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HomeMy WebLinkAboutMP22-175 Q� DR JCL la�`� YL �4 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 ACTING BUILDING & FIRE INSPECTOR Susan R.Epstein Steven E. Fews Stephanie J.Fischer David M. Heiser Salvatore W. Morlino CERTIFICATE OF COMPLIANCE January 24,2023 Stephen Avanzino Jr. &Meghan Avanzino 202 Betsy Brown Road Rye Brook,New York 10573 Re: 202 Betsy Brown Road,Rye Brook,New York 10573 Parcel ID#: 135.44-1-6 As per the Certification letter from Burke Energy dated January 19,2023, the removal of an above-ground oil tank and installation of a new above-ground oil tank under Mechanical Permit#22-175 issued on 11/21/2022 has been satisfactorily completed. Sincerely, Steven E. Fews Acting Building&Fire Inspector /to �E BRC�v� '9b2 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 - - - - - - - - - - - - - - - - - - - - INSPECTION REPORT - - - - - - - - - - - - - - - - - - - - Lc ADDRESS• DATE: PERMIT# \mil I✓ ��-I ISSUED: ( SECT: BLOCK: LOT: LOCATION: �`T C� `` OCCUPANCY: 1 ❑ 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 ❑ L.P. GAS ❑ FUEL TANK ❑ FIRE SPRINKLER ❑ FINAL PLUMBING ❑ CROSS CONNECTION ❑ FINAL ❑ OTHER �E BRCuk O� Zm 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 : DATE: PERMIT# ISSUED. ` )1 ' SECT: �> BLOCK: LOT: LOCATION: ` { 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 ❑ L.P. GAS ❑ FUEL TANK ❑ FIRE SPRINKLER ❑ FINAL PLUMBING ❑ CROSS CONNECTION ❑ FINAL ❑ OTHER i , i in i CV N N H W eu � 04 o N ir7 z Ln Ln enen A ck Lo ON 00 W Ocs zv' N 'T� 10, a i W 0. ■ C)� o y a o w a © H ")noCJ� z w a p a " ° w � Z p a H aa � � � a z � o '-� V A z U w 00 F G p U R+ zz -a � g O � ~ � �' � � vo w rf w a 4 o H o ff �,� � � v w o V HB � U O U �' o x W W od " 1 as o FI � a0 � U W aw a � Bult,DING DEPARTMENT VILLAGE OF RYE Ri;)oK NOV 16 2022 938 KING S•t`IME't R),tr Rtzoo ,NY 10573 (914)939-0668 VILLAGE OF RYE BROOK rvrs.��crtttllc.��t x I 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) H)1i ()l l l(.'E l_ISL ONL,�' 11FIRNll( . P/�-Dd,._-/ 7� Approval Date: NOV 2 2 20 Permit Fee: $ r �...._--\ Approval Signature: _ _—.--._ -- Other: Disapproved: _ (lees are non-refundable) sY*****rk ir**sF*•k1k*•Ir**�r,t,t****iel:***********,t***att,t****�:f:**:t:F***k**********xY:x**+k*:t*,k�r�r,k***,t ilx*:t,t*,k*4a�**fir yr sr** RE()UIRF,MEX1*S FOR IMILFASE OF PERMIT&CERT IFWATE;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#C105.2 or Form#U26.3 /or NY State Workers Compensation Waiver) 4. Fee per Tank: Removal,Abandonment, or Installation: S 1 per nk. 5.Dig Safely New York#(dial H 1 I): _.__._..___� _ 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. ****�:*�***�******,t*,�•***�,t+r,t+tit**,�**x**,r**,t,t****,r*******�•r****+rx�******,�***:r**rt*xrrw**,rsr****+trk.tw***�**,rs Application dated, 11/7/2©22 ,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. *#*********#*******************Yt&Vr**********ft F Ye&•k•k>F**k*•kN•A•+Y�l•Y&ir•Y.ir;t*•IP**k*fie ilr�r**9r*•kic•k•k•k**+t:k ii•ak*•A h***tr***ik ie Indicate Permit Type: Installation ()3•Removal(X) •Abandonment( )/Above Ground (x)• Buried in Ground ( ) I. Address: 202 Betsy Brown Rd,_Rye Brook 10573 SBL: 135.44-1-6 _Lone: e—/Q 2. Property Owner&Address: Me9 vanzino, 202 Betsy Brown Rd, Rye Brook, NY 10573 Phone#: 914-523-5442 Cell#: email:__ meghanavanzino@gmail.com 3. Contractor&Address: Burke Energy 475 Commerce Street Hawthorne New.York 10532 .