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HomeMy WebLinkAboutMP23-098 BRn 19 t( Jv GG 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 December 11,2023 Chad Charney&Brittany Charney 2 Wilton Circle Rye Brook,New York 10573 Re: 2 Wilton Circle,Rye Brook,New York 10573 Parcel ID#: 135.66-1-45 This document certifies that the work done under Mechanical Permit #23-098 issued on 6/30/2023 for the installation of two above-ground propane tanks have been satisfactorily completed. Sinccrcly, Steven E. Fews Building&Fire Inspector /to �yE BRC�k. O� Zm BUILDING DEPARTMENT ❑BBVILDING INSPECTOR 9"A'SSISTANT 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 - - - - - - - - - - - - - - - - -- - - ADDRESS: l�C/ '2C CX DATE: /9? PERMIT# r�3 O ISSUED: "30" SECT:I--?6• (�w BLOCK: LOT: LOCATION: R P -A 7 A4 C, • OCCUPANCY: ❑ Violation Noted THE WORK IS... dPASSED ❑ FAILED REINSPECTION ❑ SITE INSPECTION REQUIRED ❑ FOOTING ❑ FOOTING DRAINAGE ❑ FOUNDATION ❑ UNDERGROUND PLUMBING NOTES ON INSPECTION: ❑ ROUGH PLUMBING ❑ ROUGH FRAMING ❑ INSULATION ❑ N ural Gas I tZQ � -J/N Pc L.P. Gas ❑ FUEL TANK ❑ FIRE SPRINKLER s- r CG✓ . ❑ FINAL PLUMBING ❑ CROSS CONNECTION E -TINAL ❑ OTHER BUILDING DEPARTMENT 0 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: ' ` SECT: BLOCK: LOT: LOCATION: ", / OCCUPANCY: L � .1 ❑ 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 -- pppp- QyE BRC�k. BUILDING DEPARTMENT IBUILDING 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: 1 v , DATE: PERMIT# ISSUED: �O SECT: BLOCK: LOT: LOCATION: `' �-�'i� 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 ^�1 ❑ INSULATION ,V,`/�U ❑ Natural Gas 2 L.P. Gas ❑ FUEL TANK ❑ FIRE SPRINKLER ❑ FINAL PLUMBING ❑ CROSS CONNECTION ❑ FINAL ❑ OTHER w.+ �E BR(��, '9a2 BUILDING DEPARTMENT UILDING 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 REP. ORT - - - - - - - - - - - - - - - - - - - - ` �4-3) z ADDRESS : U�'\�,�1 V I DATE: PERMIT# ISSUED• �1 SECT: BLOCK: LOT: LOCATION: --'' OCCUPANCY: 1 �t> < ❑ Violation Noted 1 THE WORK IS... 01 PASSED ❑ FAILED REINSPECTION ❑ SITE INSPECTION REQUIRED ❑ FOOTING ❑ FOOTING DRAINAGE ❑ FOUNDATION ❑ UNDERGROUND PLUMBING NOTES ON INSPECTION: ❑ ROUGH PLUMBING ❑ ROUGH FRAMING ❑ INSULATION ❑ Natural Gas P. Gas r ❑ FUEL TANK ❑ FIRE SPRINKLER ❑ FINAL PLUMBING ❑ CROSS CONNECTION ❑ FINAL ❑ OTHER s a ■ N ■ ^. 1p r0 a 14 ram. N N Lp oGo �►/ � � � � � ice-. 000 rd 7-4 � O G1 f�-LI h�+ri W 'r' co o o Q cm, ,. a Uz _ 00 , s xa d ��xrr�� �i■■� ta U U � � o o � •o � W w rs" o o ° v v � � V z bb ° o "o .� v � N w �„ o d v O W � CU a° ;L41 XcnP amb BUILD, MENT VIL ' OF R OOK JUN 2 8 2023 938 KING ET RYE BR k ,NY 10573 VILLAGE OF RYE BROOK trv�tyeg do 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#: P1149C)3-0? Approval Date: J UN 3 Permit Fee: $ Approval Signature: Other: Disapproved: (fees arc non-refundable) REOUIREMENTS 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. 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. ****#*##########**###**#######********##***#####***#****##############################wwwwwwwwwwww#*## Application dated, 6/14/23 ,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 Type: Installation 4 Removal( )•Abandonment ( )/Above Ground ( •Buried in Ground( ) 1. Address: 2 Wilton Circle SBL: 135t6 p 7 Zone:,e-10 2. Property Owner&Address: Chad Chamey/2 Wilton Circle, Rye Brook, NY 10573 Phone#: 914-494-1675 _Cell#: ---email: chamey3@aol.c:om 3. Contractor&Address: Paraco Gas,Corp/800 Westchester Ave, Rye Brook, NY 10573 Phone#: 845-207-5774 Cell#: 