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VILLAGE OF RYE BROOK
MAYOR 938 King Street, Rye Brook,N.Y. 10573 ADMINISTRATOR
Jason A. Klein (914) 939-0668 Christopher J. Bradbury
www.tyebrook.org
TRUSTEES BUILDING& FIRE INSPECTOR
Susan R. Epstein Michael J. Izzo
Stephanie J. Fischer
David M. Heiser
Salvatore W.Morlino
CERTIFICATE OF COMPLIANCE
April 11,2022
Anita Vasquez
12 Osborn Place
Rye Brook,New York 10573
Re: 12 Osborn Place, Rye Brook,New York 10573
Parcel ID#: 141.28-1-22
This document certifies that the work done under Mechanical Permit#22-012 issued on 1/27/2022 for the
installation of a new oil fired boiler has been satisfactorily completed.
Sincerely,
Michael J. Izzo
Building&Fire Inspector
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'9a2 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 : 12, Oct r' t� IL, DATE: {O 2
PERMIT# 1A Z — 0 1Z ISSUED: Z� ZSECT: BLOCK: LOT:
LOCATION: 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.P. GAS
❑ FUEL TANK
❑ FIRE SPRINKLER
❑ FINAL PLUMBING
❑ CROSS CONNECTION
❑ FINAL
OTHER
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BUILD -DEPARTMENT � �' � L4
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938 KING ET RYE B!104l ,NY 10573 BAN 2 7 2622
141t
-0668
`" VILLAGE OF RYE BROOK
BUILDING DEPARWE�JT
APPLICATION FOR PERMIT TO INSTALL AND/OR REMOVE
HEATING, VENTILATION AND/OR AIR CONDITIONING EQUIPMENT
FOR OFFICE USE ONLY: PERMIT#: W 3 - d
Approval Date: JAN 2 7W Permit Fee: $
Approval Signature: Other:
Disapproved:
(fees are non-refundable)
tk�F*9r*ic***�****ir:t*SY k*�Y*****ie*�rtY*7Y�c sk�t+k�Y ik�r*fir***rk*Yr�r:F*k**��S**�k*ak�k*�FW�Y ak+k�k+k9c*9r**4e t4*�k*le it*******ic,t*�t**�**:F:F*A•*x4
REQUIREMENTS FOR RELEASE OF PERMIT&CERTIFICATE OF COMPLIANCE:
1. Properly completed& Signed Application.
2. Site/Staging Plan if Required by the Building Inspector.
3. Copy of Licensed Contractor's Liability Insurance. (Village of Rye Brook must be listed as certificate holder) &Workers
Compensation Insurance on a NYS Board form(Form#C 105.2 or Form#U26.3/or NY State Workers Compensation Waiver)
4. Payment of Fees/Unit: RESIDENTIAL=$100.00/unit- COMMERCIAL=$350.00/unit.
5. Inspection by the Building Department for removal and/or installation. (48 hour notice required
6. Electrical work requires a separate Electrical Permit&Electrical Inspection.
7. Plumbing/Gas work requires a separate Plumbing Permit&Plumbing Inspection.
Application dated, is hereby made to the Building Inspector of the Village of Rye Brook for a permit for the
installation and or removal of the HVAC equipment as listed below.The applicant and property owner,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.
I. Address: 12 OSbtla Na, SBL: !y f.28 — { 22 Zone: tee)—_t-
2. Property Owner: Aft'rQ yas"z Address: 12 ()6 ? l Qj Zg L�tcordK. IS� �0g73
Phone#: i1q-305'-95N g Cell#: email: (�
3. Contractor: Mt85tM`l/i li Co, Address: $(e N Qortw 1T�Gf 61, CT W30
Phone#: 6114-9B9 -MOO Cell#: email: SWicamd&At( po.6u
4. Applicant: - 4Yt,/ �,1P,t+'1(YI - '�(tp(�i UV►.� Address: Wxtr st _
Phone#: glq-Q3 -3ft Cell#: email: 0.KkNW11 nL' I`10LW
5. Scope of Work:New Installation( )• Replacement( •Removal( )•Other( ):
6. jLt Equipment: �VS QM E-K-i FCorti r i rt' 2 YYLP{l
t. I,
7. Location of Equipment: _&Sem ny
8. Method of Installation/Removal (list all equipment needed to performjob):
t
8/12/2021
I�M 'F r ij'e(r)
STATE OF NffW-FERR,COUNTY OF ) as:
An-kA"., KAEM&% ,being duly sworn,deposes and states that he/she is the applicant above named,
(print name of individual signing as the applicant)
and filer s tes that(s)he is the legal owner of a property to which this application pertains,or that(s)hc is the
S for the legal owner and is duly authorized to make and file this application.
(indicate architect,contractor,1gent,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 before me this JanKQc Le
day of 46 ,20 a1.1 day of o�G ,20 oMbr
Signature of Prope wner Signature o Applicant
Print Name of Property Ow Print N me f Applicant
r
Notary,Tt LirA LE Notary Public
NOTAPMPUBLIC SEAN LYTLE
My COmmlasion Expires Aug.31,,20.25 NOTARYPUB.LiC
MyCOmmission Expires r,u;. "1," '
This cpplicati,ri 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.
