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HomeMy WebLinkAboutMP22-035 VILLAGE OF RYE BROOK MAYOR 938 King Street, Rye Brook,N.Y. 10573 ADMINISTRATOR Paul S. Rosenberg (914) 939-0668 Christopher]. Bradbury www.ryebrook.org TRUSTEES BUILDING&FIRE Susan R. Epstein INSPECTOR Stephanie J. Fischer Michael J. Izzo David M. Heiser Jason A.Klein CERTIFICATE OF COMPLIANCE March 23,2022 Jane Romm 25 Talcott Road Rye Brook,New York 10573 Re: 25 Takott Road,Rye Brook,New York 10573 Parcel ID#: 135.50-1-76 As per the Certification letter from C2G Environmental Consultants,LLC dated March 22,2022, the removal of two above-ground oil tanks and the installation of one new above-ground oil tank under Mechanical Permit #22-035 issued on 3/7/2022 has been satisfactorily completed. Sincerely, Michael J. Izzo Building&Fire Inspector /tg QyE BRC��, cu � 1982 BUILDING DEPARTMENT ❑BUILDING INSPECTOR /ASSISTANT BUILDING INSPECTOR VILLAGE OF RYE BROOK f❑CODE ENFORCEMENT OFFICER 938 KING STREET . RYE BROOK,NY 10573 (914) 939-0668 FAx (914) 939-5801 www Uebrook.or - - - - - - - - - - - - - - - - - - - - INSPECTION REPORT - - - - - - - - - - - - - - - - - - - - ADDRESS : DATE: PERMIT# / rTC]`l O - ISSUED: l� SECT: BLOCK: LOT: LOCATION: i,�..':>`t'' Y, .Q�C)'f' : i lC�t. OCCUPANCY: ❑ VIOLATION NOTED THE WORK IS... [j 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 QyE BR(�� cu � 1982 BUILDING DEPARTMENT ❑BUILDING INSPECTOR ASSISTANT BUILDING INSPECTOR VILLAGE OF RYE BROOK 'tl CODE ENFORCEMENT OFFICER 938 KING STREET • RYE BROOK,NY 10573 (914) 939-0668 FAx.(914) 939-5801 www.ryebrook.org - - - - - - - - - - - - - - - - - - - - INSPECTION REPORT - - - - - - - - - - - - - - -- - - - - �zZ ADDRESS: ( t DATE' 2 PERMIT# ISSUED: SECT: BLOCK: LOT: LOCATION: ` `- /' `-1l � OCCUPANCY: 2 1 O ❑ VIOLATION NOTED THE WORK IS... ❑ ACCEPTED ❑ REJECTED/ REINSPECTION ❑ SITE INSPECTION REQUIRED ❑ FOOTING <\' V ❑ FOOTING DRAINAGE ❑ FOUNDATION ❑ UNDERGROUND PLUMBING NOTES ON INSPECTION: ❑ ROUGH PLUMBING ❑ ROUGH FRAMING ❑ INSULATION ❑ NATURAL GASH U ✓' v` ` / �� `� ` �—� ❑ L.P. GAS Nu� �a (' G Q ((�Ut'lq V<1 FUEL TANK ❑ FIRE SPRINKLER ❑ FINAL PLUMBING ❑ CROSS CONNECTION ❑ FINAL ` V-efi-A) 21 .\ ❑ OTHER L / o y o N = N N N Z tr a,A M M rya � w pool r 4 cnn a�i a 0-4 • LO Ln O b -� ai° C � N � S° �^ ' U s en X LO H � ..6 .01 °ago1-4 OF : co 00 w v CP% F�1 C% ocq ff-, d � } 00 Fv�l Z A 0 �Z = � �° �4 0 ■ ON o 'o '`° . O 20 0 a� Ln FWZ .m u ^ Fy I > o V O w A Q �z u BUILD N'G DEPARTMENT P I E VILI-AGE OF R1'F,JR0OK LIAR ' 2flZ2 938 KING S�ET,RYE 13ROM NY 10573 (914)930 6W]tF,�X(9.14)939-5801 VILLAGE OF RYE BROOK ww, t�Yk.ore t_ BUILDING 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) �r� FOR OFFICE USE ONLY: PERMIT #: ''r �]�r Approval Date; -- Permit Fee: S 10b Approval Signature: v Other: Disapproved: (fees are non-refundable) *«*#*#r#«##««*##***##r####r#*#r##•*#*►#rtr*x**#**#*r***#**#****rr***r******#*#*#r**#**#*r#*****#***r##* REOUIRF,MENTS FOR RELEASE OF PERMIT&CERTIFICATE OF CONIPLIANCE: 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) ®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: S I f 5.00 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. #*##*#r#f#*r*#*#frr#*#**►###r##*#*#***#«##r#*#*##r#r*r*i****#*#*ri##**i«####**###****«#*:#**4#*####***!