845-260-8011 email: Gina.Clements@ParacoGas.com 4. Applicant: Rachael Snilfen Phone*_84r3_2 7L1 FZZ4 Cell#: 845-260-8011 email: Gina.Clements@ParaooGas.com 5. Indicate Fuel Type:Fuel Oil( }•L.P.Gas(X)•Gasoline( )•Other( ): 6. Number and Capacity of each Tank: Two 120 gallon Above Ground Propane Tanks 7. Exact Location(s)of each Tank: Far Right rear yard t 8/12/2021 STATE OF NEW YORK,COUNTY OF WESTCHESTER _Rachael Sniffen being duly sworn,deposes and states that he/she is the applicant above named. (print name of individual mping 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 Agent/Contractor for the legal owner and is duly authorized to make and file this application. (indicate architect,ain4sct(x,agent,atturncy,etc 1 That all statements contained herein are titre 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 b re me this Sworn to before me this day of �'�`� �0 a 3 day of 20 ature o'Pmperty Ow r DIANNE ROJAS Signature of Applicant Notary Public-State of New York Chad Charney No OIR06127547 fiaGttael Srtiffen Prin Name of Property Owner Quabfied in Westchester County Print Name of Applicant Y COMMission Expues May 23,2025 N61firy Public Notary Public This application must be properly completed in its entirety and must include the notarized signature(s)of the legal owners)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 returned to the applicant. 2 STATE OF NEW YORK,COUNTY OF WESTCHESTER ) as: Rachael Sniften ,being duty 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)he is the legal owner of the property to which this application pertains,or that(s)he is the Agent/Contractor for the legal owner and is duly authorized to make and file this application.(indicate architect,contractor,agent,attorney,ctc.) 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 Sworn to before me this day of 20 y o 0 2 Signature of Property Owner t ature of Applicant Chad Charney Ra el Sniffen Print Name of Property Owner G I N A L. C L E M E N T S Pri ame licant NOTARY PUBLIC-STATE OF NEW YO Notary Public No.01 CL6446278 Notary Public Qualified in Dutchess Coun y My Commission Expires 01-17-2027 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 sigmed shall be deemed null and void and will be returned to the applicant. 2 8/12/2021 , , M 00 v'N W N \ o\o w a = a r- V) C F w I- z CL �4 w a W IT 00 Yto w x ►�+ o d v �" .� A C z x w gz Go A H W W z °O Zu z 04% C4 co ( � z CM W CI" w 00 F cn is � a z V O LL W P4 0 f'" O FO z ^ + w o z � H U 4 En z H A z a a >. Q d U, < x < , BUIL MENT 1 AUG - 3 2023 VIL OF RYE. OK i 938 KIN ET RYP B ' ,NY 10573 VILLAGE OF RYE BROOK -' BUILDING DEPARTMENT wbvi��lgrci org PLUMBING PERMIT APPLICATION FOR OFFICE USE ONLYjaw._J�?Q 3 PP# 03`Q v Approval Date: Permit Fee: Approval Signature: Other: Disapproved: (fees are non-refundable) Application dated, 7/26/23 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. I.Address: 2 Wilton Circle SBL:1,?,6-, 7S Zone:)e—JO 2.Proposed Work: Run 3/4 inch underground gas line in trench and connect from permitted propane tank for pool 3.Property Owner: Chad Chamey Address: 2 Wilton Circle, Rye Brook, NY 10573 Phone#: 914-4944--1/675 Cell#: email: Charney3@aol.com 4.Master Plumber: ��r%5 1C?t7 7%o e,52 n Address: 345 Lexington Ave Mt Kisco NY 10549 Lic.#. 579 Phone#:gqg'- Ls'7.-S'2."Cell#: email: Thuesen.mech(ablgmail.com Company Name: Thuesen Mechanical Address: AAA--- kMz 1 1 'ru ryl 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 3'd Floor 4'Floor 51 Floor Exterior 120 LP pool 2 tanks 5.