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HomeMy WebLinkAboutMP23-156 BR(1,rf CGG4°U jJ. 190 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 21,2023 Janice Israel 31 Talcott Road Rye Brook,New York 10573 Re: 31 Talcott Road, Rye Brook,New York 10573 Parcel ID#: 135.50-1-73 This document certifies that the work done under Mechanical Permit#23-156 issued on 10/23/2023 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 �yE BR��. Q�i� •F O BUILDING DEPARTMENT ❑BUILDING INSPECTOR J�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.org - - - - - - - - - - - - - - - - - - - - INSPECTION REPORT - - - - - - - - - - - - - - - - - - - - ADDRESS: 3 LC n�� -?A DATE: l 2 PERMIT# O-N P Z 3 - IS (- ISSUED: 13 L 3 3 SECT: J3S- 5D BLOCK: LOT:1� LOCATION: U R-)A$\ _ 'C I� . OCCUPANCY: Z O ❑ Violation Noted THE WORK IS... Ef�PASSED ❑ FAILED /REINSPECTION ❑ SITE INSPECTION REQUIRED ❑ FOOTING ❑ FOOTING DRAINAGE ❑ FOUNDATION ❑ UNDERGROUND PLUMBING NOTES ON INSPECTION: ❑ ROUGH PLUMBING ❑ ROUGH FRAMING ❑ INSULATION ❑ Natural Gas - Re 111 o yIA 0 � 3 3 0 A S` W i l/ /s S u e_ ❑ L.P. Gas C , ?n Ln\lc to C LO SwLn FUEL TANK ❑ FIRE SPRINKLER Re c e ve , ❑ FINAL PLUMBING ❑ CROSS CONNECTION I r 77 ❑ �FINAL I - j s4c-t l L l7t J 30 AS SArN e ❑ OTHER / 1 a C � i / b J _ a m w 'Ln N d a N a� lop.s, _ gyp, rl..0 a H Ln A o o � � a o o V] H a o0 0 O A -0 I �1 co O zfly � Z, v W o v i o Z o p Uzv a °o C7 � /en 1 � �••I \� o a = � U W m G1 z U W Z Va d o y - R. r f� e. O z © U W i O F 0 , pvo I, to v �U 0-0 _ () W F o Z z � Q x p o O o O V V W I > o o. rn a a•... .w oAg o � _ 04 a. W � w x � � � BUILDING DEPARTMENT VII.T,A E of RYE 13ROOK OCT 19 2923 I 938 KING STREET RYE BROOK,NY 10573 � --I .(914)939-0669 VILLAGE OF RYE B OK a R'ww.r ebro k,or BUILDING DEPART NT A lication for Permit to Remove Abandon and/or Install Fuel Storage Tank (*Storage Tanks in excess of 1,100 gallons require registration with the County f Westchester) OR OFFICE USE ONLY: PERMIT#: /f c�33— / `J 4✓ ,pproval Date: Permit Fee:$ 0^/A6 ,pproval Signature: Other: ►isapproved: ::t r+#++rIf=arc#r,r ion- fundabt++ra+*+t*r++ REQUIREMENTS FOERELEASE 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. rrtsa+##r#w*#+##*#####tr##+*rw#x##r#r++r#+w*+rrw#+r+r+++r+++r+rr#++++++++rrr+r+r##w++rr+#+r++#++#rrr+ pplication dated, October 4,2023 ,is hereby made to the Building Inspector of the Village of Rye Brook for a permit to move,abandon,and/or install a Fuel Tank as herein described.The applicant and property owner,by signing this document agree .at the subject fuel tank(s)will be removed,abandoned and/or installed in conformance with all applicable Village,County,State& :decal laws,codes,rules and regulations. sdicate permitType:Installation(x)•Removal(X)-Abandonment( )/Above Ground W-Buried in Ground( ) 1. Address: 31 TALCOTT RD RYE BROOK, NY 10573 SBL: 7 Zone; I�- 2. Property Owner&Address: JANICE: FRANK 31 TALCOTT RD RYE BROOK, NY 10573 