HomeMy WebLinkAboutMP22-082 L4
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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
w ww.ryebrook,org,
TRUSTEES BUILDING & FIRE INSPECTOR
Susan R.Epstein Michael j. Izzo
Stephanie J. Fischer
David M.Heiser
Salvatore W.Morlino
CERTIFICATE OF COMPLIANCE
June 13,2022
Michael Despojado&Xinwei She-Despojado
3 Talcott Road
Rye Brook,New York 10573
Re: 3 Takott Road,Rye Brook,New York 10573
Parcel ID#: 135.58-1-38
This document certifies that the work done under Mechanical Permit #22-082 issued on 5/20/2022 for the
installation of a new above-ground oil tank has been satisfactorily completed.
Sincerely,
Michael j. Izzo
Building&Fire Inspector
/to
4E 4ROtN
• 1932 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 rxebrook.ore
- - - - - - - - - - - - - - - - - - - - INSPECTION REPORT - - - - - - - - - - - - - - - - - - - -
ADDRESS :- ` cl'- � t(
DATE:
PERMIT# !��/o� ISSUED: aq SECT: LOCK: ( LOT.
LOCATION: OCCUPANCY: 1
❑ VIOLATION NOTED THE WORK IS... ;Z ACCEPTED ❑ REJECTED/ REINSPECTION
❑ SITE INSPECTION REQUIRED
❑ FOOTING
❑ FOOTING DRAINAGE
❑ FOUNDATION
❑ UNDERGROUND PLUMBING NOTES ON INSPECTION:
❑ ROUGH PLUMBING
❑ ROUGH FRAMING
❑ INSULATION , c)) A
❑ NATURAL GAS W � ` � C 1
❑ L.P. GAS
❑ FUEL TANK
❑ FIRE SPRINKLER �C�
❑ FINAL PLUMBING
❑ CROSS CONNECTION
❑ FINAL
❑ OTHER
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BUILD T = MENT
V1L E OFRY OOK
938 KING FT RYE BRO ,NY 10573 MAY 2 a 2022
VILLAGE OF RYE BROOK
BUILDING DEPARTMENT
Application for Permit to Remove, Abandon and/or Install Fuel Storaze Tank
(*Storage Tanks in excess of 1,100 gallons require registration with the County of Westchester)
FOR OFFICE USE ONLY: PERMIT#: �Od
Approval Date: Permit Fee: $
Ll
Approval Signature: Other:
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, c"?00 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 Type: Installation { • Removal( ) • Abandonment( )!Above Ground (v • Buried in Ground ( )
1. Address: SBL:t'9�.�-U-- 1 Zone:Je—/l 4-
2. Property Owner&Address: r >• A en
Phone#: '' \\ y Cell#: email: ;�6I`� Cly,n
1Contractor&Address: a7;Ay-,C- Z 7\.� cr,: nL . — AL) NNN, ��*rr ly_re n -,� CT
Phone#:S N•9:-Iq �`g�Z Cell#: email:
4. Applicant: a^ T k-Ltaa,%,
Phone#:qly-Rn •]!�gOn Cell #: emailAKV_'—C@ 1.�
5. Indicate Fuel Type: Fuel Oil (,/-L.P. Gas( ) • Gasoline( )•Other( ):
6. Number and Capacity of each Tank: nn
13
7. ExactLocation(s)of each Tank: Irv-,_tt
r14,
1
8/12/2021
Co nn eC 'A4- �e . r
STATE OF;'r.cW—[-& ,COUNTY OF WE&TeHESTER ) as:
ft 4-�'o,S y (e ter-,, ,being duly sworn,deposes and states that he/she is the applicant above named,
(print name of irigfividual signing as the applicant)
and further states tat(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 rchitect,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. / h
Sworn to before me this (//q Sworn to before me this ( �'
day ' ``` 20 day of Q ,20 v)Z.—
igna re of Prop6ty Own Signature of Applicant
nq
Print Name of Property Owner Print Name o A licant
Notary Public Notary Public
TLE
SEA'sJ L`tTI..E
No"r=cyi°L'ilLIC NOTARPPUBLtC.
WC.DMrnission CxPes-Aq,31,205 ally Commission Esplres Aug.31, 2026
This au
placation 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
D CCFDWC
3
MAY 2 0 2022
VILLAGE OF RYE BROOK
BUILDING DEPARTMENT
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Part#2335101862
Submittal Data Information ++W1
Roth DWT 1000E
YOUR ENVIRONMENT IS OUR BUSINESS.
