Loading...
HomeMy WebLinkAboutMP21-119 �yE t4 V�4 J.1 V ZEc. • ': 4t" anniuvoaW VILLAGE OF RYE BROOK MAYOR 938 King Street, Rye 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 July 25,2022 Richard Gasparino&Bridget Gasparino 6 Jaqueline Lane Rye Brook,New York 10573 Re: 6 Jacqueline Lane, Rye Brook,New York 10573 Parcel ID#: 135.35-1-61 This document certifies that the work done under Mechanical Permit #21-119 issued on 8/19/2021 for the installation of a new 500 gallon under-ground propane tank has been satisfactorily completed. Sincerely, Michael J. Izzo Building&Fire Inspector /to �yE BRC�Uk. O� 2m • 1932 BUILDING DEPARTMENT ❑I UILDING 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: v `-' I 1 N DATE: PE �! ( � ITEC�: ,RMIT# ISSUED: ��s -)BLOCK: LOT: LOCATION: �- \ 7{ � OCCUPANCY: ❑ VIOLATION NOTED THE WORK IS... li] ACCEPTED ❑ REJECTED/REINSPECTION ❑ SITE INSPECTION REQUIRED ❑ FOOTING ❑ FOOTING DRAINAGE ❑ FOUNDATION ❑ UNDERGROUND PLUMBING NOTES ON INSPECTION: ❑ ROUGH PLUMBING ❑ ROUGH FRAMING ❑ INSULATION ❑ NATURAL GAS -1}- ❑ L.P. GAS ❑ FUEL TANK ❑ FIRE SPRINKLER ❑ FINAL PLUMBING ROSS CONNECTION / FINAL ❑ OTHER I R� 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.or¢ - - - - - - - - - - - - - - - - - - - - INSPECTION REPORT - - - - - - - - - - - - - - - - - - - - lr /^ J N� �"" DATE: C ADDRESS • C32 `LJ lJ��- PERMIT# SY �\ � ISSUED: 2�ECT: BLOCK: LOT: �� C L-� OCCUPANCY: '�LOCATION: ` �� ❑ VIOLATION NOTED THE �WORK IS... ACCEPTED ElREJECTED/ REINSPECTION ©' SITE INSPECTION '����CQ�S�'I"C REQUIRED ❑ FOOTING ❑ FOOTING DRAINAGE ❑ FOUNDATION ❑ UNDERGROUND PLUMBING NOTES ON INSPECTION: ❑ ROUGH PLUMBING ❑ ROUGH FRAMING ❑ INSULATION ❑ NATURAL GAS 0 L.P. GAS ❑ FUEL TANK ❑ FIRE SPRINKLER ❑ FINAL PLUMBING ❑ CROSS CONNECTION ❑ FINAL ❑ OTHER e C ■ ri - �-I 1 N wN � .w., ° N a� N a, p w a• � � C p ■ ■ D 06 " cnFA Ey W) Ono TO o ti rn p © 00 o Q g 940. Go ' 7a O - o p o a a. z � acoar CA _ I ( n Qo z ° . y A W O vy00oCO _ co U o o U �J Y A C e T 4 O G Q S s u ■ a) Aft 00 M"^I a r a, bA C� M � Q � � � •o ro a� u 1 x CL Q tn 40 "o t � = �"'7 C7 G F A q C � •� � � � w w Q = o ca o va BUIL - { MENT VIL E of IV oOK AUG 1 6 202� 938 KING Er RVF 1#> ` ,NY 10573 (914)9 VILLAGE OF RYE BROOK f 39-58Q1 BUILDING DEPARTMENT w nl r _.-- A lication for Permit to Remove Abandon and/or Install Fuel Story a Tank (*Storage Tanks in excess of 1,100 gallons require registration with the County of Westchester) FOR OFFICE USE ONLY: PERMIT#: 0 - I ,( 1 IL Approval Date: AUG 1 n qn4i Permit Fee:$ J WIS, ' Approval Signature: Other: Disapproved: -- - {fces 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 CompensationWaiver) 4. Fee per Tank: Removal,Abandonment, or Installation: $185.00 per Tan . 5. Dig Safely New York#(dill 81 1): 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,and/or install a Fuel Tank as herein described.The applicant and property ner,by signing this document agree that the subject fuel tank(s)will be removed,abandoned and/or installed in conformance with 11 applicable Village,County, State& Federal laws, codes,rules and regulations. Indicate_Permit Type: Installation (Removal{ )•Abandonment( )!Above Ground ( )•Buried in Ground ( ) 1. Address:_] SBL:fr —1-W Zone: �/Q 2. Property Owner&Address: C� ! t� ,-�n 6 a_c a v. �^l e P I-oak N )t j-8 Phone#: -S O7 Cell#: email: CC , e .Ce 3. Contractor&Address: ';A a g �;C t J t3-d-ckrx k-t r- Phone#: 9.14S:- 2D7`57_7`/ Cell#: P1` Z60`t 61 1 email: 6,4400_. 