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HomeMy WebLinkAboutMP22-044 J; <tca . t9 40" anaiuvo aW VILLAGE OF RYE BROOK MAYOR 938 Ding Street, Rye Brook,N.Y. 10573 ADMINISTRATOR Jason A. Klein (914) 939-0668 Christopher J.Bradbury wy.-w -ebrook.org TRUSTEES BUILDING& FIRE INSPECTOR Susan R. Epstein Michael J. Izzo Stephanie J. Fischer David M. Heiser Salvatore W. Morlino CERTIFICATE OF COMPLIANCE May 18,2022 Anna Valente 11 Hillcrest Avenue Rye Brook,New York 10573 Re: 11 14illcrest Avenue, Rye Brook,New York 10573 Parcel ID#: 135.84-1-28 This document certifies that the work done under Mechanical Permit #22-044 issued on 3/28/2022 for the installation of a new above-ground oil tank has been satisfactorily completed. Sincerely, Steven E. Fews Assistant Building&Fire Inspector /to QyE BRC�k. O� Z� t7 1952 BUILDING DEPARTMENT ❑BUILDING INSPECTOR ASSISTANT BUILDING INSPECTOR VILLAGE OF RYE BROOK �J CODE ENFORCEMENT OFFICER 938 KING STREET o RYE BROOK,NY 10573 (914) 939-0668 FAX (914) 939-5801 www.Uebrook.org - - - - - - - - - - - - - - - - - - - - INSPECTION REPORT - - - - - - - - - - - - - - - - - - - - ADDRESS• 4� ` `� �� DATE: S ZUZZ PERMIT# ISSUED: _E T: BLOCK: LOT: LOCATION: (` c, 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 A ,/C)yQ r 1/7_ �� J �r , \'n l)c— ❑ L.P. GAS -FUEL TANK ❑ FIRE SPRINKLER ❑ FINAL PLUMBING �� ,\V V ❑ CROSS CONNECTION ❑ FINAL ❑ OTHER s ■ d' � � s � W � O ' ' QI N °� W v A dcxu VM1 = s .19 W = o© 1�- w olk dif 1-4 tx y' et fA.all 0 U a O00 U A Q1 o 7 mow] V� 0 -d wVON Oil" MU Za � o r h FBIGNM N O cn a U v fx M Uo o00 pt cy 1�1 a z z :S)40 E � wu 0-4 a U � B W = 0 ° z w � U V w o a� utn 04 w 0 $ w "� 0�-y0 s FBI av� > av o z O W A 0 � y E� H W z ° � ° b .. a WED BUILD, P MENT D r VIL E OF RY OOK 938 KING ET RYE BRo ,NY 10573 MAR 711 2022 4 9-0668 aok.or VILLAGE OF RYE BROOK 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) FOR OFFICE USE ONLY: PERMIT#: '�c�►—O MAR 2 9 �01Z p Approval Date: Permit Fee: $ C55. d Approval Signature: Other: Disapproved: IV (fees are non-refundable) Te e 9:':9:'r�*�*�4r***ir ixxF*k i:xde ak:k iklktr,t********klrk*k*i**k:k*iic'r:4F*fir*9r Yr*1e k.t�k F*fir SF lr Y**,t it ie*ale ik*ir F'r k'r ie ka':rY k it:k*l-:t RE UIREMENTS 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: $185.00 per Tank. 5. Dig Safely New York#(dial 811): 6. Inspection by Building Department for removal/abandonment and/or installation. 7. Submit all Manifests &Reports(after work has been completed). 8. Certificate of Compliance will be provided when all requirements are fulfilled. Application dated, is hereby made to the Building Inspector of the Village of Rye Brook for a permit to remove,abandon,anNof install a Fuel Tank as herein described. The applicant and property owner,by signing this document agree that the subject fuel tank(s)will be removed,abandoned and/or installed in conformance with all applicable Village,County, State& Federal laws,codes,rules and regulations. Indicate Permit Type: Installation (�• Removal ( ) •Abandonment( )!Above Ground (vof/. Buried in Ground ( } 1. Address: k{ ( SBL: Zone:/C�r 2. Property Owner&Address: him VAlPnie, 9$g Kt�Rw., �rooy,_ N1 1023 Phone#: Q14-q37-2$33 Cell#: email: Y03 fps Y kip.CoM 3. Contractor&Address: Ca. T Phone#: gJ4-Vr 3H00 Cell#: eml• l► ai 4. Applicant: ff. 1 � C_0, ` Phone#:�{{�{ .q jq ._,4{©© Cell#: email:�,_etrVtir!