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HomeMy WebLinkAboutMP21-144 �yE DR i s �9 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 March 4,2024 Benjamin Sheer&Carlen Sheer 4 Concord Place Rye Brook,New York 10573 Re: 4 Concord Place,Rye Brook,New York 10573 Parcel ID#: 135.44-1-51 This document certifies that the work done under Mechanical Permit#21-144 issued on 10/12/2021 for the installation of a new oil fired boiler has been satisfactorily completed. Sincerely, z )4 Steven E. Fews Building&Fire Inspector /to �E BRC��. BUILDING DEPARTMENT ❑BBUILDING INSPECTOR 24SSISTANT 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.orS - - - - - - - - - - - - - - - - - - - - INSPECTION REPORT - - - - - - - - - - - - - - - - - - - - ADDRESS : x C/-?OA) U� DATE: PERMIT# i�IP�/ ��� ISSUED: /L -2 SECT: -s 7 BLOCK: LOT: S/ LOCATION: ✓��L�'y/ 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 ll_ ❑ Natural Gas ZO/Chi -, /3i9 fFis J��✓% ❑ L.P. Gas ❑ FUEL TANK ❑ FIRE SPRINKLER ❑ FINAL PLUMBING ❑ CROSS CONNECTION ,FINAL ❑ OTHER QyE BRC�k, cu � '9a2 BUILDING DEPARTMENT ❑BUILDING INSPECTOR [J 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 : cQ� ` / DATE: `k-IAA�� �-PERMIT# ISSUED: �dr2- SECT: BLOCK: LOT: LOCATION: ��f O1 OCCUPANCY: Z V ❑ VIOLATION NOTED THE WORK IS... ❑ ACCEPTED /' EJECTED/REINSPECTION ❑ SITE INSPECTION REQUIRED ❑ FOOTING ❑ FOOTING DRAINAGE ❑ FOUNDATION ❑ UNDERGROUND PLUMBING NOTES ON INSPECTION: ❑ ROUGH PLUMBING ❑ ROUGH FRAMING ❑ INSULATION 1 I , ^ ❑ NATURAL GAS �1 1•�S Uu� l CX� � Pck( C-�c' ❑ L.P. GAS Q LZ r ❑ FUEL TANK ❑ FIRE SPRINKLER ❑ FINAL PLUMBING ❑ CROSS CONNECTION ❑ FINAL ❑ OTHER �F I DIMENSIONS � zap- t. � NSTANDARD EQUIPMENT: Suppry(C) � N SIIOOIY "' ■ Factory Tested and Assembled Cast Iron Section Assembly Ere� (jacket and collector hood are NW �nw not assembled on 7,8 and 9 2e*:� section blocks) s °' ■ Insulated Steel Jacket z Aluminized Steel Flue Collector P-WGO Front Side A-WGO Front Back Intermediate Hood with Flue Cap on Top o h Outlet (convertible to rear Outlet) Q 0,0 00 0Q ■ Swing-Away Burner Mounting Door S,, 11/2 Alternate return-"A"units only ■ Refractory Blanket and Target E, 1/2 Pressure/temperature gauge Wall in Combustion Area H 3/4 Drain Valve ■ Circulator(Taco 007)-When L 3/4 High limit/circulator control Ordered N 1/2 Piping to expansion tank or automatic air vent ■ High Limit Control with Circulator R, 3/4 Relief valve Relay and LWCO Function ■ Electrical Junction Box with Supply"C"(Inches) Dimension(Inches) Wiring Harnesses 0 0 . ■ Junction Box Cover Plate with ao �0 30 Service Switch �� a Qo m ■ Two Vent Pipe Brackets WGO-2 1 1/4(circulator flange) 11/2 11/2 10 V2 13 3/4 ■ Pressure/Temperature Gauge WGO-3 11/4(circulator flange) 11/2 11/2 13 V2 16 7/8 ■ 30 PSIG ASME Relief Valve WGO-4 1 1/4(circulator flange) 11/2 11/2 13 5/8 16 7/8 (boiler sections tested for 50 PSIG working pressure) WGC-5 11/4(circulator flange) 11/2 11/2 16 7/8 20 ■ Drain Valve WGO-6 1 1/4(circulator flange) 11/2 11/2 20 23 1/8 ■ Barometric Damper WGO-7 not applicable 11/2 11/2 23 V8 26 1/4 ■ Built-in Air Separator VJGO-8 not applicable 11/2 11/2 26 1/4 29 3/8 WGO-9 not applicable 11/2 11/2 293/8 32V2 OPTIONAL EQUIPMENT: ■ High-Efficiency Flame-Retention RATINGS Burner AHRI Minimum Oil Burner(Beckett AFG, Carlin Input Certified Chimney EZ or