4. Applicant: Phone#: ,Wf'2-U_7-S-?7 Cell#: �C-2G0=&1I email: 5. Indicate Fuel Type:Fuel Oil( )•L,P.Gas(J%Gasoline( )•Other( ): 6. Number and Capacity of each Tank: / �o N li yrA it to t 0 CO 4 e tv�F,v IC 7. Exact Location(s)of each Tank: 1 6/1/2020 i STATE OF NEW YORK, COUNTY OF WESTCHESTER ) as. (print name of individual signing as the applicant) being duly sworn, deposes and states that a/she is the applicant above named, and further states 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 a thorized to make and file this application,(indicate architect,contractor,agent,attorney,etc.) That all statements contained herein are true to the best of his/her knowledge and bel ef,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 ir accordance with the New York State Uniform Fire Prevention&Building Code,the Code of the Village of Rye Brook an all other applicable laws,ordinances and regulations. r� I� Swum to before me this Sworn to efore me this day of 20-Z/- day 20 1/ 4pg-nalure of Property Owner Signs re of Applicant C �� , `, � Print NameO Prope Owner Print a of Ap li DANIEL S. DIVEN otary Public Notary Public.State of Ne ,ttij p lic No. O1 D16098928 Qualified In Putnam Cou My Commission Expires ra "['his application must be properly completed in its entirety and must in•lude the notarized signature(s) of the legal owner(s) of the subject property, and the applicant of recor( 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. ANNA KIELBASA NOTARY PUBLIC-STATE OF NEW YORK No.01 K16378519 Qua Iifiedirl Putnam County lvly Commission Expires 07-30-2022 2 b/I/2020 dy,�yygv�:e.eJ y.p vtlpA'n� vO0tl93Atl 3NV13Nn3fgJVl9 Z80AM3N'0 ONIavdsv`J 19SZ1 NNOA M3N'ONIIMtld iol '( zz3inoazse SN01110NO0 ONIISIX3 MOH 'f�31Nt/Hlb N SNVId 1N3W3AOLidWI 3'd 39VNIV210 03SOdOidd VILLAGE OF RYE BROOK-TOWN OF RYE SECTION 135.35 _ M° or o CO R'ch Mao ?P Ln BLOCK 1 J Section 3 115� 0 0 cc Map NO. 118.00' 0& LOT 61 ass, 0 E o N 8015z �= o U O > ;° Z 00 OI ON cc F LL L6 0 a O 2 o �p [� O x ■ J rr) zQ - 58 S U _o O i N cy' z ~a O �o � J N z _ c} O 0 6 J O z Ile O ^, a 4 (U eb L O p�PE Skeeb lio pPF N �IIOM a ws6ol j id 6 20.9 Flo oliod a�ois6old �J AC m 0 9 N asnoH � /,tg• '- V a a O 0 15.8' XJp+S 4'l� o .e O 4a� ° L � HIOM auo •OPun�6o.oC is olj Z o. UoWano T a a f r 3 O ° �5 �� W\� 0 oO ti V C`St xO U J ° 00- L=36.13' c 0 o f yy S a [ECEME � � b FR c r o C `om9 9� it 8 a =.p a � � rAUG 16 2021 . $$$ o a o = 3 3 H. _ em s VILLAGE OF RYE BRO' $ g $I $ � _ j IBUILDING DEPARTM T ' f --- a � on Poll A chEL Q u f5p mull 1111 1� ul 0 U c� I raet aHtJtJt1 � ry N ry v. U T kru_ ........... Ao � 3 u-Ili IL U M{ I 1 y I 111' I li r '1'l1 1 I ('I`'V� I'r4r( � 1' „ i¢il�til'I' •I.IY t,,, 61,;ti11!I<�lil l' .i I,I7i;,l r•{ � rfi 4� (,{�. ;► I •��'II !,r` ,�"1' I IJ,', I rirlllL„' r !' II' .I ► I, 'I I r $f�(t !) II�',;�.) I rr !Jh�y�, •:I; +lI'.it �►I1r/',{,�1'UI��a�la,; ,,A,I ,r�.r;!,, '�h;�Il'\; �� I I, t�� t ►I r,�ti' 11 I , � i 4, '��' �Il'I,IjJ Ir�'J� f�Ilf'• I'4'ul7 ,��:I ,'• � ' 11 it 1'; , , .