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HomeMy WebLinkAboutMP21-152 4y J b bu 4�d Ec Lt4t�y• °�: C tc a VILLAGE OF RYE BROOK MAYOR 938 King Street, Rye Brook,N.Y. 10573 ADMINISTRAiTOR Paul S.Rosenberg (914) 939-0668 Christopher J. Bradbury www.ryebtook.org TRUSTEES BUILDING& FIRE Susan R. Epstein INSPECTOR Stephanie J. Fischer Michael J. Izzo David M. Heiser Jason A. Klein CERTIFICATE OF COMPLIANCE January 14,2022 Christine Sciandra 1 Wyman Street Rye Brook,New York 10573 Re: 1 Wyman Street, Rye Brook,New York 10573 Parcel ID#: 141.43-1-10 This document certifies that the work done under Mechanical Permit#21-152 issued on 10/27/2021 for the installation of three 120 gallon above-ground propane tanks have been satisfactorily completed. Sincerely, Steven E. Fews Assistant Building&Fire Inspector /tg 4yE BR cb, 1982 w � 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: 1 DATE: ��� PERMIT# � ISSUED: VIA L �ECT: BLOCK: LOT: LOCATION: V C51 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 ( ` ❑ NATURAL GAS ❑ L.I?GAS ❑ FUEL TANK ❑ FIRE SPRINKLER ❑ FINAL PLUMBING ❑ CROSS CONNECTION ❑ FINAL ❑ OTHER Vice BRC��` O� tim w � 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 ' DATE' I �� t APERMIT# y ISSUED: CT: BLOCK: LOT: LOCATION: " OCCUPANCY: ❑ VIOLATION NOTED THE WORK IS..,--Er ACCEPTED ❑ REJECTED/ REINSPECTION ❑ SITE INSPECTION �I REQUIRED ❑ FOOTING ❑ FOOTING DRAINAGE ❑ FOUNDATION ❑ UNDERGROUND PLUMBING NOTES ON INSPECTION: ❑ ROUGH PLUMBING ❑ ROUGH FRAMING ❑ INSULATION 1 El GAS en-n �I v (Zan C I El L.P. GAS , - S ❑ FUEL TANK ` "" ❑ FIRE SPRINKLER FINAL PLUMBING ❑ CROSS CONNECTION ❑ FINAL ❑ OTHER a a N = Ln H �..� N G � W °� a� o ■ cn aCi 6 y H a kn O M :�y W � � 0 � � 3 � � o •- � F IC L a I (Yi 3 Q �O fs7 - 8 — o x _ a w 3 r r� do en •� Ix O O �1 pp o Q� V Fo,U c O _ W Ln A z c3i cU p" a A CAc 00 `� 01 F� a Z Q � � �� � •oSno � r! > .a cu 0 c>i 'V P ca x A U O H U Q 'C- .� x se b V 0 A O •=G7 W � o� 7a••� >oo> BUILDING DEPARTMENT ® E7. (C F� �W F VILLAGE OF RYE B OOK f 938 KING STREET RYE BRO ft NY 10573 0 C T 26 2021 www.ry roc► . e VILLAGE OF RYA BROOK EUILDNG DEPARTMENT Application for Permit to Remove, Abandon and/or Install Fuel Storage Tank (*Storage Tanks in excess of 1,100 gallons require registration with the County of Westchester) FOR OFFICE USE ONLY: PERMIT#: Approval Date: Permit Fee: $ Approval Signature: Other: Disapproved: (fees are non-refundable) ****r***************** * ****t ****** *****,� REOUIREME** FOR RELEASE OF PERMIT&CERTIFICATE OF COMPLIANCE: 1. Application Completed by Bonded, Licensed Contractor. 2.Your contractor's valid proof of liability insurance. (Village of Rye Brook must be listed as certificate holder) 3. Your contractor's valid proof of workers compensation insurance. (Form#C105.2 or Form#U26.3 /or NY State Workers Compensation Waiver) 4. Fee per Tank: Removal, Abandonment, or Installation: $185.00 per Tank. 5. Dig Safely New York#(dial 811): 6. Inspection by Building Department for removal/abandonment and/or installation. 7. Submit all Manifests& Reports(after work has been completed). 8. Certificate of Compliance will be provided when all requirements are fulfilled. Application dated,/0-0�4-a/ ,is hereby made to the Building Inspector of the Village of Rye Brook for a permit to remove,abandon,and/or install a Fuel Tank as herein described.The applicant and property owner,by signing this document agree that the subject fuel tank(s)will be removed,abandoned and/or installed in conformance with all applicable Village,County,State& Federal laws,codes,rules and regulations. Indicate Permit Tvpe: Installation 0�•Removal( } •Abandonment ( ) /Above Ground (V/ _ Buried in Ground ( ) l. Address: l W q 1h of�J ne-e-� SBL: 1419 d o?—/—/a Zone: 2. Property Owner\&Address: c k r t '�I /U L I Ci AJU C!?� Phone#. C ) S(Ci;i -q 10(0 Cell#: email: (-MS 3. Contractor&Address: vv AJ 1Ck hJ 0 Cc . qVI v,' . P v fN M A19 • 6tee vw-'det 0(ot3 e Phone#1 z0�11j1nq_S 00& Cell#: 203 q(p -I(p l 7 email: Ps ac / ) eo t 4. Applicant:! Pq wI S( I CCLt 1 q wa Phone#: Cell#: 3-4 email: PS a lV e D l • A)E,-t 5. Indicate Fuel Type:Fuel Oil( P.Gas Jf•Gasoline( )•Other( ): 6. Number and Capacity of each Tank: Above b �O U N d q N K yr I D 3colovs eqcj, t 7. Exact Location(s)of each Tank: L15 DCt L K O�- kOV5C 'S+Tg l3 IkeCJ rj AJ S etIV I-ed 'C7 Ck (G ' Ca' C 4- 41 , . I 8/l 2/2021. S�TE OF NEW YOM COUNTY OF WESTCHESTER ) as: c4%Al SC t CCk t tq.yd ,being duly sworn,deposes and states that he/she is the applicant above named, (print name of individual signing as the