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Abandoned Application
QyE 4Rq), • 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 : 20 C H U r C N 1 L L-- '�o A DATE: 13 Z D Z 1 PERMIT# f/ PP I- /C.4 POIY✓ ISSUED: NO% SECT: BLOCK: LOT: 2 6 LOCATION: OCCUPANCY: ❑ Violation Noted THE WORK IS... 4�PASSED ❑ FAILED /REINSPECTION -0' SITE INSPECTION REQUIRED ❑ FOOTING ❑ FOOTING DRAINAGE ❑ FOUNDATION ❑ UNDERGROUND PLUMBING NOTES ON INSPECTION: ❑ ROUGH PLUMBING ❑ ROUGH FRAMING ❑ INSULATION ❑ Natural Gas �(� �E ��,� T U 2 Q /Z Re6 ❑ L.P. Gas %�N4 �s �'l✓.S r"A L L F Al ❑ FUEL TANK ❑ FIRE SPRINKLER ❑ FINAL PLUMBING ❑ CROSS CONNECTION ❑ FINAL ❑ OTHER Building Permit Check List&Zoning Analysis Address: 7 O G n-Gut l..l— SBL. 3 Zone'-L Use 2 Const Type: Other. Submittal Date: 'A l Lt "L Revisions Submittal Dates: Applicant: -Z-;� C-4--sara Nature of Work: 2,-z� �z.w i�� , C �r�/�To "J Z ' L, S Reviews:ZBA:A P R 1 Z021 PB: BO OK ( ) FEES:Filing. t =pmt BP: 27 C Legalization: APP: Dated: ✓ .Notarized SBI_ '� Truss ross Connection: H.O.A.: ( ) ( ) Scenic Roads: Steep Slopes: Wetlands: rm.Water Review: Street Opening. ( ) ( ) ENVIRO:Long. Short: Fees: N/A: ( ) ( ) SITE PLAN:Topo: Site Protection S/W Mgmt.: Tree Plan: Other. ( ) ( ) SURVEY:Dated: Current Archival: Sealed. Unacceptable: ( ) ( ) PLANS:Date Stamped: Sealed Copies: Electronic. Other. (� ( ) License: Workers Comp: Liability Comp.Waiver. Other. CODE 753#: Dated: N/A: HIGH-VOLTAGE ELECTRICAL.Plans: Permit: N/A: Other. ( ) ( ) LOW-VOLTAGE ELECTRICAL:Plans: Permit: N/A: Other. ( ) ( ) FIRE ALARM/SMOKE DETECTORS:Plans: Permit: H.W.I.C.:_Battery:_Other. PLUMBING Plans: Permit: Nat Gas: LP Gas: N/A/: Other. ( ) ( ) FIRE SUPPRESSION:Plans: Permit N/A: Other. ( ) ( ) H.V.A.C.: Plans: Permit: N/A Other. (� ( ) FUEL TANK:Plans: Permit: Fuel Type: Other. O O 2020 NY State ECCC: N/A: Other. ( ) ( ) Final Survey Final Topo: RA/PE Sign-off Letter. As-Built Plans: Other. BP DENIAL LETTER C/O DENIAL LETTER: Other. ( ) ( ) Other. ( )ARB mtg.date: approval: notes: ( )ZBA mtg.date: approval: notes: ( )PB mtg.date: approval: notes: REQUIRED EXISTING PROPOSED NOTES Cir Fin g� Front: Front: Ste: R&Lr. Main Cov Accs,C Ft H/Sb Sd H/Sb SFA. Tot,is Ft Imv: P Hight/S^tories• notes:v/N7�J �ECL �I.A N .11�u_(7 S 1 1 I �l� Lon, T -S t AM s qQ t 9 S C FN71AZorL DA ."4 fAJ &ALL T,t\ Jvt,�0-- 0'7- 0 ►-3 c � 7 1 Residential Building Permit Fee Work Sheet Permit#: Date Issued: SBL: Zone: Address: Property Owner&Contact Info: Job Description: For all new dwellings and for additions measuring 800 sq. ft. or more made to existing dwellings, the following fee schedule shall apply: (plus any alteration fees) Total Sq. Ft. (excluding basements) x $225.00 x $I5.00/$I,000.00 Basement Sq. Ft. x $65.00 x $I5.001$I,000.00 -------------------------------------------------------------------------------------------------------------------- New Construction Sq.Ft. • New Construction Cost • Building Permit Fee Basement= sq. ft. x $65.00 = $ x$I5.00/$I,000.00= $ ° I,Fl. = sq. ft. x $225.00 = $ x$I 5.00/$I'000.00 = $ 2"1 Fl. = sq.ft. x $225.00 = $ x$IS.00/$I,000.00= $ Attic= sq. ft. x $225.00 =$ x$I5.00/$I,000.00 = $+ Total Sq.Ft. = sq. ft. Total Cost= $ Total B.P.Fee= $ °Includes Attached Garage if Applicable. Total Amount Paid = $ Total Amount Due= $ Date: Signed L C�Cwuo tJ t� IL 19 VILLAGE OF RYE BROOK MAYOR 938 King Street, Rye Brook, N.Y. 1057,� ADMINISTRATOR Paul S. Rosenberg (914) 939-0668 Fax(9.14)939-AB0 'k Christopher J. Bradbury www.ryehtsaolto> r TRUSTEES BUILDING&FIRE Susan R. Epstein INSPECTOR Stephanie J. Fischer tW,°� Michael J. Izzo David M. Heiser Jason A. Klein NOTICE OF DISAPPROVAL Application # 21-016 April 15, 2021 Robert Jackson& Maureen Jackson 20 Churchill Road Rye Brook,New York 10573 PLEASE TAKE NOTICE that your application for a generator permit dated, April 14, 2021, for the premises located at 20 Churchill Road, Parcel ID# 135.26-1-26, has been disapproved because of non- compliance with the following section(s) of the Code of the Village of Rye Brook: 7-S-0 - 3 . Cz) CA S kp q:, ,-�k4 wv a -rj -�L.4cF� t r✓ -t-t iw r�- Az S YA,,� G F a N rs��F � �71 zs� -4 71. Please revise your plans to fully comply with the applicable section(s) of Village Code, or an appeal to this decision may be brought before the Village Zoning Board of Appeals(ZBA)in accordance with§250-13 and §250-40 of the Code of the Village of Rye Brook. Applications to appear before the ZBA are available at the Building Department or online at www.ryebrook.org. Sincerely, 1( - Michael J. Izzo Building& Fire Inspector mizzokryebrook.org ' 1ff,r ,tlfrt },� i � . l Iff 4BIN vov `. ILI I 1N3Wl2idd3(] JNIdl1no )IMI9 3,k�l -4O 3OV-111A 1jzoZ h I ddd JOHN KROELL & SON, INC. LICENSED& INSURLD PLUMPING a HVAC _ 22 BROOKDALE RD. PHONE:845628-3333 MAHOPAC.NY. 10541 FAX: 845628-333/ 4estchester County Board of Plumbing Examiners Westchester County Consumer Protection Master Plumbing License 2021. Gary Kroell DO 6: 119111954 Height:5*06 Weight200 Nair:Brown Eye:: Green Company: John Kroell 3 Son Inc 22 Brookdate Road f hlahopac.NY 10541 License No. 5%- Expires on:12l3112021 John Royce ACo ,;'12020 YYY® CERTIFICATE OF LIABILITY INSURANCE OATE( Y) 2020 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(les)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 NONE:CONTAC Donna PerMYBrden 3rnv 8 Browno'.New Yon Inc. PNON„ (849)628-4500 — (A45)628-18[k -. 11 ^25 Rocte 6 ADIAIL. df*-nward©n@bbhvtns wris INSURER(S)AFFORDING COYERADE _NAIC a MahL paL. NY 10541 INSURER A: Ohio Security Insurance Company 24082 INSURFD INSURER a. The Ohio Casualty Insurance Company 24074 John Kroell&Son,Inc. INSURER C. Wes!Amencan Insurance Company 44393 22 Brookdele Rd INSURER D: ---- INSURER E Mahopac NY 10541 INSURER F COVERAGES CERTIFICATE NUMBER: 20-21 REVISION NUMBER: I HIS 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 WfTH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE T ERN S, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLARAS. EXP LTR TYPE OF INSURANCE IN50 WVD POLICY NUMBER MFIIDONYYV ILD Y LIMITS COMMERCIAL GENERAL LJASILRY EACH OCCURRENCE s 1,DU0,000 I CL lMS-?A4DF ®OCCUR PREMISES'Ea uaiatence) S 15.0000 MED EXP(Arry one pwwr) S 15,000 A BKS5905W7 10/2412020 1Of24i2021 PERSONAL G ADV INJURY 5 1000,000 GENt AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE S 2,000,000 SRO POLICY PRODUC,S-COW,'OPAGG c 2,000.000 �,iECT LOC OTHER S _ AITTOM OBiLf LIAR L(TY COAIBMED SINGLE LIMB S 1,000,000 iEs salcenr) X ANY AU I O BODNI Y INJURY;Par pe(son) S A AU oSCrhAY _ A�cSxED 13AS59CS94HI 1UC'412020 10i24i2021 BODILY INJURY(aer accident) S HIRED NON-OWNED PROPER,Y DAMAGE S AUTOS ONLY AUTOS ONLY Per accddent' PIP-Basic 5 50,000 UMBRELLA LNB OCCUR I EACH OCCURRENCE c 1,0[X1,000 B I EXcess L" GLAIMSn!a0E USOS905B4R7 10124I2020 10124/2021 AGGREGATE- s 1,000,000 DE') I X1 REIFNTICN S 1D,000 ) S WORKERS COMPENSATION AND EMPLOYERS*LI B0.RY Y 1 N X STATUTE ER ANY PROPRIETOPJPARTNERIEXECUTNF E.L.EACH ACCIDENT $ 1,000,000 C OFFICERNMEMSFR FXCLUDED? � NIA XUVP59059487 10/24/7020 10/24/2021 (Mandatory in NH) E L.DISEASE-EA EMPLOYEE S 1,000,000 I•yes.desV'M u-de: 1,000,000 ----- DESCRIPTION OF OPERATIONS below E L DISEASE-POLICY LIMIT S DESCRIPTION OF OPERATIONS I LOCATIONS(VEHICLES(ACORD 101.Add;t;onai Rema4a.Schedule,may be attachad NI urore apace Is required) 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. Building Department AUTHORIZED REPRfSENTAT)YE 938 King SL Rye Brook NY 10573 C 1983-2015 AGORD CORPORATION. All rights reserved. ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD i I STATE OF NEW YORK WORKERS' COMPENSATION BOA} D CERTIFICATE OF NYS WORKERS' CONIPENSATIOl INSURANCE COVERAGE I a_Legal Name&Addrem of Insured(Use street address only) 1 b.Business telephone Number of Insured John Kroell&Son,inc. (845)628-333$ 22 Brookdale Rd Mahopac,NY 1OS41 1 c.NYS Unct ployment Insurance Employer Rcgisuati¢n Number of insured Work Location of Insured(On4:required if coverage is spec•if tally limited to certain locations in New York State, i.e., a Wrap-Up t d.Federal Employer Identification Number of Insured Policy) or Social Security Number 13- 876784 2.Name and Address of the Entity Requesting Roof of 3a_ Name of insurance Carrier Coverage(Entity Being Listed as the Certificate Holder) West Atryerican Insurance Company Village of Rye Brook 3b.Policy Nuinber of entity listed in box"la' Building Department XWA59g59487 938 King St. Rye Brook, N.Y. 10573 3c. Policy et*ctive period 10/24/20�O-10/24/2021 3d. The Prop ctor,Partners or Executive Officers are included. (Only check box if all partners/officers included) all exclud>d or certain partners/officers excluded. ®Included a]Excluded This certifies that the insurance carrier indicated above in box "3" insures the business referenced above in box "fa' 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 Currier or its licensed agent will send this Certificate of insurance to the entity listed above as the certificate holder in box-2". i The Insurance Carrier will aLw notify the above certifrcatc holder within 10 days IF a potiry •v canceled titre to nonpayment ofpremiums or within 30 days IF thrre are reasons other than nonpayment ofpremiums that cancel the policy or elir vinate the insuredfrom the coverage indicated on this Certificate. (These notires inert'be sent by regular mail.) Otherwise, this Certificate is v for one year after this form is approved by the insurance carrier or its licensed agent,or until the polity expiration date listed in box"3c; the. This certificate is issued as a matter of information only and confers no rights upon the ccniti atc holder.This certificate does not amend,extend or alter the coverage afforded by the policy listed,nor does it confer any tights or responsibilities yund those contained in the referenced policy. This certificate may be used as evidence of a Workers'Compensation contract of insw-ancc on while the underlying policy is in etlect. Please Note:Upon the cancellation of the workers'compensation policy indicated on th� form,if the business continues to be named on it permit,license or contract issued by a certificate bolder,the business must provide that certificate holder with a new Cer dficate of Workers' Compensation Coverage or other authorized proof that the business is complying with fire 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 went of the insurance carrier referenced above and that the named insured has the coverage as depicted on this form. i Approved by: Brian Miles (Print name of aulhorizeJ representaticc or licensed agwCof insurance carrier) I Approved by: /t! '�t�`'. i tc.rE January 7,2021 (Signature) (Date) Title: Executive\'ice President of Brown&Brown of New York,Inc.tl a Spain Agency I I SPATE OF NEW YORK WORKERS'CO.tViPENSATION BOARD CERTIFICATE OF INSURANCE COVERAGE UNDER THE NYS()ISABILITY BENEFITS LAW PART 1.To be completed by Disability Benefits Carrier or Licensee) Insurance Agent of that Carrier I a.Legal Name and Address of Insured(Use street address only) I b.Rusin s Telephone Number of Insured (845)¢28-3333 John Kroell&Son,Inc. 22 Broukdale Rd I c.NY5 Upemptoyrricnt Insutatrce Employer Registration Mahopac,W 10541 Number otInsured Id.Fedeial;Employer Identification Number of Insumi ar Social Sec>aity Number 13-2876794 ?.Name and Address of the Entity Requesting Proof of 3a. Nam4 of Insurance Carrier Coverage(Entity Being Listed as the Certificate Holder) Hartford Life and Accident Insurance Company Village of Rye Brook 3a. Puliq Number of entity listed in box"la": Building Department 812520 38 King St. Rye Brook, N.Y. 10573 3b. Policy effective period:04/01/2020-04/01/2021 i 4.Polity covers: a. ®All of the employer's employees eligible under the Newi York Disability Benefits Law a. ❑Only the following class or classes of the employer's Cmployees: i Under penalty of perjury,I certify that I am an authorized representative or licensed��$'ent of the insurance carrier referenced above arui at the named insured has NYS Disability Benefits insurance coverage as descnb3 above. Date Signed 01/07/2021 By (signature of insurance carrier's audnonzed repreaetita'Ire or NYS Licensed Insurance Agent of that insurance caner) Tele hone Number 845-628-4500 Title: Executive Vic -President IMr0KyAVr: If box-4a"is checked and this form 4 signcl try Lt-insurance ca Hier'*authorba d repTeaentative ar N'YS Licensed Inturaree Agent of drat carrier,this certificate is COM'TXTF Mail it directly to the certificate huldet If box"tb"is checked,dib cerdticate is NOT COUPLE.M for pwpucs of Satbu ZZ0,Subd.B of the D690ty timeft Law.It must he ttu0ed for compiction to the Workers'Compeawtion Board DA PF.ins Acc Uitit,20 Park Street,Albany,Now York 12207. PART 2.To be completed by NYS Workers' Compensation Board(001y if box"4b"of Part 1 has been checked State Of New York Workers' Compensation Board Acc:txding m infotnnatio n maint Tined by the NYS Workers'Congm mbon liiiartl,the above-named chtiploycr has ctxnpiicd vtith thu YS Disability Benefits Law with respoct to all of his/her employees. DdW Signed By (Sigm a cd A'YS WoeKers'Coihi xtisaticni Board Employee) Telephone Number Title Please Note.Onlv insurance carriers licensed to write NYS disability henefiis in'!trance policies and NYS licena:d imcurance age<nta of those insurance canierc are authorized to issue Fort DB-120.1. l surance brokers are NOT authorized to DB-120.1 (5-06) D BUILDI 'T\MENT VILLA OF RYE 'OOK APR 14 2021 938 KING S T RYE BRobk NY 10573 (914)939166 R FAX(9141 VILLAGE OF RYE BROOK)� 9-5801 BUILDING DEPARTMENT ' www x,gbrook.6i FOR OFFICE USE ONLY: Approval Date: Wase III cat Approval Signature: TURAL REVIEW BOARD: Disapproved: to BOT Approval Date: ; Chairman: PB Approval Date: Case# Secretary: ZBA Approval Date: Case# Other: nn Application Fee:14/00— b Permit Fees: /0b APPLICATION TO INSTALL A PERMANENT STANDBY BACKUP GENERATOR Application dated: d-f—1I—=-)/j is hereby made to the Building Inspector of the Village of Rye Brook for the issuance of a Permit to install a permanent standby backup generator in accordance with§2504.1.ofthe Code of the Village of Rye Brook,as per detailed statement described below.Please note that electrical and plumbing permit applications must be filed separately by those licensed professionals,and that separate permits are required for the installation of any related fuel tanks.Further note that all applications for commercial use will require a site plan approval from the Village Planning Board prior to the issuance of any permit. 1. Job Address: �ir�C'zV 2. Parcel ID#: � �`�(Q �O lo Zone: P45- 3. N.Y.State Construction Classification: N.Y.State Use Classification: Rk;t 4. Proposed Generator&Fuel Type(Describe in detail): OJe 166 s S/x"d M,-1 O20 e to _r9/4f eove- f=J r'OeoP'�-/E- 5. Property Owner. fYj1qtjeELn /CQ 0 6OC.T J 19 Ck SC)e? Address: —?D tAr / e�l OCQC Dk Phone# /' 9 3Y- O /`f Cell #/ Q� -aCo� - 0/9'/0 email:�'QbP' 414Ck�O�Sr 5V. ') Applicant: f ��I>��'. aL Rom'C1 / Il� C�=� Vorcrt Address: q`f-7 LrJ/'>7/YIC��'�=e. c 7� 1�fQ/tl��'70r/?� Phone# -EeHE o 5�� email: ��P Architect or Engineer(if applicable): Address: Phone# Cell# email: General Contractor: lgaexe Address: '�7s ���� c.E `�p fJj4C' /✓E N/ /OS� Phone#9/9- 769 S�JSJ Cell# 10',J}-7- /J/0 email:_ 4�6 ge 1yXVW0'MJ6P CO-4'\- 1 3/21/19 LC�� OMC BUJt,I»N6A)F.PAI z•rmF,N'r VII,I,ACK,OFRV 131tOOK PAPR 14 2021 � 938 KINGS i it,ri:•r Rvi,' B[tooil ,NY 10573 VILLAGE OF RYE BROOK (914)9394668 P;�z (91.1)939-5801 BUILDING DEPARTMENT__ q)rgo1i.gn.' AFFIDAVIT OF COMPLIANCE VILLAGE CODE 5,216 • 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 J��r V ,residing at, �G CL'/"�1�/(L -- (Pi ini name! (Addre�:t�'hr c you li�ci 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; 4() �! C�o 1(kle'cljlu' - _ , Rye Brook, NY. (.Iub;;\rkJrrssl 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. SiInmure or Pm(mi— 'Z- 8 e�2 i (Prim Name of Proruty Owner(s)}Sworn to before me this l�' C day of CLAUDIA EO F NOTARY NEW YORK QUALIFIED IN WE TCHEST ER COUNTY COMMISSION EXPIRES APRIL 12,2024_�- 3/21/19 6. Give exact dimensions tirom proposed generator to lot lines: front yard: 7�?, rear yard: ��� right side yard: 7/ left side yard:__00 7. If building is located on a comer lot,which street does it front on:` Q C-/f/, L ,q1t., 8. Will the proposed project disturb 400 sq.ft.or more of land,requiring a Storntwater Management Control Permit from the Village Engineer as per Chapter 217 of the Code of the Village of Rye Brook? Yes: No: 9, Will the proposed project require a Site Plan Review by the Village Planning Board as per Chapter 209 of the Code of the Village of- Rye Brook'? Yes: No:�_ (provide detailed drawings as per Chapter 209) 10. Will the proposed project require a Steep Slopes Pem►it as per Chapter 213 of the Code of the Village of Rye Brook? Yes: _No: ti (provide a detailed topographical survey) 11. Is the lot or any portion thereof located in a Wetland as per chapter 245 of the Code of the Village of Rye Brook'.? Yes: No: V (provide a detailed survey indicating the Wetland&Buffer Zone) 12. Is the lot or any portion thereof located in a Flood Zone as per the FEMA Flood Insurance Rate Map#361 19CO279 dated 9/28/07? Yes: No: `+ 13. Will the proposed project require a Tree Removal Permit as per Chapter 235 of the Code of the Village of Rye Brook? Yes: No: Y (a tree replanting schedule maybe required) 14. Does the proposed project involve a Home-Occupation as per Chapter 250-38 of the Code of the Village of Rye Brook? Yes:_No: Y . If so,indicate: TIER I: o TIEIt II: TIER III: 15. What is the total estimated cost of construction: $ a pQ,920 (The estimated cost shall include all site improvements,labor,material,scaffolding,fixed equipment,professional fees,and material and labor which maybe donated gratis) 16. Estimated date of completion: �*wr,t**+►«r+,r***o*�»��r+**,.+*�*v.**,.+****,r*««***«�..va�.*.«��.���.«****k.w�**�*�,rw�****.�.*�K*****w****«*�,ra STATE of NEW YOM COUNTY OF W ESTCHE",TE R ) its: .>i9i✓ Z,:-�-a ,being duly swurn,deposes and states that he/she is the applicant above named, (print name ofindividual 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)bc is the Cy y7X4GT o/1/ 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 Sworn to before me this day of ay of _,20�2�_ 4-Q:��_��_ 'i �_ Signature orPro!� waer Si atu of Applicant X� intNameofPr nyOwner &ALI UDIA UVALDO Print Name of Applicant LIC,STATE OF NEW YORK WESTCHESTER COUNTYN EXPIRES APRIL 12,2024 Notary Public Notary Pu tc 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. Please note that application fees are non-refundable. 2 ELIZABETH SARLES NOTARY PUBLIC-STATE OF NEW YORK No.01SA63828A"' Qualified in Putnam County My Commission Expires 05-20-2023 �x a mA ; >< t•� * .- _ �Ys� ., .. 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S? 7r t0 S t s @ 11 1N3VNU it 30 ONIOline N000 19 3h2j d0 3Jbllln 0 I " hlddd 7/A 3a a RC�C� � OML APR 14 2021 1 3D VILLAGE OF RYE BROOK BUILDING DEPARTMENT P � .�, 3 � � `° ✓vs; A•ply £�s �•� � ���' � aye �p } .1' f z Al .t. AN ('If t Rt'Jllt•�• 20 kW Fortress Standby Generator System Page I of 8 `lerth America English v p�ltures Specs Support Accessories Reviews Q&A �!BRIGG$r,RTRA ON*. 