Phone#: 914-355-6880 Cell#: email:JANICEMFRANK61@GMAIL.COM 3. Contractor&Address: HUDSON VALLEY PETROLEUM&ENVIRONMENTAL CORP.P.O.BOX 364 YORKTOWN NY 10598 Phone#: 914-302-2320 Cell#: email: OFFICE@HUDSONVALLEYFUELOIL.COM Applicant: JANICE FRANK Phone#- 914-355.6880 Cell#: email: 5. Indicate Fucl Type:Fuel Oil()Q•L.P.Gas( )-Gasoline( )•Other( ): b. Number and Capacity of each Tank: 1-330 GALLON FUEL OIL STORAGE TANK 1-330 GALLON FUEL OIL STORAGE TANK. Exact Locations)of each Tank: REMOVAL 330 GALLON ABOVE GROUND FUEL OIL STORAGE TANK UNDER THE DECK IN THE REAR OF Tlic#TOME.INSTALLATION OF 3M GALLON ABOVE GROUND FUEL OIL STORAGE TANK UNDER THE DECK IN THE REAR OF THE HOME 1 8/12/2021 i OF YO COUNTY OF WESTCH) STER t m beingduly ) as: tPrmc name of individual to Y sworn,de o :ALL, and es states !lain/tl t60 spphcmt) P Se5 and states at he/she is the applicant above named, tes that(a)he is the legal owner of the prop" to which this appiie lion pertains,or that(s)hc is the + 0.Pphcanoa. _for the legal gwner and is dul authorized to make and file this ( k arcaihxl,cmttractar,ascot asaaey,Nc-) coat all sutitmeate contained herein are true to the best gfhjg,ther knowledge and belief,and that any work performed.or use applicctoo at the above captioned property will be in conforrnance with the detail as set forth and contained in this appltcat:oa and to any accompanying approved plans and specifications,as well in accordance wi York State Uniform Fire Prevention&Building Code,the Code of the Vill th the New York State and regulations. age of Rye Brook and all Other applicable laws,ordinances Swam to before tare this +� —day of S orn to before me this .20�1j dSai 20� ore o Property owner _ rIe ofApp Print N e o P try thvtter P ' t blame of Appli nt r MXHAEl.ESQt11YEL L altra A. 1pKa Public POW-State of New York y stale of New York No.DIES4442359 N Public is ration no.Q4eiritiaKt i Wntche stvr Couftty f chLss C27344. My Catntrti ,I026 Commies led n 1leitche s4 County eon Expires fury 6,20 �J This appltcation must he properly completed in its entirety and mus h 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 an or not properly signed shall be deemed null and void and will be returned to the applicant. 2 0 w n 0 ��aC �d raga-�uo� O � c�cn d c� p � S TIC, c� O C'� r� i 0 M r 0 � 2 � o r cs ! ! i CL to )k a-� uz .0 LU k( | \ LL | ; | ` |!� � ■ . o � | ■ �% ` kf! ■! y � | Laura Petersen From: Laura Petersen Sent: Friday, October 20, 2023 3:48 PM To: Janice Frank Cc: office@hudsonvalleyfueloil.com Subject: RE:Tank application - 31 Talcott Road Good afternoon, Please advise as to the status of the required items listed below. Thank you Laura Laura Petersen Office Assistant Village of Rye Brook 938 King Street Rye Brook, New York 10573 Phone(914)939-0668 1 petersenCEDryebrook.org From:Janice Frank<janicemfrank6l@gmail.com> Sent:Tuesday, October 17, 2023 11:03 AM To: Laura