*### Application dated, 7`c-)c];i 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 lank(s)will be removed,abandoned and/or installed in conformance with all applicable Village,County, State&Federal laws, codes,rules and regulations. **x«x*x*x****x#x«x#r####*#########*#############r##r#r####r####*###r#####«#*######*#*###*###*###########*## Indicate Permit Type: Installation(VJ •Removal M• Abandonment( )1 Above Ground V•Buried in Ground ( ) I. Address: 25 Taicott Rd Rye Brook, NY 10573 S B L: ����— /� zone Oe4 4 �,�J i 2. Property Owner&Address: Jane Romm/25 Talcott rd Rye Brook, NY 10573 Phone#: 914-646-2760 Cell#: email::janeromm@gmail.com 3. Contractor&Address: C2G Environmental Consultants LLC 7 5 b N-e ple-1 • t D5-:�2!' Phone#: 914-357-8275 Cell#: email quotes@c2g.us 4. Applicant: Phone#: Cell#: email. 5. Indicate Fuel Type:Fuel Oil(Vf•L.P.Gas( )•Gasoline( }•Other( }: 6. Number and Capacity of each Tank: Remove(2) 275 gallon aboveground oil tanks from under deck. Install (1)275 granby aboveground oil tank under deck on concrete pad. To include gauge, alarm, and fill/vent piping. 7. Exact Location(s)of each Tank: All underneath deck. Scope of work included. STAT�OF L-W YORK,COUNTY OF WESTCHESTER ) as q'i k '0.�y ,being duly sworn,deposes and states that he/she is the applicant above named, (print tame of individual signing as the applicant) and further states that(s)hc is the legal owner of the property to which this application pertains,or that(s)hc is the C,2r!^q CA-D r for the legal uw-ner and is duly authorized to make and file this application. (indicate architect,contraetnr,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 before me this day of .202'D u day of 44 ..... 20 Signature of Property weer Signature of Applicant Ni al Name of Property Owner �Pn_�ntNelor*Ap Pic nt H1_0111 LLO tNcw York Notary Public i'ir;, 3 No �Q Public ^, r Toni L Hokanson ij I V!E i+ l'�'_-or�iOlJflhfn,-? NOTARY PUBLIC,STATE OF NEW YORK Commission Fxr)ires January 29,20 Registration No.01HO6294662 Qualified in Ulster County Commis ion Expires gece ber 23,20� This application must be properly completed in its entirety and must ' {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. DD MAR - 7 2022 VILLAGE OF RYE BROOK C2G Environmental Consultants, LLC BUILDING DEPARTMENT 7 Skyline Drive,Suite 350 Tel (914)357-8275 Hawthorne,NY 10532 Fax(845)255-4909 February 101°,2022 Jane Romm 25 Talcott Rd Rye Brook,NY 10573 Scope of work:Cut,clean,and remove(2)275 gallon aboveground oil tanks from underneath deck.Install(1)Granby 275 gallon aboveground oil tank under deck on concrete pad.To include fill/vent piping,gauge,and alarm. House Deck 0 0 0 0 Remove(2)275 gallon aboveground oil tanks Install(1)275 Granby aboveground oil tank underneath deck INSTALLATION AND MAINTENANCE 4.2. Condensation GUIDELINES FOR Condensation can form in the tank during the shipping STEEL TANKS FOR OIL-BURNER FUELS AND OTHER9 Aping and storing processes. All water and ice should be removed from the tank prior to COMBUSTIBLE LIQUIDS installation. 