2
8/12/2021
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Oilheat home heating system Domestic
Input Gross output AFUE Hot Water"
.68 GPH 83,000 BTU/HR 87.9% 170 Gal/Hr.
.74 GPH 90,000 BTU/HR 87.7% 180 Gal/Hr.
.85 GPH 104,000 BTU/HR 87.5% 202 Gal/Hr.
1.00 GPH 121,000 BTU/HR 86.2% 228 Gal/Hr.
'Domestic hot water rating based on first hour draw with 77°F rise and 40 gallon tank.
Energy Converter Weight 270 lbs.
FRONTIER •
Oilheat home heating system Domestic
Input Gross output AFUE Hot Water*
1.20 GPH 147,000 BTU/HR 87.6% 293 Gal/Hr.
1.40 GPH 175,500 BTU/HR 87.0% 334 Gal/Hr.
1.60 GPH 190,500 BTU/HR 85.5% 368 Gal/Hr.
1.75 GPH 2O6,000 BTU/HR 84.0% 395 Gal/Hr.
Domestic hot water rating based on first hour draw with 770F rise and 40 gallon tank.
Energy Converter Weight 350 lbs.
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0 0 0 Lifetime limited A
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As an ENERGY STAR"Partner,Energy Kinetics has
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Accepted For Use City of New York
Department of Buildings ME A 140 03 E web site
ENERGY
KINETICS
Easy service compact oilheat EK1 Frontier, 4�� "
with 40 gallon low boy tank and stand 51 Molasses Hill Road, Lebanon, New Jersey 08833
T: 800 323 2066 • F: 800 735 2068
visit: www.energykinetics.com
EK1 and EK2 System 2000 Frontier and Stackable Installation Dimensions
EK1:41"
EK1/EK2 Frontier Dim"A" W/O box With box "B" EK2:49" - EK1:212"
Instaa low 1pro(iled ile boiler basemensions * - 24" - 2"
* Beckett AFG 8 91/2" 9' EK2:29
or a standard boiler base.** Carlin EZ-1 9" 9 1/2" 9" t _"A" -
Shown without the required Riello 40F5 13" N/A 15" 9„ - �a
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At right:Dimensions"A"and"B" _ EK1:41" - -
depending on different burners. EK2:49"
EK1:212" -i
2419 _ EK2:292"
"A" 30"
g„
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73" 1 f Swing drawn door ,
Will
/ 40 gallon
48"** �� Lo-Boy
water storage EK1/EK2 Stackable
48
t / // E
34" tank installs Installed dimensions
94„ I Svdngtlowndoa � =xpansion beneath with stackable base.
lank stackable
t 1 boiler.
Low profile base 911. a B„ - 291 Stacka:<r
r 117"* t -- t f bile..
i 2"l installed with a low profile
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� Service clearances:20"from front door
• = • face,0"left side and right side.Clearance IR
Oilheat home heatin s stem to combustibles:4"from the rear cover;
9 Y Up to Domestic •,�l t
Input Gross output BTU/hr AFUE Hot Water' 16"above top cover;4"from flue pipe. ,
.68 GPH 83,000 87.9% 169 Gal/Hr. Included(factory piped and assembled):
.74 GPH 90,000 87.7% 180 Gal/Hr. Boiler base,blocked vent switch,dynamic _-- -
.85 GPH 104,000 87.5% 202 Gal/Hr.
1.00 GPH 121,000 86.2% 228 Gal/Hr. air elimination manifold,ON/OFF switch, •
surge protection and junction box,3/4"drain
'Domestic hot water rating based on first hour draw with 77'F rise and 40 gallon tank. valve,plate heat exchanger on hot water -
Energy Converter weight 270 ll
Zell models,circulator and door safety switch.
Draft regulator not required or recommended
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Oilheat home heating system Up to Domestic
Input Gross output BTU/hr AFUE Hot Water' .
1.20 GPH 147,000 87.6% 269 Gal/Hr. Weight 270 Ibs 350 Ibs
1.40 GPH 175,000 87.0% 313 Gal/Hr. B Resolute"RT
1.60 GPH 190,000 p5.5% 336 Gal/Hr. Water Content 2'/2 4 No chimney?No power vent?
1.75 GPH 2O6.000 84.0% 360 Gal/Hr. gallons gallons NO PROBLEM!Look at Resolute PT!
'Domestic hot water rating based on first hour draw with 77°F rise and 40 gallon tank. Air Inlet Pipe 2" 3
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Input Up to Domestic
BTU/hr Gross output BTtl/hr AFUE Hot Water' Hydronic Supply 1" 11/4"
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Energy Converter weight 270 Ibs. ErergylriWo famlyofpoducs.
