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HomeMy WebLinkAboutMP23-116 tc t J� . 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.Uebrook.org TRUSTEES BUILDING & FIRE INSPECTOR Susan R. Epstein Steven E. Fews Stephanie J. Fischer David M. Heiser Salvatore W. Morlino CERTIFICATE OF COMPLIANCE August 16,2023 Douglas Conrad&Judith Fried Conrad 42 Talcott Road Rye Brook,New York 10573 Re: 42 Talcott Road, Rye Brook,New York 10573 Parcel ID#: 135.50-1-10 This document certifies that the work done under Mechanical Permit #23-116 issued on 7/25/2023 for the removal of an above-ground oil tank has been satisfactorily completed. Sincerely, Steven E. Fews Building&Fire Inspector /to E BRC��, • 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: t ;cam DATE: U,1 LV2-�, I PERMIT# - ' l ISSUED: SECT: , BLOCK: LOT: LOCATION: �+ti--f . t 1, k. tL Q�ZS 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 ° y try L1.1 M N N W a N g. eq I�1 n i U ° w 1w, A '° ° B : o z ONa � > � Z � " n : O Oen Ln a�-1 [ N Q F 3 U w � o o � OC"It 14 Ln 00 oA co s � •=' r � w1. z00 o � C o 8 0 � ZZ p -TJ Q u u C:D) Z H (:) 0 v m 0 (),% I �2 100 W a CN Q Vim " v yw W � o o ' v9 u A oo � v � �U V. � © 0 $ wo . a .� � O �I � �+ ►� � w x � � dab BUILD IY�' _6JkPA-RTMENT � , ,; JUL 2 4 2023 VI I. � E OF RXy*i9OK 938 KING ETRY€BR6614 NY 1US73 I VILLAGE OF RYE BROOK (914)9 39-S801 ! BUILDING DEPARTMF-PJT 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#: ��t� 3 es/ /l JUL 2 5 20 J,-iOb, Approval Date: Permit Fee:$ Approval Signature: Other: Disapproved: (fees are non-refundable) REQUIREMENTS FOR RELEASE OF PERMIT&CERTIFICATE OF COMP_LIAN-CEt 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 Yank: Removal,Abandonment,or Installation: S 175.00 per Tank. 5. Dig Safely New York#(dial 81 l): _ 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. *##*###+ii##r+iiiii#+##r##w#rir#+##iiii#+#iiti*iiri#iiiiiii*iR##i#iiiiii++i##*iiii###ii+i*i**##iiiii4#ii#+* Application dated, 7/21/20 3 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. ##* #*#i*i#i**+ii####*i## Indicate Permit Type: Installation O •Removal(t -Abandonment( }/Above Ground(1�Buried in Ground( ) 1. Address: 42 Talcott Road SBL: 135.50-1-10 Zone: j;O�L 2. Property Owner&Address: Phone#: 914-417-7301 Cell#: email: doug@deccxiradepa.cc" 3. Contractor&Address:.C2G 83 S Putt Co Rd, New Paltz, NY 12561 Phone#: 845-255-4900 Cell#: email crhodes ac2g,us 4. Applicant: Phone#: 845-255-4900 cell#: email: S. Indicate Fuel Type:Fuel Oil*/•L.P.Gas( )•Gasoline( )•Other( ): 6. Number and Capacity of each Tank: (1) 275 gal 7. Exact Location(s)of each Tank: located in-the ba same nt � t b l`IS STATE OF NEW YOLK,COUNTY OF WESTCHESTER ) as: Ci a G ,being duly sworn,deposes and states that he/she is the applicant above named, (print name of individual si�ming 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 C0NK k,C, 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 A) Sworn to before me this 0121 11)day of c t ,20 0< day of lit JS4 20 c;) Q Signature of Property Owner S1gnatttre of icant D OV C M( 'c-01444 S Print e of Property Owner Print Name of A plicant o,ry Public AOMt S� otai of NMYG* Pub tc N,.otcn5073ioo APRIL C REYNOLDS tam in Westchester eour*r - NOTARY PUBLIC,STATE OF NEW YORK ��F°b't°'nor Registratitan Nta, O f R E63g 4 This application must be properly completed in its entirety and m t incQdaf#>�i�d►Aiadll toy of the legal owner(s) of the subject property, and the applicant of Q"iasibq awnty y application not properly completed in its entirety and/or not proper y stgne 7.2026 void and will be returned to the applicant. 