4.3. General location of the tank Manufactured by: Fuel oil storage tanks can either be installed inside or outside of a building. Indoor installation is preferable for heating oil applications, resulting in Granby Industries improved service, increased efficiency, reduced risks and increased life 1020 Andre-Line Granby. expectancy of the tank. Quebec.Canada,J2J 1.19. Tank location should be chosen in accordance with the following Telephone:450-378-2334 requirements: Fax:450-378-5202 The tank should be placed in an area where it is unlikely to be adversely affected by normal household activities; The tank should be placed in an area where it can be visually E-mail: inspected from all U� sides;service(a)granbytanks com • The tank label should be visible: USTE p Webslte: If possible, tanks should not be located directly under house eaves hh�//www QranbZanks com where they may be subject to falling snow and ice or dripping water. 1. SCOPE Protection should be provided if there are no other placement alternatives: These guidelines a Tanks should not be placed in intimate contact with walls or 9 pply only to the installation and maintenance of structures since leaves and other organic matter can accumulate and domestic, aboveground fuel oil tanks manufactured by Granby Industries to UL80,Steel Tanks for Oil-Burner Fuels and Other Combustible Liquids. cause external corrosion a the tank:and These tanks have an obround shape, are of a single-walled or double- Tank location shall respect the local code for distance to property bottom design,and available in capacities ranging from 120 to 330 gallons. Imes,to other energy sources or to other storage systems. These tanks must be installed in accordance with NFPA 31,Standard for 4.4. Foundations the Installation of Oil-Burning Eguipment and in compliance with any The tank should be properly supported by a level, rigid and non- applicable local codes or regulations. combustible base. The base should be designed to settling and to minimize corrosion of an of the tank restrig on the Prevent uneven The instructions in this document are intended as recommended foundation. A poured concrete basement floor provides the best option guidelines only for tank installation. For more specific installation while other options are also available. instructions.please refer to your local code enforcement agency. All tanks are at risk from base movement: especially new outside 2. TANK INSPECTION installations placed on recently disturbed ground.A well-drained sub grade Inspect the tank immediate) u should be provided for proper drainage. Six inches of crushed, dear, y pon receipt.Minor dents and scratches may mechanically compacted stone is recommended. The site should have aN be acceptable.Do not install the tank if damages are thought to affect the organic materials such as sod or bark removed and the soil mechanically integrity and performance of the tank. Contact your distributor. compacted 3. TANK HANDLING 4.5. Tank legs The tank must be lifted without dragging or dropping to prevent damage. Our domestic obround tanks are provided with four threaded leg supports. Obround tanks are to be lifted using the handles provided on the tank The tank legs that fit into these supports are Schedule 40 1V threaded heads. black iron pipes with a maximum length of 12".The le on the tank should 9 supports installed Do not move a tank unless it empty. • provide enough clearance for the tank accessories;and 4. TANK INSTALLATION • provide for proper drainage slope.The tank should be pitched longitudinally,towards the drain,at least 1/4 inch per foot of tank Authorities having jurisdiction should be consulted before the installation of length. the tank. The use of tank cradles is not recommended on any of our tanks. The installer shall ensure that all applicable Codes are met poor to installation. 