applicant) and further states that(s)he is the legal owner of the property to which this application pertains,or that(s)he is the for the legal owner and is duly authorized to make and file this application. (indicate architect,contractor,agent,attorney,etc.) That all statements contained herein are true to the best of his/her knowledge and belief,and that any work performed,or use conducted at the above captioned property will be in conformance with the details as set forth and contained in this application and in any accompanying approved plans and specifications,as well as in accordance with the New York State Uniform Fire Prevention&Building Code,the Code of the Village of Rye Brook and all other applicable laws,ordinances and regulations. },, Sworn to before me this Sworn to befor me this v day of O ( ,20a day of ,- ,20 t51 l gnature of Property ignature of Applicant "'0 1 (m" PejAl SCjCCLI'Ii4-qAJ0 t Name of Prope Owner P ' t Name of Applicant I Ic, Notaffl*'Public, State of New York No State oew or No. 01 rJIE6160063 0.01 ME6i 60063 Qualified in Westchester County/7ualified in Westchester County � Commission ExDIres January 29.20 Q Commission Exoires January 29.20� This application must be properly completed in its entirety and must include the notarized signature(s) of the legal owner(s) of the subject property, and the applicant of record in the spaces provided. Any application not properly completed in its entirety and/or not properly signed shall be deemed null and void and will be returned to the applicant. z 8/12/2021 AFFIDAVIT IN SUPPQRT OF FEE WAIVER RELAT17D TO HURRICANE IDA STATE OF IU � COUNTY (insert n0nr );ticfiag duly:swa n}dopv9es and says 1. I ani the applicant fpr a,. Building:Permi;/ ertifl�at�Q.f ftppanoy/Demolition.Permit I •>140fieb Permit/P um.ing k'onr it/Fence&Wall Permit Nle�lienical Pcrmii l Pod�powt(.circle all that apply) 2. 1 am the legsl owtior of p ldcated fit. I�1'1l . Rye Brook,New York(insert reat.o reas). l;atn:.the (Architecgcptitracter/Bnginscr/A40r tc .)(ci;Gic':q;lej;for the legal owner of propgty located.at •Rye.Brook,New York and I am-duly Y pftriZed by.9nro?�'ow to make aucl'file.the .accQmpattying:applic�tign. 3. The following is a descriptiop of(I)d?4 work.tn.be perform ¢+wader the permit.for which I any applying; arrd(2).hvw thew$x1c sib ' s:a direst result:of Fluricat�e Ida: ' :' ... •i:1. .•': .:l.'. • 1. i AJ ' r' 4. The work desedbed.herein arose as.a direct itsuh of.Ht v4�gane Ida and does not include Work which wag not awed hYuxrlcana Ida; s Swoitm to before tna°nits .. Lary Public Mo.01C080871N OCT 2 6 '2021 VILLAGE OF'RYE BROOK BUILDING DEPARTMENT ARCOSA 57 wg and 119 wg TANK Finished with ArcClad Superior Aboveground Coating Tank Features: • Taller collar to accommodate preferred regulator set-ups • Superior Coating • D.O.T. 173.315(j) permits A.S.M.E. containers to be filled for transportation • Heavy duty bottom foot ring • Re-certification not required as compared with D.Q.T. 4BW cylinders • #72 liquid level outage valve orifice Fabricated to A.S.M.E.code,Section VIII,Division 1. For more information Division 2 design available 888.558.8265 Registered with the National Board Registered with CRN(Canadian Registration Number) ARCOSA TANK Vertical A.S. M . E. Tanks GENERAL SPECIFICATIONS I,_FLOAT Conforms to the latest edition of the ASME code for GAUGE Pressure Vessels, Section VIII, Division 1. Complies 0 11/4•.FILL with N F PA 58. ya._SERVICE VALVE Rated at 250 psig MAWP from -20° F.to 1252 F. All VALVE tanks may be evacuated to a full (14.7 psi) vacuum. Vessels are pre-purge with vacuum and conforms with National Propane Gas Association #133-89(a) I'-RELIEF Alternative Purge Process. VALVE Vessel Finish: Coated with Arcckid,zinc rich FITTINGS LAYOUT epoxy primer and super durable TGIC polyester topcoat. LID 15 9/16"OD LID COLLAR -Q 15 9/16"OD COLLAR ZD l7 _ w ta 30„ J M J J 24" a OUTSIDE DIAMETER ir OUTSIDE DIAMETER M w O 0 18.40" 24" FOOTRING FOOTRING 24"OD(57 WG) 30"OD(119 WG) Est.weight: 268 lbs. Est.weight: 320 lbs. Quantity in Full Load: 208 Quantity in Full Load: 99 Cre: December 14.2018 For more information 888.558.8265 q I FEMA National Flood Insurance Program i ELEVATION CERTIFICATE AND INSTRUCTIONS IE I 1 1 { 1 i I I I I ! i DEPARTMENT OF HOMELAND SECURITY Federal Emergency Management Agency ELEVATION CERTIFICATE OMa control NembW le(3o-Gaga IMPORTANT: FOLLOW THE INSTRUCTIONS ON PAGES 9-16 t xplrallon:1 113 01201 8 opy all payee of this Elevation Certlficato and all attachmanls for(1)community officint,12)insurance a0 