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HomeMy WebLinkAboutMP22-164 Q�E DR t'L �UJJ V . 19 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 Steven E. Fews Stephanie J. Fischer David M. Heiser Salvatore W. Morlino CERTIFICATE OF COMPLIANCE June 8,2023 The Marlene Klein&The Joel Klein Irrevocable Trust Erica Klein,Jason Klein&Sarissa Montague,Trustees 60 Talcott Road Rye Brook,New York 10573 Re: 60 Talcott Road, Rye Brook,New York 10573 Parcel ID#: 135.50-1-20 This document certifies that the work done under Mechanical Permit #22-164 issued on 11/7/2022 for the removal of an above-ground oil tank and the installation of a new above-ground oil tank has been satisfactorily completed. Sincerely, Steven E. Fews Building&Fire Inspector /to QyE BR(�k, • 1982 BUILDING DEPARTMENT y-(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 - - - - - - - - - - - - - - - - - - - - l , C G� K7 (, ADDRESS : J -) DATE: PERMIT# ISSUED: SECT BLOCK: LOT: LOCATION: V �1 1� OCCUPANCY: ❑ Violation Noted THE WORK IS... 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 ❑ FINAL PLUMBING ❑ CROSS CONNECTION ❑ FINAL ❑ OTHER e : a a _ A z r W N N �Yy z N o Z w CV N N OW cq 4. o a Pr � W L 'a o � W P3 v � � O• © t��w � a Cn 4 � Ln Z Gov � ►" - a InI�t 0.y o �vp Lin � � � � i7, bA O -z� � r a Or— all C -4 a $ ° V� H o , � Cc) ° N � N x d o P4 Q z y d a Q r1 �j n - Z p `p C' a -0 v a�i u MCI rA I Q ,� oho oocn � 9 z w z a z � s w0- ICI t 4, p wC U 41 �1 D Gyd v � 51 14 r W O 14" a larn�l OV �4j, o z o � .� � T BUILDING DrP.mz,rN,1FN'r OCT - 7 2022 0 VILLAGE OF RY(, I;lt()()K R 938 KING S1 tzvi,, r Ri i Bw)(rt:.NY 10573 VILLAGE OF RYE BROOK (914)939-0068 1 BUILDING DEPARTMENT %sw H'.)-wli rotl k.1 w;; 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) 1'0It.OFFICE USE=ONLY: E'1,11111 i °=: Approval Date: N©Y _ 2021........._.............._� . _ _ Permit Fee: $ Approval Signature: _.. _ Other: _ Disapproved: w... .............__................................................� (f'e::s are non-refundable) REO UIIdFME TS FOR RELh:ASE OF PERMrr& iC ERTIFI(ATE OF Cf M111,IANC E: 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: $195.00 per Tank. 5.Dig Safely New York#(dial 811): 6. Inspection by Building Department for removal I 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. ******Y;9:**********t{,ti�riF�F*******t***************&****ah*********nt*******t******•l;k l:tic lPxxxyr*t****ir*#*****F** Application dated, 6v ,is hereby made to the Building Inspector of the Village of Rye Brook for a permit to remove,abandon,and/or inst Il 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 (A•Removal(x) •Abandonment( )/Above Ground(x)•Buried in Ground ( ) 1. Address: 60 Talcott Rd, Rye Brook, NY 10573 _ SBL: 135.50-1-20 Zone. 2. Property Owner&Address: Marlene Klein 60 Talcott Rd, Rye Brook, NY 10573 Phone#: 914-937-4222 Cell#: 914-804-3070 email: marleneklein�a hotmail.com 3. Contractor&Address: Burke Energy_475 Cornmerre Street Hawthorne New York 1[)532_,. _ Phone#:(914) ±19-3507 (Kelly) Cell#:(c�) -127-131() (Dan Lee) email: burkeoerrni s Ln-onanlp.com 4. Applicant: Burke-Energy Phone#:,(?14)„919-3545 Cell#: 14 327 1310 email:burkepermits@meenanlp.com 5. Indicate Fuel Type:Fuel Oil( •L.P.Gas( )•GasoIine( )•Other( ): 6. Number and Capacity of each Tank: Remove (1) 240 gallon.oil tank .