Petersen<LPetersen@ryebrook.org> Cc:office@hudsonvaIleyfueloiI.com Subject: Re:Tank application-31 Talcott Road Thank you Laura Tank Soilutions will be passing this on shortly Sent from my Whone On Oct 17, 2023, at 10:45 AM, Laura Petersen <LPetersenCeDryebrook.org>wrote: Good morning, The Building Department has received in the mail a tank application, a $370.00 check and the plot plan for the install and removal of oil tanks. Before the Building Inspector can review and approve the application, the following items must be submitted to our office; 1. The attached signature page must include the contractors notarized signature 2. Information on the tank that will be installed. Thank you Laura i �I Xu -�Ij 1 +I I £� I SDI 1 I p EC ENE DEC 19 2023 VILLAGE OF RYE BROOK Hudson Valley Petroleum UILDING DEPARTMENT Environmental Corp. DBA /Tanksoilutions WWWW WWI RAW* PO BOX 364 Putnam License # 794-12 Yorktown Heights,NY 10598 914-352-0500 Westchester License #WC-33112-H2O 914-980-9513 cell Ms. Janice Frank December 19, 2023 31 Talcott Road Rye brook,New York 10573 914-355-6880 Janicemfrank6l@gmaii.com Dear Ms. Frank We have completed the removal of your 330 Gallon above ground fuel oil storage tank from under the deck in the rear of your home. We have also completed the installation of your Granby 330 gallon above ground fuel oil storage tank on a 4inch concrete slab under the deck in the rear of your home.All waste oil and tank bottoms were transferred to Crown Waste Disposal Services of Mahopac NY. The fuel oil storage tank was recycled at Expressway Recycling Rt 9 Cold Springs NY. Our visual inspection showed no perforations of the tank. i erely, Don DeSandre Ct Twyfl � �Bp p[g STANDARD COLLECTION C�iiYJl(Il� ORDER FORM 936 Route 6 Mahopac, �057 NAME IVY 70541 845.803.8253 �I£E�IFERAT®L'tC ICL®Qu'Q4�mR7 DATE .7 A L_� -__ Arr- .�� �'- NAME: ETA ADOR6s& ry ATE to Ern: ADDRESS I STATE:�_TIP. l���f(/ PHONE: 0�' STATE'( I D PO:`_ TIME IN: PHONE: �--�•�..( TIME OUT SIGWATEb FACIL07r WADE AND SITE ADDRESS ' WATERWORKS 177 STEWART AVE BURGH,NY 125S0 0 LORCO PETROLEUM SUS 450 S.FRONT ST O NAME.�_ NYD98690SO85 18�''01.4111 ELIZABETH.NJ 07202 1908.820.8800 ADDRESSS: NJR00D023038 EPA ID a: DESCRIPTIOld OTY UNIT P63 USED OIL REMOVAL dINE TOTAL CHARGE MY ACCOUNT FOR THIS ANTIFREEZE REMOVAL l TRANSACTION UNLESS OTHERWISE OILY WATER REMOVAL INDICATED IN THE PAYMENT SECTION. INVOICES REFLECTING CHARGES SLUDGE DISPOSAL ARE SUBJECT TO AN INTEREST RATE VACUUM SERVICE OF THE LESSER OR 1-1/2y,PER MONTH(189'.PER ANNUM)OR THE VACUUM SERVICE HOURLY RATE MAXIMU RATE ALLOWED BY LAW ON ANY INVOICES THAT ARE NOT PAID TRANSPORTATION WITHIN 30 DAYS IN THE EVENT O DEFAULT CEtOWN PETROLEUM F r BE ENTI D O t�gLL / RECOVER SS OF CO LLE ON INCLUDI REASON- ABLE q S. IN TIME IN TIME OUT USED OIL,NON REGULATED,NOT US DOT H Ha T me0 AZARDOUSM 7°T"L �HR OILY WA ATERIALS.N/A,NONE,NONE °TM Ynno TER,NON REGULATED,NON R,C,R,A,N/A,NONE,NONE Tf V PETROLEUM CONTAMINATEDG