HomeMy WebLinkAboutMP22-165 LVLwva JJ
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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
December 29,2022
Rhonda Kupin
5 Concord Place
Rye Brook,New York 10573
Re: 5 Concord Place, Rye Brook,New York 10573
Parcel ID##: 135.44-1-55
This document certifies that the work done under Mechanical Permit #22-165 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,
Michael J. Izzo
Building&Fire Inspector
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1932 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
ciorv�V�l :�� : r Q- DATE: ' VL- -
PERMIT# ` ISSUED: ` l SECT: ' BLOCK: f LOT: V,
LOCATION: �i`�}1C��� OCCUPANCY: 21 ` -
❑ VIOLATION NOTED THE WORK IS... I ACCEPTED ❑ REJECTED/REINSPECTION
❑ SITE INSPECTION REQUIRED
❑ FOOTING
❑ FOOTING DRAINAGE
❑ FOUNDATION
❑ UNDERGROUND PLUMBING NOTES ON INSPECTION:
❑ ROUGH PLUMBING
❑ ROUGH FRAMING
❑ INSULATION O\(`� ?��
❑ NATURAL GAS v
❑ L.P. GAS (�S
FUEL TANK r
'!❑ FIRE SPRINKLER
❑ FINAL PLUMBING
❑ CROSS CONNECTION
❑ FINAL
❑ OTHER
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BUILD DEPAR MENT ECWED
VIL E OF' RYE, OOK
938 KING `-rR'E ,,r RYE BR NY 10573 OCT 2 1 2022
a, .
4) 939- (6814 ,e . 0 8VILLAGE 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#: -/ ta
Approval Date: NOV '` 7 mt Permit Fee: $ V
Approval Signature: Other:
Disapproved:
(ices 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: $185.00 per Tank.
5, Dig Safely New York#(dial 811):
6. Inspection by Building Department for removal/abandonment and/or installation.
7. Submit all Manifests&Reports(after work has been completed).
8. Certificate of Compliance will be provided when all requirements are fulfilled.
Application dated, 10 j I$l-n , 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 all applicable Village,County,State&
Federal laws,codes,rules and regulations.
Indicate Permit Tyne: Installation(4•Removal(✓�•Abandonment( ) /Above Ground (14 Buried in Ground ( )
1. Address: s nr�S'd QlaCP. SBL:� , 7 y—1 J Zone: ?.
2. Property Owner&Address: Mahw Kup'l_ a &rlcod ek z.
Phone#: Cell#: email: will-A.rom
3. Contractor&Address: WtAhW, 1PUA Co. :%C. 8G N W&►Ur 5t Gf'E?1A4,IC-bl- C"r Q(.$50
Phone#: _ 114 AM-400 Cell#:`.' email: SeftitCe r'1C&Q WiestMgf".CW
4. Applicant:. nw9i (AWM W25 mcf, -yy�r �_
Phone#: Cell#: email: Ski yrlcth `(,tD►,reStXe���,Lor,�
5. Indicate Fuel Type: Fuel Oil(J •L.P.Gas( )•Gasoline( ) Other( ):
6. Number and Capacity of each Tank: &J N �tn�yC_ G Zit foa.1l tnAlk %,n:-{' 11)11" T{ l29�
7. Exact Location(s)of each Tank: (� � }
1
8/12/2021
Ccanncck-cJ- q;3'�,-(�-e(4
TATE OF NtW--)BRK,COUNTY OF WESTeffE= ) as.
M-, being duly sworn,deposes and states that he/she is the applicant above named,
(print name of i dividual 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
H'pe, r-)` -- for the legal owner and is duly authorized to make and file this application.
(ind ate 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 confomrance 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.
rod
Sworn to before me this Sworn to before me this 3
day of n 20 - day of tDJQ-0,6ei 20 ay
S ture o)/f�Property Owner/ ,,nature of Apphcant
4�
Print Name of Pro erty Owner Print Name of Applicant
No Public CAROLYN MARIE CANNISTRARG Notary Public C^_
Notary Public-Stale of New York a``A n L, TL rr
No.01 CA6177080 A'0T.4Ic y PZ,-BLIC
Qualified in Westchester County MY Commission Expires Au;.31,2025
My Commission Expires Nov.5,2023
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. Any
application not properly completed in its entirety and/or not properly signed shall be deemed null and void
and will be retumed to the applicant.