4�� (�ttpsa/shop.briggsandstratton.co�' (/na/en...uslhome.htm l) F!:mr.Qfj�nnpye�n�,(u[s�];[h(o�m�e,.hltmi} / Geremlrws(inaien aslprodxts/aeneratcrs.htmi} !r�a/C''f5"YMf WfVIiBWW r f^ st' t S i aP r e O p reror System 20 kW' Fortress Standby Generator System Back-up power for medium to large -�- sized homes Losing power is nothing to worry about any more with the 20 kW generator.When the power goes out your backup generator seamlessly provides power to your home within seconds of a power outage. WHEgE TO BUY 20 993cc 3600 6 Year kW Displacement RPM Limited Warranty Features Symphony Il'- 6 Year Parts,Labor&Travel Limited Warranty Thanks to Symphony'II Power Management System,a smaller The longest warranty in the industry.Our most comprehensive 5 home generator system by Briggs&Stratton can meet all your year parts,labor&travel limited warranty needs and save you money in the process. (/content/dam/briggsandstratton/na/en_us/Files/pdps/warral 20kW.pdf). Commercial-Grade Engine Durable Enclosure A commercial-grade Vanguard-engine means powerful performance when it matters most. hnps://www.briggsandstratton.com/na/en_us/product-catalog/generators/standby-gcncrat... 05/10/2018 20 kW1 Fortress Standby Gencrator System 1'a c 2 of 8 Designed to weather the elements,the system's enclosure is made Features Specs Support steel to rgtWust.Its advanced powder coat paint process results in years of protection against chips and abrasions. Flexible Placement' Superior Customer Support Have a tight lot line?Worried about your curb appeal?Install your Shopping for the right standby generator for your home can be generator as close as 18"for your home.Our generators are in confusing,but Briggs&Stratton will be with you every step of the compliancy with the stringent National Fire Protection Agency 37 way.Call our U.S.-based Answer Care Representatives by calling standard. (800)743-4115 or visit the Customer Support Portal to get your questions answered now. Financing Solution We have partnered with Synchrony to provide financing solutions that fit your needs.Special financing*is available on qualified Briggs &Stratton Standby Generators on the Briggs&Stratton Standby Power Credit Card. •s,ni«,m<r.ae,PP-.t M,mm"„mo�u.ir wrm•M,Kw+rya This generator is rated in accordance with UL(Underwriters Laboratories)2200(stationary engine generator assemblies)and CSA(Canadian Standards Association)standard C22.2 No.100-04(motors and generators). Warranty details available at briggsandstratton.com. 'Installations must strictly comply with all applicable codes,industry standards,laws,regulations and provided installation manual.Running engines give off carbon monoxide,an odorless,colorless,poisonous gas so it is important to keep exhaust gas away from any windows,doors,ventilation intakes or crawl spaces.The installation manual contains specific instructions related to generator placement in addition to NFPA 37,including the requirement that Carbon monoxide detectors be installed and maintained in your home. Specs ®20 kW'Fortress Standby Generator System Model Number 040547 Running Watts(LP)* 20,000 Running Watts(NG)* 18,000 Engine Brand Briggs&Stratton Engine Series Vanguard- Engine Displacement(cc) 993 Operation Fully Automatic Voltage(V) 120/240V AC,Single Phase,1.0 pf Running Amps(LP) 83.3 Running Amps(NG) 75 Alternator Type Computer Friendly LP Fuel Consumption** 50%Load=2.31 gal/hr NG Fuel Consumption- 50%Load=187 ft'/hr Weekly Exerciser Yes Battery/Battery Charger Yes Overcrank Protection Yes Diagnostic Alerts with Remote Low Oil Shutdown,Engine Does System Status Not Start,Low Frequency,Engine Length(in) 48 Overspeed,Low Voltage,Low Battery Voltage,Oil Temp High, Height(in) 31 Transfer Switch Fault Warranty(Product)*** 6 Year Parts,Labor&Travel Width(in) 34 Limited Warranty https://www.briggsandstratton.com/na/en_us/product-catalog/generators/standby-generat... 05/10/2018 NMI Fortres4S'iiiidbv (..iener�it:, ' Svs'eT Ra-e I of 8 _9"F es Specs Support Accessories Reviews O&A .tan 1011 M. Itr Uml�n usr homt.html) I G—.emtots(ilalfn y 20 kW' Fortress Standby Generator System Back-up power for medium to large sized homes Losing power is nothing to worry about any more with the 20 kW generator.When the power goes out your backup generator seamlessly provides power to your home within seconds of a power outage. WHERE T wHF.ET 0-8—u—ly- 20 993cc 3600 6 Year kW Displacement RPM Limited Warranty Features Symphony ll'- 6 Year Parts,Labor&Travel Limited Warranty Thanks to Symphony*11 Power Management System,a smaller The longest warranty in the industry.Our most comprehensive 6 home generator system by Briggs&Stratton can meet all your year parts,labor&travel limited warranty needs and save you money in the process. (/content/dam/briggsandstratton/na/en-us/Files/pdps/warrat 20kW.pdf). Commercial-Grade Engine Durable Enclosure A commercial-grade Vanguard-engine means powerful performance when it matters most, https://w-vvw.briggsandstratton.com/na/en_us/product-catalog/generators/standby-gencrat... 05/10/2018 20 k-WI Fortress Standby (.3encrait:lr System Pagc 2 ol'8 Designed to weather the elements,the system's enclosure is made Features Specs Support A(b%@§-4lt1@4ive-9radF{ Pal steel to rQiWust.Its advanced powder coat paint process results in years of protection against chips and abrasions. Flexible Placement" Superior Customer Support Have a tight lot line?Worried about your curb appeal?Install your Shopping for the right standby generator for your home can be generator as close as 18"for your home.Our generators are in confusing,but Briggs&Stratton will be with you every step of the compliancy with the stringent National Fite Protection Agency 37 way.Call our U.S.-based Answer Care Representatives by calling standard. (800)743-4115 or visit the Customer Support Portal to get your questions answered now. Financing Solution We have partnered with Synchrony to provide financing solutions that fit your needs.Special financing'is available on qualified Briggs &Stratton Standby Generators on the Briggs&Stratton Standby Power Credit Card. •s:e�i ro uedn,ppeoval M�,�mom m��v wrm,m h*��Ma This generator is rated in accordance with UL(Underwriters Laboratories)2200(stationary engine generator assemblies)and GSA(Canadian Standards Association)standard C22.2 No.100-04(motors and generators). Warranty details available at briggsandstratton.com. 