Riello). Specify 2-Stage Fuel Rating Ratings a size a Unit(optional) if Required. C kt`o�` /:.1 rQ� ■ Vent Damper Kit nM'` q� w4�^ 0"4� a� t ■ W-M 5&10 Year Homeowner A 4 2� ar m= oee�� : aJ �°S ti'�c tic : Q3� Protection Plan o Q V ■ W-M Indirect-Fired Water Heaters wGO-2RD 0.70 98 86 75 87.0 .010 8X8 6 15 540 WGO-2 10.70 98 86 75 86.4 .010 8X8 6 1s 540 • WGO-3RD 0.80 112 98 85 87.0 .010 8X8 6 15 595 NOTES: 1. WGO-3 10.95 133 115 100 85.3 .020 8X8 6 15 595 I Add"P"for packaged boiler(WGO-2 WGO-4RD 1.00 140 123 107 87.0 .010 8X8 6 15 645 through WGO-6 only).Add" for W WGO-4 1.20 168 145 126 85.0 .010 8X8 6 15 645 boiler only(WGO 2 through GO-9). • WG0-5RD 1.20 168 148 129 87.0 .015 8X8 7 15 760 i (1) Sp 2 fuel oil-Commercial Standard Specification CS75-56.Heating value wco-s 1.45 203 175 152 85.0 015 8X8 7 15 760 of oil-140.000 BTU/Gal. ' WGO-6RD 1.40 196 173 150 87.0 .015 8X8 7 15 860 (2)Based on standard test procedures WGo-6 � 1.75 245 212 184 85.0 .015 8X8 7 1s 860 prescribed by the United States • WGO-7RD 1.60 224 197 171 87.0 .015 8X8 8 15 930 Department of Energy at combustion WGO-7 12.00 280 242 210 85.0 .015 8X8 8 15 930 I condition of 13 1/2%CO2 and -0.02" WGo-8 2.30 322 266 231 - .025 8X12 8 20 1030 W.C.draft. WGo-9 12.55 357 295 257 - .030 SX12 8 20 1135 I (3)MBH refers to thousands of BTU ._k�_ `compliant with Version 3.0 Boiler Specification of 87° AFUE only when installed at per hour. tiie reduced burner rate(R)and with the optional vent damper kit . Burners shipped with standard (4)Net AHRI ratings are based on net rate nozzle,reduced rates achieved through nozzle change-refer to inuner Instructions or boiler's installed radiation adequate for the rating label for correct selection. requirements of the building, including a piping and pickup In the interest of continual improvements In product and performance.Weil-McLain reserves allowance Of 1.15-sufficient for normal the right to change specifications without notice. Conditions.Provide additional 69.9 MWM WM1410_BRO_018_WGO C�US DOE e T;Na PP- * y g ® �""e ' allowance only for unusual piping 1132011111111111 and pick up loads. 1� Ij 1 � n ' I t ' S i 1 � i `3 Joseph F. Risoli, P.E. LLC Environmental Planners * Engineers * Surveyors 288 Valley Road Cos Cob, CT 06807 Telephone: (203)637-8036 Fax: (203)637-3968 E-Mail: risoli(a)optonline.net Website: http://w"-.risoliengineering.com November 21, 2019 w Michael Izzo Building Department Village of Rye Brook OOK 938 King Street ENT Rye Brook, NY 10573 Re: Sheer Residence - 4 Concord Place, Rye Brook, NY Dear Mr. Izzo, After completing an elevation certificate for the dwelling located at the above referenced address, it has been determined that the basement floor elevation is 125.4' and the first floor elevation is 133.2' (NAVD'88 datum). Please contact our office if you have any questions or require additional information. Thank you. S�PZE OF NEW Respectfully /" F R osep F. Risoli, PE e e � President sfc r: w�p�� CIVIL*HYDROLOGICAL*STRUCTURAL*PROJECT MANAGEMENT*LAND PLANNING"SURVEYING i U S DEPARTMENT OF HOMELAND SECURITYB No,. 