enticompany,and(3t building owner. SECTION A-PROPERTY INFORMATION FORM INSURANCE COMPANY USE Al. Building Owner's Name Policy Number: CHRISTINE&ANTHONY SCiANDRA A2. Building Street Address(Including Apt.,Unit,Suite,andlor Bldg.No.)or P.O.Route and Company NAIC Box No, Number: 1 WYMAN STREET City RYE BROOK State NY _ Zip Code 10673 A3. Property Descrlptlon(Lot and Block Numbers,Tax Parcel Number,Legal Description,etC.) 141,43-1.10 A4, Building Use(e.g.,Residential,Non-Residential,Addition,Accessory,etc.) RESIDENTIAL AG. LatitudelLongltude: Lat.40`-59'-56.4" Long.73`41"46.3" Hodzontel Datum: C NAD 1027 (:NAD 1983 Ae. Attach at least 2 photographs of the building If the Certlficate Is being used to obtain stood insurance. AT Building Diagram Number 2B A8. For a building with a crawtspace or enclosure(s): A9. For a building with an attached garage: a)Square footage of crawtspace or enclosure(&) 1276 sq it a)Square footage of attached garage sq ft b)Number of permanent flood openings In the 0 b)Number of permanent flood openings crawtspace or anclosure(s)within 1.0 foot In the attached garage within 1.0 foot above adjacent grade above adjacent grade c)Total net area of flood openings In Ae.b 0 sq In c)Total net area of flood openings In A9.b _ sq in d) Engineered flood openings? ('Yes (No d) Engineered flood openings? C Yes C No SECTION B-FLOOD INSURANCE RATE MAP(FIRM)INFORMATION Bt. NFIP Community Name&Community Number B2. County Name 83,State NY VILLAGE OF RYE BROOK 360930 WESfCHESTER B4. MaplPanel Number B5. Suffix B6. FIRM Indax Dale B7. FIRM Panel Effective/ B8. Flood Zones) B9.Base Flood Elevation(s) 350 F Revl&ed Date AE (Zone AO,use base flood 9/2812007 depth 9l2612007 32.6 810.Indicate the source of the Base Flood Elevation(BFE)data or base flood depth entered In item B9: C FIS Profile (e FIRM C Community Determined C Other/Sourco,. — 811.Indicate elevation datum used for BEE In Item 139: C NGVD 1929 (.NAVD 1988 C OthedSource: _ B12.Is the building located Ina Coastal Berner Resources System(CBRS)area or 01herwlso Protected Area(OPA)? C Yes G No Designation Date: f CBRS (OPA SECTION C-BUILDING ELEVATION INFORMATION(SURVEY REQUIRED) C1,Building elevalions are based on: ('Constnrclion Drawings` C Building Under Construction` Ci Finished Construction C2.Elevations -Zones Al-A30,AE,AH,A(with BFE),VE,VI-V30,V(with BFE),AR,ARIA,ARIAE,AR1A1-A30,AR1AH,ARIAO. Complete Items C2.a-h below according to the building diagram specified in Item AT in Puerto Rlco only,enter molars. A new Elevation Certificale will be required when con5truclion of the building is complete. Benchmark Utilized:RTK GPS TO NYS CORS NETWORK Vertical Datum: NAVD 1068 Indicate elevation delum used for the elevations to Items a)through h)below. C NGVD 1929 C+NAVD 1080 ('Othorlsource. — Datum used for building elevations must be the same es that used for the BFE. Check the measurement used. a) Top of bottom floor(Including basement,crawtspace,or enclosure floor) 20.11 (:feet C meters b) Top of the next higher floor 30.7 Co feet (—motors C) Bottom of the lowest hodzonlel structural member(V Zones only) NIA C foot C meters d) Attached garage(top of slab) NIA.— C feet C meters e) Lowest elevation of machinery or equipment servicing the building 33.2 (:feel C meters (Describe type of equipment and location In Comments) 11 Lowest adjacent(finished)grade next to building(LAG) 29.1 (:feet C meters g) Highest adjacent(finished)grade next to buiiding(HAG) 32.4 Co feel C meters h) Lowest adjacent grade at lowest elevation of deck or stairs.Including 31.6 (:feel C meters structural support — —' ELEVATION CERTIFICATE OmB Control Number 16t34.0t108 Expiration:1113012018 1 WYMAN STREET RYL-.HROOK NY 10573 SECTION D-SURVEYOR,ENGINEER,OR ARCHITECT CERTIFICATION This cedifleation is to be signed and scaled by a land surveyor,engineer,or architect authorized by law to certify alovaton Information.1 certify that the information on this Certificate represents my best efforts to interpret the data avairatge.i undorsfand that any falso statement may be punishable by fine orlmpr(sonmonf under 10 U.S.Code,Section 1001, -- Were latitude and tonglbrde in Section A Wchech here if attachrients- provided by a licensed land surveyor? OF G Yes C No Cerlifler's Name Llonnsa Number George J.Mottarella 497 52 O 9� 'ntle -- Company Name r fm- President George J.Mottarella PE,LS,PC. n - E� Address city state zip Code cP� °• 497 23 Rose Ave. Harrison - NY 10520 �/nND s� Signature Date Telephone �l / March 4 2D19 +1 (914)755-1232 C y th sides of this Elevatiohl Certificate for(1)community official,(2)insurance agentloomperry,Arid(3)building owner. Comments(including typo of equipment and location,per C2(e),if applicablo)" 1.Bailer,Hot Water heater,and Electric Panel are at elevation 33.2 2.LAO was IaWri In front of Garage Door,Garage with one story above,were canstructud later than original house.There are no penebations from garage to basement. 