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HomeMy WebLinkAboutMP22-126 4R VILLAGE OF RYE BROOK MAYOR 938 Ring 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 Steven E. Fews Stephanie J. Fischer David M.Heiser Salvatore W.Morlino CERTIFICATE OF COMPLIANCE April 10,2024 John Thomas Eggleston&Marielle Kahn Bianchi 60 Rock Ridge Drive Rye Brook,New York 10573 Re: 60 Rock Ridge Drive, Rye Brook,New York 10573 Parcel ID#: 135.36-1-15 This document certifies that the work done under Mechanical Permit#22-126 issued on 8/11/2022 for the installation of two above-ground propane tanks have been satisfactorily completed. Sincerely, Steven E. Fews Building&Fire Inspector /to �yE BR(��• O� 2m • �9a2 BUILDING DEPARTMENT AS VILDING INSPECTOR SISTANT 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: 1J 1z 1 V- DATE: 1 202,v PERMIT# 1 2 Z -1 1 C. ISSUED: S'//-Z L-SECT: BLOCK: LOT: LOCATION: OCCUPANCY: ❑ Violation Noted THE WORK IS... 9 PASSED ❑ FAILED REINSPECTION ❑ SITE INSPECTION REQUIRED ❑ FOOTING ❑ FOOTING DRAINAGE ❑ FOUNDATION ❑ UNDERGROUND PLUMBING NOTES ON INSPECTION: ❑ ROUGH PLUMBING ❑ ROUGH FRAMING ❑ INSULATION 1� I .J �Q ❑ Natural Gas ` 5 � —14 j/ /•J Xf-L.P. Gas ❑ FUEL TANK ❑ FIRE SPRINKLER ❑ FINAL PLUMBING ❑ CROSS CONNECTION FINAL ❑ OTHER �yE aRC�k o`` tim FO 198,2. 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:— OC {.. 1\ { G�Q_ e I V e: DATE:-2- 2 U ` Z U L`/ PERMIT# ?2 2 2 - ) 1 0 ISSUED: - -1Y-Z2 SECT: /_3-5r 3(, BLOCK:/LOT: 45� LOCATION: OCCUPANCY: ❑ Violation Noted THE WORK IS... 03 PASSED ❑ FAILED REINSPECTION ❑ SITE INSPECTION REQUIRED ❑ FOOTING ❑ FOOTING DRAINAGE ❑ FOUNDATION ❑ UNDERGROUND PLUMBING NOTES ON INSPECTION: ❑ ROUGH PLUMBING ❑ ROUGH FRAMING ❑ INSULATION ❑ Natural Gas ❑ L.P. Gas ❑ FUEL TANK ❑ FIRE SPRINKLER Er FINAL PLUMBING ❑ CROSS CONNECTION Q. FINAL ❑ OTHER QyE QRC��. 1982 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 : \ o-t DATE: u z� PERMIT# ISSUED: C:_ LOCK: LOT: LOCATION: �\ t C Q \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 Q L.P. GAS ❑ FUEL TANK ❑ FIRE SPRINKLER ❑ FINAL PLUMBING ❑ CROSS CONNECTION ❑ FINAL ❑ OTHER �o BUILDING DEPARTMENT ❑BUILDING INSPECTOR PeilsSISTANT 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 :— 1 DATE: PERMIT ISSUED `2 � SECT: BLOCK: LET: LOCATION: �� "l °� OCCUPANCY: Z ❑ 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 w(y �e v US ❑ L.P. GAS W CCU �'1 c, c" ❑ FUEL TANK ❑ FIRE SPRINKLER ❑ FINAL PLUMBING ❑ CROSS CONNECTION ❑ FINAL ❑ OTHER _ s s n � _ = N w _ N cq :a w �' v 00 _ ac w0. a v Cd r-4 �I F O Ln i \ G O D H © O H O N o � 30 -Ow� O F--i W O 3 2 O n N w is s w v `n Ln Q d " >, Wfi-, FM Ln � LO � � n O v f� w oo t!) z W z Av � u V o 0 b � 0 � H V z C . UN INN* �/ ICI �7 (� N PQ00 N F+�I Ay. r� A a V V oz � Ica -❑d o00 A O H z a'�� � @ Q•y z z ° D IECr0WE = MENT VIL `� Qr It -. oOK AUG - 9 10 2 938 ICING �GT�X�� :. �} NY 10573 (9I�t) 39-580I VILLAGE QF RYE BROOK W ,v r BUILDING DEPARTMENT __.._ Application for Permit to Remove Abandon anti/or Install Fuel StoraLye Tank (*Storage Tanks in excess of 1,100 gallons require registration with the County of Westchester) FOR.OFFICE USE ONLY: PERMIT#:._.._ 1%1—iv+-1 AUG 2022 440-, Approval Date: Permit Fe( : Approval Signature: Other: — Disapproved: *****Ieci** arerio***1***+*I****** **A* ItE UIREMENTS FOR--I LEASE OF'PERMIT&CERTIFICATE F COMPLIANCE: I. 