4.6. Tank piping Fill,vent and supply piping must respect all applicable codes.Piping shall In most jurisdictions, installation by a technician recognized by the be designed so that the tank is not subjected to vacuum or pressure authority having jurisdiction is mandated.Do-it-yourself installations are not exceeding 1 PSIG measured at the top of the tank. recommended and must be inspected by the authority having jurisdiction prior to placing in service. 4.7. Overfill Protection Only labelled tanks bearing the UL listing mark with a serial number are An overfill-protection device should be provided on every fuel oil supply eligible for warranty and installation. Under no circumstances shall a used tank.When a vent whistle is installed as an overfill-protection device, no tank of any design be installed. person should deliver fuel oil to the supply tank when the vent whistle does not function properly.The use of a 6 in. long whistle is recommended for 4.1. Removal of temporary tank closures obround tank models. All tank openings are shipped from the factory with temporary shipping 4.8. Plugging of remaining tank openings caps.These caps must be removed prior to tank installation. All unused openings on the tanks must be adequately plugged and sealed with liquid-tight closures before the tank is put in service GRANBY © 2010 GRANBYiNDUSTRIES UNITED PARTNERSHIP Pag©1of 2 SI-0015 rev Ca Revised 20 t 0-0SOa 4.9. Cross-connected Tanks Two oil tanks may be cross connected in accordance with the installation s• OIL TANK MAINTENANCE requirements and limits specified in NFPA 31,Standard for the Installation of Oil-Burning Eauioment. It isimportant for the homeowner to understand that the oil tank is their property and their responsibility. The tank owner should ensure that it is 4.10. Flood Plains and High Wind Areas properly maintained. Proper tank maintenance should include, but is not limited to,the following: Additional stability should be considered in flood plain areas or areas of Subscribing to a maintenance program performed by a heating oil high wind.This would require some form of shelter and/or anchoring that system licensed service technician; does not adversely affect the operation of the tank. Visually inspecting the tank(s) at least once a year. Careful visual inspection will uncover traces of oil on the tank surface: 4.11. Tank anchoring Asking a service technician to check, at least once a year, for the A tank must be anchored to its foundation(as shown below) one it meals presence of water inside the tank and to remove ik A the followingmust be conditions: ) Immediately correcting an unstable foundation or when the tank is • It is intended for outside installation;or likely to topple.The services of a licensed installer should be used; Maintaining the tank's exterior surface,at least once per year,by: • It is intended for inside installation and will not be connected to 1. Gently brushing the rusted areas on the tank's exterior with secured fill and vent pipes passing through a concrete wall or sandpaper; foundation. 