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HomeMy WebLinkAboutMP12-037 DR �C . 19 VILLAGE OF RYE BROOK MAYOR 938 King Street,Rye Brook,N.Y. 10573 ADMINISTRATOR Jason A.Klein (914)939-0668 Christopher J.Bradbury www.ryebrookny._ TRUSTEES BUILDING&FIRE INSPECTOR Susan R. Epstein Steven E. Fews Stephanie J. Fischer David M. Heiser Salvatore W.Morlino CERTIFICATE OF COMPLIANCE November 26,2024 Michael Marks&Lisa Marks 18 Mohegan Lane Rye Brook,New York 10573 Re: 18 Mohegan Lane, Rye Brook,New York 10573 Parcel I D#: 135.42-1-19 This document certifies that the work done under Mechanical Permit #12-037 issued on 5/22/2012 for the removal and installation of an underground propane tank has been satisfactorily completed. Sincerely, Steven E. Fews Building&Fire Inspector /to �E BRCS-, if Q 1. 1932 BUILDING DEPARTMENT ❑BUILDING INSPECTOR p 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 - - - - - - - - - - - - - - - - - - - - INSPECTION REPORT - - - - - - - - - - - - - - - - - - - - ADDRESS : ��O �', DATE: PERMIT# 0 3 ISSUED: SECT:BLOCK: LOT: LOCATION: •LP T } f-;?:`./' OCCUPANCY: ❑ VIOLATION NOTED THE WORK IS... ❑ ACCEPTED ❑ REJECTED/ REINSPECTION ❑ SITE INSPECTION REQUIRED ❑ FOOTING ❑ FOOTING DRAINAGE ❑ FOUNDATION ❑ UNDERGROUND PLUMBING NOTES ON INSPECTION: ❑ ROUGH PLUMBING ❑ ROUGH FRAMING ❑ INSULATION I_ ❑ NATURAL GAS _' L, Ov p L.P. GAS FUEL TANK �� o ❑ FIRE SPRINKLER L. ilk2 `j ❑ FINAL PLUMBING ❑ CROSS CONNECTION ❑ FINAL ❑ OTHER �QyE BR �uk oe, e� , 1902 BUILDING DEPARTMENT p,BUILDING INSPECTOR VILLAGE OF RYE BROOK ❑ VILLAGE ENGINEER 938 KING STREET RYE BROOK,NY 10573 ❑ASSISTANT BUILDING INSPECTOR (914) 939-0668 FAX(914) 939-5801 - - - - - - - - - - - - - - - - - - - - - INSPECTION REPORT - - - - - - - - - - - - - - - - - - - - - ADDRESS: t D fL 14 DATE: S ! Z PERMIT# hA_T 12 —01__�ISSUED: S Z SECT: ^> `l BLOCK: LOT: Q LOCATION: S 1>F_ L.QA_% OCCUPANCY: Z ( O ❑ VIOLATION NOTED THE WORK IS... ACCENTED ❑ REJECTED/REINSPECTION ❑ SITE INSPECTION REQUIRED ❑ FOOTING ❑ FOOTING DRAINAGE ❑ FOUNDATION ❑ UNDERGROUND PLUMBING NOTES ON INSPECTION: ❑ ROUGH PLUMBING !, ❑ ROUGH FRAMING �---/— ❑ INSULATION ❑ NATURAL GAS ALL C K L.P.GAS i A�1�- � q ❑ FUEL TANK L ' (, L o C S + tlb - ❑ FIRE SPRINKLER ❑ FINAL PLUMBING ❑ FINAL ❑ OTHER _ : e [� � s O a W v o , 'o � o = N a as > s QI N p = _ � � �, s s W C7 H w V = p (U W s En ^j 0. O O M W o O O M O a O > g d� Z a O F'ss� H I > cc >+ -, o o (v = z dQF" w Y " cr QI � z � ' o2t >w El : e 3 �"� r►�-� ��] 3 ;D C4 a _ ^ 3 o zy quo s �1 00 h� Ci •o Q o _ R Qn o 03 x 88 x ,• O u x � � mo a z w W O Z O A a oQoo � 1 a QI F� V1 p z CR w ; u C o .y ►� U U w 0 OQ .. ° gz IO CY, W O F E C* o chi VILLAGE OF RYE BROOK BUILDING DEPARTMENT R. 1 938 KING STREET,RYE BROOK,NY 10573(914)939-0668 FAX: (914)939-5801 ww«.r ebrMAY 2 2 2012 APPLICATION TO REMOVE ABANDON AND/OR IN BROOK _ TMENT STORAGE TANK UP TO 1100 GALLON CAPACITY (*Storage tanks in excess of 1100 gallons require registration with the County of Westchester) Permit#: N� 1 �'"d Building Inspector: Fee Paid: Z>a Date of Approval: (fees are non-refundable) REQUIREMENTS FOR RELEASE OF PERMIT& CERTIFICATE OF COMPLIANCE: 1. Application Completed by Bonded, Licensed Contractor 2. Copy of Licensed Contractor's Insurance including Liability & Workers Compensation (naming the Village of Rye Brook as Certificate Holder) 3. Fee: Removal/Abandonment: $150 / Installation: $150 4. Dig Safely New York#: 5. Inspection by Building Department for removal/abandonment& installation 6. Manifests & Reports (after work has been completed) 7. Certificate of Compliance will be provided when all requirements are fulfilled Application is hereby made to the Building Inspector of the Village of Rye Brook for the approval of a