-- Install (1) Granby 240..gallon._oil tank 7. Exact Location(s)of each Tank same.location—in. left.Sid e._oftasement_.._--_.--- - 1 8/12/2021 i S.IAKe" FNI:� N/1�h k t�ner cal bl:slrHisl�.1� ) as. oft ur gy ,tieing duly sworn,deposes and states that he/she is the applicant above named, (print name of tndtvidual 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)hc is the _ contractor _ for the legal owner and is duly authorized to make and file this application.(indicate arclurecr,contractor,agent,attorney,e!c.l That all statements contained herein are true to the best of his/her knowledge and belief,and that any work perforned,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 regulatious. Sworn to before me this L..v_ Sworn to before me this day of ���?� ,24 day of 20 �_^ �� �Owncr X S;gnature of Prop latApp leant X Marlene Klein Kelly Redlo_nlBurke Energy Print N e of Property 90<cr Print Name of Applicant of ry Public Notary Public Lavelle grilles QTARYP'uBL1C,STATEOFNEWYORK ELIZABEgTH SARLES pill �0 ) NOTARY P BLiC-i� T Rp NEW YORK This a � trati �'�4�? ��1t Meted in its entirety and must trio udc• a ncr e ch z 0.01 S 13 4 signature{s)M t ' ,`},s�; '(34)xt@OfBft suhjecf �rop4rty, arc) the applic�t ���te�i't t Vi[��Mues" provided. A11 appltcahon trot ptnam ropccly cntnplctt:d itt its entirety and��,lt�llts' MEkftes05i-`o2©23 deerned null and void and will be 1-chimed to 1ltc applicant. 2 8/12/2021 D OCT - 7 2022 VILLAGE OF RYE BROOK BUILDING DEPARTMENT lu Y O a v N N N C C y O E 00 Y ✓l p ro 7 � - � Y :.j Product# Capacity Model Gauge Dimensions Weight I (US gal.) thickness H W L (pounds) 209101 120 Vet 17 47" 23" 30" 'C 20810.1 138 Vert. 12 44` 27" 30" 160 208601 138 horiz. 12 27 44' 30" 160 s 207101 220 stubbies,'vert. 12 44' 27� 48' 220 207601 220 stubs+es.^or¢. 12 27" 44" 48" 220 203201G 230 thin/Vert.gsev 12 44' 2 2" 60" 235 203701G 230 thinihorz.grey 12 22` 44' 60' 235 202201 240 narrowlvert. 12 47' 23' 60' 265 " 202701 240 narrowlhoriz. 12 23' 47" 60' 265 204201 275 Vert. 12 44' 27" 60' 255 204701 275 horiz. 12 27' 44" 60" 2.55 1-: 211.201 275 Vert. 10 44 27" 60" 330 ` 211701 275 horiz. 1.0 27' 44' 60' 330 205201 330 Vert. 1.2 44' 27" 72' 290 205701 330 horiz. 12 27- 44" 72- 290 External finish:BLACK or GREY electrostatic powder paint Warranty*: 10 years Touch up paint: PE0030C"BLACK" PE0032C"GREY" Cylindrical: models vertical Product# Capacity Model Gauge cover Dimensions Weight (US gal.) thickness Shell Dia. Height (pounds) 3006622 150 DCV 560 11 12 30" 65' 200 3007622 185 DCV 690 11 2 30" 77" 225 3008622 220 DCV 825 1 11 12 30" 88' 1 255 External finish: WHITE polyurethane paint Warranty*: 3 years E i 1 I Cylindrical models horizontal Product# Capacity Model Gauge cover Dimensions Weight (US gal.) thickness Shell Dia. Height (pounds) I 3005224 138 horiz. 12 12 26" 60' 165 YX External finish:BLACK electrostatic paint Warranty*: 3 years 1 i q i BurkeEnergy Your local home service experts. Tillage of Rye Brook Building Department 938 King Street Rye Brook, NY 10573 475 Commerce Street Hawthorne, NY 10532 February 20, 2023 914.769.5050 T 914.769.1521 AE: KLEIN / 220706 D burkeenergy.com 60 Talcott Rd R Eli Port Chester, NY 10573 MAR 2 1 2023 R—i Permit# MP 22-164/ Oil Tank Installation Close Out Letter VILLAGE OF h.Yc BROOK00KBUILDING DEPARTMENT November 21, 2022 Burke Energy removed existing 240 gal oil tank and replaced with new GRANBY 240 gallon A/G oil tank in