*List Other Equipment/Provide Details: `\NQ.S A(--, (Notarized Signatures Required Next 2 Pages) 3/3/2023 STATE OF NEW YORK,COUNTY OF WESTCHESTER ) as: � otS� )L �2if-- /� �i''' ,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)he is the Master Plumber for the legal owner and is duly authorized to make and file this application. 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 Sworn to before me this /q day of ,20 day of ALSO 37+ ,20 Signature of Property Owner a of Applicant Chad Charney C*ns+h4-'�' Print Name of Property Owner Print N e of A pliAwa cant L- , Notary Public tary Public GINA L. CLEMENTS NOTARY PUBLIC-STATE OF NEW YOrih No.01CL6446278 Clualified in Dutchess County My Commis ion Ex 1ros01-1 •2027 This application must be properly completed in its entirety and must include the notarizeysigna�tire(s) 0 the legal owners)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- 3/3/2023 STATE OF NEW YORK,COUNTY OF WESTCHESTER ) as: __ . ,'k ,being duly sworn, deposes and states that he/she is the applicant above named, (print name of individual signing ashhe applicant) and further states that(s)he is the Master Plumber for the legal owner and is duly authorized to make and file this application. 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 worn to before me this 3 day of b a wb�20 t.7, ay of A.1eus4—_ ,20 2, lure of Property Owner DIANNE ROJAS Signa re of App. ant Notary Public-State of New York No.01 R06127547 �/ Chad Chamey Qualified in Westchester County My Commission Expires May 23,2025 Print Name of Property Owner Print N plicant No b is tart Public CL ENTS NOTARY U IC-S NEW YORK .0 6446278 IL alifie ' D chess County My Comm' s n Ex 'res 1-17-2027 This application must be properly completed in its entirety and must include the notarized gna re s, - 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- 3/32023 , . BUILDING 60ARTMENTiD VIL i►i�E OF RYt,�ftOOK AUG - 1 2023 938 KING EET RYE Bitoft,NV 10573 i (9164) -0648 ' VILLAGE OF RYE BROOK RUILDING DEPARTMENT ARfRRRRRAR}}RfRRR#ABA#RRRA#RARRRRR#RR}■ARRRfRRRRRARRRRRRRR•Aff#BARK}RRffARR#A#RRf ARf}}RRR}RARRRRRRRA}## AFFIDAVIT OF COMPLIANCE VILLAGE CODE 4216 R 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 YORK,COUNTY OF WESTCHESTER ) as: ., Chad Chamey , residing at, 2 Wilton Circle ,�'nnl n,u,c 1.Iir 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; 2 Wilton Circle Rye Brook, NY. 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. of Proppem ON%nells)) -- - Chad Charney Pint Namc of Proper(% Owici(­) — Sworn to before me this NODIbNNS Q OJg sday of r Public — c0a75 K YMY Qoalifre � 1RO612Cornmis4stchslo Pester O es413Y�320o2r5a k -3- xr t 2r2n:t m U p • m W ¢ 3 Z, W ^a Q'LU .- P O ° LLJ w W 3 J>�JJ--'� O' J i Ll' V'6,�. 0,. ul , $ � a <, Q o ap NJ Its \eo C m nN wa.5 Q ur yaFyS p 11HI 7YOIf iio dd ' W � O PO I ^ N W N p ti W A Q A 10, o 3 \ J 00' Qs s s , I� F RoE� ���i tbs lit; = r �_ F- o W ' O 5G it a I # � ak :W lL i mom) y C,,- m cop� N V, )a O li Q �' O(/� FF t LY LC �' U( Ji1 wp E"y a �� ! t D ( a W�Iwo a N O cW{� a 'P Se ' gyp ;E CEO m �i► O w zLL k: b J=I=2 D a J o Ct li a a g J a a CO c ' 1 a� can $ia Q m U La w f__- Steven Fews From: David King <david.king@paracogas.com> Sent: Friday, September 22, 2023 1:57 PM To: Steven Fews Subject: Inspection 2 Wilton Circle Attachments: processed-9841A556-3CC5-4702-8C4D-401879402OF4-6FDE10ED-C2E8-4619-8C76- E49D80428307jpeg; processed-8AEA3EDD-448A-4087-8BD2-4CF6F782DF3F-51B76CF5-1001-4AD5- A786-3076A72875BEj peg; processed-OD6A33EO-BAB8-4457-AO8C-26453FFC4F84- A0270D8F-ABCF-42AB-B5FD-7lC3EDB41DBOjpeg; processed-D1C7619D-6E31-49CB- B775-4E541E9C514C-A1128E54-OCF1-4E1A-9A63-28AD74B442B6jpeg Steven Fews, These are the photos as requested for the propane tanks included are the eye hooks for the left and right sides the center connecting them and finally the connection for the cable. Please let me know if there is anything else you need. David King. 1 .