2 i � j N U) C) c�0 C M C Q v O Q C a N w CO UO i �C LL N Z 0-1c Z j can O ca a? F-- (U cz p Z Z ONE" Q U 0 RS � c6 c : 0O O Y O 0 Q C a� O C7 V1 O OU O O co > "+1 w O > m C _0N C U _ U d w .� o c� Q w c6 0 � 0 p Y C ~ J LAll" c -c >, 0 O U L^ ^ O > n OL > F Jw , O L W L E C c z r O m >. 0 O N Z_ 2 ` N > '_ d (n U C -00 0 O / a� c V U 7 c w •� J }y 0 O O tL !/ :3 �1 U) 0 Z cII 14 > C W O - C a ICI �! Z � O C2 H J 0) C: E c c� c Q O -O m �� �m i_�-. co� c C7 Et 0) m OUJg a� tar 3 = o cO `� w � c , a-. p O� )N C C Z ' c L. C O r it n M L LL - `r' cv a a LLJ Lij C i C) O �_ J J 1.Generator 10 Nrsnbe IONTgA RUOUS 2.Page 1 of' �,—Emergency Response P one 4.Waste Tracking Number WASTEMANlFEST (6 �p b-Generator's Name and Mailing Address � ' Q Gen IoPs Site Address(if different than mailing address) Generator's Phone: ?t 6.Transporter 1 Company Name t U.S.EPA ID Number I.Transporter 2 Company Name 006 U.S.EPA ID Number i 6.Designated Facility Name and Site Address t" U.S.EPA ID Number 5'' ''F�- FaoiF s Phone: E 9.Waste Shipping Name and Description 10,Containers 1.Total 12.Unit + No. Type Quantity Wi.Nol. Ir so 2. w 0 I je i N 4 — r 1 4 13.Special Handling Instructions and Additional lq rmatlon I + VFW,. �, 14.GENERATOR'S/OFFEROR'S CERTIFICAT I her declare that he contents of this consignment are fully anc accurajely desc' ove by the pro r shipping name,and are cl9iiied,pa marked and labeiedlplacarded,and are in all res i ' r Condit jar transpod according to applicable intern lional and mental r atio . �' GeneratorsJOfleror s Printedliyped Name ! 4 Signature I M !i+ Day Year -.r 15.international Shipments ❑ {�Import to U.S. ❑Expon from U.S. Pon of entry/exit: z TransporterSi nature for ex rtsonl to leak] U.S.: w 16.Transporter Acknowlodgment of Receipt of Materials Transporter 1 PrinledlTyped Name { Signature a 1CJS rl �1� I J:' ih Day r Year z Transporter 2 Printedrryped Name Signature Drty+, Year ' I 17.Discrepancy 17a,Discrepancy fndicatfon Space ❑ Quan _' -- Type. Residue —Manifest Reference Numbe ) y 17b.Alternate Facility(or Generator) h E�"�°�'° 'e .2 3 a Facilitys Phone: r j nature of Alternate Facility u 17c.Signature (or Generator) `Qgq Year PA ,, DIJILDINC w r s i 6i V L ; .€ "'b .. 'l of-" P.c 3•_,, s. ,r ,�,,;r r;' .. f 9 Facility P on of p1 of material covered by the manifest except a Y i8.Designated Facil Owner or Operator.Cemficatl' s Haled in Item i 7a + Printed/Typed Name Signature Me Day Year 69-BLS-C 6 10497(Rev.9109) 4 oPY t I U . 7E 1 e' E I NON HAZARDOUS 1.Generator ID Number 2.Page 1 of 3. e�Response Phone 4.Waste Tracking Number WASTE MANIFEST ` ,� . 