma ow mlaggumiw SCHEDULEA lap-42mm; (1/95) Ia. b. such mppurttneac'h? . 5% 2. ?scalyaar: Ifrauplm" show Wat's:wade Concisesiam?pmposaof Amomn (h?m?orhnsinesg) Mammoth]: mmp?m?nn. TOTAL b. Approved?wmepaynm TOTAL SCEEDUIE A. 13 Yes No 3. Ifys: a. Fan] Inb) b. U-L ?gure; a Camw 6" ?Uuq? rel/2w Awkwa- Er? a:ng ?ex Qewmu?n student runninsinachonl? No d. aparliculnr employu)? .. Yes No themd. PartC?Hos?nlorganin?nns la- Nursinng b. SCHEDUIEA (V I I 14 (1/95) . l' 22. Yes No Hmmems?mS. 12ny b. Numbu-afbais: . (2)Phyainluaahnmt (BMW c. Doespr No 311qu uphill. (1. Does Yes No Eyes: (1) Hunteran (2) Nunba?ofmn'ses e. fac?i?es)? Yes No yes: (I) (2) Yes No t: Yes It'yes: Yes No ?35121510303563? Yes SCHEDULE A 15 RP3420-aIb-Org(1195) PartG~Hosp?nl?Eha?ms (continued) 3. mai?nnofthemu?calm??. _Yes No IfyusHun.me 9. havawi?: SULEA I a 16 RP?420-alb-Org (1/95) Pauli-an I. Is?lemgmizmhnaml? Yes NO Hmskipmqmimufyes a. Wtypeofschoolisif? pm Secondary Collame (M) h. EdUC-n'twn Hugh Sol-mas] Laws omd We! sud/ta; . uGivennmbaro? (DFamhymunbem 4'1 man-mm a: um-?mastndams d. 2. program? Yus _Nn 3. Yes Dmibe?laac?vi?esofthumgmin?an ?1 mm)? SCAM, SCHEDULEA l7 MI-Hamesfor?uugul l. Yes No 2.. Emmaq?l18 SCHEDULE A (U95) Veri?cation State :1me York -) Com of ROG. ?58: AF: I gm ofthe applicant - . .: a?n'e this ?dayofmzuL XW 'oner?fdeedsornotarypuhlic JUDVL CAM-TIT. Notary Pu'wc 3?22 0" Hal: York Ho 0189516315 Quali?ed ir' Ra?-End nu - Commiss an Ema-res '5 7r? RP- 462 (9108) NEW YORK STATE DEPARTMENT OF TAXATION FINANCE OFFICE OF REAL PROPERTY TAX SERVICES APPLICATION FOR EXEMPTION FROM REAL PROPERTY FOR PROPERTY AS RESIDENCE OF CLERGY OR la. Nmofraligiouscorpm-atian b. Name of of?cia?ng clergy 9 7a. Divrreul Telephone no. of clergy Day E-mail address (optional) IVsy?address Location of propaty Village (ifany) City?? School dist-int Property see tax bill or roll) Tax map numbn- or sec?on/blockllot TaxLaw?? IZIY Emgive?rlldeta?s. DYes IjNo Ifno, explain. DYes pmposes? [Was [No o?leruse. Ifthe forresidmoeofof?cia?ngcla'gy. ATTACH ADDITIONAL SHEETS WHENEVER NECESSARY Submit form RP-420-a-Org (available ?orn assessor) or RP-420-afb-Rnw-I, if renewal, and all RP-462 (9/03) 2 VERIFICATION State of New York Comlyof . of the of provided by law. Notary Public. Stale 0 a sworqto rams 20 U8 ed Of A Commission Expires July 23. 20 "5 Commissionerdf - public GENERAL INFORMATION AND FILING REQUIREMENTS 1. realpropertytaxa?onforpmperw 2. MW tion is suf?cient. whichyouareresponding. Thetlssessor 3. Placeof?lingapplication assessor. Services. 4. Timeof?lingapplica?on In mxablestatusdateisMamhl. Westche?ar Inv?lngandci?gthe InNewYorkCity, inxable status-data islanuary forthis mp?onmny be ?ledanorbefmeMarch 15.. SPACE BELOW FOR USE ONLY Applicant religiom mammalian: Date applica?on ?led Application El Ammved El Disapwuved Assessed valua?on Taxable Empt Documeutmy cvidmoepesented Assessing unit Assmsor's signahn'e Date August 2014 The of the State of New York THE STATE EDUCATION DEPARTMENT Office of Facilities Planning Room 1060 Education Building Annex Albany, New York 12234 NONPUBLIC SCHOOL BUILDING FIRE SAFETY REPORT (PLEASE PRINT) All burldings which are owned, operated. or leased by nonpublic schools must be inspected annually for compliance with applicable sections of Regulations of the Commissroner of Education and for compliance with the New York State Uniform Fire Prevention and Burlding Code (NYSUFPBC) School Name i) lVi NA Facility/Buildin th Au Street Address (NO PO Box Numbers) 6 A 0 I Cit lTownNillage Zip Code houset 104:1 Name of Munic ipality Responsible for Local Code Enforcement 0 OF UN Nonpublic School BEDS Code OOHO 5L a; sort INSTRUCTIONS Read the ?Manual for New York State Nonpublic School Facility Fire Safety Inspections" prior to inspecting the facility. A separate report must be completed for each building and location. Part I: General Information. School officials must complete this section annually. Part ll-B Regulations of the Commissioner 155.25: This sectlon must be completed for schools with electrically operated partitions (Question 8, Non-Conformance Report Sheet) pursuant to the Fire Code and Property Maintenance Code of New York State. Questions 9-26 on the Non-Conformance Report Sheet must be completed for all schools. Part Ill Certifications. To be completed by individuals as indicated This form must be kept on file at the school for three years and must be available for public review. Submitting the Report: The final submission package includes a total of five pages. After the inspection. sign the Certifications page (Part p5), staple the pages together. and mail to the address above. 