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 V faiver) 4. Fee per Tank: Removal,Abandonment, or Installation: $185.00 per Tan , 5. Dig Safely New York#(dial 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, / 2- y ,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 ill applicable Village,County,State& Federal laws,codes,rules and regulations. *** **** ** Indicate Permit Type: Installation (Removal( )•Abandonment( )/Above C nd W.Buried*********in Ground ( ) I. Address: /�f r+ --- SBL: �Zone:)e /0- 2. Property Owner&Address;T / W. M. 4-fJ�3 Phone#:a 332 Cell#: email: 1-Ac-k-egVlejA" 3. Contractor&Address: -101141-r� Phone Cell# email: ,,, ' f 4. Applicant: i4� Phone#; c-2z7 Cell#: email• OW 5. Indicate Fuel Type:Fuel Oil ( )•L t Gas( Gasoline( )•Other( ): r G. Number and Capacity of each Tana _ JF 7. Exact Location(s)of each Tank; i 6/I/2020 I wrATV OF NEW Y()1t;K,t'OLINTY t+ FWf.SIt'Ift"IfR as I 1Prill411siv ertndtrlrfri, - heinR duly swtun,deptuiea and states that she is the applicant above ninied, 4f1egt w��rcwaity ead I" atp that("he is file legal owner ufthe pmpeity it)which this apPlicatit i pertains,fir Ihat(s)u is the � - Rif the IcRal owner and is duly authorized to make and rile th,a aPt+ltrAfinn ricer, �rt�i+ioct,..Wwf - _ I hat all statements aarht contained he are trite to the heat of hi4 her knowledge awl tiel ef,and that any work performed.fir us, ecmducted at the at%wve caPlioned Property will he in confonnanee with the details as set forth and centained in this apPtitaatiun and in any accMPAnYing aPMved plans and specifications,as well as its accordance with the Now York 5twe `mkxm Fire Prtvditet}n dt t3uilding(:ix1e, arid requlaliona file(ode of the VillaKe(if Rye Brook sn4 all other applicable laws,ordinaimc% 1 } twom 11)be tnctthtr it - Swora 1"I? file this day of 4— - day t ?0 Signature roe (l � .� P rt5 owner Si dire of Appliraar Pnnf Name of Pro } L C/E"••• Aim Pru Ktanie of. ticanr MtT-SLMJ SEGum 1"hN,c•Slate of New York Notaryhuhlic ^'�'ttJ'.Gtaf6tr,4337 - - �' 6rphr Cat eiy �„tal, lit: CHEI,rrL A. ZASTENCHIK }„01 Erpiret Mar 1,1014 Notary Public State of New York No.0]ZA6098466 Qualified In Putna Cotartty applicalitrlr irlust he properly crtmplelcd in its entirely and muss inFludt:III. My Commisston Explres� ol'Ille legal awrrrrr(S)ul.the suh�et.t pritpeny,and the applicant of record in the.Vafcts;pf,fiviLlcrl. Anv rtPplic3litm'liot properly cols pleteil in its entirely acid/fir not property si netl shall he deemed null arul void and will he returned to die applicaon f r <ZZ pH V St � �LU•1 %� g 6llI O TU d ,ai TLl � N ^ b w N O W , d W 1♦A }g�yM� �.,W O F R - �p 01 W d � d of q Cc �! V C4 I sit S �2o R d �w d - T _H 8 3.ftMCC S p ,00'SLI W .o-.e� jh - CQ zz cnr- Z� A E A W LA � o ' N a a in o 02 '' Ga CD o � d . 0 P O M = OS O 1- N O ¢ 3 M w W ao N .0 _N \ OZ N n C) w � N = � § �o s o L� W i N UV I) O \ 2 N 2 ON Of Z it U—LLJ Z Lp of 2 N U &i U L,J H ^ N J QQZ W U O W 2 O O 0 ,\n, Z Q o a LL d . O N X U J ( cnd py D Z (D a0 � fl O cV >� x a C� CD e Z cV P � O \W Q p O M O Q W C) /I Z g Z Fuj 4N.I (V U 6 � N Cn O Z w w 04 _ O:f wo r O ¢N Uj ix O O < U O Q rn CO CL n.w��C3 N \ N O O CL. Q CO J I � d Ad C) O O d O O_ rl N d O Z O O O O Z= Z C)=� O \ N U�3 o J = w5>c !w Pw>O W U ZN WU W �0 O or r O N H d W 2 M U CD N �OZ A Z ND y m L u AS w= J p 2-5 m NOlion00bd aOd 03SV3 3N ?o�Q ?ino d0 03AOaddV £lOZ VON30OV/3000 z cv�i o r� N Z O a vo- Laura Petersen From: Gina Clements <gina.clements@paracogas.com> Sent: Tuesday,August 9, 2022 2:00 PM To: Laura Petersen Subject: RE:Tank Application - 60 Rock Ridge Drive Importance: High Apologies—I forgot to write down the number 2. The permit is for two 120 gallon AG LP tanks. Scope of work:Install two 120 gallon AG LP tanks with pads and connect to plumber's gas line after brought to tank location and inspected. Please confirm. Thank you, Gina L. Clements Paraco Gas,Corp/Permit Admin 845-207-5774 From: Laura Petersen<LPetersen@ryebrook.org> Sent:Tuesday,August 9, 2022 1:51 PM To: Gina Clements<gina.clements@paracogas.com> Subject:Tank Application -60 Rock Ridge Drive IYou don't often get email from Petersen@ryebrook.org. Learn why this is important [Alert: External Email] Good afternoon, The Building Department has received in the mail the tank application as well as the fee for the above ground tank installation at 60 Rock Ridge Drive. Please verify the number of above ground tanks being installed. Thank you Laura Laura(Petersen Office Assistant Village of Rye Brook 938 King Street Rye Brook, New York 10573 Phone(914)939-0668 I Fax(914)939-5801 1 Petersen(a)ryebrook.org 1 i o N � � \ W N N Ln a N \ c w a 00 vi In v (n Ln r" °-- a Z V ,� W z a z LO " H p H � z x w $ x d Zo z Ln Ln Ln lz p r�TT r � Lta oo Ln z 10 io,o U ,. V' w00 � � z w `n WF1 C� H O en z 00 0 Z Ac Mw cn ►--� O ►� z Q \o w r wo z a A z z ., w z H H " a LL O4 W w C ■ w CDz F. x " a w z x 0o +� a r. W V as a a �l w r ` HBUILDING DEPARTMENT 2 Z 2022 VILLAGE OF RYE BROOK 938 KING STREET RYE BROOK,NY 10573 VILLAGE OF RYA BROOK (914)939-0668 BUILDING DEPARTMENT www.fy�brook.org PLUMBING PERMIT APPLICATION FOR OFFICE USE ONLY A& D ' �p PP#: [ [ O AUG 2 5 202 1 -75 ,D�- , Approval Date: Permit Fee: $ Approval Signature: Other: Disapproved: (fees are non-refundable) Application dated, LZ 22- is hereby made to the Building Inspector of the Village of Rye Brook NY,for the issuance of a Permit to install and/or remove Plumbing as per detailed statement described below.The applicant&property owner,by signing this document agree that said plumbing work will be in conformance with all applicable Federal,State,County and Local Codes. 1.Address: &( QOC k R ; a 5 C Q r;vJ Q IZYG rook � /V /SBL: � 1.36 —1—IS Zone:I�p —)C) 2.Proposed Work: i �+ '/nD- /✓� /_Jd �'- d/ 5­� e . 3.Property Owner: C�-/i Address: A.6 y ie Phone#: Cell#: `� - ��7"33��email:� 4.Master Plumber:F�-_r✓!a VI cL-) Po YY q a n Address: )A S St A P-F.3 0/v Ll t 14 i✓1 5 N� Lic.#: )561S Phone#: Cell#: S 65 d,N),S email: r, r;YM/I a,,j 19_/,0 jo A01 W Yv1 Company Name: F, A , P 1 u rh i q g 8 f 1a-f-/1 J Address: P6 L.dl ka, S t P b..3 O A! ( n,t Cc, ►a i Y1S �1 INDICATE FIXTURES&LINES TO BE INSTALLED AS PER THE FOLLOWING SCHEDULE: Location Water Urinals Drinking Sinks Showers Bath Laundry Domestic Fire Sanitary Natural/ Other* Total Closets Fountains Tubs Tubs Service Service Sewer LP Gas Basement 1st Floor 2nd Floor 31 Floor 4m Floor 5''Floor Exterior I 5.*List Other Equipment/Provide Details: (Notarized Signatures Required Next 2 Pages) 4- 8/12rzo21 STATE-OF NEW YORRK,COUNTY OF WESTCHESTER ) as: 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)ha is the legal owner of the property to which this application pertains,or that(s)he is the ✓ 4y - -le 4 A, r4 CV//, 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. Swom to before me this Y' 6 Sworn to before me this day of ,20 2- Z. day of ,20Q_ nSignaof P operty Owner 7of Applicant Mgy A( t e of Pr p er Print Name of Applicant