left side of basement. We installed new 2" fill, vent pipes,vent alarm, tank gauge, new oil line to boiler, shut off value all necessary pipe and fittings to complete new installation. The old oil tank(s) were removed, cut and cleaned on site and disposed of at a recycling center, scrap manifest provided. The waste oil was disposed of at an approved waste oil recycling center, manifest provided. Deeply appreciate your help with this matter. Any further questions, please don't hesitate to contact Joanna - 914-919-3563 - Install / Permit Department. Thank you, ` C John Burns / Install Manager / Burke Energy 914-769-5050 iburns@meenanlp.com burkepermits@meenanlo.com Heating I A/C I Propane I Oil Tank Removal I Generators I Home Security&Automation • Crown STANDARD COLLECTION � Patrolal im ORDER FORM 1896 t�1 WasteServices 936 Route 6 Mahopac, NY 10541 845.803.8253 NAME DATE , , GENE"TOPJLOCATION BILL TO €:- r�- r AIAM _ �?"_ -- -- - _ NAIvtE: - F :. ATT• ! (, � / / �� ETA: J` ATr: Elk ADDRESS " l�44 ` I!" f{%f%1f1 ADDRESS: CITY: STATE: f. ZIP: t -1- '_If CITY: �A (,� ': FY' STATE: /f i ZIP: PHONE: PO: PHONE: TIME IN: TIME OUT: DESIGNATED FACILITY NAME AND SITE ADDRESSe�lE:_ ❑WATER WORKS 1 77 STEWART AVE ❑LORCO PETROLEUM SUS 1 450 S.FRONT ST ADDRESS&_.._- " iPA NEWBURGH,NY 12550 1 845.561.4111 ELIZABETH,NJ 07202 1 908.820.8800 NYD986908085 NJR000023036 EPA ID#: DESCRIPTION QTY UNIT PR LINE TOTAL CHARGE MY ACCOUNT FOR THIS USED OIL REMOVAL TRANSACTION UNLESS OTHERWISE INDICATED IN THE PAYMENT SECTION. ANTI-FREEZE REMOVAL INVOICES REFLECTING CHARGES OILY WATER REMOVAL ARE SUBJECT TO AN INTEREST RATE OF THE LESSER OR 1-1/2%PER SLUDGE DISPOSAL MONTH(18%PER ANNUM)OR THE MAXIMU RATE ALLOWED BY LAW ON VACUUM SERVICE ANY INVOICES THAT ARE NOT PAID VACUUM SERVICE HOURLY RATE WITHIN 30 DAYS IN THE EVENT OF DEFAULT CROWN PETROLEUM SHALL TRANSPORTATION BE ENTITLED TO RECOVER COSS OF COLLECTION,INCLUDING REASON- -, S ABLE ATTORNEY'S FEES. INITIAL: TIME IN TIME OUT US DOT DESCRIPTION CONTAINERS TOTAL UNR NO.TYPE O1V WT/VOL USED OIL,NON REGULATED,NOT US DOT HAZARDOUS MATERIALS,N/A,NONE,NONE TT / I G OILY WATER,NON REGULATED,NON R,C,R,A,WA,NONE,NONE TT G PETROLEUM CONTAMINATED SLUDGE,NOT REGULATED,NOT US DOT HAZARDOUS MATERIALS,NA/,NONE,NONE TT G GENERATOR WARRANTS AND REPRESENTS THAT THE MATERIALS PROVIDED CROWN PETROLEUM HEREUNDER HAVE NOT BEEN MIXED,COMBINED,OR OTHERWISE I CERTIFY THAT MY TOTAL WASTE BLENDED IN ANY QUANTITY WITH MATERIALS CONTAINING POLYCHLORINATED BIPHENYSL(PCB)OR ANY OTHER MATERIAL DEFINED AS HAZARDOUS WASTE UNDER STREAMS ARE WITHIN ONE A THE APPLICABLE LAWS,INCLUDING BUT NOT LIMITED TO 40 CFR PART 261.GENERATOR AGREES TO INDEMNIFY AND HOLD CROWN PETROLEUM HARMLESS FOR ANY DAMAGES,COSTS.ATTORNEYS FEES,CT.ARISING OUT OF OR IN ANY WAY RELATED TO A BREACH OF THE ABOVE WARRANTY BY THE GENERATOR. FOLLOWING CATEGORIES: CROWN PETROLEUM,ITS AGENTS AND CONTRACTORS HAVE THE CAPACITY AND ARE AUTHORIZED AND PERMITTED IN ACCORDANCE WITH ALL APPLICABLE LAWS OTO 220 LBS/MONTH AND REGULATIONS,TO TRANSPORT,ACCEPT,STORE,RECLAIM OR AND/OR DISPOSE OF THE WASTE LISTED ON THIS DCOUMENT. INITIALS: GENERATOR CERTIFIES THAT THE WASTE IS USED OIL ❑USED ANTI-FREEZE ❑OILV WATER O OTHER 220 LBS TO 2,200 LBS/MONTH INITIALS: --=PRINTED NAME: ,. �_,_ :a,�- -�.