•a • • N • t +' - 4 • 4 •4 . .,/ y r 4 ♦ , �, 'may±` lb r � w 3 a �- ` ` oilm Ono' gni Pq � / / ,acoR ® CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDD YYYY) 12/28/2022 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 NAME: Thomas Heiple Edgewood Partners Insurance Center PHONE - FAx - 1 American Lane • 203-658-0506 A/c No): Greenwich CT 06831-2560 ADDRESS: tom.heiple@epicbrokers.com INSURERS AFFORDING COVERAGE _ NAIC# INSURER A:Travelers Property Casualty Co of Amer 25674 INSURED PARAGASC INSURER B: Lloyd's of London 25186_ Paraco Gas Corp; Paraco Gas of CT Inc Paraco Gas of NJ LLC; Paraco Gas of NY Inc. INSURER C:The Charter Oak Fire Insurance Company 25615 800 Westchester Ave,Suite 604 INSURER D:Travelers Casualty and Surety Company 19038 Rye Brook NY 10573 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:212110147 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 D POLICY EFF POLICY EXP LIMBS LTR POLICY NUMBER MMlDD/YYYY MM/DD/YYYY C X COMMERCIAL GENERAL LIABILITY 6601P009026 1/1/2023 1/1/2024 EACH OCCURRENCE $2,000,000 DAMAGE TO R CLAIMS-MADE F�_I OCCUR PREMISES Ea occurrence 000,000 MED EXP(Any one person) $5,000 _ PERSONAL 8 ADV INJURY $2,000.000 _ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $2,000,000 POLICY JECT PRC ❑LOC PRODUCTS-COMP/OP AGG $2,000,000 X IRO- OTHER: $ A AUTOMOBILE LIABILITY TRJCAP7K029970TIL23 1/1/2023 1/1/2024 COMBINED SINGLE LIMIT 52.000,000 Ea accident X ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY Per accident $ B UMBRELLALwB X OCCUR UKPCB2300025300808 1/1/2023 1/1/2024 EACH OCCURRENCE $5,000,000 X EXCESS LIAR CLAIMS-MADE AGGREGATE $5,000,000 DED RETENTION$ $ C WORKERS COMPENSATION ER TH- U88N6879022351D 1/1/2023 1/1/2024 X STATUTE ER D AND EMPLOYERS'LIABILITY Y/N UB8N6862232351 R 1I7/2023 1I112024 ANYPROPRIETOR/PARTNER/EXECUTIVE ❑ N/A E.L.EACH ACCIDENT $1,000,000 OFFICE R/MEMBER EXCLUDED? (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 1 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 AUTHOR IZED REPRESENTATIVE Rye Brook NY 10573 1 ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD vo�1c Workers' CERTIFICATE OF STATE Compensation 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 1c. NYS Unemployment Insurance Employer Registration STE S604 Number of Insured RYE BROOK, NY 10573 Work Location of Insured(Only required if coverage is specifically 1 d. Federal Employer Identification Number of Insured or Social limited to certain locations in New York State,i.e.,a Wrap-Up Policy) Security Number 13-3149941 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 Village of Rye Brook 3b. Policy Number of entity listed in box"la" 938 King Street UB-8N687902-23-51-D Rye Brook, NY 10573 3c. Policy effective period 01-01-2023 to 01-01-2024 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 "T' insures the business referenced above in box "'Ia" 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: Kim Owen (Print na uthorized representative or licensed agent of insurance carrier) Approved by: 12-21-2022 (S' nature) (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