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HomeMy WebLinkAboutMP22-139 t L�'eu+Jy C♦ L 4 Vy V,W J VIA anniumaW VILLAGE OF RYE BROOK MAYOR 938 King Street, Rye Brook,N.Y. 10573 ADMINISTRATOR Jason A. Mein (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 October 25,2022 27 Garibaldi Place LLC 27 Garibaldi Place Rye Brook,New York 10573 Re: 27 Garibaldi Place,Rye Brook,New York 10573 Parcel ID#: 141.43-1-33 This document certifies that the work done under Mechanical Permit#22-139 issued on 9/12/2022 for the removal of an above-ground oil tank and the installation of a new above-ground oil tank has been satisfactorily completed. Sincerely, Michael J. Izzo Building&Fire Inspector /to �Q J932 OuJ�7'(' 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 i - - - - - - - - - - - - - - - - - - - - INSPECTION REPORT - - - - - - - - - - - - - - - - - - - - ADDRESS: t i ` �!'� DATE: ( 17-) PERMIT# ISSUEDIAil ECT: BLOCK: LOT: 51� �J ``may 2 LOCATION: SY� ,/ OCCUPANCY: "oe ❑ VIOLATION NOTED THE WORK IS... ❑ ACCEPTED ❑ REJECTED/REINSPECTION ❑ SITE INSPECTION REQUIRED ❑ FOOTING ❑ FOOTING DRAINAGE ❑ FOUNDATION ❑ UNDERGROUND PLUMBING NOTES ON INSPECTION: ❑ ROUGH PLUMBING ❑ ROUGH FRAMING [IINSULATION Z ❑ NATURAL GAS ❑ L.P. GAS FUEL TANK ❑ FIRE SPRINKLER ❑ FINAL PLUMBING ❑ CROSS CONNECTION ❑ FINAL ❑ OTHER i r.. G� 14 er w ON � a V VL 1L1- 4 wyy W O i I1 Ln p 0Aoo w ° ° � Cc) H M V u o L4 T © N .� LO ' �r oo �. Dfr Z a 00 � o�x -0 � ro 1 u w y 14. O� F� z P. U z v a M p o U 00 Z E ra Vw 00 ~ U U O O o,� e ' nc. �J 0 a z Orb aw A a ca ° g V it 0 ai O F tL ^a ICI z � " a U N q a W � :;) wu PG ff - I a a a w x BUILD1, �EP MENT D VIL �k'GE OF R:Y OOK SEP - 8 2022 938 KING ET I'J,E BR NY 10573 VILLAGE OF RYE BROOK BUILDING DEPARTMENT Application for Permit to Remove, Abandon and/or Install Fuel Storage Tank (*Storage Tanks in excess of 1,100 gallons require registration with the County of Westchester) FOR OFFICE USE ONLY: PERMIT#: Approval Date: SEA (2 2022 Permit Fee: $ 3 70! /-a Approval Signature: \4 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: S 185.00 per Tank. S. 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. Aation dated, ,is hereby made to the Building Inspector of the Village of Rye Brook for a permit to e abandon,' sta Fuel Tank as herein described. The applicant and property owner,by signing this document agree e 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 {J Removal( •Abandonment( )/Above Ground („f• Buried in Ground ( ) I. Address:-a-I czgl '►--OAA, �X_. SBL: ii{ _Zone: 2. Property Owner&Address:M Gar:6aAJ1P , _ yp)� � � i0b-- 3 Phone#: Ip` • n Cell#: email: •c_. . 3. Contractor&Address: ��rc�^e.emu,� (cam- }�an �1,br �. , T �5zi r �7 Phone#: Vy • Cell#: email: 4. Applicant: Phone#: a - �_Cell#: ZOO-_5-31- Qn email: Py � Atr'Cr�31.� 1'YXV�,Qy 5. Indicate Fuel Type: Fuel Oil V- L.P. Gas( ) •Gasoline( )•Other( ): 6. Number and Capacity of each Tank: mc y)r-, 2 7. Exact Location(s)of each Tank: i 8/12/2021 S AT OF i4 , COUNTY OF ) as: Prn M ,being duly sworn,deposes and states that he/she is the applicant above named, (print name of individ al signing as the applicant) and furth r states tha (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. i icate 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 me this t S�` Sworn to before me this Ak day of ,20'Z--L day of �P��krr fj ttr 12 _ Signature of Pro rty Owner Si nature of Applicant 4 Skonj(L-N-Li e% VIt`d n "`i 7 '(11 Print,Name of ro erty Owner Print Name of Ap ica Notary Pub NA GAL Notary—Public Notary public,State of New YorkSEAN LYTLF- No. 4763183 r NOTARYPUBLIC Qualified in Westchester County �� My Commission�iirea A+sg,31,z025 C ssion Expires November 30,20 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. 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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. 