2. Cleaning the sanded surface;and 3. Applying a coat of rust proof metallic paint(readily available at Anchoring method: any hardware store). If needed, Granby Industries has color _ matched touch-up paint canisters. Contact the order desk for more details. Maintaining the tank's exterior surface is a good practice and the ' application of touch-up paint will not void the warranty of the tank • Maintaining the tank liquid level as high as possible during the summer months to limit water condensation within the tank;and • Verifying the status of a double-bottom tank model,at least once per year,by performing the following: 1. When the tank is full,look into the monitoring opening on top --- F _ of the tank, 2. If the red"FAIL"indicator can be seen,it indicates a problem; DETAIL B contact Granby Industries (16x)7/."dia.x 1W long'Co to Tapcong Screws ` jr- , (4x)1'1/"NPT f or flanges (4x)111Z Schedule 40 pipes of appropriate length 5. TESTING Aar tanks that leave the factory have been tested twice for leakage.The oil tank could have sustained unforeseen damage during handling, transportation, installation and connection. The installer, oil company representative or a designated person shad be in attendance at the initial filing of the tank. This person shall visually inspect all tank seams and fittings for leakage once the tank is full WITHOUT APPLYING PRESSURE INTO THE TANK. Tanks that are not filled immediately after installation shall have all lines blocked and the fill pipe shall be marked to prevent inadvertent filling to ensure that the first fill inspection is performed. GUNBY ® 2010 GRANBV INDUSTRIES LIMBED PARTNERSHIP Page 2of 2 SI-0015 rev Ca Revised 2010-0504 NEVI 0215 FID011% CORP o 642 Abee1 ST Kingston, NY, 12401 (845) 331 -3312 N.Y .S D .M.V 7105074SCP NAME. ENVIRONMENT INVOICE# 247006 Closed t0 Cash purchase DATE TIME4 4/1/2012 4.45.31 PM CASHIER : ANNA STATION ; 01 Customer Info Customer: ENVIRONMENT C2G #1 STEEL (Unprepared)-027_.__-____�._.��._.�.� 9200 $0. 13 $1 , 196,00 Subtotal______.�-__�.___�.�._-___-_-$1 , 196.00 PC 101h $1 , 196,00 Cash $1 , 196.00 Amt Tendered $1 , 196.00 Change $0.00 SERVICE DONE ON 03/14/2022 Mon-Fri 7am-5pm Sat 7am-2pm NO TAX ON SCRAP METAL SIGNATURE C2G Environmental Consultants, LLC 83 S. Putt Corners Rd www.c2g.us Tel(845) 255-4900 New Paltz,NY 12561 Fax (845)255-4909 March 22, 2022 R [E C IE �n/](E Mr. Mike Izzo MAR 2 3 2022 Village of Rye Brook Building Department 938 King Street VILLAGE OF RYE BROOK Rye Brook, NY 10573 BUILDING DEPARTMENT Re: Jane Romm—Residential Property 25 Talcott Road Rye Brook,New York 10573 Please allow the following to serve as a summary of the investigation performed by C2G Environmental Consultants, LLC at the above referenced site. On March 16, 2022, C2G technicians removed two (2) 330-gallon horizontal above-ground #2 fuel oil storage tanks from below the deck at the subject property. The tanks were emptied, cleaned and removed to be disposed of as scrap metal at a certified facility. The soil below the tanks were field screened with a properly calibrated PID meter, which had a non-detect reading. A new 275-gallon horizontal above-ground #2 fuel oil storage tank was installed on pads below the deck the same day. Thank you for the opportunity to work with you on this project. If you have questions or concerns, please feel free to contact our office. Sincerely, Julie Healy Project Manager C2G Environmental Consultants,LLC i v Q) C O L CV Z o Z 0� 3 coo �= Y z — � Q O U C W C C p C O 0 o o O