3.This property is adjacent to a regulatory floodway.No Information was found regarding limit of floodway. SigneiturY Date SECTION E-BUILDING ELEVATION INFORMATION(SURVEY NOT REQUIRED)FOR ZONE AO AND.:ONE A(WITHOUT l3FE) For Zones A0 And A(without BFE),complete Items -E5.If Me Certificate is Intended to auppod a LOMA or LOMR-F request,complete Sections A,B,and C.For Items Elf-E4,use natural grade,if available.Check the measurament used.In Puerto Rico only,enter meters. E1-Provide elevation Information for the following and Oiactc the appropdato boxes to show whether the elevation Is above of below file higlrest adjacent grade(HACK)and the lowest adjacent grade(LAG). I a)Top of bottom floor(including basement,crawlspace, above or below tho HAG, of enctosure)Is f feet meters © ❑ i 1 i b)Top of bottom floor(including basement,crawlspace, ('feel meters ❑aboveor �.�botowthe LAG, (" Or enclosure)is i Fz For Building t7iagrarns 5-9 with permanent flood openings provided In Section A Items 8 arultur 0(see pages 8-9 of Instructions),the next higher floor(elevation C2,b In the diagrams)of the building Is C feet f maters E above or ❑below the FLAG. i E---3.Attached garage(top of slab)Is C feet ('meters ❑above or ❑below the HAG. E4.Top of platform of rrrauh€nery and for equipment 11 6orvlcing the building Is __ -- C feel C meters ❑above or ❑below the HAG. j E5.'Lone AO only,It no flood depth number Is available,is t rh he top of Me bottom floor elevated in accordance with o community's floodplain I management ordirwnce9 (^Yes C No C Unknown. The local official must certify this information in Semen G. SECTION F -PROPERTY OWNER(OR OWNER'S REPRESENTATIVE)CERTIFICATION The property owner or owners authorized reFresen ative who completes Sections A,B,and E for Zone A(without a F MA-lssued or community-issued BFE)or Zone.AO must sign here.The statern_e_nis In sections A,u,and E are cored to the best of my knowledge. Property owner or Owner's Authorized RepresentaWa's Name: _ Address City - - Slate ZIP Code! I Signature _ Date Telephone Comments I i ❑Check here If attachmants- cc.aA C.—n4a.A.11 1701 A% Renlarnn all nrauinim Arlitinne rape 4 of 15 1 party of the first part, and ANTHONY SCIANDIZA and ROS:� SCIPUNDRA, his wife , ci both residing at 276 South regent Street, Port. Chester , New York. party of the sectend part, 'WUNESSETH,that the party of the first part,in consideration of Ten Dollars and other valuable consideration "Y paid by the party of the second part, does hereby grant and release unto the party of the second part, the heirs or successors and assigns of the party of the second part forever, ALL that certain plot, piece or parcel of laud, with the buildings and improvements thereon erected, situate, lying and being in the Town of Rye , Westchester County, State of New York, which is more particularly bounded and described as follows: - -7 BEGINNING at a point on the southerly side of Wyman Street distant 195 feet as measured al on the souther l g y side of Wyman Street from •`� F Lot No. 1 Block D, Map of Chester Terrace, filed in the Westchester County Clerk' s -Office as Map No. 2650; thence running 90 degrees at ', an angle to Wyman Street, South 12 degrees 39 minutes 15 seconds West 100 feet to the land now or formerly of Lundell , thence along said land now or formerly of Lundell, North 77 degrees 20 minutes 45 seconds West 91.91 feet (91.92 ft. survey distance) to the center. line of Blind Brook; thence rune nc ��,�*-� the following courses, North 4 degrees 37 minute;, 30 seconds East 5 8S feet thence North 28 u - •_ s �C3L ttCS �J iui3lu a.ca �.r �c:...v...,.r. ...i....� �...•s feet; thence North 21 degrees 47 minutes 50 seconds West 5.14 feet to the southerly line of Wyman Street; thence along the southerly side of Wyman Street, South 77 degrees 20 minutes 45 second: East 67.84 feet to the point and place of beginning. it I V{4•It Y: 71 _. j I w♦ TOGETHER with all right, title and interest, if any, of the party of the first part in and to any streets and roads abutting the above described premises to the center lines thereof; TOGETHER with the appurtenances � . and all the estate and rights of the party of the first part in and to said premises; TO HAVE AND TO -- HOLD the premises herein granted unto the party of the second part, the heirs or successors and assigns of the party of the second part forever. 