5.Generator's Name and Mailing Address Gene rallors Site Address(if different than mailing address) a N\tuv eq. i057 AS WAIF Generator 3 s Phone: 1 6.Transporter I Company Name ( U.S..�EP/A ID Number 7.Transporter xnkr� { (ult�u�j °�1 / V spode Company Name U.S.EPA ID Number 8.Designated Facility Name and Site Address ya k �f IJ U.S.EPA ID Number t��1 r r , Fact' s Phone: r 7 Q' 9-Waste Shipping Name and Description 10.Containers 11.Total 12.Unit r I No. Type Quantity WUYoI- LZ U LU 2. 3 VJ E 4. III iI ! II I 13.Special Handling knstruclions and Additional Information;' LL., 11 i ty p 14.GENERATOR'SJOFFEROR'S CERTIFICATION:I her declare thatithe contents of this consignment are fully an accurately described apqx&by the proper shipping name,and are classified,parka marked and labeledlptacarded,and are in all re ir,roper condll&ior transport accorrrng to applicab4e intern tonal and na i emmen lati Generator'slOBew s Printed/Typed Name r I SGgnahue Month Day " Year -r 15. n emallonal Shipments �? I- ❑Import to U.S. ❑Export from U.S. Port of entry/exit: Z Tra rter Signature for exports on t av Lr m 16.Transporter Acknowledgment of Receip of Materials Date le U.S.: Transporter 1 Printed/Typed NameJ Signature Month Day Year a a Iranspoder 2 Printed/Typed Name S• I re I Month Day ii Year 17.Discrepancy 17a.Discrepancy Indication Space - ❑Quantiy J ❑Type _.- [ ��ariial Rejection .�, k Full Roj n 17b.Attemate Facility(or Generator) I SE S. l 1 U tL Facility's Phone: R o r'� f3dO G O F rti m 17c.Signature of Altemale Facility{or Generator) ! �) (� __, r M Ih Day Year a et , -''� 18.Designated Facility Owner or Operator Certification of r� ty p except of matena covered by the manifest except as noted i ham 17a Printedffyped Name %nature Day Year i 169-13LS-C 6 10497(Rev.9/09) Copy C213 Job No: Certificate of Tank Cleaning & Disposal 13475 Conrad, Doug Conrad,Doug (}caner: g Location: g 42 Talcott Rd. 42 TalcotY Rd. UU '° SEP � 5�Q73 I--� VILLAGE OF RYE BROOK Rye Brook,NY 10573 Rye Brook, NY 10573 I BUILDING r)FRARTMENT NYSDEC PBS Facility Spill No. Tank Reg No. This certificate is to verify that the tank(s) originating from the location stated above has/have been cleaned by C2G Environmental Consultants, LLC pursuant to all New York State Department of Environmental Conservation and United States Environmental Protection Agency Regulations. Tanks Size Tank ID# Type Product 330 1 sws #2 fuel oil Cleaning Corey Simmons 2023-08-08 Technician: Date: Tank Condition/Status: cut open cleaned out removed for disposal Disposal Location: West Kingston Recycling Corp 642 Abeel Street Kingston,NY 12401 Accepted By: Date: 2023-08-08 C2G Environmental Consultants, LLC Long Island Operations Westchester Operations Hudson Valley Operations Connecticut Operations New Jersey Operations 165 Sherwood Avenue 7 Skyline Drive,Suite 350 83 S.Putt Comers Road 25 Mallane Lane 1 International Blvd,Suite 400 Farmingdale,NY It 735 Hawthome,NY 10532 New Paltz,NY 12561 Naugatuck,CT 06770 Mahwah,NJ 07495 Office:631-414-7757 Office:914-357-9275 Office:945-255-4900 Office:203-437-6717 Office::201-574-0555 Fax:631-843-6331 Fax:845-255-4909 Fax:845-255-4909 Fax,845-255-4909 Fax:631-843-6331 RE' COr SEP 15 2023 VILLAGE