HomeMy WebLinkAboutMP23-091 CD
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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 Steven E. Fews
Stephanie J. Fischer
David M. Heiser
Salvatore W. Morlino
CERTIFICATE OF COMPLIANCE
July 19,2023
Michael Sylvester&Lori Speckenbach
100 North Ridge Street
Rye Brook,New York 10573
Re: 100 North Ridge Street, Rye Brook,New York 10573
Parcel ID#: 135.67-1-46
This document certifies that the work done under Mechanical Permit #23-091 issued on 6/15/2023 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
�E BRC�v�
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 - - - - - - - - - - - - - - - - -- --
\. �. -7 f
ADDRESS:— DATE: 1 1
PERMIT# � ISSUED: �� f, SECT: j 'BLOCK: / LOT:
LOCATION: � -S V� OCCUPANCY: Z
❑ 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 �' ', � �\� A ,41
❑ Natural Gas
❑ L.P. Gas
❑ FUEL TANK
❑ FIRE SPRINKLER 2-'--(V 0 ) Oil
❑ FINAL PLUMBING
❑ CROSS CONNECTION
❑ FINAL
❑ OTHER
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BUILD ,p� MENT
VIL ' GIB: OF IZYF;;: OOK JUN 15 2023
938 KING '11ZLEf Rvr Bx4, ,NY 110573
14)939-060 VILLAGE OF RYE BROOK
eb s . 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: Permit Fee: $ 3 /0 146
Approval Signature: 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#C105.2 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, ,is hereby made to the Building Inspector of the Village of Rye Brook for a permit to
remove,abandon,and/or in tall 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 PermitlyM Installation ( • Removal • Abandonment( )1 Above Ground • Buried in Ground ( )
1. Address: I OO t,.rk,Aac c—.A-• SBL: _0-1 Zane:
2. Property Owner&Address: Urt*—i ,1�ccku r, ("D
Phone#:q�y . Q • 1lA W5 Cell#: email:
3. Contractor&Address: FueA
Phone Cell #: email: c+�-Poh,l2e�mxlel¢�.erx�
4. Applicant:UftVMM1WWX atAx-• Cif? )a)W— sk- .( cr
Phone#:glry •92fi •38M Cell#: email: �(jf �jlp�*1t��r (� �ll •«
5. Indicate Fuel Type: Fuel Oil X•L.P.Gas( )•Gasoline( )•Other{ );
6. Number and Capacity of each Tank: ���� VIl on
7. Exact Location(s)of each Tank;�a�m1 l7
4 , P�D1 `�1en L°lf,l Sid f1�L1111N3r �OS [!rl
8/12/2021
a 1111"S"C-C't�- RZ r"
STATE OF NjE*WI-0,M,COUNTY OF WEFTEE as:
=AnA+%pn,. Mexaq -,being duly sworn,deposes and states that he/she is the applicant above named,
(print name off!individual signing as the applicant)
and further states that(sJhe is the legal owner of the property to which this application pertains,or that(s)he is the
L_�r,' (Yl C _�-C1� for the legal owner and is duly authorized to make and file this
application. (indicate 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 f Sworn to before me this ��
r
day of --I O 0E ,20 0-3 day of
nature o roperty Owner Signature of Applicant
�f21 &E�W-D)E1 3`-'tr
Print Name of Propert Owner Print Applicant
SCO.TT W.CRAIG
Notary Public RG R9g056 otary Public
COMMISSION EXPIRES 04/15/2027 y ^
S Z'-A N} 'LY i pL E
7r f tJLACYYP r 7J�ZIC
MY GOliVMIISW 4plree Aug.31,20
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. 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
8/12/2021
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'AC" Ez DATE(MM/DD/YYYY)
�.. CERTIFICATE OF LIABILITY INSURANCE 04/19/2023
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).
CT
PRODUCER NAArME: CLIENT CONTACT CENTER
FEDERATED MUTUAL INSURANCE COMPANY
HOME OFFICE: P.O. BOX 328 (A/C,No,E:t):888-333-4949 FAX No):507-446-4664
OWATONNA, MN 55060 ADDRIESS:CLIENTCONTACTCENTERabFEDINS.COM
INSURERS AFFORDING COVERAGE NAIC#
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 06830-5886 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 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 POLICY EFF POLICY EXP LIMITS
X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $1,000,000
CLAIMS-MADE ❑X OCCUR DAMAGE TO RENTED PREMISES $100 000
MED EXP(Any one person) $5,000
A N N 9062815 06/01/2023 06/01/2024 PERSONAL a ADV INJURY $1,000,000
GEN L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $2.000.000
X POLICY �CT ❑LOC PRODUCTS 8 COMP/OP ACC $2,000,000
OTHER:
INE
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $1,000,000
Ea n
X ANY AUTO D BODILY INJURY(Per Person)
A OWNED AUTOS ONLY]SCHE
S ULED N N 9062815 06/01/2023 06/01/2024 BODILY INJURY(Per Accident)
HIREDAUTOS OWNLYNON- WNED PROPERTY DAMAGE
AUTO ONLY
X UMBRELLA LIAB ICLAIMS-MADE
OCCUR EACH OCCURRENCE $7,000,000
A EXCESSLIAB N N 9062816 06/01/2023 06/01/2024 AGGREGATE $7,000,000
DED I RETENTION
WORKERS COMPENSATION X PER STATUTE OTHER
AND EMPLOYERS'LIABILITY
ANY PROPRIETOR/PARTNER/EXECUTIVE E.L EACH ACCIDENT $500,000
A OFFICERIMEMBER EXCLUDED? L N/A N 9917566 06/01/2023 06/01/2024
(Mandatory in NH) E.L DISEASE EA EMPLOYEE $500,000
If yes,describe under
DESCRIPTION OF OPERATIONS below E.L DISEASE POLICY LIMIT $500,000
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached it more space is required)
CERTIFICATE HOLDER CANCELLATION
330-130-6 35 0 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED
VILLAGE OF RYE BROOK
938 KING ST BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
RYE BROOK, NY 10573-1226 ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED REPRESENTATIVE A,�kL
O 1988-2015 ACORD CORPORATION.All rights reserved.
ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD
PORK Workers' CERTIFICATE OF
STATE Compensation NYS WORKERS' COMPENSATION INSURANCE COVERAGE
Board
la.Legal Name&Address of Insured(use street address only) 1 b. Business Telephone Number of Insured
203-531-6800
Westmore Fuel Company Incorporated 330-130-6
86 N Water St
Greenwich,CT 06830-5886 1 c.NYS Unemployment Insurance Employer Registration Number of
Insured
Work Location of Insured (Only required if coverage is specifically limited to 1 d. 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 Holder) Federated Mutual Insurance Company
Village Of Rye Brook #35
938 King St 3b.Policy Number of Entity Listed in Box"1 a"
9917566
Rye Brook NY 10573-1226
3c.Policy effective period
06/01/2023 to 06/01/2024
3d.The Proprietor,Partners or Executive Officers are
Included.(Only check box if all partners/officers included)
�X 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"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 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: Elizabeth Petersen
(Print name of authorized representative or licensed agent of insurance carrier)
Approved by: 9 Q"�r 04/19/2023
(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 NOT
authorized to issue it.
C-105.2 (9-17) www.wcb.ny.gov