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HomeMy WebLinkAboutMP10-018 RECENE VILLAGE OF RYE BROOK NOV 1 9 2010 BUILDING DEPARTMENT 938 KING STREET,RYE BROOK,NY 10573 VILLAGE OF RYE BROO(014 939-0668 FAX(914)939-5801 www.ryebrook.or(T BUILDING DEPARTMENT APPLICATION TO INSTALL AND/OR REMOVE FUEL BURNER BOILER OR HOT WATER HE Permit#: I V` V O Building Inspector: Fee Paid: Date of Approval: (fees are non-refundable) REQUIREMENTS FOR RELEASE OF PERMIT&CERTIFICATE OF COMPLIANCE: 1. Properly Completed & Signed Application. 2. Copy of Licensed Contractor's Insurance including Liability& Workers Compensation naming the Village of Rye Brook as Certificate Holder. 3. Fees: $75 per unit. 4. Inspection by Building Department for removal and/or installation. 5. Certificate of Compliance will be provided when all requirements are fulfilled. 6. Any electrical work requires an Electrical Permit and Electrical Inspection. 7. Any gas/plumbing work requires a Plumbing Permit and Plumbing Inspection. Application is hereby made to the Building Inspector of the Village of Rye Brook for the approval of a permit for the installation and or removal of the equipment as listed below.The applicant,by signing this document agrees that said equipment will be installed and/or removed in conformance with all applicable Local, County, State&Federal laws, codes,rules and regulations. 1. Property Owner's Name: -C-�,e -}� ,A; f Phone#: y6� 14 5 2. Job Address: Phone#: 3. Parcel l.D#: 135.314-1 q 1--5-)2.GD9 Zone: 4. Contractor: Cn-rY,.jzjiS , Phone#: gL1lo SSSR 5. Contractor Address: ? C-ec-4 -ok Ave W,�;�e-Q(vFSx: EaS 5 ,� 6. Scope of Work: Install, ; Remove Cam, -Fuel Burner ❑; Boiler E; Water Heater 7. Type of Equipment&Fuel: S&FBA/ 8. Location of Equipm t: Signature of Applicant: `� Date: .1�• \��\l7 Printed Name of Applicant: �r—��,�L cr,"DLa, Phone#: �yE BRC��. 1982 BUILDING DEPARTMENT BUILDING 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.org - - - - - - - - - - - - - - - - - - - - INSPECTION REPORT - - - - - - - - - - - - - - - - - - - - ADDRESS: (�A L LJWA `y DATE: PERMIT# C� \ ��f ISSUED:` l Z? SECT: C3 BLOCK: LOT: LOCATION: ^ � OCCUPANCY: ❑ Violation Noted THE WORK IS... 0 PASSED ❑ FAILED REINSPECTION ❑ SITE INSPECTION REQUIRED ❑ FOOTING ❑ FOOTING DRAINAGE ❑ FOUNDATION ❑ UNDERGROUND PLUMBING NOTES ON INSPECTION: ❑ ROUGH PLUMBING ❑ ROUGH FRAMING ❑ INSULATION ❑ Natural Gas p L.P. Gas ❑ FUEL TANK ❑ FIRE SPRINKLER ❑ FINAL PLUMBING ❑ CROSS CONNECTION ❑ FINAL ❑ OTHER �E BR(b O Z� • �9�2 BUILDING DEPARTMENT ❑BUILDING 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 Uebrook.org - - - - - - - - - - - - - - - - - - - - INSPECTION REPORT - - - - - - - - - - - - - - - - - - - - ADDRESS : ` C ` - DATE: PERMIT# y�\ 1' 1 (D,� ISSUED: SECT: BLOCK: LOT: LOCATION: �a" �� �) OCCUPANCY: ❑ Violation Noted THE WORK IS... ❑ PASSED ❑ FAILED REINSPECTION ❑ SITE INSPECTION REQUIRED ❑ FOOTING ❑ FOOTING DRAINAGE ❑ FOUNDATION ❑ UNDERGROUND PLUMBING NOTES ON INSPECTION: ❑ ROUGH PLUMBING ❑ ROUGH FRAMING `` /��__ ( \ !(� ❑ INSULATION �\�� y=J� \ �QV �-� ❑ Natural Gas \\ ❑ FUEL TANK ❑ FIRE SPRINKLER i �� tL� ( 4--,- ❑ FINAL PLUMBING ❑ CROSS CONNECTION ❑ FINAL ❑ OTHER Westchester Count} Board of Plumbing Examiners Westchester County Clerk's Office Master Plumbing License 2010 Mario Bruni r O.O.B: 1012N1940 a Height:5'0V W601111' j Wri F Hair: Browtn �': .Eyes:` Company: Bruni and.Campisi Pj n Htg 300 Centrak Park Ave • . - White Plains; NY,10600 License No.:179 Expires on:12/31/2010 Mark R.Courtien Westchester County Board of Plumbing Examiners Westchester County Clerk's Office Master Plumbing License 2010 Frank Campisi D.O.B: 03/03/1948 Height: 5'07 Weight: 175 Hair: Brown Eyes: Brown Company: f Bruni and Campisi Pig and Ht0 i i }, 300 Central Ave White Plains, NY 10606 License No.: 2 Expires on: 12/31/2010 / G i Mark R. Courtien 1 1 1 q�pJ� (MM�DDIYYYY) �R CERTIFICATE OF LIABILITY INSURANCE OPI DDtdL 1 DATE 09/19/10 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE J.M. Glover Agency/Elmsford HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR 45 Knollwood Rd, 5th Floor ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Elmsford NY 10523 Phone: 914-909-5320 Fax:914-909-5321 INSURERS AFFORDING COVERAGE NAIC# INSURED INSURER A 6xc*laioz Inauranc• Company INSURER Peerless Insurance Company I Bruni C pisi Plumbing & Heating nc NSURERC The first Rehabilitation Lila . 