cm m .Ln z � _U N a Y O U O x O CD hhnn � f— w. � crW WV ,� � rn > O o � j -O 3 } co T ` O a* � Q W N �Q ` cB s 2 o O Q O o O O >, ^, — fU E Q w N ` (a O to Z co oar ZJ E c 00 U Z a) •d ~ J 7 U 4) ` Q W •I�1 J O H En m C 0O � ) I� O � z Cm Ch p � w ( I U t; u U � co W C O =3 -01 p p �I/ O U p a C H O Q O W O N NO (B U z N C N � O W � c cn p U CD a) co Uco o Q a) C2G Job No: Certificate of Tank Cleaning & Disyosal 111125 Owner: Romm, Jane Location: Romm, Jane 25 i .Rd 25 T aicott Rd Rye Brook, NY 10573 Rye Brook, NY 10573 NYSDEC PBS Facility Spill No. Tank Reg No. This certificate is to verify that the tank(s) originating from the location stated above has/have been cleaned by C2G Environmental Consultants, LLC pursuant to all New York State Department of Environmental Conservation and United States Environmental Protection Agency Regulations. Tanks Size Tank 1D# Type Product 330 r.� a Cleaning Technician: Y ►1 Date: 2022-03-1 a Tank Condition/Status: rxff c)Id- Disposal Location: west Kingston Recycling Corp 642 Abeel Street Kingston, NY 12401 Accepted By: Date: W22-03-AT 8 C2G Environmental Consultants, LLC Long Island Operations Westchester Operations Hudson Valley Operations Connecticut Operations New Jersey Operations 165 Sherwood Avenue 7 Skyline Drive,Suite 350 83 S.Putt Comers Road 25 Mallane Lane 1 International Blvd,Suite 400 Farmingdale,NY 11735 Hawthorne,NY 10532 New Palm,NY 12561 Naugatuck,CT 06770 Mahwah,NJ 07495 Office:631-414-7757 Office:914-357-9275 Office:945-255-4900 Offco;203437-6717 Otl'ice::201-574-0555 kax:63144S-6331 tax:84:o-2S_%4909 tax:843-2:-4409 kax:'843455- sPU9 Fax:63'1443-6331 Mar 16 22,05:37p C2G ENVIRONVENTA_CT 2037146159 . �*•USA•(W)321486E•pnMetmn•pon4id b 1n UnMO SWW '• �OKNEP4iF 4 a1�1lhr �' 1 .''RL Y pa t dmergercyAeoponsa Plane kir R .. - C�rxrabfs she Adams(R el4'e,enl nan--v . 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Iq�1�11♦ !,��AB'FI:.�y•'rtif �9�A�a!(trY�11 .:ttVl� ��/,tl�,�I.. filt° A �It l�'I�t,;•'i13 �a�Ar� t'�1♦ •r {A� q `,t ��',�#� A,...� 5. •�A7 I71Y Ny �.. A ut f� 1f jl!'t! A . III! t'. � 4,, r A. {p,�Al�rlrl A t S !r (A i• YF�I � ` I�rJ.� �QD• �.'fl��,�o }51r{lt�, 17 :O\ ' itr r ��`" � \1�Y �0� �t.t,51 r •'� �tiYw�r ;+(�0� '!n� � �o? y�'. �4 ;� r�.r�+;/ .�,Isy�kvt v•.:: t R/v�, n�.�- , r�'.v\�` ti4.fv ! �.. n,t-'�v�'�.�` , M v{"s`�,, ,.��I ��rt1 i, a`�,' ACOR" CERTIFICATE OF LIABILITY INSURANCE 7MWDDffYYYI ro112021 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 Lucyna Gryczynska NAME: Stern&Dragoset Assoc (Div of James A Connors) PHOiVC.NN X (732)248-8900 .,No): (732)248 9960 2 Ethel Road E-MAIL ADDRESS Suite 202B INSURER(S)AFFORDING COVERAGE NAIL i Edison NJ 08817 INSURER A: Homeland Insurance Company of DE 14231 INSURED INSURER B: Selective Insurance Company Of America 12572 C2G Environmental Consultants,LLC INSURER C: 83 South Putt Corners Road INSURER D: INSURER E- New Paltz NY 12561 INSURER F COVERAGES CERTIFICATE NUMBER: CL2112168169 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 ADDL SUBIR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER MM/DDlYYYY MMlDDM'YY LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE S 5,000,000 CLAIMS-MADE ®OCCUR PREM SESOEaEoccu ence $ 100,000 Professional Liability MED EXP(Any one person) S 10,000 A X Pollution Liability 7930072590004 12/12/2021 12/12/2022 PERSONAL&ADV INJURY $ 5.000,000 