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LIFETIME LIMITEDWARRAN7 ASME pressure visit www.energykinetfcs.com
Input Up to Domestic vessels.see Iris As an ENERGY STAR°Partner,Ener Kinetics
BTU/hr Gross output BTU/hr AFUE Hot Water' ENERGY actual warranty 9Y
KINETICS ETICS r. for details. has determined that model EKt meets the
175,000 153,000 87% 278Gal/Hr. ENERGY STAR°guidelines for energy efficiency
200,000 172,000 87% 308 Gal/Hr. for oil heat input from 0.68 to 0.85 gph.
225,000 192,000 85% 339 Gal/Hr. ®The color yellow for heating boilers is a
250,000 209,000 84% 365 Gal/Hr. ¢ ,,{nR AS U registered trademark of Energy Kinetics.
'Domestic hot water rating based on first hour draw with 7rF rise and 40 gallon tank. "� Z Sl ME ®The color yellow for heating boilers is a
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10-2098 FEB 2021 N
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CCOREIII
'4 CERTIFICATE OF LIABILITY INSURANCE 1 1
osroevlarz,
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
FEDERATED MUTUAL INSURANCE COMPANY NAM ' CLIENT CONTACT CENTER
HOME OFFICE:P.O.BOX 328 PA CNNo En:888-333-4949 FAX
No:507-4464664
OWATONNA,MN 55060 ADDRESS:CLIENTCONTACTCENTER FEDINS.COM
INSURER(SI AFFORDING COVERAGE NAIL p _
INSURER A:FEDERATED MUTUAL INSURANCE COMPANY 13935
INSURED 330-130-6 INSURER B:
WESTMORE FUEL COMPANY INCORPORATED INSURER C:
86 N WATER ST
GREENWICH,CT ON30-5886 JINSURER D:
INSURER E:
INSURER F:
COVERAGES CERTIFICATE NUMBER:35 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 SUSR POLICY NUMBER POLICY EFF POLICY EXP LIMITS
LTR IN SR WVD MM/ DIYYYY MMI /YYYY
X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $1,000,000
CLAIMS.. ❑X OCCUR DAMAGE TO RENTED $100,000
MED EXP(Any one person) S5,000
A N N 9062815 06/01/2021 06/01/2022 PERSONAL S ADV INJURY S12000,000
F'L AGORE ECT LIMIT APPLIES PER: GENERAL AGGREGATE $2,000,000
XP.LI.y1jJ PRO ❑LOC PRODUCTS•COMPIOP AGO S2,000,000
OTHER:
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $1 000,000
X ANY AUTO 4WIfffn
BODILY INJURY IPer person)
A OWNED AUTOS ONLY AUTOOSULED N N 9062815 06/01/2021 06/01/2022 BODILY INJURY(Per—,dent)
HIRED AUTOS ONLY NON-OWNED PROPERTY DAMAGE
AUTOS ONLY
Per eeclden
X UMBRELLA LIAR X OCCUR EACH OCCURRENCE $7,000,000
A EXCESS LIAR CLAIMS-MADE N N 9062816 06/01/2021 06/01/2022 AGGREGATE 57,000,000
,DED I RETENTION
WORKERS COMPENSATION X PER STATUTE OTH-
AND EMPLOYERS'LIABILITY ER
ANY PROPRIETORIPARTNERIEXECUTIVE E.L.EACH ACCIDENT
A OFFICERIMEMBER EXCLUDED? NIA N 9917566 06/01/2021 06/01/2022
IMandatory in NH) E.L.DISEASE-EA EMPLOYEE $500,000
If yea,describe under
DESCRIPTION OF OPERATIONS below I E.L DISEASE•POLICY LIMIT Ent»000
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarts Schedule,may be enodwd it more space is required)
CERTIFICATE HOLDER CANCELLATION
330-130-6 35 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
O 1988-2015 ACORD CORPORATION.All rights reserved.
ACORD 26(2018103) The ACORD name and logo are registered marks of ACORD
{Nrw 'Workers'
- YORK : CERTIFICATE OF
1 �TdT£;Compensationt
Board NYS WORKERS' COMPENSATION INSURANCE COVERAGE
1a.Legal Name 8 Address of Insured(use street address only) 1 b.Business Telephone Number of Insured
WESTMORE FUEL COMPANY INCORPORATED 203-531-5656
86 N WATER ST
GREENWICH,CT 06830-5886 1c.NYS Unemployment Insurance Employer Registration Number of
Insured
Work Location of Insured(Only regtured of coverage is specificallylimded to 1 d.Federal Employer Identiftcation Number of Insured or Social Security
certain kmations in Now York State,i.e.,a Wrap-Up PMicy) Number
06.0730367
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 Q
Village Of Rye Brook #35 3b.Policy Number of Entity Listed in Box'1a'
938 King St
Rye Brook,NY 10573-1226 9917666
3c.Policy effective period
06/01/2021 to 06i01/2022
3d.The Proprietor,Partners rrr Executive Officers are
EJ included.(Only cheek box it all partners0of hers Included)
® all excluded or certain partners/officer-.excluded.
This certifies that the insurance 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 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 white 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,Dense 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: April Myer
(Pant name of authorized representative of licensed agent of insurance Gander)
Approved by: 4Aa2"
ii,tignature) 17 (Date)
Title: Authorized Representative
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