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HomeMy WebLinkAboutMP22-070 a � �V c�4du j�� . 19 404 Cln amo aW VILLAGE OF RYE BROOK .MAYOR 938 King Street, Rve Brook,N.Y. 10573 ADMINISTRATOR Jason A. Klein (914) 939-0668 Christopher j. Bradbury www.ryebrook.org TRUSTEES BUILDING & FIRE INSPECTOR Susan R Epstein Michael j. Izzo Stephanie J. Fischer David M.Heiser Salvatore W. Morlino CERTIFICATE OF COMPLIANCE August 10,2022 Peter LiMarzi 283 Neuton Avenue Rye Brook,New York 10573 Re: 283 Neuton Avenue, Rve Brook,New York 10573 Parcel ID#: 135.67-2-57 As per the Certification letter from Burke Energy dated July 20,2022,the removal of an above-ground oil tank under Mechanical Permit#22-070 issued on 4/29/2022 has been satisfactorily completed. Sincerely, Michael j. Izzo Building&Fire Inspector /to QyE BR(��, 1932- t7 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:- ��� '' `p DATE: �\l -7 I lo-Z2 PERMIT# ISSUED:SECT: 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 n _ c� v� ou-Q ❑ NATURAL GAS `(� ❑ L.P. GAS ❑ FUEL TANK ❑ FIRE SPRINKLER ❑ FINAL PLUMBING ❑ CROSS CONNECTION ❑ FINAL ❑ OTHER �E BRnuk 193,2 w � BUILDING DEPARTMENT ❑B ILDING INSPECTOR ASSISTANT BUILDING INSPECTOR VILLAGE OF RYE BROOK 10 ❑CODE ENFORCEMENT OFFICER 938 KING STREET • RYE BROOK,NY 10573 (914) 939-0668 FAx (914) 939-5801 www ryebrook.org - - - - - - - - - - - - - - - `- - - - INSPECTION REPORT - - - - - - - - - - - ADDRESS• DATE.. PERMIT# ISSUED: SECT. � BLOCK: LOT: � pv .� 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 Cy� ❑ NATURAL GAScLa ❑ L.P. GAS FUEL TANK ❑ FIRE SPRINKLER ❑ FINAL PLUMBING ❑ CROSS CONNECTION ❑ FINAL ❑ OTHER e � W � a U en O � -� wA H � co 00 � � Fr � W U c�q O � 'y ° ►••� `n r� aobY � v 41 ren1 w O Q O � Qyg . to H O A (2N p x oo CC) v) �p � a� _ 0 .ti W o � o qj r-wo`no F-� U O O V °' �' M C7 Z 00 Z O N H w a O 0 �-, w � c v U BLlll..,D11Vc: DirwARTMEIN F APR 2 5 2022 Vlt.l,,1(.1 OF Itl'V 13tttai;'l. VILLAGE OF RYE BROC)K 938 KINGS rttr:H r Rt t,l3t<fat�I:,1�°1' 10573 BUILDING DEPARTMENT (914)919-0669 1tw��.r•�clrruni;,ot• Application for Permit to Remove, Abandon and/or install Fuel Sto1Agj Tank (*Storagc Tanks in excess of 1,100 gallons require registration with the County of 2 �� Westcltcsier')�7 �Y 22 qpGQ— Approval Date: _ _ _ Permit Fee: $ / 60 /-U 'A'3�5' Approval Signature: __. __-- Other: .. Disapproved;.. (fees ate non•ief.nd4b1c) hR**x####xxk*x##-k#t##k##xk##**#*#A-##*kt#°F#►####x*'G**4**#t**#*#*###*#*##*k#*##*#*##tA°*k*R#t*ik*#Yk#*#####x ltt<(lullrt R#FNTS FOR RELEASE OF PERMIT&CE.RTIFICAT ,O F COMPLIANCE: 1. Application Completed by Bonded, Licensed Contractor. 2. Your contractor's valid proof of liability insurance.(Village of Rye Brook must he listed as certificate holder) 3.Your contractor's valid proof of workers compensation insurance. (Form#C,105.2 or Fonn# U26.3 I or NY State Workers Compensation Waiver) 4. Fee per Tank: Removal,Abandonment,or Installation: t85.00 per'1'ank. 5.Dig Safely New York#(dial 81 6. Inspection by Building Department for removal I abandonment and/or installation. 7. Submit all Manifests&Reports(after work has been completed). 8.Certifr•afr of Compliance will be provided when all requirements are fulfilled. Application dated.�ro�s ,is hereby made to the Building Inspector of the Village of Rye Brook for a permit to remove,abandon,and °r E, .