Loading...
HomeMy WebLinkAboutMP21-029 Qy� 4RC� � O VILLAGE OF RYE BROOK MAYOR 938 King Street, Rye Brook,N.Y. 10573 ADMINISTRATOR Jason A. Klein (914) 939-0668 Christopher J. Bradbury www.ryebrook.org TRUSTEES BUILDING& FIRE INSPECTOR Susan R. Epstein Steven E. Fews Stephanie J. Fischer David M. Heiser Salvatore W. Morlino CERTIFICATE OF COMPLIANCE January 5,2024 Andres Gonzalez&Johanna Gonzalez 2 Country Ridge Drive Rye Brook,New York 10573 Re: 2 Country Ridge Drive, Rye Brook,New York 10573 Parcel ID#: 129.60-1-3 This document certifies that the work done under Mechanical Permit #21-029 issued on 2/23/2021 for the installation of a new 120 gallon above-ground propane tank has been satisfactorily completed. Sincerely, Steven E. Fews Building& Fire Inspector /to QyE BRC�k BUILDING DEPARTMENT �❑BBUILDING INSPECTOR 9 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: � \ ,)�f �E DATE: ) ' PERMIT# t� Z ISSUED:, SECT: Z C•0 BLOCK: i LOT: ~ LOCATION: J �Nou1P_ • OCCUPANCY: /0 ❑ Violation Noted THE WORK IS... Qy PASSED ❑ FAILED REINSPECTION ❑ SITE INSPECTION REQUIRED ❑ FOOTING ❑ FOOTING DRAINAGE ❑ FOUNDATION ❑ UNDERGROUND PLUMBING NOTES ON INSPECTION: ❑ ROUGH PLUMBING ❑ ROUGH FRAMING ❑ INSULATION ❑ Natural Gas ❑ L.P. Gas EK FUEL TANK ❑ FIRE SPRINKLER ❑ FINAL PLUMBING ❑ CROSS CONNECTION [f FINAL ❑ OTHER 00,00, N 46°34'30" E 107.61, RIN LAWN OF TREES 3.9's08. ; . E 2,4'N N rn � y _ :AWN ON O CO M L0 �K n V � Z! 5, 1 STORY. •- r-——N_ Q W 5 — 3 O cV 0 'F 'T LEI LAWN 'UME C = C/) 2 C6 41.es'w GARAGE `" _ E.G F.T. STONE CURB l. ? Mh v W Y U m 55��'pp 4.Cl1RBr 1.22'S� �'*!T � -k NING STONE w00 0 / 11.30' 11.4 E R=1 oa S 46034'30" 98.61' L- �' COUNTRY 01 uE DR '1 r § CD44 § k • cv ■ & k ƒ n 7 | & k 9 � 4 a2p 7 § ;2do § )� > i - ■ [ � Ln » q / R u � $ / � RMB km w M { �) 'co y2 /a Xo k Q/ / C; § G\ & § H 7 ko ce T- --------- --------- 2 a , _ §§ | ~ ts;;;§ ®kkk �� E - KK . co � �k// 2) / \ 2 {§� KR k< ' S�)§/ kk mlMk � O�� §fwwta « k dO n3AUddV ne/■mom CV/2m ,zo�� 0i 4-1 I rp wq,vp-1 AW, 44 0 ui I,- LO Ot OC tf 0 CL U) .4% G CL. CD Oo r3'. ;}yy C Z (�7 �;�F+lug' ''%' p .14 L 06 IIN I Op 1 DATE iMMIDD/YYYY) L ACOR > CERTIFICATE OF LIABILITY INSURANCE 1I8/2021 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 have ADDITIONAL INSURED provisions or 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 Edgewood Partners Insurance Center PHONE Amanda Massa FAX 1 American Lane 203 658-0507 1 lac,No): Greenwich CT 06831-2560 ADDRESS: amanda.massa@epicbrokers.com INSURERS)AFFORDING COVERAGE _ NAIC# INSURER A:Charter Oak Fire Insurance Company 25615 INSURED PARAGASC INSURERB:Travelers IndemnityCompany 25658 Paraco Gas Corp; Paraco Gas of CT Inc INSURERC:AXIS Surplus Insurance Co 26620 Paraco Gas of NJ LLC; Paraco Gas of NY Inc. 800 Westchester Ave, Suite 604 INSURER D: Rye Brook NY 10573 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:799914031 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. INPOLICY EXP TR TYPE OF INSURANCE ADDL SUER POLICY NUMBER MM/DDY EFF RWVVD MMIDD/YYYY LIMITS A X COMMERCIALGENERALLIABILMY Y1N6601P009026COF21 1/1/2021 1/1/2022 EACH OCCURRENCE $2,000,000 CLAIMS-MADE � PREMOCCUR DAMAGE T RENTED PREMISES Ea occurrence $300,000 MED