�IPrn.c�k�t�tt�1 �t�lt i^ry9f t� 5. Indicate Fuel Type: Fuel Oil X•L.P.Gas O•Gasoline( )•Other 6. Number and Capacity of each Tank: 7. Exact Location(s)of each Tank.71­n SP M p i 8/12/2021. ATE OF AfE"dd�`FTRIC,C NTY s: �In p��� ,being duly sworn,deposes and states that he/she is the applicant above named, (print name of individual signi a th plicant) a d Furth r sta 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 ap cation.(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 before me this 7 day of flurck- ,20 3? day of (11 A ,20 r �1 Signature of Property Owner �gnature of Applieanftt P AtIlame of Prope OwnerO rint Name f Applicant Notary Puoii Notary Public SEAM,L,`TLE �`� h'O.T�t��T�.,�:1..,r' -•MY Comm{sslon 6xplros Lg.31,2025 N'OTA.1tPPU�3LIC Illy Commisslort Explres Aug.31,2023 This applivatioti must be properly completed in its entirety and must include the notarizes. signature(s) of the 'legal owner(s) of the subject property, and the applicant of record in chc spaces provided. Any appli;;ation 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 _ < $ ram - - - rm \ 2 LLJ \ \ ® { \ 3 CD w \ co* �kGeee \)\ c m c� w E§%3\c k ® ! � u � ~ 2 ® � k > %k�2 ƒ � ± r§ 2\!ko � c � m , C �,ge 2!n « O _ � �k ST ) %¢ g zz \ \ �� /« / / < / CD < Ln \ / geaaeee ® = c \ \ - \ E d § °\ ! % / \ ¥ rR ° ma ° 6CIJ M r4 r4 , 3 & a ® CL Cl t ® C14ell ) CD " OCD j ® ) \ \ ±@> cu CD 3:6)_ m & m£ \ < �� � m. / \- t= \ =`L o ® o)I * - 8CO \ k Ez \ CD00 § izz B ® e \ W $ _ .� �� � )j 2 : g , \\ \� § )) }/ - \ }) w a)/ = u . / (\ $ §} « c k_ U)w o U)0 w� && a Icr <0 z < 77 IM| u,a <,alF a | � | E | ( | \ c | | � | � � 10 < �a�'.y �. � .► r ,•.,,,. : '.fin � ;vl. �, rv. ' R �S-..v, ..� s4 r- •�. l,�ih'i'�: !���'1 !�i0ci � .lh�il��i �yci/��R'! 1��i1P'!,_ !�'I�PiI� .� . . .. . . . . . . . . . . . . . . . . . . ... .. . . . < v r• e o �. N n y > o 00 00 r :•.... •�e01 U O v� O {r 03 .%� O L �.y o ui rn ��• Lo_�:I Oy r to o r' W ce)00 o o tiec.ron W rAv' �a COP a oui � .� '•�. o - �. _ws ' W Z CD H :a W co o O gas cssii! X w z )s U) • • w : i W Y�<}. CO O NO l `j [ O •� L ate+ U »j• } ,� g l,1�1.1./! � �,��1`I��,� }y�(� t,„4� �,►�1�1�1,� �;r�r• i,l•1,1�1,, 3q ',,�•1�+l,! 1 !,; �1, n '��11�,! ��`�� "'� A •• A ♦• A �♦ A •• A •♦ 1� ^ ,^r ly+���qrvr,.YkT� � 1. V�''�n ' %i�.{ '� SS�I, Kw �•:! '� -vim i �. q?