ANTHONY TEN Public SHARI MELILLO A-c� =�,u& Notary Publicic-Statee of of Newew o York �' 140.01TE6324959 Notary Public,State of New York Qualified in Westchester County No.OIME6160063 My Commission Expires Jun 21, 2023 Qualified In Westchester County Commission Expires January 29,2 This application 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. Applications 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 IE BUILDING DEPARTMENT '-�'� f C VILLAGE OF RYE BROOK Ll AUG 2 2 938 KING STREET RYE BROOK,NY 10573 202� (914)939-0668 VILLAGE Of= RYE (3ROOK viWw.rArook,ore BUILDING DEPARTMENT t AFFIDAVIT OF COMPLIANCE VILLAGE CODE §216 - STORM SEWERS AND SANITARY SEWERS THIS AFFIDAVIT MUST BEAR THE NOTARIZED SIGNATURE OF THE LEGAL PROPERTY OWNER AND BE SUBMITTED ALONG WITH ANY BUILDING OR PLUMBING PERMIT APPLICATION. ANY BUILDING OR PLUMBING PERMIT APPLICATION SUBMITTED WITHOUT THIS COMPLETED AND NOTARIZED FORM WILL BE RETURNED TO THE APPLICANT . STATE OF NEW YOORK, COUNTY OF WESTCHESTER ) as: 31, Ma✓ I C B IO yl.0 k lr , residing at, 20 U �- 8 7,,d f, f 2 /�/LL✓X A, Al (Print name) (Address where you live) being duly sworn, deposes and states that(s)he is the applicant above named, and further states that(s)he is the legal owner of the property to which this Affidavit of Compliance pertains at; Rye Brook,NY. (Job ddress) Further that all statements contained herein are true, and that to the best of his/her knowledge and belief,that there are no known illegal cross-connections concerning either the storm sewer or sanitary sewer,and further that there are no roof drains, sump pumps, or other prohibited stormwater or groundwater connections or sources of inflow or infiltration of any kind into the sanitary sewer from the subject property in accordance with all State, County and Village Codes. (Si ature of P erty wner(s)) M 6 r rz I l c 3 i G✓lc yi k' (Print Name of Property Owner(s)) S orn to efore me this lG O ' 20 ANTHONY S TERRANERA Notary Public-State of New York NO.01TE6324959 Qualified in Westchester County (Notary Pub ) My Commission Exp+ et.h,n 21, 2023 -3- 8/12/2021 Fc� ENEF DI AR 2 0 2024 L--� VILLAGE OF RYr BROOK John Eggleston BUILDING DEPARTMENT 954-557-3322 jackeggleston24*gmail.com 60 Rock Ridge Drive,Rye Brook,NY 10573 March 15,2024 To whom it may concern, I affirm that the oil tank that was previously used for heating at my home at 60 Rock Ridge Drive, Rye Brook, NY 10573,was disconnected by FB Plumbing.The remaining oil in the tank at the time of disconnection was removed safely and used elsewhere.There is no longer an oil tank on our property.The tank was removed and recycled. Please do not hesitate to reach out to me via phone(954-557-3322)or email (iackeggleston24Qgmail.com)with any further questions. Sincerely, ��ew Swom to and subscribed John Eggleston before me this Nota)A/VublicNE ROJgS i�Of 20,` ' M Qualified°n01 RO6 e.f New York Y COmrtliss;o eXAtchester 2 un ty s MaY 2,3,225 on. �+..(; nl i !+ M1 r. Y', M t .�i.7 1 •°+'"1Q�y -N( •�I, :i �'Fi vA r{• + � d., e'}'J' •.. -( �.{A,W.r...: r •n,{�il Nf1 •.,::.. i.:li!iiPtr'+ Ik I>5TI`,( „l v t'J�•�",r 4.. „„ r t A r.aM'• t „' . :.?,'(� ' "14tr}It!. 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PIrr, {.`4�� 1 r ? td4 I I fi 1199 .1 , 7 f• N �� h 1} }� 1 l 71 q!( p 1,•y ,,}c :•• � 1� 1 t��'F� �• 1 �,y �. '� h I d r r�l���� �., •y��� tt13� Aj�f#Q � Y+���, F17: I�• , �7t�1 5 J.'�I :.I )�.