1 ?l . Indicate the primary use of this facility: (check one box) a) Studenthiristruction Part I: General Information and FireILife Safety History (to be completed annually) hall. physical education building. etc.) I. is there a fire sprinkler system in this facility? No If yes. is the sprinkler alarm connected with the burlding alarm? Yes 51 No Is there a ?re hydrant system for facility protection? Yes No 51 If yes. indicate ownership of the system. Public Owned School Owned Other (specify) indicate the ownership of this facility. Leased Owned \f Other (specify) What is the current gross square footage of this facility? (to the nearest whole ten feet) 5 do if this facility is used for instruction, complete otherwise go to question #7 a} b) Average time to evacuate this facility. Fire drills were held in accordance with Section 807 of State Education Law and Sections F405 and F408 of the New York State Fire Code. Yes No 5?8 Seconds Minutes 0) Arson and ?re prevention instruction was provided in accordance Section 808 of d) If the fire alarm was activated since the last annual fire inspection. was the fire department immediately notified? State Education Law; which requires every school in New York State to provrde a minimum of 45 minutes of instructions In arson, fire prevention, injury evention. and life safety during each month that school is in session Yes No Employee fire prevention, evacuation. and fire safety training was provided and Records maintained in accordance with Section F406 of the New York State Fire Code No No tries?? 8. Have there been any fires in this facility since the last annual fire inspection? If yes, indicate: Yes a) Number of ?res b) Total number of injuries c) Total cost of property damage I l?l. Part II: Nonpublic School Fire Safety Non-Conformance Report Sheet School Name 9 'w fI C/?i?llm Building NameTT [abb?l/ WIS. Part Part Part 120-2 19E-1 088-2 19F 1 080-2 133-2 196 1 OED-2 14A-2 19H 2 GEE-2 20A-1 USA-2 140-2 208?1 098-2 14D-1 200-1 090-1 14E-1 21A-3 15A-2 22A-3 09F-2 158-1 228-3 096-2 150-2 220-3 10A-2 23A-1 108-2 23le 163-2 100-1 16 0-2 2304 17A-3 230-2 178-2 24A-3 11B-1 170-2 110-2 17D-2 If any additional 1 1D-2 non-conformances 11E-1 are observed, check item 12A.1 176.1 25A-3 and list the Code 123-3 section below. 120-2 til-2 12D-2 17M 12E-1 17K-1 12F-1 17L-1 126-1 18A-2 12H-1 188-2 . M5191 12H 180-2 The Inspector has been 12? 1802 provided with a to? olfithe prevaous year?s so 00 ire 11 safety report: 12M-1 190-1 No?? 12N-1 190-1 1 All schools complete Section 8 only ol the buddan has electrically-operated foldino partitions. Inspection: Fire Safety Inspeclor? Name Ab?s/p?imw Date Part Nonpublic School Certi?cations Section Ill-A. Fire Inspector The individual noted below inspected this building on (date) and the Information in this Report represents, to the best of their knowledge and belief. an accurate description of the budding and conditions they observed. The individual that performed this inspection has maintained their certification requirements pursuant to Title 19 Part Telephone Name: Ado/willw Title: Registryii 6 (as dealgnaled 8 Fire Administration f" i Sig nature? M- Section Ill-B. Building Administrator or Designee The individual noted below certi?es that this building was inspected as indicated in Section ill-A above. Name: ?rl 3? Telephone 773" 90 Mm; Jtm'?/ Title: Section Ill-C. School Administrator, Director, or Headmaster I I hereby submit this fire inspection report on behalf of the Board of Trustees and certify that' 1. Public notice of report availability has been published, and that 2 Any nonconformances noted as corrected on the Nonpublic Fire Safety Non-Conformance Report Sheet portion of this report were corrected on the date indicated, and that - 3 For any uncorrected nonconformances that appear on this report. the Board of Trustees. at the meeting held pursuant to Section 807-a of New York State Education Law. adopted a written plan of correction for those nonconformances, and such plan is available for public inspection. Name: [Jaw/?W1 Telephone#? Alfmf?l't??gy Signature .. Title: Section Ill-D. Local Municipal Code Enforcement Official The nonpublic school official shall enter the name and telephone number of the local municipal code enforcement official having jurisdiction over this facility. and the name of the municipality where this nonpublic school facrlity is sited 0 Telephone Name. City/TownNillage' (lg