8 Iw�3Q Federal Emergency Management Agency irettort�t 2018 National Flood Insurance Program ELEVATION CERTIFICA SEC J o Important: Follow the instructions on pages 1 2019 Copy all pages of this Elevation Certificate and all attachments for(1)community official, (2)insu� 3) ng r. SECTION A-PROPERTY INFORMATION USE Al Building Owner's Name Policy _ CARLEN SHEER 8 BENJAMIN SHEER A2 Building Street Address(including Apt, Unit, Suite,and/or Bldg No)or P.O.Route and Company NAIC Number. Box No 4 CONCORD PLACE City State ZIP Code RYE BROOK New York 10573 A3 Property Description(Lot and Block Numbers,Tax Parcel Number, Legal Description, etc) SECTION 135 44, BLOCK 1, LOT 51 A4 Building Use(e g Residential. Non-Residentia Addition Accessory etc) RESIDENTIAL A5 Latitude/Longitude. Lat 41'01'14 05" Long 73°40'41 96" Horizontal Datum ❑ NAD 1927 ] NAD 1983 A6 Attach at least 2 photographs of the building if the Certificate is being used to obtain flood insurance A7 Building Diagram Number 2A A8 For a building wth a crawlspace or enclosure(s) a) Square footage of crawlspace or enclosure(s) 130.00 sq R b) Number of permanent flood openings in the crawlspace or enclosure(s)within 1 0 foot above adjacent grade 0 c) Total net area of Flood openings in AB b 0 00 sq in d) Engineered flood openings? ❑ Yes X No A9 For a budding with an attached garage a) Square footage of attached garage 520.00 sq It b) Number of permanent flood openings in the attached garage within 1 0 foot above adjacent grade 0 c) Total net area of flood openings in A9 b 0.00 sq in d) Engineered flood openings? ❑Yes ❑x No SECTION B-FLOOD INSURANCE RATE MAP(FIRM) INFORMATION B1 NFIP Community Name&Community Number B2 County Name B3 State RYE BROOK, VILLAGE OF 360930 WESTCHESTER COUNTY New York B4 Map/Panel B5 Suffix B6 FIRM Index B7 FIRM Panel B8. Flood B9 Base Flood Elevation(s) Number Date Effective/ Zone(s) ;Zone AO use Base Flood Depth) Revised Date 36119CO293F F 09-28-2007 09-28-2007 AE 1314 B10 Indicate the source of the Base Flood Elevation(BFE)data or base flood depth entered in Item B9 ❑FIS Profile ❑ FIRM ❑Community Determined ❑ Other/Source B11 Indicate elevation datum used for BFE in Item B9 ❑ NGVD 1929 ❑x NAVD 1988 ❑ Other/Source 812 Is the building located in a Coastal Barrier Resources System(CBRS)area or Otherwise Protected Area(OPA)? ❑ Yes ❑x No Designation Date ❑ CBRS OPA FEMA Form 086-0-33(7/15) Replaces all previous editions Form Page 1 of 6 lVt'- EOV� EC 10 2019 OMB No 1660-0008 ELEVATION CERTIFICATE 1 Expiration Date November 30,2018 IMPORTANT: In these spaces,copy the corresponding 6iila i;;n c n' K FOR INSURANCE COMPANY USE Building Street Address(including Apt Unit Suite and/or Bldg Nc ,or P 0 Rotrte and&ii No Policy Number 4 CONCORD PLACE City State ZIP Code Company NAIC Number RYE BROOK New York 10573 SECTION C-BUILDING ELEVATION INFORMATION (SURVEY REQUIRED) C1 Building elevations are based on ❑ Construction Drawings' ❑ Building Under Construction' ❑x Finished Construction 'A new Elevation Certificate will be required when construction of the budding is complete C2 Elevations-Zones Al-A30,AE,AH A(with BFE), VE.VI-V30 V(with BFE),AR AR/A. AR/AE, AR/A1-A30 AR/AH,AR/AO Complete Items C2 a-h below according to the building diagram specified in Item A7 In Puerto Rico only,enter meters Benchmark Utilized OPUS IRS GEOID28B Vertical Datum NAVD 1988 Indicate elevation datum used for the elevations in items a)through h)below ❑ NGVD 1929 [K NAVD 1988 ❑Other/Source Datum used for building elevations must be the same as that used for the BFE Check the measurement