'Installations must strictly comply with all applicable codes,industry standards,laws,regulations and provided installation manual.Running engines give off carbon monoxide,an odorless,colorless,poisonous gas so it is important to keep exhaust gas away from any windows,doors,ventilation intakes or crawl spaces.The installation manual contains specific instructions related to generator placement in addition to NFPA 37,including the requirement that Carbon monoxide detectors be installed and maintained in your home. Specs jo 20 kW'Fortress Standby Generator System Model Number 040547 Running Watts(LP)* 20,000 Running Watts(NG)* 18,000 Engine Brand Briggs&Stratton Engine Series Vanguard- Engine Displacement(cc) 993 Operation Fully Automatic Voltage(V) 120/240V AC,Single Phase,1.0 pf Running Amps(LP) 83.3 punning Amps(NG) 75 Alternator Type Computer Friendly LP Fuel Consumption** 50%Load=2.31 gal/hr NG Fuel Consumption** 50%Load=1871t'/hr Weekly Exerciser Yes Battery/Battery Charger Yes Overcrank Protection Yes Diagnostic Alerts with Remote Low Oil Shutdown,Engine Does System Status Not Start,Low Frequency,Engine Length(in) 48 Overspeed,Low Voltage,Low Battery Voltage,Oil Temp High, Height(in) 31 Transfer Switch Fault Warranty(Product)*** 6 Year Parts,Labor&Travel Width(in) 34 Limited Warranty https://wrA,-�,v.briggsandstratton.com/na/en_Us/product-catalog/generators/standby-generat... 05/10/2018 - of k��•7g'�t�����. �0A J J,Qq��. 6eb0a� Q'� i1 .."+'R. t i ' '/� i�+alaQ7i,'ia �� ti4iirY` f �,iz�ri�Q�t ;5 e �j' •i 3 i Q .s. s„c �'r ii§li iyeaQC $.t At 4 4 v U , a Fs OP �P � N ca W N W C7 U vs o xection Uj- cr- Lij W v Co aci LO _ cn R - '4I ,. a T I cUC i� NO X y ' t0 LO _ cY � ' 2��" e`^: CJ •� co-, � T ` • �� �� �.� a U 3' i b J #,_ w '�.r�''��.,.}•„' "J }�'.b..��Y k mot+i. d�ii• ' :({ + ,_p a VIR _ y ♦E..?`��IZ ' 4c ;-1� � 1.",`Tbx � �j"f.�, :,�.c �'.�� •u �� �}t"' Y y� ""�� , DArEtNxrm,nvYY1 q`C�ftl7 CERTIFICATE OF LIABILITY INSURANCE a:v7 S ISSUED AS A MATTER F INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLD R—` THIS CERTIFICATE 1 I SU O HIS 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(les)must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WANED,subject to the terms and conditions of the policy,certain pollCIOS may require an endorsement. A statement on this certificate does not confer rights to the certificate holder In Rou of such Dndorsement(s). PRCDUCER CONTACY Eren.NAB: PaulMart-4wi `dash USA,Inc. - rAlt 1166 Avenue of thu Alrlarlc:s' PI L (2121345 5227 A f4 fto. {')C.a., New York,NY 10336 l w►a Pao FizM'Lnri um;rsn.can Alen At"-f-AS..:.. _ --•_—_ .. _....... IxsunErsislArroaolnccoyrnACE.. i NAII'e CN101414eW,1L fkO•ACORD•20- INSUREtt A:National UI!on File Ins Co P145w t PA t1:5 .........._ ---- ....._.. INSURED INSURER B:No-*14.IIi NW;11.tlaa,M CO_ 2384 MEENAN OIL GO.LP 0A 81,RKf HEAT AND BU2KE FUEI OIL CO KsuaER c;lPa vtCfVt� rxwa Ca!pnnY_. 19437 475 C)WAERCE STREET 19399 HAWTHORNE.NY 10532 xsu R o_�IU t tiurarce Co INSURER E INSURER F- COVERAGES CERTIFICATE NUMBER_ NYC-M.225WA REVISION NUMBER: TI IIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED DELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDIT104 OF ANY CONTRACT OR OTHER DOCUMENT MTI4 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.LIM.TS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. WORT— �5 . !Aoa suBR -POfJOY EFP Pa1CYEXa A. TYPE OF INSURANCE ( POLICY NUMBER lTR; A X jCOMMERCIAL GENERAL LIAOILIY GL7=28 16D1!102D' tG.4i72021 fALy{aLtRRENcc j, LtmO,000 pitllAGFTOltF37TEt3--- I _ CLAIMS-MALE X-j OCCUR 1711:-M$Ls IIA orpnencal I S _. 1Cj0,0U3 1XCU WEREXP(AnY.t peraa,)—I t 5 X CorAw-tua' P_ERSOY+U_d.ADV IN.IURY, ii ..._i,l'ADIbO GEN'L AGGREGATE LIMIT APPLIES PER: I GENERAL AGGREGATE `1; 5,000,� _ . t !! _ X�POLICY Ir�lg OC PRODl i!f Lh,TS-(0AP:'OY AGG!,s 2,000,001 01YN;N SIR $ i. OtT,G7u A AUTOMOBILE LIABILITY CA 726.0953(AG;) 10101020 101012021 :D%INGLF LIIAI S 2,000,010 A X AttY AUTO CA 726935l(MA) 10101020 1010=1 BODILY INJUR (Pe!pers Yon) F A OWNED j" SCHEOU � ) _ED ( CA A +IN1020 10101J2021 BODILY INJURY(Per aoclded) _ AUTOS ONLY AUTOS S HIRED ' NONAWNED I M10P07Y AUTOS ONLY i AUTOS ONLY t IS X UMBRELLA I" IX OCCUR 102}43Q599 110,01j20Z0 1010112021 EACH OCCURRENCE_ S S.IIUO'(1D0 OfCE95 UA8 G.J.IMS.tlAOE I AGGREGATE T S,�O,ODO I.EO I X I R[TENTI DN S 1Q040 0 WORKERS COMPENSATION WC WMWi( T,DE,GA,MD,ME TW1212D 10-112021 X I PER AND EMPLOYERS'LIAAKITY YIN ( -_ STATUTE kR MI,NY,RI,SC.TN,WV N+wIO�wE7WN•ARINLRIEItECUnVE — I E.L.EACH ACCIDENT S .. ._ 1,000,0�) B OFF ICCRR/@GeERExr)1LOCO? N� NIA WC63M93 _..._. --.4 _ _. . 1,000,0Lb (Mandalay In NM {MA ND,OH,WA WY) }ON11202(1 tO01l2021 E.L.DISEASE-EA EMPLOYE_ S It yes describe undtr ._ ... -.._ 1 DES/;RIPTfOH Or DPC3JA}K7ttS Le'ax I ELDISEASE•POLICY LIMIT !z i I DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Addiftnal Remarks Schedule,may be attached If Mors spat.Is r.4.Ired) THE CERTIFICATE HOLDER IS INCLUDED AS ADDITIONAL INSURED AS RESPECTS THE NAMED INSUREDS OPERATONS CERTIFICATE HOLDER CANCELLATION .. VILLAGE OF RYE BROOK SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 938KINGSTREET THE EXPIRATION DATE TIIEREOF, NOTICE WILL BE DELIVERED IN RYEBROOK,NY 10573 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE of Marsh USA Inc. I David A.CDble!ghr,�v-•,/G!l�y711 ©1988-2016 ACORD CORPORATION. All rights roserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD 'Workers' ' YORKorers CERTIFICATE OF sTatt Boat tf ompensatior~ NYS WORKERS' COMPENSATION INSURANCE COVERAGE 1.ila, t.egal Narrr 8 Address o insured(i t:cct address only) ,h riu .es,Te ei)hore Number of Insured M--NAN OIL CO,LP 91� l69-5^S0 JdA BURKF HEAT AND PURKE FUEL Oil CO 475 COMMERCE STREET 11c.NYS Unumpluymerlt Insurance Employer Registration Number of HAAITHORNF.,NY 10532 Insured 831142S-2 Work Location of 1.ieurad(Onlyrroqurred if coversys is sfincificeMY firni!eo to ;1d Federal Employer Identification Number of insured or Social Securty certain.ecations in S New York ale,i.c.,a Wrap-up Fbticy) i Number 113083408 ----..__..._-.__ _._..----� ._. ............................. .�..._.._._—...T---- ---- -------------......... _..... 2.Name and Address of Entity Requesting Proof of Coverage 3a Name of Insurance Carrier (Entity Being tisied as the Cerlificale bolder) All)Insurance Company 3b,Policy Number of F..nilly Listed in Box"la" Village of Ryebrook WC 63850892 938 King Street Ryebrook,NY 10573 3c.Policy effective period 10/01/2020 to 10101/2021 3d.The Proprietor,Partners or Executive Officers are 0 included.