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HomeMy WebLinkAboutMP22-120 Q� 40A annimwaW VILLAGE OF RYE BROOK MAYOR 938 King Street, Rye Brook,N.Y. 10573 ADMINISTRATOR Jason A. Fein (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 16,2022 Cohen Purchase Building Company LLC 975 Anderson Hill Road Rye Brook,New York 10573 Re: 975 Anderson Hill Road, Rye Brook,New York 10573 Parcel ID#: 129.34-1-42 This document certifies that the work done under Mechanical Permit#22-120 issued on 7/28/2022 for the removal of a pump dispenser unit and piping on a 1,000 gallon above-ground gasoline tank has been satisfactorily completed. Sincerely, f f , u Steven E. Fews Assistant Building&Fire Inspector /to QyE BR(��• cu � 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 :— C'A--� 6-��so" 'Ao\ (L(a DATE. 122 —22 —1-20 -c" PERMIT# ISSUED: -I* SECT:� '� BLOCK: LOT: LOCATION: ` ► \ !" `-`<-)(k OCCUPANCY: ❑ VIOLATION NOTED ` THE WORK IS... P ACCEPTED ❑ REJECTED/ REINSPECTION ❑ SITE INSPECTION W\[ � �C_ REQUIRED ❑ FOOTING ❑ FOOTING DRAINAGE ❑ FOUNDATION ❑ UNDERGROUND PLUMBING NOTES ON INSPECTION: ❑ ROUGH PLUMBING ❑ ROUGH FRAMING \ �e ❑ INSULATION ❑ NATURAL GAS ❑ L.P. GAS FUEL TANK \ 1 n ❑ FIRE SPRINKLER ❑ FINAL PLUMBING ❑ CROSS CONNECTION ❑ FINAL ❑ OTHER O q 00 eq 00 rWr 'p N : W ppyy v p L C a .Y a _ cn O. N .wr ,] N p % b + � O :Ln by I~ 00 oQ � o ° ws A M � � q ° c � 1 q 0 o o o � � � �� � O O © N CDo o o "y .. q M H W far W �+ P-4 v F z o v W V °Op �"+ Q x c� H a v° ° c U , per _ O (Oj W U Z a WI�I Z I 0 vQ ay �j ICI cn G1 O c`rl A (7 � W � g V U O `-' Ili aw 09W W ,� N a0 ,5 z o v w v r' o • z °a a.d v P-4 U V v $ o ° `° ' w Y v Vin o � x °a v o Y b • �E I3RC�iJ Q V2i' ' VILL "OF BROOK ("T BU NG DEEP MENT JUL 2 6 2022 938 KING FT YE K,NY 10573 (914)93 ebrook.or VILLAGE OF RYE BROOK --_7Y_YL-- BUILDING DEPARTMENT APPLICATION FOR PERMIT TO INSTALL, MODIFY AND/OR REMOVE MECHANICAL EQUIPMENT OFFICE USE Permit#: 0 _ Building Inspector: Application Fee: v -7� Date of Approval: Atir Permit Fee: -$ c3 /,5--Ab Bldg/Use Class: Res. ( ); Comm. O; REQUIREMENTS FOR RELEASE OF PERMIT: (A CERTIFICATE OF COMPLIANCE 19 REQUIRED TO CLOSE OUT THIS PERMIT) 1.Properly Completed& Signed Application. 2.Payment of Application Fee: Residential= S 100,00; Commercial =$250.00 (lees are non-refundable) 3. Site/Staging Plan as required by the Building Inspector. 4. Sealed Construction/Installation Documents&Specifications as required by the Building Inspector. 5. Copy of Licensed Contractor's Liability Insurance. (Village of Rye Brook must be listed as certificate holder)& Workers Compensation Insurance on a NYS Board form (Form#C 105.2 or Form#U26.3/or NY State Workers Compensation Waiver) 6. Payment of Permit Fee: Residential —S 15.0011000.00 of Construction/Materials Cost with a minimum fee of S 100.00. Commercial =$25.00/1000.00 of Construction/Materials Cost with a minimum fee of$275.00. 7. Inspection by Building Department for removal and/or installation. (48 hour police required) 8. Any electrical work requires a separate Electrical Permit and Electrical Inspection. 9. Any gas/plumbing work requires a separate Plumbing Permit and Plumbing Inspection. Application dated, !—t 4 is hereby made to the Building Inspector of the Village of Rye Brook,NY,for a permit for the installation,modification,and/or removal of the specific Mechanical Equipment as listed below.The applicant and property owner,by signing this document agrees that said equipment will be installed and/or removed in conformance with the approved plans,and with all applicable Local,County, State&Federal laws,codes,rules and regulations. 1.Address: SBL:),)9,37—/"7 e Zone: u 2.Property Owner: `1kdVqP al Address: e� Phone#: 9A —91/y -0?( `i/ Cell#: //��� ,,,,,, ,,,,,,•• em�aiil::, y�'` ,arcu & �w 3.Contracto{{r��:rr�� / ,5� ,( / W�'Y� U / Address: 9�AUQ & /Ahox( Phone#:Xjt CRo , ! Cell,#:/ email:h �!l 4,Applicant � ` � fVUWW) L� � 1�/I Address: : � Phone#: ��L1'olb� p Cell: email: 14111 5. Scope of Work:New�tallation( )•Replacemeent( )•Removal K)•Otherl, 1 /6.Type of Equipment: M $ � vl T e'W© 7.Location of Equipment: 9F M-klkoam POW 8.Cost of Equipment including Installation Cost: $ 1 8/12/2021 STATE OF NEW YORK,COUNTY OF WESTCHESTER ) as; kkw? -Fyozel/ ,being duly sworn,deposes and states that he/she is the applicant above named, (print name of individual signing as the applicant) and further states that(s)he is the legal owner of the property to which this application pertains,or that(s)he is the Ott- for the legal owner and is duly authorized 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 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 this �01 'V d Sworn to before me this j day of ,?O o day of G . 