OF RYE BROOK BUILDING DEPARTMENT— 116'[ RINGSTON RECYCLING CORP 642 Abeel 3T Kin stop NY,12401 845) `?31-3312 V.Y. D.M.V 7105074SCP WiM C2G E INVOICE# iB6321 Closed to Cash Purchase DATE TIME: 9,/7/2023 6,10:19 AM CASH EId: 100101 STATION: 01 Customer Info Customer C2., ENVIROMENT #1 STEEL (Unpre-ared)-027---------- 10480 $0.09 $943.20 Sublota3s�___ -__--_--_--$94 . GRAND TDTbL $' 3 20 Cash $943.20 BOTH METAL C3NTAINERS SERVIC= DATE I 09,06.23 A Mon-Fri NO TAX ON SC4AP METAL.am-2pm r SIGNATURE 41 d�i7ef t h y} .n, po yti�•1'w'i> �, t �•, ,� i w'' • O� . , a � * ,07 r!, yAjtti •r, Pill v` tin. ..\(vqi v �t '� 1 �r r U v ( \ •. [ �,(6¢v �' ♦♦ , � jyA'tt•/(�;�hit v ! 1 •♦ 11 • A •fir wht!) v q??I" •• :" �j` , ♦••vfl, •r,y -� •• t t•If� ;\.. -�!/�{+�'i_110'Oil �'rl��ill'1'Is'r�� ( ,11)(11, _ 1 �l ,1)IIp/1, 1311tE[�.1��4. •//, ��3f�' ,•••1 ((1++�)I (•( �E3(Z��._K -. ., +�. sC.t,,ll s.r,d 1 1;,-. .1�� 1.i ,.• ..1,11/11,1,�::-�IIIII,I.ii�F_ 1,�"'ISM E`;= it ..a�:�q ��((rr)> % tatip 1�11 'il;.d t-it: ,1�11,id•d li, 11 iV � E %Vi; 11� 1 ..t tp 11�11:.�,.d ti.i'•ii 1 11 .?I:;e tYt: 1 F �lu «O)> � r L•. a �ii !, . z 04 CC O ! w tfo Fs)s00 rA rA LO IN CO WJ 1 0 ' 111 ection Jr OAo 3 � w olu ,' �'�,/ �'`' ►.� �_ � � O �n Q� o :� � U / 7 •�. !• �- �A � � � LL. mil/ Hti X - f] 04 «O1))�j, •• iril y � uui��t�) :a 4r `° ; . ° co b lu .••'i��ti. tilt' O H N NN N U `:IA "e�31`� �. C'.•!�>:. 4 �,, 434,1 may «o)) '1 t 1 117 ,&� 5?i 1�I'•1i:;'y ;j? Inr,,ii45fh�Td`r`;lj;' ts) 1 ,la'.t. . Fr,..? �m •--t i..a-t.y �r z> - Jr 1 1 1a�.,', 1�1 C 1.I IN 1 0 11111 L fy. t 1�11'Ij1 � r 1111�/fll f'1111,1+11 �s111111 '!'111/1r1= r�11/11 1d•'•' 4f �! 1.1.1 �tl 01/ � �IIJ 11tli1 111 {lii �l1! ' ►11�' art ft f ji►g tYtp tlG'�� .A•. y ♦• ,, ^ tl •• (, ,.Ai ii •• 1� A t ♦♦ I >, �• �� 1t � � fl�1 ��� d •4ff� �� � � f1 � g 'Iµ��,`, 1 � :� y 1�1,y1���v l i>. �� '{!, v dtvi. -�.^ �► tsv :.. , vt� y�� e";,il�v ts� �� �r�t !It(F� bs Il�rr�M d.:.- r�.`v��r C2GENVI-01 LGRYCZYNS" ACORO CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) llb. i 4/19/2023 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). PRODUCER NAONTACT Craig Cecere James A.Connors Associates PHONE FAX 225 Madison Ave A/C,No,Ext: AC, No): Morristown,NJ 07960 .ccecere@jamosaconnors.com INSURE S)AFFORDING COVERAGE NAIC N INSURER A:Homeland Insurance Company of New York 34452 INSURED INSURER B Selective Insurance Company of America 12572 C2G Environmental Consultants,LLC INSURER 83 South Putt Corners Rd INSURER D New Paltz,NY 12561 INSURER E INSURER F COVERAGES CERTIFICATE NUMBER: 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 ADDINSDL,SUBR POLICY NUMBER POLICY EEFF POLICY EXP LIMITS A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE 51000,000 CLAIMS-MADE X OCCUR 793-00-72-59-0005 12/12/2022 12/12/2023 DAMAGE TO RENTED 100,000 X Contractor Pollution MED EXP An one person) 10,000 PERSONAL 3 ADV INJURY 5,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE 5,000,000 X POLICY j&pf 7 LOC PRODUCTS-COMP/OP AGG 5,000,000 X OTHER Professional Liability E&O 5,000,000 B AUTOMOBILE LIABILITY COMBINED accidents INGLE LIMIT 11000,000 Ix ANY AUTO S 2307223 4/29/2023 