10 AND the party of the first part covenants that the party of the first 'part has not done or suffered anything - whereby the said premises have been encumbered in any way whatever, except as aforesaid. AND the party of the first part, in compliance with Section 13 of the Lien Law, covenants that the party of the first part will receive the consideration for this corrveyance and will hold the right to receive such consid- eration as a trust fund to be applied first for Ube purpose of paying the cost of the improvement and will app;v the same first to the payment of the cost of the improvement before using any part of the total of the same for any other purpose. !`- + The word "party" shall be comtrued as if it read "parties" whenever the sense of this indenture so requirr.5, IN WUNESS WHEREOF,the party of the first part has duly executed this deed the day and year.first abvvc. written. IN PRFSZNCE OF: "�t"ZI".s� "t•—++ i� F - M JO N J.E ticr,LEY XDtarp Public-State of New Vork Appainted for WLstchester County _A- Ccza-ission Iixp!res\L arch 30,lA / --- _.- - t STATE OF NEW YORK,CQr';:� j� as; I STATE CF NEW a�`�4�`QLJI�TY CIF On the d-r of 19 before me On the clay of 19 , before me personally cmme , / personally came to me known,who, being by rile duly sworn, did depose and the subscribing witness to the foregoing instrument, with say that he resides at No. whom I am persoriallv-acquainted, bo, being by me duly scvom, did depose and say thht he resides at No. that he is the of that he IatowS: ,the corporation described in and which executed the foregoing instrument; that ' he :o be the in.%-Mr-A knows the seal of said corporation; that the seal affixed describedr in and whc executed tl-� foregcag i;istnumc,t; to said instrument is such corporate seal; that it was so that he, said subscribing witness. was osesent mnd szw affixed by-order of the board of directors of said corpora- execute the same; and that he, said vri_ness, tion, and that he signed h name thereto by like order. at the same. tirrrt subscribed h =rnz as witness thereto. ,;' ff'fi f ar 4 l4 o f s,tF5;Gi¢Sl:• Recorded in the Office� the G�..,?�n, , �.. Cat�rry (Misi�on of Lanz Rec�:as3 on...._.Y- ..:... - ..,.,4 .S"..... at.A"7:1 P....f%:,in Lt Ng�...�.�_ _.._ur D, fitness my Viand and v;iicial Seal, te -41 f � ' 1 +w .. It,a U ii � C ti tl b :.► :v �� ii n j�11 �� �S `t `Q L.f VI W � icy YY p r C :� N 41 fie H U t V CM CM W 4-3 -3 t r�1 Ca 4 N ---- r..w... t W Oib ' `i'� 3 'g „•' '. •� r ' eeff" a SSham � ',�,,•_: �. ys° (ff a ;' � off�` V f,�, '� �♦ & y �1, �- _� .k� �;.'.�t-1�1� r'` v ��r-to 1�~ .. D��r'' � 1 !{+♦i? � Jll'��i�f! :Lvyi�r�:l1 Ij t ti �r��..�il Yvt::�a'a'":�7)11111�, ' + �1111/{{!/5 .) _ #Y' �dta�" W �(♦C�Df��yv,� U Sr �(�)? L cd N { c C. O ' u X N : = L.0 f _ cu u U Cd lU Q)rA LU LU co JU LLI .. ��'• •ice . � J � � � ++� i• /' 4-o LLI W nWN/ (D ~ cz 1° 3-4 o r� 1(cssl>t ���: •� a E-� v�i � i � �v�tw�i)>j\ co �t -rat � L U Z CV w.3_^'`.✓r�i1c / ', �+�ti)`k'Nlsu �• f!{{ '�. - {1 ivs .,- 11 °. } '•{i 11----r3s + 'z� 1 }k $T��•;1 11' ✓Ima '�ClslD? 1 .. A .. • - ♦. �•.� ♦i• �a _ �+•�+ d,�tit � •1,+4 •11•Tw. iilll { i , �� •a1�1.� A ii� ,�. 7P-�•�r , ' W4, f p alid' 'r d t �.t•,.�" '�-A +r ra/�:� '4 VI or-yj+.. '. ti.✓° ` '.;..,.t3 '`�.,.•tt ,R,�+� ,uV'..!'.t '` .�-c�s t4' �`+:r '�' DATE(MMM> , CERTIFICATE OF LIABILITY INSURANCE D5120/202, 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 endorsements. PRODUCER CONTACT CLIENT CONTACT CENTER FEDERATED MUTUAL INSURANCE COMPANY PHONAME` HOME OFFICE: P.O.BOX 328 A CNNo Eat):888-333-4949 IA No):507-0464664 OWATONNA, MN 55060 AIL ADDRESS:CLIENTCONTACTCENTER FEDINS.COM INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:FEDERATED RESERVE INSURANCE COMPANY 16024 INSURED 263-9334 INSURER B: NEW ENGLAND OIL CO INC INSURER C: 469 W PUTNAM AVE INSURER D: GREENWICH,CT 06830-6895 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:52 REVISION NUMBER:0 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 TYPE OF INSURANCE DL SUBR POLICY NUMBER POLICY EFF POLICY EXP R INSR WVD MMIDD/YYYY MMIDDIYYYY LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $1,000,000 DAMAGE TO RENTED $100,000 CLAIMS-MADE X OCCUR I Ea oca ren MED EXP(Any one person) $10 000 A N N 9414028 07/01/2021 07101/2022 PERSONAL a ADV INJURY $1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $2,000,000 