� -- -�-_ -TITLE: GREATER THAN 2,200 LBS/MONTH SIGNATURE: DATE: INITIALS: --- I PAYMENT RECEIPT Brookfield Resource Management 100 Lamont Street Elmsford, NY 10523 914-592-5250 Receipt:1769288 Date:11/4/2022 Customer:1915 Time:3:27 27 PM BURKE HEAT 475 Commerce Street Hawthorne, NY 10532 ID Number: Ticket:1814163 Weigh In:11/4/2022 3:19:22 PM Operator:Diane D Weigh Out:11/4/2022 3 27:25 PM Al we:ahts are in oo-^ds unless otherwss no'.e:! Commodity Gross Tare Net Price TOTAL$ #2 Unprepared 12,740 12,360 380 3.7000/CW 14.06 ------------------------------------------------------------------------ Ticket Total: 14.06 No.of Tickets:1 EZCash Paid: $14.00 Payment Method:EZCash Round Amt: ($0.06) Total Paid: $14. For current pricing,hours and * contact inforrpation check us out on the web @brookfieldscrap.com Join Brookfield Scrap on Facebook @webuyscrap t ■' c , � .�. � � . � � � � � . . . ��.� . � ! � — � .�_. . .—. ... . � - � } k \ � � �� �� }\ �\ Z � . �. �| - � � �� � % � � .E . � . , � .\ fi } f \ � : ! ! \ \. � e ¥ � ° > � - � ; � � ` �� , � �} i � \ � � �! ,& . � ! . 6� §! }) \d/ ] ` � \k � �}/ � ^ �:�����: . \ � . . �9 Ofl Y9 •a +• ._.. a o a J T^ ` 0 CCD ® o m ® P a i v Lo all le , 72 ck ea ca a � O W z o ccp vl _ a F rv; 44 ~ w ' wo co r w m 'v E W iv ►� E o I.1 . N rOr F .d O BurkeEnergy w F Your local home service experts. D D ' APR 2 4 2023 VILLAGE OF RYE BROOK 475 Commerce Street BUILDING DEPARTMENT Hawthorne,NY 10532 914.769.5050 T 914.769.1521 F burkeenergy.com April 20, 2023 Village of Rye Brook Building Department 938 King Street Rye Brook, NY 10573 RE: 60 Talcott Rd, Rye Brook Permit#MP-22-164 Please find enclosed a check for$500.00 in payment of the legalization fee due for an oil tank removal/replacement completed prior to the scheduled inspection. Please contact our office with further requirements to close out permit#MP-22-164. Thank you for your assistance. Dan Lee Burke Permits Department 560 N Main Street Brewster, NY 10509 burkeoerm its rDmeenanIr.com 914-919-3545 Heating I A/C I Propane I Oil Tank Removal I Generators I Home Security&Automation 1� 0 z o M a Lr CNIJ y LL m 0 w Zp wQ U U oO UU io. o O 0 c L Z w Z Z > Q O w o v 00 2 O0 ¢ a m April 19, 2023 April 2023 May e2023 Th SuMo TuWe Th Fr Sa SuMo TuW Th Fr Sa 1 1 2 3 4 5 6 Wednesday 9 10 11 12 13 14 15 14 15 16 17 18 19 20 16 17 18 19 20 21 22 21 22 23 24 25 26 27 23 24 25 26 27 28 29 28 29 30 31 30 WEDNESDAY 19 • STEVEN E.FEWS-Acting Building Inspector 7 AM 8 9 2 Mulberry Court-Final Re-Inspection and Walk the Site 10 16 Sunset Road-Final Roof(RP 22-019) -Ms.Thomas(914)886-2803 11 20 Old Orchard Road-Gas Test-Paul 203-496-1617 5 Elm Hill Drive-Rough Plumbing&Framing -Oswaldo(914)708-7768 1 2 pM LUNCH 1 60 Talcott Road - MP22-164 Tank Install-Kelly 919-3507 Office Time 2 /D ('s �./ 3 4 Cloucipermit,Open Questions for Rye Brook;https.//cloudpermit.zoom.us/i/85678669Sl8?from=addon;Frank Ficaro 5 —Vzytl `I— 1.�Tr� Gv� SOC7 S Gc� 6 7:30pm-9:00pm A.R.B.Meeting /— 1 Steven Fews 1 4/19/2023 1:56 PM ACC?R"® DATE(MM/DD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 09/1912022 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 Chris Looes Marsh USA,Inc. NAME: PHOEFAX 1166 Avenue of the Americas AICNN Ell: (212)345 6833 AIC No): New York,NY 10036 nooss: christine.looes@marsh.com AIL Attn:NewYork.certs@Marsh.com INSURERS AFFORDING COVERAGE NAIC# CN101414839-PETRO-ACORD-22- INSURER A:National Union Fire Ins Co Piftsburgh PA 19445 INSUREDMEENAN OIL CO.,LP INSURER