(Only check box 1!of parinerstofficers included) E]all excluded or certain partnerslofricers 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 Itern 3A on the INFORMATION PAGE of the workers'compensation Insurance policy). The Insurarre 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 elirnnate 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.I his 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 oil this form. Approved by: David McElroy — (Print n`ar(c of aull"izcd representative or licensed eg¢nt of insruanee carrier) September 28,2020 Approved by: \' (Stgnahire) (Care) Title: C.E.O,North America Telephone Number of authorized representative or licensed agent of insurance carrier: 212-77G-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 Workers' CERTIFICATE OF INSURANCE COVERAGE vou�lt Compensation ��>aTe Board under the NYS DISABILITY AND PAID FAMILY LEAVE BENEFITS LAW PART 1.To be completed by Disability and Paid Family Leave Benefits Carrier or Licensed Insurance Agent of that Carrier Ia.Legal Name &Address of Insured (use street address only) lb.Business Telephone Number of Insured Meenan Oil Company,L.P. 1000 Woodbury Road Suite 110 Woodbury,NY 11787 1 c.Federal Employer Identification Number of Insured or Work Location of Insured (Only required ifcoverage is specifically Social Security Number limited to certain locations in New York State,i.e., Wrap-Up Policy) 11-3083408 Meenan Oil Company,L.P.dba Burke Heat and Burke Fuel Oil Co. 475 Commerce Street Hawthorne,NY 10532 2.Name and Address of Entity Requesting Proof of Coverage 3a.Name of Insurance Carrier (Entity Being Listed as the Certificate Holder) CIGNA LIFE INSURANCE COMPANY OF NEW YORK Village of Ryebrook 938 King St 3b.Policy Number of Entity Listed in Box"la" Ryebrook,NY 10573 NYD074787 3c. Policy effective period 1/l/2021 to 1/l/2022 4.Policy provides the following benefits: ®A.Both disability and paid family leave benefits. ❑B.Disability benefits only. ❑C.Paid family leave benefits only. 5. Policy covers: ® A.All of the employer's employees eligible under the NYS Disability and Paid Family Leave Benefits Law. ❑ B.Only the following class or classes of employer's employees: 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 NYS Disability and/or Paid Family Leave Benefits insurance coverage as described above. Date Signed December 15, 2020 By (Signature of insurance carrier's authorized representative or NYS Licensed Insurance Agent of that insurance carrier) Telephone Number J1-866-761-4236 Name and Title Underwriting Director IMPORTANT: If Boxes 4A and SA are checked,and this form is signed by the insurance carrier's authorized representative or NYS Licensed Insurance Agent of that carrier,this certificate is COMPLETE. Mail it directly to the certificate holder. If Box 4B,4C or 513 is checked,this certificate is NOT COMPLETE for purposes of Section 220,Subd.8 of the NYS Disability and Paid Family Leave Benefits Law. It must be mailed for completion to the Workers'Compensation Board,Plans Acceptance Unit,PO Box 5200,Binghamton,NY 13902-5200. PART 2.To be completed by the NYS Workers' Compensation Board (Only if Box 4C or 5B of Part 1 has been checked) State of New York Workers' Compensation Board According to information maintained by the NYS Workers'Compensation Board,the above-named employer has complied with the NYS Disability and Paid Family Leave Benefits Law with respect to all of his/her employees. Date Signed By (Signature of Authorized NYS Workers'Compensation Board Employee) Telephone Number Name and Title Please Note: Only insurance carriers licensed to write NYS disability and paid family leave benefits insurance policies and NYS licensed insurance agents of those insurance carriers are authorized to issue Form DB-120.1. Insurance brokers are NOT authorized to issue this i,r ll DB-120.1 (10-17) III III(- 1 I'III'll"'IIII'lll'll.- BUILD, I &PARTMENT VILLAGE OF RYE BROOK APR 14 2021 938 KING STREET RYE BROOK,NY 10573 (914)939-0668 FAx(914)939-5801 VILLAGE OF RYE BROOK BUILDING DEPARTMENT Application for Permit to Remove, Abandon and/or Install Fuel Storne Tank (*Storage Tanks in excess of 1,100 gallons requir a with the County of Westchester) FOR 01-1-ICE: [_'SF..•. ONLY: IT r=: Approval Date: rmit Fee: $ 3 -70 — P46 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: 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. ******************* ********************************************************************************** Application dated, �'a 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 (•f•Removal( )•Abandonment( )/Above Ground ( )•Buried in Ground( ) I. Address: '/1 J C,ny��� T�� SBL: Zone: 2. Property Owner&Address: '(\0Cr1i,0t- c,C h4S QA - '�O U()U cyu l I )P)d Phone#119-IM-OI 19 Cell#:91-1:aVI-09 02 email: l•CCrq 3. Contractor&Address: &�:)bt E�)tf:ql - H-oyyyy Phone#: Q Cell#: C)(q-3`�� '13I U email: 4. Applicant:�n t ©I 0)-,�, Phone#: Cell#:�I4 3��(- ��J�O email: d I �Y y1?--trcu)LP cvm 5. Indicate Fuel Type:Fuel Oil( }•L.P. Gas(Gasoline( )•Other( ): 6. Number and Capacity of each Tank: (2) I20 .(ig Iton q.wa Q r l'ld 7. Exact Location(s)of each Tank: o'n LIR: 1 ' Pod on r-Ao t F-Si l-R' DP ,L?0f.{Dp 9*-. t 6/1/2020 STATE OF NEW YORK,COUNTY OF WESTCHESTER ) as: E[d d tt .being duly sworn,deposes and stales that he/she is the applicant above ttamed, (print natf"f 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 C znt-v%C,to r __for the legal owner and is duly authorized to make and file this applic-ation. (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,ot•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. Sworbefore me this _ Sworn to before me this day of__✓��%✓ c l 20 -�— day of_ � .20_:)-I_ Signature of erty Owner Si a �e of Applicant `"Print Name of Propect Own Print nine of Applicant Z��C —btA UYALDO L IVotacy Public �C ATE OF NEW YORK Notary P tic ~_ NO.01 UV610785 - QUALIFIED IN WESTCHESTER COUNTY ELIZABETH SARLES COMMISSION EXPIRES APRIL 12,2024 NOTARY PUBLIC-STATE OF NEW YORK No.01SA6392045 Qualified in Puinem County This application must be properly completed in its entirety and nitist includer� C� i li��i6rt` '�t' €k�r0 = 0 023 the legal owner(s)of the subject property, and the applicant of record in the spaces provided, not properly completed in its entirety and/or not properly;igtied s}1all be deemed null and void and .vill b; returned to the applicant. •2- 3/21/19 R [E C E ME BUII.I)ING 1)h:l';� wrMENT VILLA( L'0I1 l:YL BROOK APR 14 2021 938 KING S i fire,•r Rvi: Mtooi:,NY 10573 VILLAGE OF RYE BROOK (914)939-0668 FAx (914)939-5801 BUILDING DEPARTMENT w��w�ch1•oul:afr� AFFIDAVIT OF COMPLIANCE VILLAGE,COTE 5216 • ST01Mi SEWERS AND SANITARY SEWERS THIS AFFIDAVIT MUST BEAR THE NOTARIZED SIGNATURE OF THE LEGAL PROPERTY OWNER AND BE SUBMITTEb 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. STATES PS NEW YORK, COUNTY OF WESTCHESTER } as: ' T �i-Z V residinb at, �GRIO C t�L'��I ILA it __-- (Pi int nane! (A(Idres,whu c.)ou 1i%.0) 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; ICJ C��G`2GJ�1GL _04� _ -, Rye Brook,NY. Club Addres! Further that all statements contained herein are true, and that to the best of his/her knowledge and beliet 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. tIm'11,11urcorpropc+ ; (Prini Nance of Prorcriv Owner(s)) — — Sworn to before me this day of ���1'� �— !' Go,iy Pn:ic) NOTARY P BUCD,STATE OFVALNEW YORK NO.01UV6J07856 QUALIFIED IN WE T&ESTTER COUNTY COMMISSION EXPIRES APRIL 12,2024 3121/19 1�• � � I ' � ,,.,^;y ►t.S4'.c 1 •;:.., . • i' is t. I k 1N3W12Jbd3a JNlaiins >10088 3,QJ 30 BOVIIln 1111 11 ddd o 3AM33 Q :Yakn„c's �acit .F�• � p'. J L 1i 7. :a t i a� itt+t L j L51,a w u5 � •/ r N$ ........: . ���4L / ► SPEOFlCAMONS G M1,I�I.G(I.Qri) : VYS�IY}.