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 FEDERATED MUTUAL INSURANCE COMPANY .N-AME: CLIE_NLCONTACT.CENT.EB.__...-..._—_—_—. HOME OFFICE:P.O.BOX 328 PA/c.N I;888 -4949 NE FAX No):507-446-4664 OWATONNA,MN 55060 1.DMDRess:CLIENTCONTACTCENTERQFEDINS.COM INSURER(S)AFFORDING COVERAGE NAIL if INSURER A:FEDERATED MUTUAL INSURANCE COMPANY 13935 INSJRED 330-130-6 INSURER B: WESTMORE FUEL COMPANY INCORPORATED INSURER C: 86 N WATER ST —T-- - � - GREENWICH,CT 06630-5886 INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:35 REVISION NUMBER:0 THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD ;NDICATED. 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 NSR TYPE OF INSURANCE OL SUER POLICY NUMBER POLICY Err POLICY EXP LIMITS TR MMIDDry YYY MM/DDIWV`/ X COMMERCIAL GENERALLIABILITY EACH OCCURRENCE $1,000.000 CWMS-MADE OX OCCUR DAMAGE TO RENTED S100,000 PltCtdl:ES.-!Ea 4Srwltnf!1 MED EXP(Any—pa m) S5,000 A N N 9062815 06/01/2022 06/01/2023 PERSONALS ADV INJURY S1,000,000 G 'L AGGR GA E UM IT APPLIES PER. GENERAL AOOREOATE $2,000,000 X POLICY JET O LOC PRODUCTS-COMP/OP AGO $2,000.000 OTHER: NTAOMO:LOE LIABILITY COMBINED SINGLE LIMIT $1,000,000 a•NY 80DILY INJURY(Per person) OWNED AUTOS ONLY SCHEDULED A AUTOS N N 9062815 06/01/2022 06/01/2023 BODILY INJURY(Per accidwo !HIRED AUTOS ONLY NON OWNED PROPERTY OAIAAGE 1--1 AUTOS ONLY IP r r idenU I X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $7.000.000 A EXCESS LIAR CLAIMS-MADE N N 9062816 06/01t2022 06/01/2023 AGGREGATE S7,0D0,000 DED RETENTION WORKERS COMPENSATION X PER STATUTE OTN AND EMPLOYERS'LIABILITY Y/N ER ANY PROPRIETOMPARTNERIEXECUTIVE E.L.EACH ACCIDENT S500,000 A OFFICERIMEMBER EXCLUDED? N 1 A N 9917566 06/01/2022 06/01/2023 -- -- - — IMandalory ie NH) E.L DISEASE-EA EMPLOYEE S500,000 (I Yr S.desclUO Under DESCRIPTION OF OPERATIONS Erlew El DISEASE POLCY LIMIT S500,000 DESCRIPTION OF OPERATIONS 1 LOCATIONS I VEHICLES(ACORD 101.Addifi—I Remarks Schedule,may Ue ItIN—d i1 more space Is rmp ired) 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 © 1988-2015 ACORD CORPORATION.All rights reserved. ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD New °rI<furs" CERTIFICATE OF 1.. .. ._ YORK Compensation Board NYS WORKERS' COMPENSATION INSURANCE COVERAGE to Legal Name&Address of Insured(use street address oniy) tb.Business Telephone Number of Insured Westmore Fuel Company Incorporated 203531-9656 85 N Water St Greenvdch CT C6830-5886 tc.NYS Unemployment Insurance Employer Registration Number of Insured Work Location cf Insured(Only required if coverage is specifically fm fed to td Federal Employer Identification Number of Insured or Social Security certain rocarions in New York State,i.e.,a Wrap-Up Policy) Number 06-C739367 2.Name and Address of Entity Requesting Proof of Coverage 3a.Name of Insurance Carrier (Entity Being Listed as the Certitcate Hoider) Federated Mutual Insurance Company ViEage Of Rye Brook 938 King St Rye Brook,NY 10i73--226 991758(i 3b.Policy Number of Entity Llsled in Box'ta' 3c.Policy effecttve period 06i01i2022 to 0610V2023 3d.The Proprietor,Partners or Executive Officers are included.(only che:k box if ail partnezlefrice:s irlUW-d) �X a!I excluded or certain partnerVotf,cers 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 Insuraece to the entity listed above as the certificate holder in box"2". The insurance carrier must nolifv the above certificate holder and the Workers'Comper:sabon 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 or.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 cerificate does riot 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'Compensa,,icn contract of insurance only while the underlying policy is in eaect. 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 (Punt ramp of aulhorized rep:eseri]Mive or licensed agerr,of iworati—carrie.ri Approved by 1)^,,u,1&0 (t, 04/26/2022 (signature) (Dale) 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) veww.wcb.ry gov