III:AIU Insurance Co 19399 D/B/A BURKE HEAT AND BURKE FUEL OIL CO INSURER c:Lexington Insurance Company 19437 475 COMMERCE STREET HAWTHORNE,NY 10532 INSURER D INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: NYC-009222598-87 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 TYPE OF INSURANCE ADDL SUBR POLICY NUMBER MMIDDY EFF POLICMMIIDDI EXP LIMITS LTR A X COMMERCIAL GENERALLIABILrTY GL7032451 10101/2022 10/01/2023 EACH OCCURRENCE $ 1,000,000 DAMAGE TO CLAIMS-MADE �OCCUR PREMISES EaENTEoccurrence) $ 500,000 X XCU MED EXP(Any one person) $ 10,000 X Contractual PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 5,000,000 X POLICY��4 LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: SIR $ 1,000,000 A AUTOMOBILE LIABILITY 8682566(AOS) 10/01/2022 10/01/2023 COMBINED SINGLE LIMIT $ 5,000,000 Ea accident B X ANY AUTO 8682567(MA) 10/01/2022 10/01/2023 BODILY INJURY(Per person) $ A OWNED SCHEDULED 8682568(VA) 10/01/2022 10/01/2023 BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY Per accdent X UMBRELLA LIAB X OCCUR 021430599 10/01/2022 10/01/2023 EACH OCCURRENCE $ 5,000,000 EXCESS LIAB CLAIMS-MADE AGGREGATE $ 5,000,000 DED X RETENTION$10,000 $ B WORKERS COMPENSATION WC 063850976(CT,DE,MA,MD,MI,NH, / 10/01/2 X PER oTH- AND EMPLOYERS'LIABILITY YIN STATUTE I ER ANYPROPRIETOR/PARTNER/EXECUTIVE NJ'NY'PA'RI'VA'WV) E.L.EACH ACCIDENT $ 1,000,000 OFFICER/MEMBEREXCLUDED? N❑ N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 1���� If yes,describe under 1 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ ,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) THE CERTIFICATE HOLDER IS INCLUDED AS ADDITIONAL INSURED AS RESPECTS THE NAMED INSUREDS OPERATIONS CERTIFICATE HOLDER CANCELLATION VILLAGE OF RYE BROOK SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 938 KING STREET THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN RYEBROOK,NY 10573 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE iZZQCc ©1988-2016 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD YORtcorlters' CERTIFICATE OF STATE Compensation NYS WORKERS' COMPENSATION INSURANCE COVERAGE Board 1 a.Legal Name&Address of Insured(use street address only) 1 b. Business Telephone Number of Insured Meenan Oil Co..LP 845-782-8161 dba Burke Heat and Burke Fuel Oil Co. 475 Commerce Street 1c.NYS Unemployment Insurance Employer Registration Number of Hawthorne,NY 10532 Insured 8311425-2 Work Location of Insured(Only required if coverage is specifically limited to 1d.Federal Employer Identification Number of Insured or Social Security certain locations in New York State,i.e.,a Wrap-Up Policy) Number 11-3083408 2.Name and Address of Entity Requesting Proof of Coverage 3a.Name of Insurance Carrier (Entity Being Listed as the Certificate Holder) AIU Insurance Company Village of Ryebrook 3b.Policy Number of Entity Listed in Box"1 a" 938 King Street Ryebrook,NY 10573 WC 063850976 3c.Policy effective period 10/1/2022 to 10/1/2023 3d.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 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: Michael Price (Print name of authorized representative or licensed agent of insurance carrier) Approved by: 41_ 09/19/2022 (Signature) (Date) Title: CEO North America Telephone Number of authorized representative or licensed agent of insurance carrier: 212-770-7000 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