permit for the removal,abandonment and/or installation of a Fuel Tank(s)herein described.The applicant,by signing this document agrees that said Fuel Tank(s)will be installed,abandoned and/or removed in conformance with all applicable Local, County,State&Federal laws,codes,rules&regulations. Indicate either above ground tank or buried in-ground tank. 1. Property Owner's Name: ,AC 1 i4"L ,>i/144- ,E's Phone#: 1-3.3 -6e2-9 2. Job Address: Phone#: 33-� 3. Parcel I.D. #: 1�. -I (I-W-41 Zone: 4. Contractor: e., e� Phone#: �14 5. Contractor's Address: xmr ,. / Fax #: 6. Exact location of tank to be Installed: above ground :] in ground 7. Exact location of tank to be Removed: above ground❑ in ground 8. Exact location of tank to be Abandoned: in ground only r 9. Distance of Tank from Structure: 3a 10. Distance of Tank from Property Line: /o 11. Type of Fuel: Oil:0; Propane:/Gasoline:0: Other: 12. Number& Capacity of Each Tank: Signature of Applicant: —-` Date: T- / Printed Name of Applicant: Phone#: 05/07/2012 17:27 914-933-3901 LISA MARKS & ASSOC. PAGE 05/05 " �"`"`Y�_�'� ��g�'LZ•Fsl�N50N. SUNVBXOR, AND FILED'IN TILE OFpICE OP TUC CLERK OF THE COUNTY OF WESTCHESTER, DIVISION OF LAND RECORD, NOVEMBER 15. 1957 AS NAP No. 11307. V MOh'zL__G,Q/V ,285.33. 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O _ \ A \ of W rA _ <(o (0))It i�\ _ -/•' ''s==,:` / 1`.; ;..Ly a.,.:ac•1 1 a' = .1.. 1,� cv::::;..1."`r, ,• 1-%cr �O).. �' `'`'1,/11{Illy a-�'(:,�IIII/{Illy __ �=dull{Illy -. �.1,11/{/IIII _.-1,11/{/II,1_,�- d111{/hh ;`" ''At��.>• • • _` _�-1/111�111 ` ;A�_ t. 11111 f A 111/111 IINI y a� ///11 y�'� 11111 _ o \ � A ♦N J1TA� � N f#�t^ _ F{� •1 a f .^''Ii3 �� a t�,. A y �1 �t �A ♦• A �t k, 1i1 ; \ AC" CERTIFICATE OF LIABILITY INSURANCE112/28/2011 DATE(MM/DD/YYYY) �r THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must 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 NAME: Alice Lara Fairfield County Bank Insurance Services PHONE FAX 401 Main Street A/C No Ext:203-R94-'AlA/C No: - - Ridgefield CT 06877 E-MAIL al ice.lara@fcbins.com PRODUCER CUSTOMER ID0:PARAC-1 INSURER(S)AFFORDING COVERAGE NAIC 8 INSURED INSURER A:Liberty Mutual Ins. Group 23043 Paraco Gas Corp., Paraco Gas of CT Inc. INSURERB:Starr Indemnity & Liab Cc 38318 Paraco Gas of NJ LLC, Paraco Gas of NY, Inc. 800 Westchester Avenue, S604 INSURER C:Lexington Insurance Company Rye Brook NY 10573 INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:1482450943 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.ADDLISUBRI ` INSR TYPE OF INSURANCE POLICY NUMBER MM/DDmYY MM/DD� LIMITS LTR • GENERAL LIABILITY TB164G435685032 1/1/2012 1/1/2013 EACH OCCURRENCE $1,000,000 DAMAGE TO RENTED X COMMERCIAL GENERAL LIABILITY PREMISES Ea occurrence $50,000 CLAIMS-MADE FX]OCCUR MED EXP(Any one person) $5,000 PERSONAL&ADV INJURY $1,000,000 GENERAL AGGREGATE $2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER,- PRODUCTS-COMP/OP AGG $2,000,000 X POLICY PRO LOC $ A AUTOMOBILE LIABILITY AS1641435685042 1/1/2012 1/1/2013 COMBINED SINGLE LIMIT $1,000,000 (Ea accident) X ANY AUTO BODILY INJURY(Per person) $ ALL OWNED AUTOS BODILY INJURY(Per accident) $ SCHEDULED AUTOS PROPERTY DAMAGE $ X HIRED AUTOS (Per accident) X NON-OWNED AUTOS $1,000 PPT DED $ $5,000 TRUCK DED $ rA UMBRELLALIAB X OCCUR SISCSEL01693112 1/1/2012 1/1/2013 EACH OCCURRENCE $5,000,000 X EXCESSLIAB CLAIMS-MADE AGGREGATE $5,000,000 rR DEDUCTIBLE $ RETENTION $ $ WORKERS COMPENSATION WC264G435685052 1/1/2012 1/1/2013 X WCSTATU- OTH- AND EMPLOYERS'LIABILITY TORY ANY PROPRIETOR/PARTNER/EXECUTIVE Y/N E.L.EACH ACCIDENT $1,000,000 OFFICER/MEMBER EXCLUDED? ❑ N/A (Mandatory In NH) E.L.DISEASE-EA EMPLOYE $1,000,000 H yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $1,000,000 