„+,' :t t ., I i unk 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. I udirate Permit Type: Installation( )•Removal(X)•Abandonment( )/Above Ground(x)•buried in('7roitiad( } euton Avenue Rye Brook,New York 10573 1. Address: 283 N . _ '�lil 135.61-2 57 _ Zone:,AP_�_ 2. Property Owner&Address: Peter U Marzi 283 Neuton Avenue Rye Brook, New York 10573 Phone#: Cell# .. —_ ._- email: ironman5t406@gmail_coin_----_,.. 3. Contractor&Address:.Burke Energy..47.5.Gomtnerce.Street. Hawthorne.New York'10632 Phon+(#:(914)91.9-3563 (Joanna) Cell#:(91.4)_32_7-13.10.fDan t.ee)._ email: burkeper nJ%@meenanlp_QoxrL___ 4. Applicant-. Burke Energy Phone#: 914 919-3545 Cell#: email:burkepermits@meenanlp com 5. Indicate fuel Type: Fuel Oil(x)•L.P.Gas( )•Gasoline{ )•Other 6, Number and Capacity of each Tank: One Granby 275 gallon AST 7, Exact Location(s)of each'Tank: Back left corner of the home 8.12,2021 S:LAT.E OF NFVffOFtI�,C-OLINTY OF WFSTCHESTER ) as: t being duly sworn,deposes and states that heishe is Elie<appliewil above named, r,rinl atmc�C�ndivt aZ1.igntn�as t4c Itcantl� .ind further states that(s)he is the legal owner of the property to which this application pertains,or that(s)he is the C0f\A-4'ox_*a�(— for the legal owner and is duly authorized to make and file this application.(indicate nreLitoo,contractor,agent,aeorhey,etc) That all statements contained herein are true to the best ofhis/bur 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 Slate Uniform Fire Prevention&Building Cade,the Code of the Village of Rye Brook and all other applicable laws,ordinances and regulations.Sworn to before me this I� Sworn to before me this Cr day ni (i f 20_„ day of kti �c Signature of Property Owner S�gacute of App1, x PQ- r _1-A(vL i rn S �a Pr Name of Property Owner Print Name of Applicant Notary lliblit Notary k1h*1. This application must be prop rly(xiiil;luted 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 nulI and void and vvill tic returned to iltc applicant. DANIELLE GUILDERSON Notary Publlc,State of New York No.01 GU6270311 Qua led In Westchester County, i Commleslon Expires 10-15-20 1 2 cj 14 F. , { .. r\� W s r�:• .z � .,.�.x � �..:,iiiil i��i ill�Ylli�i��"i�r r_ , :�,�,. iE&Vr t _Aq i `�y�;f .+��,a ?� �t�t771 n , `'�x!�F +t'�r,Je.�i����, •\�Lt�'�"'.\z.. 4„" �. �:.-•r�j�'"`'3� Product# Capacity Model Gauge Dimensions Weight �) 4 (US gal.) thickness H W L (pounds) a� 209101 120 vert. 12 4, 23" 30" 170 2.08101 138 vert. 12 4W 27" 30" 160 208601 138 horiz. 12 27` 4W 30" lfi0 207101 220 stubbec:vert. 12 44" 27` 48' 220 207601 220 stubbies!*iz. 12 27" 44" 48" 220 2032CIG 230 thintaert.grey 12 44' 22" 60" 235 203701G 230 thin/horiz.grey 12 22 44" 60" 235 202201 240 narrow/ver:.. 12 47" 23" 60" 265 202701 240 narrow/horiz. 12 23" 47" 60" 265 r 204201 275 vert. 12 44" 27" 60" 255 204701 275 horiz. 12 27" 44" 60" 255 € 211201 275 Vert, 10 44" 27" 60" 330 s 211701 275 horiz. 10 27" 44" 60" 330 1 205201 330 vert. 12 44" 27" 72" 290 205701 330 horiz. 12 27" 44" 72" 290 External finish.BLACK or GREY ele^trosfafic powder paint Warranty*: 10 years Touch up paint: PE0030C"BLACK" PE0032C"GREY" Cylindrical, models vertical Product# Capacity Model Gauge cover Dimensions Weight (US gal.) thickness Shell Dia. Height (pounds) 3006622 150 DCV 560 11 12 30" 65" 200 3007622 185 DCV 690 11 12 30" 77" 225 3008622 220 DCV 825 11 12 30" 88" 255 Extern(finish: WHITE polyurethane paint Warranty*: 3 years a Cylindrical models horizontal Product# Capacity Model Gauge cover Dimensions Weight (US gal.) thickness Shell Dia. Height (pounds) 3005224 138 horiz. 