used a) Top of bottom floor(including basement, crawlspace or enclosure floor) 125.4 feet ❑ meters b) Top of the next higher floor 133.2 feet ❑ meters c) Bottom of the lowest honzontal structural member(V Zones only) N/A feet ❑meters d) Attached garage(top of slab) 131.0 0 feet ❑ meters e) Lowest elevation of machinery or equipment servicing the building x (Describe type 125.8 feet meterspe of equipment and location in Comments) ❑ ❑ f) Lowest adjacent(finished)grade next to budding(LAG) 130.2 0 feet ❑ meters g) Highest adjacent(finished)grade next to building(HAG) 130.9 [] feet ❑ meters h) Lowest adjacent grade at lowest elevation of deck or stairs including structural support _ 125.9 0 feet [] meters SECTION D-SURVEYOR, ENGINEER, OR ARCHITECT CERTIFICATION This certification is to be signed and sea ed by a land surveyor engineer or architect authorized by law to certify elevation information t certify that the information on this Certfficate represents my best efforts to interpret the data available I understand that any false statement may be punishable by fine or imprisonment under 18 U S Code, Section 1001 Were latitude and longitude in Section A provided by a licensed land surveyor? ❑Yes n No ❑x Check here it attachments Certifier's Name License Number JOSEPH F RISOLI PE 056368 *tl of NEW y� Title S PRESIDENT v+� F W fl Company Name a C JOSEPH F RISOLI PE LLC Address 288 VALLEY ROAD City State ZIP Code (,*t COS COB Connecticut 06807 Signatur Date Telephone Ext. 11-22-2019 (203)637-8036 Copy all es of this evat i icate and all Atachments for(1)community official (2)insurance agent/company.and(3)budding owner Co ents(including type of equipment and location per C2(e) if applicable) MACHINERY SERVICING THE BUILDING WITH THE LOWEST ELEVATION IS THE HOT WATER HEATER AND FURNACE LOCATED IN THE BASEMENT GENERATOR PAD ELEVATION(EXTERIOR)= 130 7 8 AIR CONDITIONER PAD ELEVATION (EXTERIOR)= 130 9 FEMA Form 086-0-33(7/15) Replaces all previous editions Form Page 2 of 6 D OMB No 1660-0008 [1 Expiration Date November 30,2o1e ELEVATION CERTIFICATE DEC IMPORTANT: In these spaces,copy the corresponding informiew from Section ki FOR INSURANCE COMPANY USE Building Street Address(including Apt, Un,t Suite and/or Bldg No.1 or P.0 Route an GCW j Policy Number 4 CONCORD PLACE OJT j City State ZIP Code Company NAIC Number RYE BROOK New York 10573 SECTION E-BUILDING ELEVATION INFORMATION (SURVEY NOT REQUIRED) FOR ZONE AO AND ZONE A(WITHOUT BFE) For Zones AO and A(without BFE), complete Items El-E5 If the Certificate is intended to support a LOMA or LOMR-F request, complete Sections A Band C For Items El-E4, use natural grade if available Check the measurement used In Puerto Rico only, enter meters E1 Provide elevation information for the following and check the appropriate boxes to show whether the elevation is above or below the highest adjacent grade(HAG)and the lowest adjacent grade(LAG) a) Top of bottom floor(including basement crawlspace, or enclosure)is ❑feet ❑meters ❑above or ❑below the HAG b) Top of bottom floor(including basement crawlspace,or enclosure)is ❑feet ❑meters ❑above or ❑below the LAG E2 For Building Diagrams 6-9 with permanent flood openings provided in Section A Items 8 and/or 9(see pages 1-2 of Instructions), the next higher floor(elevation C2.b in the diagrams)of the building is ❑feet ❑meters ❑above or []below the HAG E3 Attached garage(top of slab)is ❑feet ❑meters ❑above or ❑below the HAG E4 Top of platform of machinery and/or equipment servicing the building is ❑feet ❑meters ❑above or ❑below the HAG. E5, Zone AO only If no flood depth number is available,is the top of the bottom floor elevated in accordance with the community's floodplain management ordinance? ❑ Yes ❑ No ❑ Unknown The local official must certify this information in Section G SECTION F-PROPERTY OWNER(OR OWNER'S REPRESENTATIVE)CERTIFICATION The property owner or owner's authorized representative who completes Sections A, B and E for Zone A(without a FEMA-issued or community-issued BFE)or Zone AO must sign here The statements in Sections A, B,and E are correct to the best of my knowledge Property Owner or Owners Authorized Representative's Name I Address City State ZIP Code Signature Date Telephone Comments I ❑Check here if attachments. FEMA Form 086-0-33(7/15) Replaces all previous editions Form Page 3 of 6 I • D ccm VV E DEC 1 rf 2019 OMB No 1660-0008 ELEVATION CERTIFICATE Expiration Date November 30,2018 loll I IMPORTANT: In these spaces,copy the corresponjin nfhrmatie 1Forh!9o-c or—t k , FOR INSURANCE COMPANY USE Building Street Address(including Apt Unit Suite andror&cq No;oL 0 R®� Policy Number 4 CONCORD PLACE City State ZIP Code Company NAIC Number RYE BROOK New Ycr.< 10573 SECTION G-COMMUNITY INFORMATION(OPTIONAL) The local official who is authorized by law or ordinance to administer the community's floodplain management ordinance can complete Sections A, B. C(or E), and G of this Elevation Certificate Complete the applicable item(s)and sign below Check the measurement used in Items G8-G10 In Puerto Rico only enter meters G1 ❑ The information in Section C was taken from other documentation that has been signed and sealed by a licensed surveyor. engineer or architect who is authorized by law to certify elevation information (Indicate the source and date of the elevation data i^the Comments area below) G2 ❑ A community official completed Section E for a budding located in Zone A(without a FEMA-issued or community-issued BFE) or Zone AO G3 ❑ The following information(items G4-G10)is provided lo,community floodplain management purposes G4 Permit Number G5 Date Permit Issued G6 Date Certificate of Compliance/Occupancy Issued G7 This permit has been issued for ❑ New Construction ❑ Substantial Improvement G8 Elevation of as-built lowest floor(including basement)of the building feet ❑ meters Datum G9 BFE or(in Zone AO)depth of flooding at the building site C feet ❑ meters Datum G10 Community's design flood elevation ❑ feet ❑ meters Datum Local Official's Name Title Community Name Telephone Signature Date Comments(including type of equipment and location,per C2(e), if applicable) I ❑ Check here if attachments FEMA Form 086-0-33(7115) Replaces all previous editions Form Page 4 of 6 Q � � u �J BUILDING PHOTO HS oM .'1 8a000e d; 6 ELEVATION CERTIFICATE See Instructions far Item A8 DEC W&piration Date November 30,2018 IMPORTANT:In these spaces,copy the corresponding information from 8ec0 O INSURANCE COMPANY USE Budding Street Address(including Apt Unit Suite and/or Bldg No )or P Q;"tbt IQ.Y- 'icy Number 4 CONCORD PLACE `�--���DEpA,, City State ZIP Code Company NAIC Number RYE BROOK New York 10573 