—.._ _ Phone#:(914) 919-3507 (Kelly) Cell#:(g14) 197-1310 (Dan Lee) email: burkepennits me-enanl.p,com 4. Applicant: Burke Energy Phone#:A9 14) 919-3545 Cell#: (914) 327-1310 email:burkepermits@meenanlp.com S. Indicate Fuel Type:Fuel Oil(3•L.P.Gas( )•GasoIine( )•Other 6. Number and Capacity of each Tank: Remove (1) existing 275 g I n AG oll tank Install (1) new Granby 275 gln AG oil tank 7 ExactLocation(s)ofcachTanl. Removal & install of tanks at same front left area of basement xf1212021 STATE OF NEW YORK,COIIN'rY OF WiESTCHESTER ) as! Kelly Redlon/ Burke Energy_.,being duly sworn,deposes and states that helshe 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 contractor _ for the legal owner and is duly authorized to snake and file this application.(indicate architect,conaactor,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 p�� Sworn to before me this 10 day of 20V3— day of N — ,20_, `ainahtre f Property�wnct Sign ur of p icant x S' P EN y '�A! X�. Print Name of Prop Owner Print Name of pplicant )MX� __ Notary Public Notary is This application inust be properly completed iu its entirety and must include the notarized signatures)of the legal owncif s)of the subject property,and the applicant of record in the spaces provided. Any application.not propet9y completed in its entirety And/or not properly signed shall he deemed null and void and will be returned to the applicant. ELIZABETH SABLES AMANDA PUTERBAUGH NOTARY PUBLIC-STATE OF NEW YORK NOTARY PUBLIC-STATE OF NEW YORK No.01 SA63920A5 No.01 PU8340126 Qualified in Putnam County Oualtiied in Nassau County �y Commission Expires 05-20-2023 My Commission Expires 04-11-2024 2 8/12/2021 Al Product# Capacity Model Gauge Dimensions Weight = r (US gall thickness H W L (pounds) 209](11 ]20 ve" 12 ( 47" 23" 30' 170 z ( ! 20870? 138 vert. 12 44` 27" 30" 160 208601 138 hor z 12 27' 44' 30" 160 207101 220 stuffeswert. ]2 44' 27' 48' 220 2.07601 220 stubiesl^oriz. 12 27" 44" 48" 220 203201G 230 thinNert.g-ey 12 44" 22" 60" 235 203701G 230 thinthorz grey 12 22" 44" 60" 235 202201 240 narrowtvert. 12 47' 23' 60" 265 202701 240 narrowlhor'a. 12 23' 47' 60" 265 x k 204201 275 vert. 12 44° 27" 50" 255 204701 275 horiz. 12 27' 44" 60" 255 211201 275 vert. 10 44' 27" 60" 330 r 211701 275 horiz. 10 27' 44' 60' 330 205201 330 vert. I 44' 27' 72' 290 205701 330 ttoriz. 12 1 21' 44" 72" 1 290 External finis':. BLACK or GREY ele^(rostatic powder paint Warranty*: 10 years Touch up paint: PE0030C"BLACK" PE0032C"GREY" Cylindrical models vertic, I 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 12 30" 77' 225 3008622 220 DCV 825 11 12 30' 88' 255 External finish: WHITE polyurethane pair! Warranty*: 3 years I I Cylindrical models horizontal Product# Capacity Model Gauge cover Dimensions Weight (US gal.) thickness Shell Dia. Height (pounds) 3005224 138 horiz. 12 12 26" 60" 165 External finish:BLACK electrostatic paint Warranty*' 3 years i ��""� — i i f � t ii � � �t 1 _;_ ' � � .�, � w- � � i F S a � � ��� � I � ! � r � � S Z � � � � �, � � y BurkeEnergy Your local home service experts. Village of Rye Brook Building Department 475 Commerce Street 938 King Street Hawthorne,NY 10532 914.769.5050 T Rye Brook, NY 10573 914.769.1521 F burkeenergy.com January 19, 2023 RE: AVANZINO / 6482187 �� � ��� 202 Betsy Brown Road ED Rye Brook, NY 10573 JAN 2 0 2023 Permit# MP 22-175 / Oil Tank Installation Close Out Letter VILLAGE OF RYE BROOK BUILDING DEPARTMENT December 12, 2022 - Burke Energy removed existing (1) 275 