�•;'�` II�'�;, ,I,�;,�( , rn,;I,,�ii IKt !� l;',,,r„',,1' � I b �,�,?� '(,�f 'L, ir.,I���i,,l,l C l�') '��1� '�t+ ,,,uJH,l,y{q / + � � 111 I�,I,1'1, 1' ' �,+,I:11 4 �11 rl I � ,,1 I ' 'd� ; I ,:� , I. r •4,{�1�, I i i II++��I'',I, I `1 � I;�r, .VI I �•',�,'; I��f1111�� �y�•, �II'� ,•�' Y r',';1� II '+ / 111 "��+I � �.�Y t I I Ohl � `1� I,I 1 � lI`1 ! 1 �I• I�'11' (��,`III /Ir;., I� I ,I „ f II , :'1, r,�l'41V � Ili S Y d•�II�I J,�I P,'I„LPr'rl� IrIrU;llr!'�(�;Iff.!, '.) I II,JLI,"•':I�, I'Ir �I I'./ ,1 I f l r: Ir✓t,:llll� Ili: I,/1/ 1 �I II I!r, I al�; +1• /.il; 11•,li I ` I�1. ,;r�1l,r I II:111 II• I .1.1 1 {":�'.1' !,,,!• r. , �) II I , 'I I Il{ 'LII,�� lyl+�,I,. (,,,1 y11, I, �, ILlri::� LLr '�l 1•J}5� Y' I{�II, ,li; ��tl''; 11, t I �� �; ! rr,'11ldl ;) //J,111:11 �I 1 i�' Y!Y !�„i� ,III�'ISlll llli^l'>Il nl�i i� I:tll,'r,{iidm ILXi �' Alr/,,p l' ;,.r!,r .,1 ,IrrNli:,'� ( � I III fr f. •, � ,:\ �� I �PI!l.,}I I'y ! .4 I'I. ,• 1 •,• ,I, ,1�7 n J t:•�1�ib h„ ,;�Yh' 6..11�1I11,ti w`:�!r+ r;l,l. ,�,I 11.;;.,, )I�J,r;11 1 ,)1. I' Ii I i'•; 1 ,c �� ,�,71, '� 1 'v[,.• I'�II!I I(��v vl„ �, i11 i I':1 t `� }� I ��r f►,, p�l I I �� I;. ,,,.• ! �I,:!; ! ' 'I� ..)�•,1.:'Ir 1 , II..c,l ,,L.I,h /,11 l 1 I r'�.'I;I r,.11l:,' .I,,I�'�/�lll yli.,tipti,►r:,, I'I�,I�Iir,�� ���I� �! (� I ,I DIY I 1 ,�.J►� �y I. .M► if 1 Ylip Vfll� .l h•, I, l4 L j6 � 1 �� � �� 1►la� ull�� � ;'�;u 1� ''•'j ';�,II 1l, I/uMl I 1 ! 1 I 1 �;��I I�ylr�;r lia;'� ':I trfl f,' +��;.11�'Irl,.I�,,, 1(IIf!JtL • ' � r I I), 1 1�{( fll•I ,,r' f 1 I��I I r�• , , II /1 1 ��SI� � ''� `�'; 111•II(,'.,•61�1,.�'I' ) , ,..,I'11,d!!''!�.:).fl.{Ili'��; 'I%�14r .dl ll ,I � I '•�,t' � ,� 'J �(f 5 Y�I,'711 A'�'",I II,;••.n41�r1! /:r� !1 '. S�� r 111: J' i (,� � �' �!' 1''!Ir71/� I� „�. + ��9 ;yll ��f�('i I.(ylri 1�!',1.� �1 �, h 11; J�,1�''!��Ill- , �',�IP+•If,�{Il�p, ',, !'If•Prl'1 I � �, ,`�I� h I. , ^ R I• +� � !;;.�,� t , / ,I>,!., I,l �� 1 ,It, �� Iyp ZII I.,,lr '� ' I � !t 1 rh I� I�b{l� I�,Ie P7 r r ,� �� 1�•'�,I`:/I l � ( ,l+i171. '.1 , ,,i r 1�{I;e ' 1 ,�: �� 'V '� 1 �I{t I I Y �. V, '� !. dJ (!/r !I((l1${','/ n)I 1 !V/, d i4 I/yI�r ' �•i i ' 17 ,)Ql r � Ir\I -!1 ��I II;/l 1 , � ,Y1� ' (� �'I� �1�� ' !,),�L•4,1111 ,:�',i•�;,�.:.1� !l �1J l/l�'il' If I,• ,I�r'll 1 `I 'U)� >rlU ((,�y lr• �r,,;' ' �,I ;, I � �. ,,!I 'A ��'u C ,{u�l/, /!,; I g�1�I,I � �'I, I,�� ,.��� , ��/�;I � � I 1! I ,I v 1,I�„I'C+��!�,rr��•,(r�'�I�{I 1 ,t( '•�+ry, `` la,,.1 I i,rr, �it I�I +1 Y;/V ( r I+ I'll. I'f !t I I r' �ll `r! Llu:,l ! •t,(, �I,�� ��.I,. .,i•! Y ,! ' �jil, 11`ti'!r ro- •I (�r. +>1 I'� I I1, Illhn I r' ��•,I I,�1:,,;!I w.':,, ,���, ..,f' �� I rr>Ir' , b 't' �,y,I '1 j�lq' �� '1, ,i fill t:, l,lp;� l•ti.,��+� J!; rl% '�'(�'�11'�'+����p/r' 1 r j r'i! � , �JI �",: IIII'1,�,� r' ►,�,',1�������II1 in 1 DATE(MMIDD/YYYY) ACORO� CERTIFICATE OF LIABILITY INSURANCE 1/8/2021 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 NAME: Amanda Massa Edgewood Partners Insurance Center PHONE FAX 1 American Lane 203-658-0507 lac,No): Greenwich CT 06831-2560 ADDRESS: amanda.massa a icbrokers.com INSURERS AFFORDING COVERAGE NAI!CA INSURER A:Charter Oak Fire Insurance Company 25615 INSURED PARAGASC INSURER B:Travelers Indemnity Company 25658 Paraco Gas Corp; Paraco Gas of CT Inc INSURER