� +� ���• 1ip �„�'•• .I;�'•+t'�(�7r �i� '',� ?,��J1. �, J ; 7�Q�1 44, �1'�•dAY/ 7f 1'�J&. J'�l.'. ,ri?'�a Ic � .f� :� .Ar.y7/A•�!'y7� ��,t IQIti •U' ,�I�i Cx14f,Yr'1"'. �t}t!!i� 'lltu ptl^' ll!`)4� �j r u 1j+�� 'Yk (, �G,�',�{IjR�i� 1=t7rjf�, ! �t711..ar,nl,l�}_=�JL 9G 1� Ar� al 11ryW'Il1t . � N�t�,,,.'. 11 t�i'1 r III ': fl'1%� Ij,�', yl�` �i�11i ;i y�Vl ,./ .�Id}' 'i. �?I •1 y r.i rf.�5r�?;.I .r�'„ltly 7Y}�t� ,;. a�1 �..' :}SY� 1�',�'.�'•..., r 9t,i 1 A�{f.>r1�+�1�� ii;' h '+(�} �/}J 1't, }:�jry�,t , ,.'I, 1�3111T(PI�I�l yirr , y J - i�>1. 91II14f_ �+t tl •, t I +++'444 ACORO� CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDD/YYYY) 12/27/2021 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 Edgewood Partners Insurance Center PHONE Amanda Massa FAX 1 American Lane (AIC.No Extl:203-658-0507 (AIc No): Greenwich CT 06831-2560 ADDRESS: amanda.massa@epicbrokers.com INSURERS AFFORDING COVERAGE NAIC# INSURER A:Charter Oak Fire Insurance Company 25615 INSURED PARAGASC INSURER B:Travelers Indemnity Company 25658 Paraco Gas Corp; Paraco Gas of CT Inc INSURERC:AXIS Surplus Insurance Co 26620 Paraco Gas of NJ LLC; Paraco Gas of NY Inc. 800 Westchester Ave, Suite 604 INSURERD:Travelers Property Casualty Ins.Co. 36161 Rye Brook NY 10573 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:541915213 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 POLICWVD POLICY NUMBER MM/DDY EFF POLICY MI I DYE LIMITS A X COMMERCIAL GENERAL LIABILITY Y1 N-660-1 P009026-COF-22 1/1/2022 1/1/2023 EACH OCCURRENCE $2,000,000 CLAIMS-MADE �OCCUR -DAMAGE T RENTED PREMISES Ea occurrence 000,000 _ MED EXP(Any one person) $5,000 PERSONAL 6 ADV INJURY $2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $2,000.000 POLICY JECTPRO ❑LOC PRODUCTS-COMP/OP AGG $2,000,000 X PRO- OTHER: 1 $ D AUTOMOBILE LIABILITY TRJCAP7KO29970TIL22 1/1/2022 1/1/2023 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 $ P $ AUTOS ONLY AUTOS ONLY Per accident C ,UMBRELLA LIAB X OCCUR P-001-000755209-01 1/1/2022 1/1/2023 EACH OCCURRENCE $3,000,000 X EXCESS LIAB CLAIMS-MADE AGGREGATE $3,000,000 DIED RETENTION$ $ PER J A WORKERS COMPENSATION UB-8N687902-22-51-D 1/1/2022 1/1/2023 X ISTATUTE I I ERH B 'AND EMPLOYERS'LIABILITY YIN UB-8N686223-22-51-R 1/1/2022 1/1I2023 ANYPROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $1,000,000 OFFICE R/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 NEW Workers' YRK STATE Compensation CERTIFICATE OF Board NYS WORKERS' COMPENSATION INSURANCE COVERAGE 1a. Legal Name&Address of Insured (use street address 1b. 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 1d. Federal Employer Identification Number of Insured or Social limited to certain locations in New York State, i.e.,a Wrap-Up Policy) Security Number 133149941 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 3b. Policy Number of en'ity listed in box 1a" Village of Rye Brook UB-8N687902-22-51-D 938 King Street Rye Brook, NY 10573 3c. Policy effective period 01/01/2022 to 01/01/2023 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 "la" 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 wo-kers' 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: Kim Owen (Pri fp thonzed representative or licensed agent of insurance carrier) Approved by: 12/28/2021 ( gnature) (Date) Title: Manager, Domestic Operations Telephone Number of authorized representative or licensed agent of insurance carrier: 804 527 4872 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