EXP(Any one person) $5,000 PERSONAL&ADV INJURY $2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $2,000,000 POLICY PRO- ❑ LOC PRODUCTS-COMP/OP AGG $2,000,000 X JECT OTHER $ B AUTOMOBILE LIABILITY Y1N8109J6196941ND21 1/1/2021 1/1/2022 COMBINED SINGLE LIMIT $2,000,000 Ea accident X ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY Per accident $ — — C UMBRELLALIAB �J OCCUR P00100005161203 1/1/2021 1/1/2022 EACH OCCURRENCE $3,000,000 X EXCESS LIAB CLAIMS-MADE AGGREGATE $3,000,000 DIED RETENTION$ $ A WORKERS COMPENSATION UB8N6879022151D(AOS) 1/1/2021 1/1/2022 X PER OTH- 5 AND EMPLOYERS'LIABILITY YIN UB8N6862232151 R(MA Only) 1/1/2021 1/1/2022 STATUTE ER ANYPROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $1,000,000 OFFICER/MEMBEREXCLUDED? ❑ NIA (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below I I E.L.DISEASE-POLICY LIMIT $1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) CERTIFICATE HOLDER 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 AUTHORIZED REPRESENTATIVE Rye Brook NY 10573 4 ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD NEW Workers'sACERTIFICATE OF E Compensation Board NYS WORKERS' COMPENSATION INSURANCE COVERAGE 1a. Legal Name&Address of Insured (use street address 1 b. Business Telephone Number of Insured only) 914-250-3700 Paraco Gas Corp. 800 Westchester Ave Suite 604 1c. NYS Unemployment Insurance Employer Registration Rye Brook, NY 10573 Number of Insured Work Location of Insured(Only required if coverage is specifically 1 d. Federal Employer Identification Number of Insured or Social limited to certain locations in New York State,i.e.,a Wrap-Up Policy) Security Number 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) THE CHARTER OAK FIRE INSURANCE COMPANY VILLAGE OF RYE BROOK 3b. Policy Number of entity listed in box"la" 938 KING ST UB-8N687902-21-51-D RYE BROOK, NY 10573 3c. Policy effective period 01-01-2021 to 01-01-2022 3d. The Proprietor, Partners or Executive Officer are ® 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 "3" 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 "2". The insurance carrier must notify the above certificate holder and the Workers' Compensation Board within 10 days IF a policy is canceled due to nonpayment of premiums 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. This certificate is issued as a matter of information only and confers no rights upon the certificate holder. This certificate does not amend, extend or alter the coverage afforded by the policy listed, nor does it confer any rights or responsibilities beyond those contained in the referenced policy. This certificate may be used as evidence of a Workers' Compensation contract of insurance only while the underlying policy is in effect. Please Note: Upon 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: STEPHANIE BAKER (Print name of authorized representative or licensed agent of insurance carrier) Approved by: , ""` 12-30-2020 (Signature) (Date) Title: SR CUSTOMER SOLUTIONS REPRESENTATIVE Telephone Number of authorized representative or licensed agent of insurance carrier: 804-527-4852 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. C-105.2(9-17) www.wcb.ny.gov W31F3117