gallon AG oil tank from the basement and replaced with a new Granby 275 gallon AG oil tank in the same basement location. The old oil tank was removed, cut and cleaned on site and disposed of at a recycling center. The scrap manifest is provided. The waste oil was disposed of at an approved waste oil recycling center and the manifest is provided. Deeply appreciate your help with this matter. Any further questions, please don't hesitate to contact Kelly(914-919-3507) in the Burke Permit Department. Thank you, John Burns / Install Manager / Burke Energy 914-769-5050 ibu rns(a)ineena nlh.com bu•keperin i tsOpmeenan I IT.com Heating I A/C I Propane I Oil Tank Removal I Generators I Home Security&Automation Novella's Scrap Yard 5 Thorpe Street,Danbury,CT 06810 (203)743-5275 Date !/ U�/ -2 Address Weight DescriPoom Amount Aluminuun Side Aluminum Tura, Aluminnnt Aluminum W. Aluminum Urals L. Brw H. _ Gb_[ er tl Wine #I Tube (M-Ins ——- Copper S7►eet Lad Radidors Stain.sted —- Wire Ins. Batteries Iron _ Electric Motors Received Bit_ TOW frie-y -1/6 (, ' GA,r11 / cla-t NON-HAZARDOUS ' Generator ID Number 2 Pape 1 of 3.Emergency Resporse Phone 14.Waste TmekIng Number WASTE MANIFEST I EXEMPT 1 516-374-1500 ' ' 6 Ii,,c Nil—.u.�f.rl"1,r` r � ^ J Gcrieral(dx Site AdMess(d Odf-r,•u than awiling atiaressl 6 Transporter 1 Company Name I V U.S.EPA ID Number MILRO GROUP LLC INYR000237214 1r n„r 2 Company Name - EPA ID Number i Desianated Fari K,Name end Site Address U S.FPA ID Numbe TRADEBE CTDO02593887 50 CROSpSpST.. B/RIIpDGEPORT, CT 06810 I NCa l•s Phc iw 888-27d-ON7 9.1Yas1n Sttippinq Name and Lmripron 10 Cortainers 11.total 12 Urrl No. Type Uuenlily WtNol isl 1 WASTE, #2 FUEL OIL P_ NON DOT/NON RCRA REGULATED MATERIAL 001 TT /0 /,— �� I v I I 4 -- . 13 Spoclai 1 a[Wiing Inslnwikens and Add:r'onal InG—imi(•r, 11)1000247190 14.ISENERATOR'S/OFFEROR'S CERTIFICATION:i hereby declare that he,contents o1 this col si:7nrtwd if fully and ulati4y desedhed above L'y rho lin Poor shlpptng name,and are classdleo,packaged, • 1 x_0 L hr leaf f).�.rd­i,and are in all respects in proper oordi!icn tor Iransporl acoadmg to apfdiable nh u4, aLumi aun d quvou n clip.: fill., 11�..;Name ..,, ,h�rr rrrorth o-ay Year is lit r n vc,l Shbmenl3 I I Impel to U.S. -xpo from I: �. y of ordrylexiC rcin..f . _,Jn,air. Ik r.•.L, _IY) _.._ ___ Pat,.loavirnt 11 16.Transporter Acknowledgment el Receipt of Matersis Tr.wsp,.rWrlPi*40,Vlyl:ONditte �'•grhur .omit, Day Year 1 IL N — Z Transporler2 Prirhed/ryped Nama Signature ........_ Month Day Year 17.Discrepancy '7a.Discrepancy Inaira!on Space I (Uuarldl _—y I I Type ❑Residue �.__I Partial Reerl'ron I I Fuli Rujeclion !A.anitmt Relemrice NunllrN I%f Alternate Faral;y(rr Generator) LI S.EPA ID Number J U u- I,, Phone. H17c Signature of Altemak:Facility(or Generator) PAonlh tray Year" uJ 0 I '5 Designated Facilily Owner or Operator:Coddication of recoipl of materials-overfed h;1he manlesl exceot as noted In Item 17a Prinled?ypr.J Naire Signature Month Day Year I I 169-BLS-C 5 11979(Rev.9/09) DESIGN;-!ED FACILITY TO GENERATOR `, :..�1 -�; aFn Y"?A b��'/�h Y�. A .K`- ly> A'' \J : h✓'�'•:4•jll�' �.��\ �o a I��+`�'� ,{ l ,�•1�•:�}gyk tixp+� � M �`F R� �� �aY as �;=♦3a�S iE�t}�}}* t��~!� n�ri. �:� r.`c Y ra Y. ? Z'i v��� .z h r I c On, j d c* N O Y N C L y W e— t�k. O O N =j N e— t•`.`.v < cl x c v� •mm W N O r m ._ .*. d W ce) U to -j o o ctiop ,3 _ LLI E Y U O > z mui � " O W � Q �•- -w � �rP a 0 mom > `- O u o ccaor si: �s a I .tom,, •= o � �:'��� ►�e m cs `y O LO L y o C ' Qo .