SLUDGE,NOT REGULATED,NOT US DOT HAZARDOUS MATERIALS TT G OENEAATORw NA4,NONE,NONE TT BLENDED IN ANIS AND REPflESETifSTHAf THE MATERIALSP G ANY OUANTlTY-TH MATBULSCONTAINING I'MYCH ORWATER&CROWN HEREUNDER HAVE NDT BEEN MIXED.Co APPLICABLE LAWS,N�WDWG 8IJTNOTUMREDTOMCFR PART 261.OFN PHENYSL POD)OR ANY 0TlIE hZN D,OR OTHEAWISE DAMAGES'COSTS•AT70RNErS FEES.C7 ARLSWG OUT OF OR IN ANY GEwmwoA AGRFF6 TO INDEMNIFY MILTeRLAL°��AS HAZARDOUS WASTE UNDER I CERTIFY THAT MY TOTAL WASTE WAY REL4TEDTOA6REMHDOF THr ANgpyE qr HOLD CROWN PCTROLR1b+HARMLESS FOR ANY STREAM CROWN PETROLCUM.RS AGENM AND CONTRAGTC R3 HAVE THECAPACITYANOAREAUIH ARRANTY RY THE GENERATO;L S ARE WITHIN ONE OF THE AND FOLLOWING CATEGORIES.. REOUTATIDN9�T0 TTLWSPgTT;A�TSTORF,RECUVMOR AHD/OA DISPOSE OF ORLZF�ANO PEAANTfEp IN ACCDROARCE WITFIALIAPPLICA8IE LAWS THE WASTE LISTED ON 7W9 DCGIIN¢Nf OTO 220 LBS/MONTH OEHE4TORO-nFIES7HATTHE WgSIE Ly CSUSEDOIL C]USED INITIALS: AND-FREEZE O OILY WATM On" PRINTED NWE, 220 LBS TO 2.200 LELS/MONTH TITLE INITIALS: SIGNATURE:_ fI.%/ � DATE GREATER THAN 2,200 LBS/MONTH INITIALS: PAYMENT RECEIPT PRE tY ��85�-8 OY9-s633 34S► RT g Cold Spring N.Y. Receipt: 116927 _ Customer:101489 `Jrne: 37 PNI TONY OSTRANDER 32 VAN WYCK DR POUGHKEEPSIE, IVY 12601 ID Number 123475665 Ticke!: 118431 ROL: Operator:Admi.n PO. Weigl,Ir.: - ?C23 12'S6:t': PM hef: Waign Out. 2's'i 2.37 commodity - - Grosr '?re Net Price TOTAL^� ,ill Steei 1 Prep- —"-F -" Unprep Mix `0' --.360 C.08b0/1_13 202.30 - •-----•------------------------ Ticket Toiat: 202.30 No,of Ticketa:l Payment Method:Casn Total Paid: $262. 001 1 hereby state that I'm the lawful owner of the material described heron,that i have a right to sell same and that for payment received in full.hereby acknowledged I suit and convey title of same to Expresway Recycling Inc. Thank you for your business, Expressway Recycling,Inc � i � 5 �� �_ _ � -: �� r -� • � ,I' ���� ' � � _ ��� L y . I' _�V ��;R7 d n 1 .,,,.r• J ��- •r- der. ,q. �:k ' ��- v '�� - _ ""�=+i1 FA i` !� % • - i ��� G t r� ti b a � 1 �_'7a:y r�l r i ��1i .'a0�"`• �" t E ` f�'t,=9�.�. ss-,,,,�� r1 `m,• l/?f�• � _ '� °��" ii. o �jQ�i{'_ �`3itiv•• xyy rr..�� - �• .�;.o [7dJ ` �' ` t.�� .erg' 9 �'r � �Y:i�� •1''�,-'-m..s/�:• ��y4. - �•H 8E] e�1y ' Yam,r i�.�'D{'„a'i•ti; i' p� f. `�-+�.�" d'• `".a_..1.°.mac I q � .�' --i���`vO�f° Jam:, :•�', � eo k:�C:A � C .+•j• � EA.r. F !•,. �}Joy �° •..,'; •-•� �i�'�. s ` pai = ITU ro .H. •��•• ./. d.x• 91 T. ,-.r� ;y, � r •.ray °.• a -- _ r � .:, h31 l� INN, • � i, T f Q�,�,�.f-��; f�,f•�.