12 12 26" 60" 165 External finish:BLACK electtostatic paint Warranty*: 3 years i 1 .OLBurkeEnergy Your local home service experts. Village of Rye Brook Building Department 938 King Street R 475 Commerce Street ye Brook, NY 10573 Hawthorne, NY 10532 July 20, 2022 914.769.5050 T 914.769.1521 k: LIMARZI / 220429 burkeenergy.com 283 Neuton Avenue Rye Brook, NY 10573 Or Permit# MP 22-070 / Oil Tank Installation Close Out Letter May 23, 2022 - Burke Energy removed existing (1) 275 gal tank The old oil tank(s) were removed, cut and cleaned on site and disposed of at a recycling center, scrap manifest provided. The waste oil was disposed of at an approved waste oil recycling center, manifest provided. PLEASE call the Village of Rye Brook 914-939-0668 to schedule a final inspection per your availability, if final inspection was completed just follow up with the Village of Rye Brook building department to make sure permit(s) have been closed. Also have provided tank completion form and capital improvement form for your records. Deeply appreciate your help with this matter. Any further questions, please don't hesitate to contact Joanna - 914-919-3563 — Install / Permit Department. Thank you, �r r John Burns / Install Manager / Burke Energy 914-769-5050 jbu►-ns@meenanlp.com burkepermits@meenanlp.com Heating I A/C I Propane I Oil Tank Removal I Generators I Home Security&Automation .OLBurkeEnergy e Brook of R a Your local home service experts. Village y Building Department 938 King Street Rye Brook, NY 10573 475 Commerce Street July 20, 2022 Hawthorne, NY 10532 914.769.5050 T 914.769.1521 'RE: LIMARZI/ 220429 D burkeenergy.com 283 Neuton Avenue f Rye Brook, NY 10573 UL 26 2022 '--1 LJ -____-1 Permit# MP 22-070 / Oil Tank Installation Close Out Letter VILLAGE OF RYE BROOK BI ILDIV( DEPAI;TIVIF_LJT May 23, 2022 - Burke Energy removed existing (1) 275 gal tank The old oil tank(s) were removed, cut and cleaned on site and disposed of at a recycling center, scrap manifest provided. The waste oil was disposed of at an approved waste oil recycling center,manifest provided. Deeply appreciate your help with this matter. Any further questions,please don't hesitate to contact Joanna- 914-919-3563 - Install / Permit Department. Thank you, I John Burns / Install Manager / Burke Energy 914-769-5050 jburns(fticenanlp.com burkepermits(C1)ineenanlp.com Heating I A/C I Propane I Oil Tank Removal I Generators I Home Security&Automation i PAYMEN I RECEIPT Nrc:okfield Resource Management 1 DO Lamont Street Elmsford, NY 10623 914-592-5250 Receipt:1742765i Date:6/3/2022 Customer:1915 Tlme:9.20:09 AM BURKE HEAT 475 Commerce Stree': Hawthorne, NY 1063;� ID Number: Ticket:1784330 — — Weigh In:6/3/2022 9:11 03 AM Operatorplane D Weigh Out:6/312022 9.20:07 AM .V rwitf �"O'Wse r,Agu Commodity Groes Tare Net Price TOTAL S N 2 Unprepared 12.420 11,860 560 6.8000/CW 38.08 Ticket Tate]: 31.01 No,of Tickete:1 EZCash Paid: $38.00 PaymentMethod:EZCash RoundAmt: ($0.08) Total Paid: $38. For current pricing,hours and contact Information che,k us out on the web (Mbrooklleldecrap.eom Join Brookfield Scrap of Fecehook @webuyscrap N0"AZAR000S 1 GaneraWr ID Number 2 Pago 1 of 3.Emergency Response Phone r4WUtsTreeldng Number WASTE MANIFEST j 914-769-5_050 5.Oeneraror s Name and Malting Address Grwro eta'a Sde Address 1 6 nt o+an mailing ak s,l BURKE ENERGY 475 COMMERCE STREET—HAWFHORNE, NY 10532 y7Zvt A✓� �� c,«laratoes n one: 914-769-5050 -- - - I ._ _ 6.Transporter t Compwy Name U.S-EPA 10 Number MEEN_AN_OIL/BURKE ENERGY NYR000086801 ' 7.Transporter 2 Company Name - - -- - U.S.EPA ID Number 6.Oesgnated Facility game and Site Addross — - - - — U.S.EPA ID Number ENVIRO-WASTE OIL RECOVERY NYD044825636 279 RT. 6—MAHOPAC,NY 10541 fi►:11 'S Phone _ 44-79--0263 9.Waste Shipping Name and Description _ 10.CenmYtera 11.Told 12.Link --- No. Type Quandly w1Nol. 1 PETROLEUM CONTAMINATED WATER (NON HAZARDOUS) cc NON RCRA, NIA, NONE, NONE / TT LU 3 13. Special Handfmg Inslructlons and Additional Informalion - 14.GENERATOR'S CERTIFICATION:I_ 1 regulations for reporting proper disposal of Hazardous Waste. artily the materials described above on this maniiesl are not sub Ic federal GeocraiofJOfloror's PnnleolTyped Name - Signature Month Day Y 15.International Shipments - -- ❑Import io U.S. ❑F_xppd from U.S. Port of enlrylexil: franc mw-j SSr natmqAU-axRwts 22Ar1 _ - -- -- —_Dab YnNn➢U.S. _ Ix 16.Transporter Acknavledgmenl of Rae*of Materials Transporter 1 PMtedyTyped Name �� -SlgneMae Monon Day Year Z Transporter 2 Prrnmd?yaed Name 9lpraMo Year 17 Discrepancy 17a,Discrepancy Indication Space ❑Ouantily U Type ❑Residue U Partial Rejection ❑Full R*dlon Manaesl Reference Number. c},1 17b.Alternate Facility(or Oenerstor) U.S.EPA ID Number LL Factitys Phone: I 2 17c.Signature of Alternate Facility(or Geno ator) Month Day Year L O 16.Designalod Facility Owner or Oparala Codification of receipt of materials covered by the manifest except as noted In Item 17a PMledlTyUrdNamcj (� `/�O f - -- Slgnahxe - / Ih Ony—YoM MMP 64206 DL?$IG MTED FXILITYTO GENERATOR Fo4r y 1 ^ �:��� �lyi ;?r^t r.. �!�:�4 w s�y�`"<"'�'�'�.•A� � ', 5 f� 7•rat":.' Nt .' _ Lf f .•7+�, N �it lJ,, .,;J IA r4� .. J1ifl � � H J11�' yl y kt +y+ A r � Y IP,R •♦ Y ♦♦ Y It a Y ♦ Y YOU �� -.,y .�u -,�'-'�'�►ifyil 7,'�k�".sl 6 � "� b _ ��� )��:'�'�T' '�'a'ii'�,1 a�;m�� �if'1►f►.: -s%�,�'�r r' '�� . . . . . . . . . . . . . . . . . . . . . . . . . . . `fix •�- I I 1j � r=.., v04 I // I E L y Q fyC,4CS � G � � U W � ,•, . U 0 ,2 t f.. . llc� ri 04 o y ct ( "ection rr\ `�► s ` uj +'q V �/ ►n Q o e aQ J 4.4 cn CD co ' �• y V y 4•+ � � i �`'�} i i - s'b �/ � � �A.. X S +� ��Ar� t4 4� �' �A. • r• �► r!��G iT�� � ri. ►�+ �' t' •-�- ^.•, t �4\� 7 DATE(Iv1M/DDIYYYY) ACC)R" CERTIFICATE OF LIABILITY INSURANCE 090 021 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 David Cobleigh Marsh USA,Inc. NAME ( _ - 1166 Avenue of the Americas W-G.�1t!Es,tL—(212)345-6834 - -- ---- I.(pc,.No}; New York,NY 10036 E-�L _ Attn:NewYork.certs@Marsh.com gDOREss;___ -Dav d A.Cobleigh@marsh.com INSURER 3 AFFORDING COVERAGE NAIL 0 CN101414B39-PETRO-ACORD-21- INSURER A:National Union Fire Ins Co Pittsburgh PA 19445 INSURED INSURER a:AIU Insurance Co 19399 MEENAN OIL CO.,LP D/B/A BURKE HEAT AND BURKE FUEL OIL CO INSURER C:Lex lgton Instuartce Company 19437 475 COMMERCE STREET _- HAWTHORNE,NY 10532 INSURER o INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: NY0009222598-82 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. ILTI