NOTHER: PRO- LOC ECTPRODUCTS-COMPIOP AGO $2,000,000 POLICY El AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $1,000,000 Ea c' e t X ANY AUTO BODILY INJURY(Per person) A OWNED AUTOS ONLY SCHEDAUTOSULED N N 9414028 07/01/2021 07101/2022 BODILY INJURY(Per accident HIRED AUTOS ONLY NON PROPERTY DAMAGE AUTOOSS N ONLL Y P X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $4,000,000 A EXCESS LIAR CLAIMS-MADE N N 9414031 07/01/2021 07/01/2022 AGGREGATE $4,000,000 DED RETENTION WORKERS COMPENSATION OTH- AND EMPLOYERS'LIABILITY Y/N X PER STATUTE ER ANY PROPRIETORIPARTNERIEXECUTIVE E.L.EACH ACCIDENT $1,000,000 A OFFICER/MEMBER EXCLUDED? NIA N 9414032 07/01/2021 07/01/2022 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $1,000,000 If yes,describe Linder DESCRIPTION OF OPERATIONS below E.L DISEASE-POLICY LIMIT $1,000,000 DESCRIPTION OF OPERATIONS 1 LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) CERTIFICATE HOLDER CANCELLATION 263-933-4 52 0 VILLAGE OF RYE BROOK SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 938 KING ST THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN RYE BROOK, NY 10573-1226 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE G 9 19t18-2015 ACORD CORPORATION.All rights reserved. ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD 1sTK Workers' CERTIFICATE OF ATE Compensation Board NYS WORKERS' COMPENSATION INSURANCE COVERAGE 1a. Legal Name&Address of Insured(use street address only) 1b, Business Telephone Number of Insured NEW ENGLAND OIL CC INC 203,869.5869 469 W PUTNAM AVE GREENWICH, CT 06830 1c. NYS Unemployment Insurance Employer Registration Number of Insured Work Location of Insured (Only required if coverage is specifically limited to 1 d. Federal Employer identification Number of Insured or Social Security certain locations in New York State,i.e.. a Wrap-Up Policy) Number 06-0670146 2.Name and Address of Entity Requesting Proof of Coverage 3a. Name of Insurance Carrier (Entity Being Listed as the Certificate Holder) Federated Mutual Insurance Company VILLAGE OF RYE BROOK 52 938 KING ST 3b. Policy Number of Entity Listed in Box"1 a" RYE BROOK NY 10573-1226 9414032 3c.Policy effective period 0 710 112 02 1 to 07/01/2022 3d The Proprietor, Partners or Executive Officers are ©X Included.(Only check box if all partners/officers included) 0 all excluded or certain partners/officers excluded. This certifies that the'insurance carrier indicated above in box"T' insures the business referenced above in box 1 a"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 Melissa Kopperud (Print name of authorized representative or licensed agent of insurance carrier) Approved by: tr � �_ 05/20/2021 (Signature) D:v, Title: Certificate Center Representative II Telephone Number of authorized representative or licensed agent of insurance carrier 888-333-4949 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 ■ i ■ P'� Q w L L O ■ Ln • � w a = ,c € O r W Icc F O o � S ti tn pLU Or Q i CL rl i. G� a co r = O o '� � .1, O�% r ►fir E"' 1 Owl W) IL U v E E y n r woo E"' 01 :3 L ` 0 OE r z W /'� O ; c0-0 do Lo coo CN = ze " 1+1 0.w z u ?� r' s o �. 4 � .. o `~ ca= � m � V •• U O C � O � � c — w ONON 0 E E _ Q � V 0Gam"' .^ � L z (.., V �so Q U gw a ;D && oP = r i.r i 4 = Vd1 F^ ea 0 ri r c P t 4 s z ( 44 z ¢ e 04 s s Q ,y[ 4 z a a = REVISE Bu�L l L'IC I OCT I9 1011r: VIL � t f} �.938 KING A, VILLAGE OF RYE B OOK (914)9 39- ENT w o r Apulfication for Permit to Remove Abandon and/or Install Fuel Stora a Tank (*Storage Tanks in excess of 1,100 gallons require registration with the County of Westchester) FOR OFFICE USE ONLY: PERMIT#: Approval Date: o C Permit Fee: $ Approval Signature: Other: ;I>A �ZDIL�-ti `➢11N � Disapproved: (fees are non-refundable) REQUIREMENTS FOR RELEASE OF PERMIT&CERTIFICATE OF COMPLIANCE: 1.Application Completed by Bonded,Licensed Contractor. 2. Your contractor's valid proof of liability insurance. (Village of Rye Brook must be listed as certificate holder) 3. Your contractor's valid proof of workers compensation insurance. (Form #C 105.2 or Form# U26.3/or NY State Workers Compensation Waiver) 4. Fee per Tank: Removal,Abandonment, or Installation: $185.00 per Tank. 5. Dig Safely New York#(dial 811): 6. Inspection by Building Department for removal/abandonment and/or installation. 7. Submit all Manifests&Reports(after work has been completed). 