4/29/2024 BODILY INJURY PerOWNED SCHEDULED AURRTEEO��S ONLY AUUTNOpSyy p BOODILY INJURY Per accidentZTOS ONLY X AUTOS ON Y PPeoa �t MAGE UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE DED I I RETENTION$ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY YIN ANY PROPRIETOR/PARTNER/EXECUTIVE ❑ E.L.EACH ACCIDENT W.F.1yR/MEMg�I EXCLUDED? N I A (Mandatory in NH) E.L.DISEASE-IPA EMPLOYE If yes,describe under DESCRIPTION OF OPERATIONS below _ E.L.DISEASE-POLICY LIMB A Contractor Pollution F93-00-72-59-0005 3-00-72-59-0005 12/12/2022 12/12/2023 Liability 5,000,000 A Transport.Poll. Lia 12/12/2022 12/12/2023 Transp. Poll.Liab. 1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS/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 Village of Rye Brook THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 9 Y ACCORDANCE WITH THE POLICY PROVISIONS. 938 King Street Rye Brook,NY 10573 AUTHORIZED REPRESENTATIVE ACORD 25(2016/03) ©1988-2015 ACORD CORP The ACORD name and logo are registered marks of ACORD N Y S I F PO Box 66699,Albany,NY 12206 New York State Insurance Fund I nysif.com CERTIFICATE OF WORKERS' COMPENSATION INSURANCE A A A A A A 200882662 ■❑• '❑■ LOVELL SAFETY MGMT CO.,LLC , 110 WILLIAM STREET 12TH FLR NEW YORK NY 10038 ■ SCAN TO VALIDATE AND SUBSCRIBE POLICYHOLDER CERTIFICATE HOLDER C2G ENVIRONMENTAL CONSULTANTS LLC VILLAGE OF RYE BROOK 83 S.PUTT CORNERS ROAD 938 KING STREET NEW PALTZ NY 12561 RYE BROOK NY 10573 POLICY NUMBER I CERTIFICATE NUMBER POLICY PERIOD DATE Z 1412 798-9 843078 04/01/2023 TO 04/01/2024 03/16/2023 THIS IS TO CERTIFY THAT THE POLICYHOLDER NAMED ABOVE IS INSURED WITH THE NEW YORK STATE INSURANCE FUND UNDER POLICY NO. 1412 798-9, COVERING THE ENTIRE OBLIGATION OF THIS POLICYHOLDER FOR WORKERS' COMPENSATION UNDER THE NEW YORK WORKERS' COMPENSATION LAW WITH RESPECT TO ALL OPERATIONS IN THE STATE OF NEW YORK, EXCEPT AS INDICATED BELOW. IF YOU WISH TO RECEIVE NOTIFICATIONS REGARDING SAID POLICY, INCLUDING ANY NOTIFICATION OF CANCELLATIONS, OR TO VALIDATE THIS CERTIFICATE, VISIT OUR WEBSITE AT HTTPS://WWW.NYSIF.COM/CERT/ CERTVAL.ASP. THE NEW YORK STATE INSURANCE FUND IS NOT LIABLE IN THE EVENT OF FAILURE TO GIVE SUCH NOTIFICATIONS. THIS POLICY DOES NOT COVER THE SOLE PROPRIETOR, PARTNERS AND/OR MEMBERS OF A LIMITED LIABILITY COMPANY. THE POLICY INCLUDES A WAIVER OF SUBROGATION ENDORSEMENT UNDER WHICH NYSIF AGREES TO WAIVE ITS RIGHT OF SUBROGATION TO BRING AN ACTION AGAINST THE CERTIFICATE HOLDER TO RECOVER AMOUNTS WE PAID IN WORKERS' COMPENSATION AND/OR MEDICAL BENEFITS TO OR ON BEHALF OF AN EMPLOYEE OF OUR INSURED IN THE EVENT THAT, PRIOR TO THE DATE OF THE ACCIDENT, THE CERTIFICATE HOLDER HAS ENTERED INTO A WRITTEN CONTRACT WITH OUR INSURED THAT REQUIRES THAT SUCH RIGHT OF SUBROGATION BE WAIVED. _ THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS NOR INSURANCE COVERAGE UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICY. NEW YORK STATE INSURANCE FUND DIRECTOR,I SURANCE FUND UNDERWRITING VALIDATION NUMBER: 209824356 �iiir ooao 00 00010102040911111 Form WC-CERT-NOPRINT Version 3(09/29/2019)[WC Policy-U 1279891 210 (00000000000113420479](0001-0000141279891[t 1111