TYPE OF INSURANCE R POLICY EFF POLICY EXP LIMITS LTR POLICY NUMBER MMIDDIYYVY MMn)O A X COMMERCIAL GENERAL LIABILITY GL 7032451 10A1/2021 10,01/2022 EACH OCCURRENCE S 1,000,000 -- CLAIMS-MADE L^ I OCCUR PRE] ES(Eaocw $ 500,000 _._X...XCU MED EXP A one person $ 10,000 X Contractual PERSONAL 6 ADV INJURY $ 1,000,000 Gf_N'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 5,000,000 --- X POLICY PRO EJ LOC PRODUCTS-COMPIOP AGG $ 2,000,000 — JECT OTHER SIR $ 100,000 A AUTOMOBILE LIABILITY 8682566(ADS) 1010112021 10101/2022 COMBINED SINGLE LIMIT $ 5,000,000 A ---- (En ..encaer0 X ANY AUTO 8682567(MA) 10/01/2021 10101/2022 BODILY INJURY(Per person) $ A OWNED I SCHEDULED 8%2568(VA) 101012021 10/01/2022 BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE _E AUTOS ONLY AUTOS ONLY Per acc' t X UMBRELLA LIAO X OCCUR 021430599 10/01/2021 1OM1i2022 EACH OCCURRENCE 3 5.WO,000 EXCESS UAB CLAIMS-MADE _AGGREGATE $ 5,000,000 DED X !RETENTION$10,000 — $ B WORKERS COMPENSATION WC 063850976(CT,DE,MA,MD,MI,NH, 10MI120211 *01/20 X PTAM OT i AND EMPLOYERS'LIABILITY YIN FN] NJ,NY,PA,RI,VA,WV) 1 000 00(1 ANYPROPRIETOR/PARTNE.4lEXECUTIVE E.L.EACH ACCIDENT $ B OFFIC ER/MEMBER EXCLUDED? NIA WC 10Ai12021 10/01/2022 (Mandatory In NH) ) E.L.DISEASE-EA EMPLOYEE_____ _ S 1,0W,000 If yes,describe under 1,000,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached It more space Is required) THE CERTIFICATE HOLDER IS INCLUDED AS ADDITIONAL INSURED AS RESPECTS THE NAMED INSUREDS OPERATIONS CERTIFICATE HOLDER CANCELLATION VILLAGE OF RYE BROCK SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 938 KING STREET THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN RYEBROOK,NY 10573 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE :zz� 2CS� �orc. ©1988-2016 ACORD CORPORATION. All rights reserved. ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD a , 2 v"'W Workers' CERTIFICATE OF STATE Compensation NYS WORKERS' COMPENSATION INSURANCE COVERAGE Board dress only) 1b.Business Telephone Number of Insured 1a.Legal Name&Address of Insured(use street ad Meenan Oil Co,LP 845-782-8161 dba Burke Heat and Burke Fuel Oil Co. 475 Commerce Street 1c.NYS Unemployment Insurance Employer Registration Number of Hawthorne.NY 10532 Insured 8311425-2 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 11-3083408 2.Name and Address of Entity Requesting Proof of Coverage 3a.Name of Insurance Carrier (Entity Being Listed as the Certificate Holder) AIU Insurance Company 3b.Policy Number of Entity Listed in Box"l a" Village of Ryebrook WC 063850976 938 King Street Ryebrook,NY 10573 3c.Policy effective period 10/01/2021 to t 0/01/2022 3d.The Proprietor,Partners or Executive Officers are 0 included.(Only check box if all partners/officers included) all excluded or certain partners/officers excluded. .. ........... --- ...---. ._.. This certifies that the insurance carrier indicated above in box Z'insures the business referenced above in box"It 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: Michael Price (Print name of authorized representative or licensed agent of insurance carrier) v Approved by: :. September 28,2021 (Signature) (pate) ^ Title: C.E.O.North America Telephone Number of authorized representative or licensed agent of insurance carrier: 212-770-7000 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