GEN'L AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE S 5,000,000 POLICY JEa LOC PRODUCTS-COMPIOPAGG $ 5,000,000 OTHER Pollution Liability s 5,000.000 AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000 Ea accident ANYAUTO BODILY INJURY(Per person) S B OWNED SCHEDULED S 2307223-02 04/29/2021 04/29/2022 BODILY INJURY(Per accident) 5 AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE S AUTOS ONLY AUTOS ONLY Per accident S UMBRELLA LAB OCCUR EACH OCCURRENCE S EXCESS LIAB CLAIMS-MADE AGGREGATE S DED I I RETENTION S $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY STATUTE ER YIN ANY PROPRIETOR/PARTNER/EXECUTIVE ❑ NIA E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ Transportation Pollution Liability A 7930072590004 12/12l2021 12/1212022 Limit $1,000.000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additlonal 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 Village of Rye Brook ACCORDANCE WITH THE POLICY PROVISIONS. 938 King Street AUTHORIZED REPRESENTATIVE Rye Brook NY 10573 �..� ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD NY S ' F 199 CHURCH STREET,NEW YORK,N.Y.10007-1100 New York State Insurance Fund I nysif.com CERTIFICATE OF WORKERS' COMPENSATION INSURANCE A A A A 200882662 LOVELL SAFETY MGMT CO.,LLC 110 WILLIAM STREET 12TH FLR NEW YORK NY 10038 ❑ V SCAN TO VALIDATE AND SUBSCRIBE POLICYHOLDER CERTIFICATE HOLDER C2G ENVIRONMENTAL CONSULTANTS LLC VILLAGE OF RYE BROOK 83 S. PUTT CORNERS ROAD 938 KING STREET NEW PALTZ NY 12561 RYE BROOK NY 10573 POLICY NUMBER CERTIFICATE NUMBER POLICY PERIOD DATE Z 1412 798 9 109173 04/01/2021 TO 04/01/2022 02/26/2021 THIS IS TO CERTIFY THAT THE POLICYHOLDER NAMED ABOVE IS INSURED WITH THE NEW YORK STATE INSURANCE FUND UNDER POLICY NO. 1412 798-9, COVERING THE ENTIRE OBLIGATION OF THIS POLICYHOLDER FOR WORKERS' COMPENSATION UNDER THE NEW YORK WORKERS' COMPENSATION LAW WITH RESPECT TO ALL OPERATIONS IN THE STATE OF NEW YORK, EXCEPT AS INDICATED BELOW. IF YOU WISH TO RECEIVE NOTIFICATIONS REGARDING SAID POLICY, INCLUDING ANY NOTIFICATION OF CANCELLATIONS, OR TO VALIDATE THIS CERTIFICATE, VISIT OUR WEBSITE AT HTTPS:/NVWW.NYSIF.COM/CERT/ CERTVAL.ASP. THE NEW YORK STATE INSURANCE FUND IS NOT LIABLE IN THE EVENT OF FAILURE TO GIVE SUCH NOTIFICATIONS. THIS POLICY DOES NOT COVER THE SOLE PROPRIETOR, PARTNERS AND/OR MEMBERS OF A LIMITED LIABILITY COMPANY. THE POLICY INCLUDES A WAIVER OF SUBROGATION ENDORSEMENT UNDER WHICH NYSIF AGREES TO WAIVE ITS RIGHT OF SUBROGATION TO BRING AN ACTION AGAINST THE CERTIFICATE HOLDER TO RECOVER AMOUNTS WE PAID IN WORKERS' COMPENSATION AND/OR MEDICAL BENEFITS TO OR ON BEHALF OF AN EMPLOYEE OF OUR INSURED IN THE EVENT THAT, PRIOR TO THE DATE OF THE ACCIDENT, THE CERTIFICATE HOLDER HAS ENTERED INTO A WRITTEN CONTRACT WITH OUR INSURED THAT REQUIRES THAT SUCH RIGHT OF SUBROGATION BE WAIVED. _ THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS NOR INSURANCE COVERAGE UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICY. NEW YORK STATE INSURANCE FUND DIRECTOR, INSURANCE FUND UNDERWRITING VALIDATION NUMBER: 970702825 II II II II I IIIII IIIII IIIII IIIII IIIII IIIII IIIII IIIII IIIII IIIII11111IIIII IIIII IIII I I I I I II 00000000000090931566 Form WC-CERT-NOPRINT Version 3(08/29/2019)[WC Policy-14127989) U-26.3 206 f00000000000090931566lf0001-0000141279891I##Z1f15581.431fcert NoP-CERT 11f01-000011