>�� Lh O :O'. a •'.SN M/$Q W�NN3' �y+� TE ' ACOORLDIP CERTIFICATE OF LIABILITY INSURANCE � osrosrz020 1� , 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 corder rights to the certificate holder In lieu of such endorsements. PRODUCER NAME:CT CLIENT NTA T CENTER FEDERATED MUTUAL INSURANCE COMPANY HOME OFFICE:P.O.BOX 328 PHONE EXt:888-333-4949 nic me):507-446-4664 OWATONNA,MN 55060 ADDResS:CLIENTCONTACTCENTER FEDINS.COM INSURER(S)AFFORDING COVERAGE NAIL# 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 06830-5886 INSURER 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. ADDLSUBR INSR TYPE OF INSURANCE SR WVO POLICY NUMBER POLICY EFF POLICY EXP LIMITS LTR INSR MMIDDIYYYV MMIDDIYYYY X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $1,000,000 _7E ToCLAIMS-MADE IX OCCUR PRE ES RENTEDEe ocar_ $100,000 MED EXP(Any ore person) $5,000 A N N 9DB2815 06/01/2021 06/01/2022 PERSONALS ADV INJURY $1,000,000 x'L AOOli�O AT,E LIMIT APPLIES PER: GENERAL AGGREGATE $2,000,000 X POLICY UJECT ❑LOC PRODUCTS•COMPIOP A00 $2,000,000 OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $1,o0O,000 IE a a<Iden X ANY AUTO BODILY INJURY(Per person) OWNED AUTOS ONLY SCHEDULED A AUTOS N N 9062815 06/01/2021 06/01/2022 BODILY INJURY IPar aai Nnl HIRED AUTOS ONLY NON-OWNED PROPERTY DAMAGE AUTOS ONLY Per ac IEen X UMBRELLA LIAR X OCCUR EACH OCCURRENCE $7,000,000 A i��EXCESS LIAB I CLAIMS•MADE N N 9062816 06/01/2021 06/01/2022 AGGREGATE $7,000,000 DED RETENTION WORKERS COMPENSATION X PER STATUTE OTH AND EMPLOYERS'LIABILITY ER ANY PROPRIETORIPARTNERIEXECUTIVE E.L.EACH ACCIDENT $500,000 A OFFICERIMEMBER EXCLUDED? NIA N 9917566 06/01/2021 06/01/2022 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $5()0,()00 11 yea,describe under DESCRIPTION OF OPERATIONS below E.L DISEASE•POLICY LIMIT $500,000 7 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101.Additional Remarks Sdwdule•may be etbdted 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(2016/03) The ACORD name and logo are registered marks of ACORD NEw Workers' ;- YORK : CERTIFICATE OF STATE i BOMPenSatlOnBoard NYS WORKERS' COMPENSATION INSURANCE COVERAGE 1a.Legal Name 8 Address of Insured(use street address only) 1b.Business Telephone Number of Insured WESTMORE FUEL COMPANY INCORPORATED 203-531-5656 86 N WATER ST GREENWICH,CT 06830-5886 1 c.NYS Unemployment Insurance Employer Registration Number of Insured Work Location of Insured('Only required ri coverage is specifically limited to 1 d.Federal Employer Identification Number of Insured or Social Security certain locafions in Now York State,i.e.,a Wrap-Up Policy) Number 06-0739367 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 #35 3b.Policy Number of Entity Listed in Box'I a* 938 King St Rye Brook,NY 10573-1226 9917566 X Policy effective period 06/0112021 to 06i0112022 3d.The Proprietor,Partners or Executive Officers are ❑ included.(only che(*box it all partnersinfricars included) ® all excluded or certain partners/officers excluded. This certifies that the insurance carrier indicated above in box'3"insures the business referenced above in box"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 Certiflcate 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 aultionzed representative or licensed agent of insurance cramer) Approved by: � C1 a,- .:,I o✓ gnature) (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) wwmr.wcb.ny.gov