If using the Elevaacr Certificate to obtain NFIP flood insurance affix at least 2 building photographs below according to the instructions for Item A6 Identify all photographs with date taken "Front View"and"Rear View" and, if required, "Right Side View"and "Left Side View" When applicable, photographs must show the foundation with representative examples of the flood openings or vents,as indicated in Section A8 If submitting more photographs than will fit on this page, use the Continuation Page JW I - s• .F,_� i � 4� � ..�..,mow-:. • r,yi fit• .. �' f-� :r- �. Photo On Photo One Caption FRONT VIEW-PHOTO TAKEN ON 11/20/2019 Ctesr Photo One 1� p �o�c iNo Photo Two Caption REAR VIEW- PHOTO TAKEN ON 11/20/2019 Clear Photo Two FEMA Form 086-0-33(7/15) Replaces all previous editions Form Page 5 of 6 BUILDING PHOTO S OMB No. 1660.0008 ELEVATION CERTIFICATE Continuation Page �rDa(e November 30,2018 IMPORTANT: In these spaces,copy the corresponding Information from SectlolL,A,__ FOR INSURANCE COMPANY USE Building Street Address(including Apt Urrt Suite and/or Bldg No )or P 0,ROtAbwW45bx,b1� I-' PofiW l�rn�er 4 CONCORD PLACE t bUILGING DE,-- -?TA1E:NT I City State ZIP Code Company NAIC Number RYE BROOK New York 10573 If submitting more photographs than will fit on the preceding page affix the additional photographs below Identify all photographs with date taken "Front View" and "Rear View", and, if required "Right Side View" and "Left Side View" When applicable. photographs must show the foundation with representative examples of the Flood openings or vents as indicated in Section A8 A _ Al / 4 .'4. 1 P"do TMM Photo Three Caption RIGHT SIDE VIEW-PHOTO TAKEN ON 11/20/2019 Clear Photo Three I Photo Four Caption LEFT SIDE VIEW-PHOTO TAKEN ON 11/20/2019 Clear Photo Four FEMA Form 086-0-33(7/15) Replaces all previous editions Form Page 6 of 6 1 1 � ��r • ��� �!.�. 1►IIIf11/11' �� �;�'a 11►I/f111►1 ������' 11►11r11i11,`��$*=4/� . 1�►1/f11i11 ���# 11►1/111111 '�� �. Ib11f11i11',y��� ���� j111j111111 [�_ �.�"' '`Yp1. 'rbd"u: s• 111�111.?::Sa •% '-e:111�111:�ar �4:=:iFal/�lll::f�;a�c�-� sgz{'•E.11/�111,' Siiii 11 111:' '= i 1 1 i,. �. �.;.t 1 1 .G'Ts�3 z Y AN 0 co cu L WR \ ce) -C — to 4+ O �`'� � � (A Z � COO� tote .141. to ' =�• , U O O U 3 v C I •' /¢ aK r`MCP 4-0 /. tolima Co € ' > � � . V = N 00 CD ZE _ .• (� C 1 P L V z N04 —_ g�• L w e� O --• �,u� 1,1,1�11 `sppa -�`'Y� .`sti; �11j (11'i^,�a� s. .t 1`,fll'• •-'111 fl; ..�.. .5-. �.11j/11��;s. my�(o))3 Ill/lfl >/g_�y 111 ►1- 111,1,1,1,1 fit! �,1,,,1,1,, \i �Alk,p., N+ iA{. [V'•'r t:� �,V y IAi. l �� .-Y ,+� A t •♦ A ♦♦ - A NA \ ���_j(���Jy ll�Y 4 I t�\�'�Q�?t' �`:\,��c��n'�— .- VL^•OV�'t4Y d Opt O�>r�' �� ...... ' trfj��a .-'' a�tYvk:: .-'• _.�,S' -' .v��.tn'` ��r�v' ,.��t,t ��J AC�® r ATE(MM/DDNYYY) �� CERTIFICATE OF LIABILITY INSURANCE 1/4/2021 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 NAME: Tammie Pattanite Arthur J. Gallagher Risk Management Services, Inc. PHONE 888-273-8155 FAX.No):856-273-3663 4000 Midlantic Drive Suite 200 IA N Mount Laurel NJ 08054 ADDRESS: tammie_paftanite@ajg.com INSURERS AFFORDING COVERAGE NAIC N Licensek BR-724491 INSURER A:New York Marine And General Insurance Company 16608 INSURED SINGHOL-02 INSURER B: Singer Holding Corporation d/b/a Robison Oil One Gateway Plaza,4th Floor INSURER C Port Chester NY 