•�°^•::�a�.._._. _ e •�ri j!.y�r �•1� A��® DATE(MMIDDIYYYY) CERTIFICATE OF LIABILITY INSURANCE 10/04/2023 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 CONTACT Angela Nacri NAME: Marshall&Sterling,Inc. PHONE (845)454-0800 FAx (845)454-0880 A/C No Ext: AIC.No): 110 Main Street E-MAIL anacri@marshallsteding.com ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC# Poughkeepsie NY 12601 INSURERA: Union Insurance Company 25844 INSURED INSURER B: Acadia Ins Company 31325 Hudson Valley Petroleum&Environmental Corp INSURER C: GuideOne National Insurance Company 14167 PO Box 364 INSURER D: INSURER E: Yorktown Hgts NY 10598 INSURER F: COVERAGES CERTIFICATE NUMBER: CL2372044005 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 AUUL ZUbK POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER MM/DDIYYYY MM/DD LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 OCCUR E 300,000 CLAIMS-61F�E D M PREMISES Ea occurrence $ MED EXP(Any one person) S 10.000 A Y CPA551984611 07/20/2023 07/20/2024 PERSONAL&ADV INJURY $ 1,000,000 GEN'LAGGREGATE LIMITAPPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY D JECOT- ❑LOC PRODUCTS-COMP/OPAGG $ 2,000,000 OTHER: Employee Benefits $ 2,000,000 AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000 Ea accident ANY AUTO BODILY INJURY(Per person) $ A OWNED SCHEDULED CAA551984711 07/20/2023 07/20/2024 BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY Per accident UMBRELLA LIAB OCCUR EACH OCCURRENCE $ 5,000.000 B EXCESS LIAB CLAIMS-MADE CUA551984811 07/20/2023 07/20/2024 AGGREGATE $ 5,000.000 DED I X RETENTION$ 10,000 $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY YIN STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ OFFICERIMEMBER EXCLUDED? N I A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ Pollution Pollution Liability Per Occ $1,000,000 C ENV56201104301 07/20/2023 07/20/2024 Pollution Liability Agg $2,000,000 Contractors Professional $2,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Village Of Rye Brook is an additional insured if required by written contract,per endorsement number CLCG04931018. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN Village Of Rye Brook ACCORDANCE WITH THE POLICY PROVISIONS. 938 King Street AUTHORIZED REPRESENTATIVE Rye Brook NY 10573 ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD NYSIF New York State Insurance Fund PO Box 66699,Albany, NY 12206 1 nysif.com CERTIFICATE OF WORKERS' COMPENSATION INSURANCE or.� ^A^A^^ 421749379 FRIEDLANDER GROUP, INC. xvl Y. 2500 WESTCHESTER AVE-#400A PURCHASE NY 10577 SCAN TO VALIDATE AND SUBSCRIBE POLICYHOLDER CERTIFICATE HOLDER HUDSON VALLEY PETROLEUM VILLAGE OF RYE BROOK & ENVIRONMENTAL CORP 938 KING STREET PO Box 364 RYE BROOK NY 10573 Yorktown Hgts NY 10598 POLICY NUMBER CERTIFICATE NUMBER POLICY PERIOD DATE G2574 766-8 785226 07/01/2023 TO 07/01/2024 11/412123 THIS IS TO CERTIFY THAT THE POLICYHOLDER NAMED ABOVE IS INSURED WITH THE NEW YORK STATE INSURANCE FUND UNDER POLICY NO. 2574 766-8, 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:/IWWW.NYSIF.COM/CERT/CERTVAL.ASP.THE NEW YORK STATE INSURANCE FUND IS NOT LIABLE IN THE EVENT OF FAILURE TO GIVE SUCH NOTIFICATIONS. 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 STAT SUR NCE FUND 4 tl ZI DIRECTOR,INSURANCE FUND UNDERWRITING VALIDATION NUMBER: 392420922 U-26.3