Effective:September 2007 Su ercedes:
Job: Engineer: Contractor: Rep:
ITEM PART NO. ITEM DESCRIPTION MANUFACTURER
42335101862 275 Gal.(1000 Liter)Double Wall Tank Roth
comes with a detached saddle base which the tank is
placed on at the time of installation.
= The tank shall be placed into service in accordance
with local codes and the listed use(indoor or outdoor)
on a flat,level and stable surface,away from heat
( sources,corrosive atmospheres or fluids,potential
mechanical damage or rapid temperature changes.
The final location must have the tank label visible
after installation. A minimum of 2"(50 mm) from
all walls or obstructions is recommended for normal
tank expansion and visual inspection. The integral
base support shall not be removed and raising the tank
- _ height is not allowed except on a continuous concrete
platform at least 6"(150 mm)wider than the tank
base at all sides. All local fire code set-backs for fuel
The Roth Double Wall Safety Fuel Oil Storage Tank oil storage tanks must be observed.
(DWT)is made with a seamless blow-molded
polyethylene inner tank and a 19 ga. galvanized outer Tanks installed indoors shall not be exposed to direct
tank.The outer tank is formed by joining cold rolled sunlight on any plastic parts. Tanks installed outdoors
sheet steel,used to form the sides and bottom from a shall be assembled with the required cover,Roth
single piece,with two stamped metal end pieces. The #2335100747 for the 1000L. All tanks must be
edges between the sides and ends have sealant applied installed with an approved vent alarm(Roth Vent
to them and are then rolled to create leak-proof seams. Alarm#235000999,or equivalent sized UL listed
A stamped top is then pressed and riveted into place to whistle vent) in order to maintain warranty
complete the assembly of the DWT. The DWT is UL® requirements.
listed in the United States and Canada under SU2258
and approved under NFPA 31 (2001)and CSA B-139- Tank Model DWT 1000L
04 as non-metallic fuel oil storage tanks. Nom.Capacity US gal(liters) 275(1000)
Length inches(cm) 43(110)
Width inches(cm) 28(72)
Both inner and outer tanks are pressure tested at the Height Inches(cm) 61 (155)
factory during assembly according to UL®standards Min Height Req'd inches(cm) 66(168)
and do not require further field testing. The DWT also Tank Weight lbs.(kg) 167(76)
Shipping Weight lbs.(kg) 185(84)
Your Environment is Our Business.®
ROTH Industries, Inc,268 Bellew Avenue South,Watertown, NY 13601 Telephone: (315)755-1011 Fax:(315)755-1013
ROTH Industries, Inc, 1607 rue de I'Industrie, Beloeil,QC J3G 4S5 Telephone: (800)969-7684 Fax:(450)464-7950
Visit our website at:www.roth-america.com Copyright 2007
n.m 2 TA1K TOP PIECE IS FASTENED 26(ALAI
WITH RIVETS(NOT ROLLED) 32
! I X / 25--
2.98
LL2
RcttT /_29 ow n,wn
20 �' y
5fi.'79
1
2 2
J 27 14
Idt NR[u6 uq BLTCr) IMw�A
l
—_.--_— Lj 1 97 %
HANDLE IS FASTENE:TO FACE
OF TANK WITH FOUR RNETS.
4:'S Nae mbletl
27.
33
34 Iw wn
35
32 ° .'a 9 3610
BUTYL SEALING CASKET IS COMPRESSED
BETWEEN THE TOP OF THE CONTAINMENT
TANK AND ESCUTCHEON POCKET.
® a 25--
( ) WITH SEALANT
INT1�E� LLFFiUL TESIM OF THE
FINSHFp SEAM 15 1MTFI THE•AILTEC-LFIX
FINDER METND0. TEST CRffFRN CAN BE
FOUND IN Tf TEST PROTOCOL(NOT ATTACIIED)
Your Environment is Our Business.®
ROTH Industries,Inc,268 Bellew Avenue South,Watertown, NY 13601 Telephone:(315)755-1011 Fax:(315)755-1013
ROTH Industries,Inc, 1607 rue de I'Industrie, Beloeil,QC J3G 4S5 Telephone:(800)969-7684 Fax:(450)464-7950
Visit our website at:www.roth-america.com Copyright 2007
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`�� CERTIFICATE OF LIABILITY INSURANCE DAT04I271O/YYYY
47272022
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: 11 the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed. It
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 Ileu of such endorsements.