-tj',^•5� flEC<.:�:.t' 1t�I� ( h% 50 35 40 52 II J 1270 889 .. 1016 1.32141 99.1 ..... <... 8.7 r ..._. _..»... ..» .........................._. m0 ;yj 239...................,.._......._...�9........_.......s..._............................._........,.....,..._.....,.454........... . °ty.s ah ACTfY tK�i _..... _...... rr 1084 .......................... .10..... _......._....i.........__....215...................;........._... ��, -i - 250 250 250 250 "tr MAVIII ` : .ems { pu 17 17 _. 17 14 5 18 24 30. .............. �ry1 F_..... .......... . ....._.........»................». 762 4 CWNDERlkAh1ETE)ttii;F c� i t 369 457 610 m CYIINOER VbU1ME ti F%fizz ` 6 629 6 629 _ »13.120 27 680 r .....,. 6, ......... _ ....»» i cYljhDER vOiuMC(t(TEA).` s 215 108.7 108.7 4S4 ...............{........ ............................... v.. COILAR bIAMC111t(IN.) 11.4 i 6 ..:., .., ............... ............. .... 406 /µ✓ . 1� __.., . ..................... ..... 460`.6 COtIARDIAMETR(� ._.... )..................i ..........................._... . . 406 6.9 COLLAR nFIGItipN) 64 6.9 ...........» ..... ..•........................ . .......... 17� 175175 ccait (1CICII1M) 163 ._ ..._........aL L 22 FOOTRIN4 DiAmrTER(IN) > 14.5_--- i 16.6 ..__. _ 559 tpOTRINGDIntu1ET'ER(MM) ......._ 368 ? ...4�......... ......... ...._.._....3....._—........ASME................. 19 srnNOnRQ SPEanCATION ASNE...............i...............AS..... ............ ........................_..._..................,... .. ................. 483 ASME as ....................... ..-._........ ... ._. r u 55 •MAWP z Max.mum Allowabl a Working Ptenure w r W WORTHINGTON CYLINDERS AMb.lh Ito 1 d ft C q iry v ifA. "b 200 Old Wilson Bridge Road Columbus,Ohio 43085 4r Toll-free:866.WCTANCS(866,928.2657) Phone:614.438.3013 fax 614.438.3083 ;E CylindersOWorthingtonlydustries.com WorthingtorCylinder:.mm oieo6 wwn+,T.•4rduanwrnv.r.,.�a.�n,fe.t.mrrofo6 >`,�,'`ib•: Side 2 3 ZEN} "2s, �o- � {a"i' fH K}.+.'Vj�%i';_:c "7�:o� a°..'�• OftIft- '77--- Aivl i Y �y, •: y,� p s •.ti �sy�tl�tty, ' fp Sv{d1 'hie c Of r'r�Y•Ct,�,�P�f,,9�i- \ :� i;` A'`' kL "� •v YS i1 v.. ; �J'A '"' f�„i '�!+:� v 'C.,W 'n.`. t��' �'Sf��; sJ. °,fi�� �j� s s \4` " , w (i i't►+ ,.c(;++��+►+ Y �;'+►i � '�` #'�'rr�'i+i�+ .;3'; '� 4i►�'►►�+/y/\. Y i a +��'�'++ � "fp _f+,('►�+ 1<«c�o)s� ��"- +� d'•`4� s.zssbls:s+,�n�.�1,f�` .,� + !(�u+'..���� �-�f,�+�+.:Sr?3 i.3,.,��++�iu+!h£cle.., v,:�ne'ti!,�+�,�r=.4ir r�i."'r,-,i�+.�i!1�':=f. �,.<(ecs)>i f a cOi I `oat TJ N i sue.. w 10. Cd 4� \ rLl •r� W � O p i ) Qj �.+ H o affection Sys ..t � � I LIJ LO �,• �� i.+ ►ter �r y LLI o O .. cj CIO ti ' 3 LJ U Ns \r e`� ai M is• f �� -.fit' -,,� a `" `a :, � cOi � U rt� ,,� `��•",i RIFT, a insF +�� �+ g +,1 ,� �' `7'�f�\� p�G {gs�,'��+(:►► r, pry .r++ +'+h � � - , �7 � + ,.�t' tY sin;�i��+►yl►� t��A� i 1'��� ([y�i.�Y7 `�At'+� i�' �T�A�� (�+ i���f`+�I�}�' i �1►1► .:"��iR .,f .. �. iy ���• \! :i�Yf^'�'yy,F„� ,,. n: i/.•++..y`�i dt.�•• ''. $�„� ,�•� �' 'R��t�' '^w�•. L�f 1 +& note l�vawrvrYl Ac: c7RC� CERTIFICATE OF LIABILITY INSURANCE _. 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,tho policy(les)must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,conaln policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such ondorsement(s), PRCOUCER 'R NA cy I Paul Martelloni Marsh USA,I c 1166 Avam o(Iw Aviedcas )to Ex". C212)346 5227 New York,Ph iO3 ` tt� P�LI M--ne`M a�marsnx Alin.W*YorkwtQ1Ywct xr -- _INBURE.N�,'JIAffOROaaG COVERAGE _ NAIC• CN101414639 PETHO•ACORD-20- NSURCR A:National Lin n Fire Ins Co PYsburgh PA 9445 INSURED ...... - _. .... NsuneRo:NgaH�mFsMrelnu nceCa 23841 MEENAN OIL CO,LP L'A31A BURKE HEAT AND BLIRKE FUFI OIL CO HvBt�RFN c,Lei n J�SUrafr a Oar my 19437 475 COMMERCE STREET NStIRLR D:AIU'93urarlca Co 19399 HAWTHORNE,NY 1Uti32 •._._.__.. ..._.._..__ _......._„.. ........ Iw&uReR E: _ aISURER F .- COVERAGES CERTIFICATE NUMBER: NYC•009222l&-76 REVISION NUMBER: _ Ti IS.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 Wi1I1 RESPFCT TO WHICH THIS CERTIFICATF 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,LIM;TS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. IkiRj_-. TYPE OF INSURANCE n�SVOR• _.POLICY NUMBER ...-. .POLICY YFP III POUC -' _. LWT5 LTR A X <COMMERCIAL GENERAL LIABILITY GL 702428 10'01112020 10101awl EACI{•JC.(;LKtRENC-e_ S 1.DOD,00{`. DAbiAf?f TOTtIIdfT'6 — _ X� _. CLAIMS-AMUE UCWT4 pRE.Me ;1(1SlK' M bT. ,f _ .iJUO XCU M EX (Any o r P-TwFq f 5,000 X Coraraclual PERSONAL&AOV INJURY IS i,COD•6I10 GEML AGGREGATE LIM: AaPLIESPF.R. GENERALIgGREGATE I 5000,000 X POJCY ,� (I.00 PRODUCTS COMP,10P AGG b 2000.000 J �..-_____,.__ ._ SIR ;5 I.-M.000 A AUTOMOBILELIARILITY CA'269953(.ADS) 11"1020 INIQ021 C==SINGLE LOMA I1 s 2.0W,000 A a i AhY AUTO CA 726BB51(M.A) 10/0112020 1070V2021 BODILY INJURY(Per person) S __._ OWNED sCHEW ED CA 7269952 VA 1DIOti2020 t0A172021 A ( 1 BODILY INJURY(Per aocldent) f _. 141RED ONLY AUTOS HIRED NON-0WNED R -. AUTOS ONLY „_. AUTOS ONLY f t O X UMBRELLALIA6 X OCCUR 02143C5a9 i0,4172(i� 10A1i2021 EACH OCCURRENCE f 5•Ih0•fr30 EXCESS LIAR C.AIirS•MADE 1 AGGREGATE T S,gD,DOO -_.. ..._._ _...- ...__._..... .._._w.....-_. __. CED X RLTENTiINE10000 S D WORKERS COMPENSATION WC 63850892(CT,DE,GA,MD,ME 110101021 X TA 1 t AND EMPLOY[Rs,LIATULjTY WIN -. MI,NY,kl,SC.7N.WV 2CC MO OrT-Ic RARE-MOHX'ARTMCRI�%ECUTIYIi E.L.EACH ACCIDENT 6 OKFICEIVIAEMBEREILC«7.UOEOT NIA ..-`---•--..