10573 INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:945532112 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. INSR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE ADDL SUER POLICY NUMBER MMIDD/YYYY MM/DD/YYYY LIMITS A X COMMERCIAL GENERAL LIABILITY PK202000020101 12/31/2020 12/31/2021 EACH OCCURRENCE $1,000,000 CLAIMS-MADE Pil OCCUR A PREMISES Ea occurrence $100,000 MED EXP(Any one person) $5,000 PERSONAL&ADV INJURY $1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $2,000,000 X POLICY PET LOC PRODUCTS-COMP/OP AGG $2.000,000 OTHER: $ A AUTOMOBILE LIABILITY AU202000017525 12/31/2020 12/31/2021 COM EaBINEDaccident SINGLE LIMIT $1,000,000 X ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS X HIRED X NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY Per accident A UMBRELLA LIAR X OCCUR EX202000001405 12/31/2020 12/31/2021 EACH OCCURRENCE $5,000,000 X EXCESS LIAR CLAIMS-MADE AGGREGATE $5,000,000 E. RETENTION$ $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY Y/N STATUTE I I ER ANYPROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ OFFICER/MEMBE R EXCLUDED? F-1 N/A (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Village of Rye Brook Building Department is named as an additional insured with respect to the above General Liability Policy,if required by a written contract executed prior to services performed. 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 Building Department 938 King Street Rye Brook NY 10573 AUTHORIZED REPRESENTATIVE ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD NEW Workers' s ATE Compensation CERTIFICATE OF Board NYS WORKERS' COMPENSATION INSURANCE COVERAGE 1 a.Legal Name&Address of Insured(use street address only) 1 b.Business Telephone Number of Insured ADP TotalSource FL XVII,Inc. 9143455700 10200 Sunset Drive Miami,FL 33173 UC/F 1 c.NYS Unemployment Insurance Employer Registration Number of Singer Holding Corporation DBA Robison Oil Insured 1 Gateway Plaza 4th Floor 45045108 Port Chester,NY 10573 1 d.Federal Employer Identification Number of Insured or Social Security Work Location of Insured(Only required if coverage is specifically limited to Number certain locations in New York State,i.e.,a Wrap-Up Policy) 133121491 2.Name and Address of Entity Requesting Proof of Coverage 3a.Name of Insurance Carrier (Entity Being Listed as the Certificate Holder) New Hampshire Ins Co Village of Rye Brook Building Department 3b.Policy Number of Entity Listed in Box"I a" 938 King Street WC 038381464 NY Rye Brook,NY 10573 II worksite employees working for Singer Holding Corporation paid under ADP TOTALSOURCE,INC's payroll,are covered under the above stated policy. 3c.Policy effective period 7/1/2021 to 7/1/2022 3d.The Proprietor,Partners or Executive Officers 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"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 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 referenced above and that the named insured has the coverage as depicted on this form. Approved by: Adriana Sanchez (Print name of authorized repr tative or licensedPaf insurance carrier) Approved by: 6/30/2021 (Signature) (Date) Title: Account Specialist II Telephone Number of authorized representative OF lieensed agent Rf Aaffiei= 800-743-8130 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.