PRODUCER 7141 NAMEACT CLIENT CONTACI
CENTER
FEDERATED MUTUAL.NSURANCE COMPANY
HOME OFFICE:P.O.BOX 328 IANcNNo '688- 4 4 IA c.No 507-446-4664
OWATONNq MN 55060 ADDRESS:CLIENTCONTACTCENTERg�FEDINS.COM
IHSURER SI AFFORDING COVERAGE NAIL Ili
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 o:
INSURER E:
INSURER F:
COVERAGES CERTIFICATE NUMBER:35 REVISION NUMBER:D
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE L STED 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 rypE OF INSURANCE DL SUBR POLICY NUMBER POLICY Eii POLICY EXP LIMITS
LTR Ea MMIODrYYYY MMIO IYYYY
X COMMERCIALGENERALLIABILITY EACH OCCURRENCE $1,000,000
CWMS-MADE ❑X OCCUR DAMAGE TO RENTED _ j1OO,000
PREMI^ES fE&
MED EXP(Any-.Ptnon) S5,000
A N N 9062815 06/01/2022 06/012023 PERSONAL&ADV INJURY $1.000,000
FXO 'L AGOR GATE LIMIT APPLIES PER. OENERAL AOOREOATE $2,000,000
R POIICY �.JPECO-
T 71 LOC PRODUCTS-COMP/OP AGO S2.000,000
OTHER:
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT S1,000,00O
t•
X ANY AL1T0 BODILY INJURY(Per p--)
OWNED AUTOS ONLY SCHEDULED
A AUTOS N N 9062815 06/012022 06/01/2023 BODILY INJURY(P.r—Id-0
HIRED AUTOS ONLY AUNO$ONND I'ROPERe Y All ADI
X UMBRELLA LWB X OCCUR EACH OCCURRENCE $7.000,000
A EXCESS LIAR CLAIMS-MADE N N 9062816 06/012C22 06/012023 AGGREGATE S7,000,000
DED I I RETENTION
WORKERS COMPENSATION X PER STATUTE OTH
AND EMPLOYERS'LIABILITY y I N ER
ANY PROPRIETORIPARTNERIEXECUTIVE E.L EACH ACCIDENT S500,000
A OFFICERIMEMBER EXCLUDED? N I A N 9917566 06/01/2022 06/012023
IM.ndNary In NN) EL DISEASE-EA EMPLOYEE S500,000
II ytt.a.so10.und.r El DISEASE-POUCY LIMIT
DESCRIPTION OF OPERATIONS 601— S500,000
DESCRIPTION OF OPERATIONS I LOCATKINS I VEHICLES(ACORD 101,Addih—R--%SrNedufe,m.T Ue tIY—if mere%P— S reRuired)
CERTIFICATE HOLDER CANCELLATION
330-130-6 350
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 1998.2015 ACORD CORPORATION.All rights reserved.
ACORD 25(2016/03) The ACORD name and logo are registered marts of ACORD
NEW
YORK ` or(«rs" CERTIFICATE OF
sTATE Compensation
N.� Shard NYS WORKERS' COMPENSATION INSURANCE COVERAGE
to Legal Name&Address of Insured(use street address only) tb.Business Telephone Number of Insured
kNestmore Fuel Compaiy Incorporated 203-531-5656
85 N Water 3t
Greenwich CT C6830-5886 to.NYS Unemployment Insurance Employer Registration Number of
Insured
Work Location of Insured(Only required if coverage is specifically limited to 1d Federal Employer Identification Number of Insured or Social Security
certain locabon=ran New York State,i.e..a Wrap-Up Policy) Number
05 C739367
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
ViFage Of Rye Brook p y
933 King St
Rye Brook,NY 10573-'226 3b.Policy Number of Entity Lrsled in Box'ta'
9917656
3c.Policy effective period
06101i2022 to 06/01/2023
3d.The Proprietor,Partners or Executive Otfcers are
❑ included.(Only cl,v:k box it all parrne:veitice:a x:rhded)
] a:I excluded or certain partners/officers excluded.
This certifies that the insurance carrier indicated above in box"3"insures the business referenced shove in box"I 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 veil)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'Compensabon Board within 10 days IF a policy is canceled
due to nonpayment of premiums or within;30 days IF there are reasons other than ner.payment 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 elect.
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 DANIELLE SACKETT
tPf P1t r.Ame Ot dUM`M V.ed rP{865P�IAIiM O ICP.pSRA B7C�:Or Ri JrdlKx C9frprj
t�27uc/[;<
Approved by: 04/26/2022
Slgnau:re) (pale)
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) vrww.wco.n.y gov