AXIS Surplus Insurance Co 26620 Paraco Gas of NJ LLC; Paraco Gas of NY Inc. - 800 Westchester Ave,Suite 604 INSURER D: Rye Brook NY 10573 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:799914031 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. I�7R TYPE OF INSURANCE ADDL SUER POLICPOLICY NUMBER MMIDDY EFF POUIMMIIDOfYYYY LIMITS A X COMMERCIAL GENERAL LIABILITY Y1N6601P009026COF21 1/1/2021 1/1/2022 EACH OCCURRENCE $2,000,000 DAMAGE TOR N CLAIMS-MADE LJ OCCUR PREMISES Ea occurrence) $300,000 MED EXP(Any one person) $5,000 PERSONAL&ADV INJURY $2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $2,000,000 POLICY JECTPRO- OTHER ❑LOC PRODUCTS-COMP/OP AGG $2,000,000 _X : $ B AUTOMOBILE LIABILITY Y1N8109J6196941ND21 1/1/2021 1/1/2022 COMBINED SINGLE LIMIT $2,000,000 Ea accident X ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE $ - - AUTOS ONLY AUTOS ONLY Per accident C UMBRELLA LAB X OCCUR P00100005161203 1/1/2021 1/1/2022 EACH OCCURRENCE $3,000,000 X EXCESS LIAB CLAIMS-MADE AGGREGATE $3,000,000 DED RETENTION$ $ A WORKERS COMPENSATION UB8N6879022151D(AOS) 1/1/2021 1/1/2022 X PER OTH- B AND EMPLOYERS'LIABILITY STATUTE ER _ YIN UB8N6862232151R(MA Only) 1/1/2021 1/1I2022 ANYPROPRIETOR/PARTNER/EXECUTIVE F--1 E.L.EACH ACCIDENT $1,000,000 OFFICER/MEMBER EXCLUDED? N/A -- (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $1,000,000 If yes,describe under -- DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $1,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES (ACORD 101,Additional 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 ACCORDANCE WITH THE POLICY PROVISIONS. Village of Rye Brook 938 King Street Rye Brook NY 10573 AUTHORIZED REPRESENTATIVE ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD Workers' y T E Compensation CERTIFICATE OF Board NYS WORKERS' COMPENSATION INSURANCE COVERAGE 1a.Legal Name&Address of Insured (use street address 1 b. Business Telephone Number of Insured only) 914-250-3700 Paraco Gas Corp. 800 Westchester Ave Suite 604 1c. NYS Unemployment Insurance Employer Registration Rye Brook, NY 10573 Number of Insured Work Location of Insured (Only required if coverage is specifically 1 d. Federal Employer Identification Number of Insured or Social limited to certain locations in New York State,i.e.,a Wrap-Up Policy) Security Number 13-3149941 2. Name and Address of the Entity Requesting Proof of 3a. Name of Insurance Carrier Coverage(Entity Being Listed as the Certificate Holder) THE CHARTER OAK FIRE INSURANCE COMPANY VILLAGE OF RYE BROOK 3b. Policy Number of entity listed in box"la" 938 KING ST UB-8N687902-21-51-D RYE BROOK, NY 10573 3c. Policy effective period 01-01-2021 to 01-01-2022 3d. The Proprietor, Partners or Executive Officer are ® 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 "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 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: STEPHANIE BAKER (Print name of authorized representative or licensed agent of insurance carrier) Approved by: ' 12-30-2020 (Signature) (Date) Title: SR CUSTOMER SOLUTIONS REPRESENTATIVE Telephone Number of authorized representative or licensed agent of insurance carrier: 804-527-4852 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 W31F3117