�WV Qo t ^� a� i t _ rn ACOR/7 CERTIFICATE OF LIABILITY INSURANCE °ae2on° n 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 Chf'SLooes Marsh USA;Inc. NAME _ ............ NE 1166 Avenue of the Americas tac N Ell --3--- - (NC,No): New Yak.NY 10036 L-MAIL Christine.looes marsh.com AV:NewYork.certs@Mrish.com ADDRESS � INSUR 4sl AFFORDING COVERAGE NAIC If CN101414839-PETRO ACORD-22- INSURER A;National Union Fire Ins Co Pitlsburgh PA 19445 INSURED MEENANOIL CO.,LP INSURER a.AIU Insurance Co DIBIA BURKE HEAT AND BURKE FUEL OIL CO INSURER C:Lexington Insurance Company 19437 475 COMMERCE STREET wSURER D: HAWTHORNE.NY 10532 INSURER F.: INSURER F: COVERAGES CERTIFICATE NUMBER: NYCDD9222598-81 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 EF R--- ADDL)SUBR POLICY F ........... L - POLICY ERP I.TR TYPE OF INSURANCE INSD,WV0 POLICY NUMBER fMNIDOIYYYY LIMITS A X COMMERCIAL GENERAL LIABILITY GL7032451 1N10022 10ro1,"2023 EACHOCCURRENCE $ 1,D00,000 U 4MAuE fi O REN ft�— i CLAIMS-MAOE X ;OCCUR 7 PREM15Efi1Ea occurrmcsj S �'� X I XCU MEO EXP(Anyone person) 5 10,000 _. ... X Contraclual PERSONAL 8 ADV INJURY _. ..._.. -- f 000,000 GEML AGGREGATE LIMIT APPLIES PER: GENERAL AGGR GATE S 5,000,000 X 'POLICY l X JECT LOG PRODUCTS-COMPIOPAGG 2,000000 SIR s 1,000,000 OTHER' A i AUTOMOBILE LIABILITY 10682W(AGS) 10101,F20 2 10!0112023COMBINEn SINGLE LIMIT $ 5,000,000 ... B X (ANY AUTO 180567(MA) 10101,2022 10/0112023 BODILY INJURY(Per person) $ A OWNED r__ 'SCHEDULED I8662566(VA) 10ro1;2022 iDro112023 BODILY INJURY(Per accident) $ — AUTOS ONLY AUTOS HIRED NON-OWNED j W615ERTYDAMAGE S --- - „„,.... AUTOS ONLY ....._.. AUTOS ONLY I _tP4.!! PD-___ y c X UMBRELLA uae X ;OCCUR ! 021430595 10101/2022 100112023 EACH OCCURRENCE S 5,000,000 EXCESSLIAB i CLAIMS�AADE� AGGREGATE, $ 5,000,000 OFD X RETENTION s 10 ODO i S U WORKERS COMPENSATION WC 063850976(CT,DE,MA,MD,MI,NH, 22 1OM112023 PERJ. OTH AND EMPLOYERS'LIABILITY YIN -,STATUTE __ ER __ NJ,NY,PA:RI,VA, 'ANYPROPRIETOR/PARTNERIEXECUTIVE � �D,DOO OFFICERNEMBEREXCLUE � NIA E.L.E EACH ACCIDENT S (Mandatory In NH) — E.L.DISEASE-EA EMPLOYEE S -1,000,000 If yes,descr be under0.000 DESCRIPTION OF OPERATIONS below F—L DISEASE-POLICY LIMIT S DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 1111,Additional Remarks Schedule,may be attached it more space Is required) THE CERTRCATE 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 %i�L�Gf1LaZlS ��J1T �iLC. ©1988.2016 ACORD CORPORATION. All rights reserved. ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD voRK i Workers' CERTIFICATE OF STATE Compensation NYS WORKERS' COMPENSATION INSURANCE COVERAGE Board 1a.Legal Name&Address of Insured(use street address only) 1b Busine,;>Telephone Number of Insured Meenan Oil Co.,LP 845-782-8161 dba Burke Heat and Burke Fuel Oil Co. 475 Commerce Street 1 c 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-llp 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"l a" 938 King Street Ryebrook,NY 10573 VtrC 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 partnersloKcers included) all excluded or certain partnerstofficers 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 A 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 .........._........... ._....--.................__.._. t (Print name of authorized representative or licensed agent of insurance carrier) Approved by. t1<< - 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