2( Vria. perty Owner Signature. Applican I�Pd klroperty caner Print me of Applicant fC h I i c Notary Public PATRICIA LEWIS MADELINE C. CITRONE NOTARY PUBLIC-STATE OF NEW YORK Notary Pubtic. State of New York No.Ot LE6�77006 No. n1 NIP 6030446 Qualified in WPStchester County�.< 0usllfled In PutnemCounty This application t�%"'A g `t i�iti ire entirety and must include the nota oe iatlo8@;0h*a W111-z0ZS 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. 2 8/112021 DUTCENV-01 BERMII FACORO DATE(MMIDD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 6/14/2022 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: Emery i Webb,Inc. PHONE 845 896-6727 ,C,No: 845 896-6877 989 Main Street (ac,No.E■t): ( ) ( ) Fishkill,NY 12524 ADORE : INSURERS AFFORDING COVERAGE NAIC# INSURER A:Great Divide Insurance Company 25224 INSURED INSURER B:Ohio Casualty Group 24074 DutchesS Environmental Construction,Inc. INSURERC:Technology Insurance Company 936 Route 6 INSURER D: Mahopac,NY 10541 INSURER E INSURER F: COVERAGES CERTIFICATE NUMBER: 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 SUBR POLICY EFF POLICY EXP TR TYPE OF INSURANCE I D yyyp POLICY NUMBER YYY MM D LIMITS A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE ❑X OCCUR X ECP2003674520 9/2/2021 9/2/2022 DAMAGE TO RENTED 100,000 X Pollution MED EXP(Any oneperson) 5,000 X Professional Liab PERSONAL BADVINJURY 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE 2,000,000 X POLICY PRO-- LOC PRODUCTS-COMP/OP AGG 2,000,000 X OTHER:Limited Contractual $ B AUTOMOBILE LIABILITY (Ea accidentlCOMBINED SINGLE LIMIT $ 1,000,000 X ANY AUTO BA058545341 5/20/2022 5/20/2023 BODILY INJURY Perperson) $ OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY Per accident HIRED NON-0WNED PROPERTY AMAGE AUTOS ONLY AUTOS ONLY Per accident UMBRELLA LIAB OCCUR EACH OCCURRENCE EXCESS LU16 CLAIMS-MADE AGGREGATE $ DED I I RETENTION$ C WORKERS COMPENSATION X I PERTUT OTH- AND EMPLOYERS'LIABILITY YIN TWC4113969 5/20/2022 5/20/2023 1,000,000 ANY PROPRIETOR/PARTNER/EXECUTIVE a NIA E.L.EACH ACCIDENT OFFICER/MEMBER EXCLUDED? (Mandatory n ) E.L.DISEASE-EA EMPLOYE 1,000,000 If yes,describe under 1,000,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Certificate Holder is included as Additional Insured with respect to General Liability,as required by written contract or written agreement,subject to the language of the policy. 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 AUTHORIZED REPRESENTATIVE Bldg Dept 9 King Street Ry e Brook NY 10573 l ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD ' STATE OF NEW YORK WORKERS' COMPENSATION BOARD CERTIFICATE OF NYS WORKERS'COMPENSATION INSURANCE COVERAGE Ia.Legal Name&Address of Insured(Use street address only) lb.Business Telephone Number of Insured (845)628-3610 Dutchess Environmental Construction Inc. 936 Route 6 lc.NYS Unemployment Insurance Employer Registration Number of Insured Mahopac,NY 10541 Work Location of Insured(Only required if coverage is specifically Id.Federal Employer Identification Number of Insured limited to certain locations in New York State,Le,a Wrap-Up Policy) or Social Security Number 16-1533676 2.Name and Address of the Entity Requesting Proof of Coverage 3a.Name of Insurance Carrier (Entity Being Listed as the Certificate Holder) Technology Insurance Company Village Of Rye Brook 3b.Policy Number of entity listed in box"la" Bldg.Dept. 938 King St. TWC4113969 Rye Brook,NY 10573 3c.Policy effective period 5/20/2022 to 5/20/2023 ;d.The Proprietor,Partners or Executive Officers 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"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 PACE 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 premium 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 the 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: John C.Webb III (Print name of authorized representative e or lice n ed agent of insurance carrier) Approved by: OL V• 5/19/2022 (Signature) (Date) Title: President&Chief Operating Officer Telephone Number of authorized representative or licensed agent of insurance carrier:(845)896-6727