C Excess umbrella 013136583 1/1/2012 1/1/2013 $5M 4,9gregalLe ` $5M Occurrence DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES(Attach ACORD 101,Additional Remarks Schedule,If more space Is required) CERTIFICATE HOLDER CANCELLATION 30 Days Notice of 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. Village of Rye Brook 938 King Street Rye Brook NY 10573 AUTHORIZED REPRESENTATIVE ©1988-2009 ACORD CORPORATION. All rights reserved. ACORD 25(2009/09) The ACORD name and logo are registered marks of ACORD STATE OF NEW YORK WORKERS' COMPENSATION BOARD CERTIFICATE OF NYS WORKERS' COMPENSATION INSURANCE COVERAGE la.Legal Name&Address of Insured(Use street address only) lb. Business Telephone Number of Insured 914-250-3700 Paraco Gas Corp. 800 Westchester Avenue,S604 lc.NYS Unemployment Insurance Employer Rye Brook,NY 10571 Registration Number of Insure& 67-109415 Work Location of Insured(Only required ifcoverageis specifically Id. Federal Employer Identification Number of Insured limited to certain locations in New York State, i.e., a Wrap-Up or Social Security Number Policy) 13-3149941 2.Name and Address of the Entity Requesting Proof of 3a. Name of Insurance Carrier Coverage(Entity Being Listed as the Certificate Holder) Liberty Mutual Fire Insurance Company Village of Rye Brook 3b. Policy Number of entity listed in box"la" 938 King Street WC264G435685052 Rye Brook,NY 10573 3c. Policy effective period 1/1/12 to 111113 3d. The Proprietor,Partners or Executive Officers are X included. (Only check box if all partners/officers included) ❑ all excluded or certain partners/officers excluded. This certifies that the insurance carrier indicated above in box "Y' insures the business referenced above in box "la" for workers' compensation under the New York State Workers'Compensation Law.(To use this form,New York(NY)must be listed under Item 3A on the INFORMATION PAGE of the workers'compensation insurance policy). The Insurance Carrier or its licensed agent will send this Certificate of Insurance to the entity listed above as the certificate holder in box"T'. The Insurance Carrier will also notes the above certificate holder within 10 days IF a policy is canceled due to nonpayment ofpremiums or within 30 days IF there are reasons other than nonpayment of premiums that cancel the policy or eliminate the insured from the coverage indicated on this Certificate. (These notices may be sent by regular mail.) Otherwise,this Certificate is valid for one year after this form is approved by the insurance carrier or its licensed agent,or until the policy expiration date listed in box"3c",whichever is earlier. Please Note: Upon the cancellation of the workers' compensation policy indicated on this form, if the business continues to be named on a permit,license or contract issued by a certificate holder,the business must provide that certificate holder with a new Certificate of Workers' Compensation Coverage or other authorized proof that the business is complying with the mandatory coverage requirements of the New York State Workers' Compensation Law. Under penalty of perjury, I certify that I am an authorized representative or licensed agent of the insurance carrier referenced above and that the named insured has the coverage as depicted on this form. Approved by: Robert E. Spadaccia (Print name of authorized representative or licensed agent of insurance carrier) 12/28/11 Approved by: (Signature) (Date) Title: President—Fairfield County Bank Insurance Telephone Number of authorized representative or licensed agent of insurance carrier: 203-894-3145 Please Note: Only insurance carriers and their licensed agents are authorized to issue Form C-105.2. Insurance brokers are NOT authorized to issue it.