8. Certificate of Compliance will be provided when all requirements are fulfilled. Application dated, is hereby made to the Building Inspector of the Village of Rye Brook for a permit to remove,abandon,and/or install a Fuel Tank as herein described.The applicant and property owner,by signing this document agree that the subject fuel tank(s)will be removed,abandoned and/or installed in conformance with all applicable Village,County,State& Federal laws,codes,rules and regulations. Indicate Permit Tyne: Installation -Removal( )*Abandonment( )/Above Ground ;**Biu*r*i*e*d*i*n**G*r*o**u*nd ( ) I. Address: SBL: ` L �nE ��'L=� 2. Property Owner Address: � �`j,T�Yl� 'S Phone#:(ciLM561p -q\()(p Cell#: email: 3. Contractor&Address: V1,e_, Phone#:�Lk - -SV, ell#: email:. 4. Applicant: cx Phone#: CLILI-fi+{o�c-ri4� Cell#: email: 5_ Indicate Fuel Type:Fuel Oil( )•L.P.Gas't9•Gasoline( )•Other( ): 6. Number and Capacity of each Tank: 2) 1qoAl o li d n W 7. Exact Location(s)of each Tank: �h (v�R x 7� ATa (aln sop__ � k 6/1/2020 S�F N �V Ikli,11"1.0UNTY OF WESTC] ESTGR ,being duty sworn,deposes and states that he/she is life applicant above named, pant name o-in n a al sr mg e applicant) and further states that(s)he is the legal owner of the property to which this appl ication pertains,or that(s)hc is the for the legal owner and is duly authorized to snake and file this appliCation.(indicate architect,contractor,agars,attorney,etc.) That all stalemeats contained herein are true to the best of his/her knowledge and belief,and that any work performed,or use conducted at the above captioned property will be in conformance with the details as set forth and contained in this application and in any accompanying approved plans and specifications,as well as in accordance with the New York State Uniform Fire Prevention&Building Code,the Code of the Village of Rye Brook and all other applicable laws,ordinances and regulations. Sworn to b ore me this Sworn t ,before me this day of_Vjn6_�kxlt ,20 — day of 'YJV ,20 2 l� � ignal a of Property wncr Signature of Applicant rint Man of Propert Owner Pr' Marne of Applican ' CH � 50 L Nola Public ONNA M,CO UNG Notary Public F OF NEW YORK k • public—$fete 01 New York No.01 R U6313298 G fto.0lC0306T898 Qualified In Putnam County uatitlod In Weettriester County My Comtnlulon Expires 10128/2022 My Commission Expires 10-20-2022 This applicatiotl must he properly collipleted ill its entirety and must inClltde the notarized si"nature(S) 01'111c INVI Owiler(S)of the subject property, and the;applicant of record in the spaces provided. Any application not properly completed in its entirety and/or not properly signed Shall be deenled hull and void and will be returned to the applicant. 2 8;12i2021 r -°: fin ?n 1 w N 1 h 1S nQ djG r� .e `R n1 IY�b ~tl n tt1 A1, MX 0 0 I�S'r4 1 � + A!�`• i,t. !' 7�p r ep '•e.� t �•' (,. p- f 1i,. r , � .�I L ,'�.� 1"irlSl �` qi`!� G �78 111*! v ♦. Yt.. rIP^' 1. '.tt r l � {�"'.�`a •.,.- •.fih•. 111/t+•, , /// '" , �f�jl/• t •� • A ♦• )t ''Ct, v ��k, ,.y�' �ta�s)>" 4�il�l+++ s �• 11++1 �� 6. +1 141j1 11+►Ic/}+ a • r tl� �,> , I yy p•y k r . . �111+ y[ �"crl (ri ++,� 1 Im I�lll�+ 3 ' Ry CN iM O v�i al 10, Y ..A1 ry 73 1 f A•. � W W G1 r• N LLJ : � t . • � ptiecffph c, bey .�ti rA F�1 11J & G 4yj f0 * N / v� LU v 4 wU U) CIO W Q3 1 s U �,:.a.t + � � � ° �: :ate• co 2r CA a� �,�°'�',;. � r'�1►�/+/�i ;=1�1+/+►+i�+. , 11++1++y *s r+l i 1 � 1 �1 =,� :'�+'+1•,• �5; . .} , • .1.:. • ,.• e �+ ". 4►,/, .; r 4►•� r 1/►/;�++, 11{•►+/�,+ +�l►ll , 1,�►�++,+ 11++/��+1+,; z c � s to. 9 i t w ali • / 1/11+ � A � yy S�,rwfn;•� I nr,s � ti.A. �t �� ,.Av ��' •♦ , �r�'' ��ya�151,t j� y. xfri�� F�r •�a,:, <;f<� ��,r"s- •1.�� ��,,,�h,,,�.'L�i! � �" �'t � "�5:-,a�.,,r+� � �• �� CC yp DATE(MMIDINYYYY) A 00 CERTIFICATE OF LIABILITY INSURANCE OK70021 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(les) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subjoct to the terms and conditions of the policy, certaln policies may roquiro an endorsement. A statement on this certificate does not confer rights to the certificate holder In lieu of such endorsements). PRODUCER NAME: -- MARSH USA.INC PHONE -- Fax _ 445 SOUTH STREET lAIG.No.EXU� - AIC,No: _--. - MORRISTOWN,NJ 07960.6454 E 4 AIL AM MonlslownCertRequest@marshcom Fax.212948.0979 AQUIRf$41 - WSURER(5)AFFO DING COVERAGE NAICI SP LP CLIE INSURER A:Liberty Mutual Fire Insurance Company 23035 INSURED INSURER a:UM Insurance g2g9 ton 33600 SUBURBAN PROPANE PARTNERS,L.P - 42404 240 ROUTE 10 WEST INSURER C:Lltleft Insurance 929Mal19 . WHIPPANY NJ 07981 INSURERD: INSURER E: - INSURER F COVERAGES CERTIFICATE NUMBER: NYC-OD9138921 43 REVISION NUMBER: A THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED NOTWTHSTANDING ANY