8/t 12021
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A CERTIFICATE OF LIABILITY INSURANCE DATEIMMIDD/YYYY
OW27RQ22
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: It the certificate holder is an ADDITIONAL INSURED, the poliry(ies) must have ADDITIONAL INSURED provisions or be endorsed. II
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 CON7ACT
FEDERATED MUTUAL INSURANCE COMPANY NAME: CLIENT CQ TACI_C.ENSER-_ -
PHONE
FAK
HOME OFFICE:P.O.BOX 328 lac No gm:686-3 3-494 Arc No:507-446-4664
OWATONNA,MN 55060 ADOIIEss:CLIENTCONTACTCENTER FEDINS.COM
INSURER(S)AFFORDING COVERAGE NAIC C
INSURER A:FEDERATED MUTUAL INSURANCE COMPANY 13935
INSURED 330 130-6 INSURER B:
WESTMORE FUEL COMPANY INCORPORATED INSURER C:
86 N WATER ST �---
GREENWICH,CT 06B30-5886 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 .SSUED 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
INSRI TYPE OF INSURANCE OL SUBR POUCY NUMBER POLIO FFF POLICY EXP LIMITS
LTRN MMID Dry YYY MMIDDiYVYY
X COMMERCIALOENERALUA131UTY EACH OCCURRENCE $1,000.000
CLAMS-MADE O OCCUR DAMAGE TO RENTED 3100 000
P1tChll:E11Ea sS.
MED EXP I"ant Ptnm) S5,000
A N N 9062815 06/01/2022 D6/01/2023 PERSONAL&ADV INJURY 31,000,000
N'L AGOREIGATE UMIT APPLIES PER. GENERAL AGGREGATE S2,000,000
X POLICY �J JECTPRO-
7 LOC PRODUCTS-COMPIOP AGG S2,000,000
OTHER:
AUTOMOBILE LIABILITY COMBINED SINGLE UMIT S1,000,000
t SC
dril
X ANY AUTO BODILY INJURY(Per person)
OWNED AUTOS ONLY SCHEDULED
A H Auros N N 9062815 06/01/2022 06/01/2023 BODILY INJURY IPtr tceManD
MIRED AUTOS ONLY AUTOS ONN P OPERTY 0AIAAGE
H tr tr de
X UMBRELLA LIAD X OCCUR EACH OCCURRENCE $7.000,000
A EXCESS LIAB CLAMS-MADE N N 9062816 06/01/2022 06/01/2023 AGGREGATE S7,000,000
OED RETENTION
WORKERS COMPENSATION X PER STATUTE OTH
AND EMPLOYERS'LIABILITY ER
y/N
ANY PRO PRI ETORIPARTNER/EXECUTIVE E.L EACH ACCIDENT S500 D00
A OFFiCERIMEM13ER EXCLUDED7 E'N I A N 9917566 06/01/2022 06/01/2023 --
(M.ndtlory In NH) E.L DISEASE-EA EMPLOYEE S500,0w
II Y 1,d-11b.undo
DESCRIPTIONOF OPERATIONSttlpw ElDISEASE-POLICY LIMIT SSOO,DOO
DESCRIPTION Or OPERATIONS I LOCATIONS I VEHICLES ACORD 101,Addib—I RemtrKt S&E,111e,mty ta<tlOCed it more V.ce It required)
CERTIFICATE HOLDER CANCELLATION
330.130-6 35 0
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
O 1988-2015 ACORD CORPORATION.All rights reserved.
ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD
RK yO Workers CERTIFICATE OF
sTATF. Compensation NYS WORKERS' COMPENSATION INSURANCE COVERAGE
i Board
In.Legal Name&Address of Insured(use street address only) 1b.Business Telephone Number of Insured
Westmore Fuel Company Incorporated 203-531-%56
86 N Water St
Greenwich CT 06830-5886 1c.NYS Unemployment Insurance Employer Registration Number of
Insured
Work Location of Insured(On!y required if coverage is specifical y 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
06-0739367
2.Name and Address of Entity Requesting Proof of Coverage 3a.Name of Insurance Carrier
(Entity Being Listed as the Certificate Ho!der) Federated Mutual Insurance Company
Village Of Rye Brook
938 idng St
Rye Brook,NY 10573-i226 3b.Policy Number of Entity Listed in Box'1 a'
9917566
3c.Policy effective period
06101i2022 to 06r01/2023
3d.The Proprietor,Partners or Executive Officers are
Included.tonly drack box if ail paitnersroRces k,4W-d)
�X all excluded or certain partnerVofficers excluded.
This certifies that the insurance carrier indicated above in box'3'insures the business referenced above in box"1a'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 responsibil Ries 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: DANIELLE SACKETT
(Print name.of aultrorved reprasmintivn or limmPri agent of incurs:K marries)
i�,,,,,(��< 04/26/2022
Approved by:
Ac
(signature) (Date)
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 No7
authorized to issue It.
C-105.2(9-17) vrww.wcb.ny gov