300 Central Avenue INSURERD. White Plains NY 10606 INSURER E COVERAGES 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.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS LTR NSR TYPE OF INSURANCE POLICY NUMBER DATE(MMIDD/YYYY) DATE(MW1DD/YYYY) LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1000000 A X COMMERCIAL GENERALLIABILITY CPP101852710 02/16/10 02/16/11 PREMISES(Eaoccurence) $ 100000 CLAIMS MADE rx-1 OCCUR MED EXP(Any one person) $5000 X Contractual & PERSONAL B ADV INJURY $ 1000000 X Hold Harmless GENERAL AGGREGATE $2000000 GENT-AGGREGATE LIMIT APPLIES PER PRODUCTS-COMP/OPAGG $2000000 POLICY X PR LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1000000 B X ANY AUTO BA101852710 02/16/10 02/16/11 (Ea accident) ALL OWNED AUTOS BODILY INJURY $ SCHEDULED AUTOS (Per person) x HIRED AUTOS BODILY INJURY $ x NON-OWNED AUTOS (Per accident) PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO OTHER THAN EA ACC $ AUTO ONLY AGG $ EXCESS/UMBRELLA LIABILITY EACH OCCURRENCE $5000000 B X OCCUR CLAIMSMADE CU101852710 02/16/10 02/16/11 AGGREGATE $5000000 $ DEDUCTIBLE $ x RETENTION $10,0 0 0 $ WORKERS COMPENSATION X TORY LIMITS ER AND EMPLOYERS'LIABILITY Y/N B ANY PROPRIETOR/PARTNER/EXECUTIVE ❑ WC8198741 09/15/10 09/15/11 E.L EACH ACCIDENT $500000 OFFICER/MEMBER EXCLUDED? (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $500000 If yes,describe under SPECIAL PROVISIONS below EL DISEASE-POLICY LIMIT $500000 OTHER C NY Disability DBL273565 02/06/07 Contin. Statutory DESCRIPTION OF OPERATIONS I LOCATIONS 1 VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF.THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR Village of Rye Brook REPRESENTATIVES. Building Dept. AUTHOR ZED RE ESENTAn VP 938 King Street e Brook NY 10573 ACORD 25(2009/01) ©1988-2001 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD • STATE OF NEW YORK WORKERS' COMPENSATION BOARD CERTIFICATE OF NYS RVORKERS' COMPENSATION INSURANCE(:OVERAGE 1 a. Legal Name and address of Insured(Use street address onl,. , 1 b.Business Telephone Number of Insured Bruni &Campisi Plumbing& 914-220-5300 Heating, Inc. He Central Avenue 1 c. NYS Unemployment Insurance Employer Registration 300 A-1ite Plains,NY 10606 Number of Insured Work Location of Insured (Only reyrtired if cover•ctge is 1 d.Federal Employer Identification Number of Insured or specifically limited to certain locations in l.ew fork State, i.e. a Social Security Number Tvrap-Up Policy} 2.Name and Address of the Entity Requesting Proof of 3a. Name of Insurance Carrier Coverage(Entity Being Listed as the Certificate Holder) Village of Rye Brook Peerless Insurance Company Building Dept. 938 Ding Street 3b.Policy Number of entity listed in box"1a": Rye Brook NY 10573 WC8198741 3c. Policy effective period: 09/15/10 to 0911.5,111 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 innstrance carrier indicated above in box "3" insures the business referenced above in box "Ia" 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 Tdi send this Certificate of Insurance to the entity listed above as the certificate holder in box"2". The Insurance Carrier will also notii i,the above certificate holdermrithin 10 days IF policy is canceled drre to nonpayment of premiums oririthin 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.) Uthemhse,this Certificate is ralid far a ntatiimunt of one year after this fornt is apprm ed br the insurance carrier or its licensed agent,or until the police c Tiration 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: John M Glover Agency (Print name of authorized representative or licensed agent of insurance carrier) Approved by: 5� September 14 2010 (Signature) (Date) Title: President Telephone Number of authorized representative or licensed agent of insurance carrier: 914-909-5320 C-105.2(9-07)