REOUIREMENT, 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. EXCLUSIONSAND CONDITIONS OF SUCH POLICIES LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS WSR - TAODL UBR POLICY EFF -POLICY EXP -� LIMITS LTR TYPE OF INSURANCE P Y NUMBER MMlDOIYYri MNODOJYYYY A X COMMERCIAL GENERAL LIABILITY TB2.631-507915081 10'011021 10001 022 EACH OCCURRENCE S 2'000^WD DAT,TAGETO REFi 250.000 CLAIMS MADEX ,OCCUR PREMISES-LEe OCWnOn0l S - LIED EXP( one P"w) s 10.000 PERSONAL a ADV INJURY S 200.000 GEbrL AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE S_ 2,000.000 % PRO. LOC PRODUCTS-COMPIOP AGG S 2,000.000 POLICY�X JECT S OTHER A AUTOMOBILELIAMLITY AS2 631.507975.071 1010irmll 10.U112022 a aBINED SINGLE L 3 2,000,000 i%x ANY AUTO BODILY INJURY(Per Parton)) S X OWNED X SCHEDULED BODILY INJURY(Per GW Mq) S AUTOS ONLY AUTOS OPERTVDAMAd HIRED % NON-OWNED Per S AUTOS ONLY AUTOSONLY -- S UMBRELLA ItAe OCCUR EACH OCCURRENCE S ElICE55 LIAB CLAIMS-MADE AGGREGATE f DED RETENTIONS 6 g WORKERS COMPENSATION A5.83D-SD 75• (A05) % STAT I PER UTE R _ AND EMPLOYM'LYl6WTY C' ANYPROPRIETOWPARTNEMEXECUTIVE YIN WA7630-507975-101 (MA) ,10'1011021 10Q112022 EL EACH ACCIDENT S B OFFICERWEMBEREXCLUDEDT NtA WC5.631-507975-111 {WI) 10.01Q021 10A1Q022 1013,000 (Mandatory In NH) EL DISEASE-EA EMPLOYEE S It yes,desmt>e under 1,000.000 DESCRIPTION OF OPERATIONS belaro EL DISEASE-POLICY LIMIT S DESCRIPTION OF OPERATIONS I LOCATIONS t VEHICLES(ACORD 101.Addnlonal Rernarts schedule,may be attached M more apace Is raqulmd) VILLAGE OF RYEBROOK IS SHOWN AS AN ADDITIONAL INSURED SOLELY WITH RESPECT TO GENERAL LIABILITY COVERAGE AS SHOWN HEREIN AND SOLELY IN THE EVENT THIS STATUS 15 REQUIRED BY WHIT TEN CONTRACT BETWEEN SUBURBAN PROPANE.LP.OR ITS SUBSIDIARIES OR AFFILIATES AND CERTIFICATE HOLDER. CERTIFICATE HOLDER CANCELLATION VILLAGE OF RYEBROOK SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE ATTN'BUILDING DEPARTMENT THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 938 KING STREET ACCORDANCE WITH THE POLICY PROVISIONS. RYEBROOK,NY 10573 AUTHORIMI)REPREMENTAME O 1988-2016 ACORD CORPORATION. All rights reserved. ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD NT O W ' Workers' YR CERTIFICATE OF i STATE Compensation Board NYS WORKERS' COMPENSATION INSURANCE COVERAGE la.Legal Name&Address of Insured(use street address only) 1b.Business Telephone Number of Insured Suburban Propane Partners, L.P. 973-887-0500 240 Route 10 West Whippany NJ 07981 1c.NYS Unemployment Insurance Employer Registration Number of Insured 892-18602 Work Location of Insured(Only required if coverage is specificafiy limited to certain locations in New York State,i.e..a Wrap-Up Policy) 1d.Federal Employer Identification Number of Insured or Social Security Number 22-3410353 2.Name and Address of Entity Requesting Proof of Coverage 3a Name of Insurance Carrier (Entity Being Listed as the Certificate Holder) LM Insurance Corporation Villa a of Rye Brook 3b.Policy Number of Entity Listed in Box"ia" 938 King Street Rye Brook NY 10583 WA5-63D-507975-091 3c.Policy effective period 10/1/2021 to 1011/2022 3d. The Proprietor.Partners or Execulive Officers are ® Included.(Only check box it all partners/officers mcluded) ❑ all excluded or certain partnerslofficers excluded. This certifies that the insurance carrier Indicated above in box'T'insures the business referenced above in box-1a"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 ant 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: Courtney Connally --3nlat,nsurenee earner) �;t7ticrt.tnt t m.Ql�mnt Approved by: 9/15/2021 (Signature) (Date) Title: Senior Client Service Coordinator Telephone Number of authorized representative or licensed agent of insurance carrier. 857-224-9248 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.web.ny.gov 63099636 1 U'I_6e6 1 :9J2I-la/:: C10S.2 I TrOY ACY.annun 19/IS/20:3 11:1::29 A: ICV— Pa9c 1 Or ," • * j ---am ' r 0 Z t a LT-1 0� a OCT 2 2021 %%%w, titate ;, PLAN S . DATEDJp 60 Emma � ..'� - - - C i wi'.3'?'4 rb++ti ) •v, X.:.. �ir st' : - � � r•.w��. � �� � . Lij -;-ML 7po Lij i i L �.f 0 < L. CD (09-- P. T •. n > ) .. . ,..f. PERMIT SBL# � - . .' •' . • ..• ' . � • .�� - .. . :- �.,�,,��r: - . . � =� .� .. • - - . . DATE APP 'VE OCT 2 7 2021 4 .'' N ECT il4a •of B to a , F. BUILDING Ish g Rye roots, : ►, `' - - f- t LL ' , }• �� F.. , � ♦ i•• 1. ' .• • C � •, - ♦..• ` - , • - •� • • •vim. ...W. NOW 7.7 wo L A(4., 77 1-H FIEL' '0 BOOK JP5 e f I' Y'n f 1 fi �, fit 1► '' .,,;.r�" �, �. ' . `� • .' �` ' .. y.;' r �.. a t.♦ � .'`_�. •' ... �' PAG��