— B (Mandatory In NH) WC G3850E93(61A,NC,:Ri,WA,WY) (10,0i12020 1010112021 E.L.DISEASE•G EMPLOYEE $ 10000'0 I yy��eeee describe under ._..,,_,... _ GES4RIPTION OF OP€14AI ION4 be'ax r E.L.DISEASE•POLICY LIMIT S .000,030 F1 I i DESCRIPTION OF OPERATIONS ILOCATIONS I VEICLES(ACORD101,AddWonai Remarksschedvle,maybeatlachedlrm"owpwolsrequked) THE CERTIFICATE HOLDER IS INCLUDED AS ADDITIONAL INSURED AS RESPECTS THE NAMED INSUREDS OPERATONS CERTiFICATE HOLDER CANCELLATION VILLAGE OF RYE BROOK SHOULD ANY OF TILE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 930 KING STREET THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN RYE13ROOK,NY 10573 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE of Marsh USA Inc. David A.Coblemh > C 1988-2016 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD Nfw Workers' YA CERTIFICATE OF V S ATt Compensation NYS WORKERS' COMPENSATION INSURANCE COVERAGE 4— Dow d . ..... is l.egal Narne,&Addrets,o'Insured(olne•-Ii"I h Business Tetephons Num_Lx_r-of_Insurod MEENAN 011.CO.,LP 914-769-5050 DBA BURKF HEAT AND BURKE FUEL OIL.CO 475 COMM17 i RGE STREET 1L;.NYS Unumplupwitil Insurance Employer Registration Number of FfAATTJiORNF,NY 10532 Insured 8311425-2 Wort,Location of lrieurpd(Only nNqurvd if covelaye is specific".jOY finnted to Id Federal Employer Identification Number of Insured or Social Spcuhly certain to it?New Yorh Slafe,i.c,a Wrap-Up Policy) Number 113083408 .............. 2.Name and Address of Entity Requesting Proof of Coverage 3a Name of Insurance Cartier (Entity Being listed as the Ceffificile Holder) Aft)insurance Company 3b.Policy Number of Fraily Listed in Box"la" Village of RyeUrook WC 63850892 938 Kmg Street Ryebrook,NY 10573 3c Policy effective period 1010IT2020 to 10W/2021 .3d.The Proprietor;Palates to Executive Officers are 0 included.(Onto check box P all paeiners/officers included) E]all excluded or certain partrieWofficers excluded. This certifies that the insurance carrier indicated above In box"31"insures the business referenced above in box"I a'for workers' compensation under the New York State Workers'Compensation Law.(To use this form,Now York(NY)must be listed under it 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 elim'nate 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: David McElroy (Print narric of authorized rcC"N3liVe or licensed ar.rd of insurance carrier) Approved by: September 28,2020 (Signature) (Dale) Title: C.E.O.North America ............ Telephone Number of authorized representative or licensed agent of insurance carrier: 212-770-70DO 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) vvwvv.wrt1.ry gov 1r NI EW Workers' s-- Yoal< Compensation CERTIFICATE OF INSURANCE COVERAGE STATE Board under the NYS DISABILITY AND PAID FAMILY LEAVE BENEFITS LAW PART 1.To be completed by Disability and Paid Family Leave Benefits Carrier or Licensed Insurance Agent of that Carrier l a. Legal Name &Address of Insured (use street address only) I b.Business Telephone Number of Insured w Meenan Oil Company,L.P. 1000 Woodbury Road Suite 110 Woodbury,NY 11787 lc.Federal Employer Identification Number of insured or Work Location of Insured (Only required ifcoverage is specifically Social Security Number limited to certain locations in New York State.i.e., lVrap-G'p Policy) 11-3083408 Meenan Oil Company,L.P.dba Burke Heat and Burke Fuel Oil Co. 475 Commerce Street Hawthorne,NY 10532 -- - -- ------- -.._.._— — 2.Name and Address of Entity Requesting Proof of Coverage 3a. Name of Insurance Carrier (Entity Being Listed as the Certificate Holder) CIGNA LIFE INSURANCE COMPANY OF NEW YORK Village of Ryebrook 938 King St 3b. Policy Number of Entity Listed in Box"ia" Ryebrook,NY 10573 NYD074787 3c. Policy effective period 1/1/2021 to 1/1/2022 .......................... _.__..... ........................................... _........ _..-- -- _ ._...--..... 4.Policy provides the following benefits: ®A.Both disability and paid family leave benefits. ❑B.Disability benefits only. ❑C.Paid family leave benefits only. 5.Policy covers: ® A.All of the employer's employees eligible under the NYS Disability and Paid Family Leave Benefits Law. ❑ B.Only the following class or classes of employer's employees: 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 NYS Disability and/or Paid Family Leave Benefits insurance coverage as described above. Date Signed December 15, 2020 By (Signature of insurance carrier's authorized representative or NYS licensed Insurance Agent of that insurance carrier) Telephone Number 1-866-7614236 Name and Title Underwriting Director IMPORTANT: If Boxes 4A and 5A are checked,and this form is signed by the insurance carrier's authorized representative or NYS Licensed Insurance Agent of that carrier,this certificate is COMPLETE. Mail it directly to the certificate holder. If Box 413,4C or 5B is checked,this certificate is NOT COMPLETE for purposes of Section 220,Subd.8 of tire NYS Disability and Paid Family Leave Benefits Law. It must be mailed for completion to the Workers'Compensation Board,Plans Acceptance Unit,PO Box 5200,Binghamton,NY 13902-5200. PART 2.To be completed by the NYS Workers' Compensation Board (Only if Box 4C or 5B of Part 1 has_been_checked) State of New York — Workers' Compensation Board According to information maintained by the NYS Workers'Compensation Board,the above-named employer has complied with the NYS Disability and Paid Family Leave Benefits Law with respect to all of his/her employees. Date Signed By (Signature of Authorized Nl'S workers'Compensation Board Employee) Telephone Number Name and Title ... ...........-.._.._.._...... .----..__.__....._..__..._...-------_---_____.....---.�_.._. Please Note: Only insurance carriers licensed to write NYS disability and paid lanfily leave benefits insurance Ixtlicies and NYS licensed insurance agents of those insurance carriers are authotized to issue Fonn DB-120.I. Insurance brokers are NOT authorized to issue this rrrar. DB-120.1 (10-17) RC� C�C�M� APR 1 4 2021 BUN.-RI DEPARTMENT VILLAGE OF RYE BROOK VILLA E op RvF:I3M)K BUILDING DEPARTMENT 938 K1NtiitftfXTRyi4 IIR60 .NY 10573 (914)914 it ti8 AX(0 4)939-5801 «vv��yclj�ital;_off PLUMIONC:PERMIT APPLICATION VOR()FFICE USt' OXI-V RP M PP#: Approval Date: _ Permit Fee: $ Approval Signature: Other: �— Disapproved: (fees*re nap-re(awtrhle) Applicatiott dateri, _ 1.4 a Lis 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 tlud said plumbing work still be in conformance with all applicable Federal,State,County and Local Codes. ��1V(Qij k�_P SBL:4CiCA t r� 7.une:1.Address: ,. i_� —IS 2.Proposed Work: 1 1 5 `r 1 r P} t'^i -fW 1T 3.Property Owner: ���� t�dA_'Addressr:+•� --- Ph«re�f �'.I i.Li�S�ll`.7 Y _.Cell#: !::�S 'f�.�'_ll' Sc_1 _email: CT.�.lY � `�1�`�r�(��iil lit1 ACT'1 __.. d.Mastet Pltanbcr: � flM.}_� Address:�Z _ f `t(K�(�1? IIhC xt C, Aft Lic.#: Phone#:S+S fi "3]l.�c e11#:._-. email: cl-11,1'1 Ql to p—In- LA CO A-1 Company Nnrne:Jfiy� LL�_�jXiY1, _--- Address: INDICATE FIXT RES&LINES:[O BE TNSTAI.i.FD AS PER THE FOIJAMWG SC_HEDULE: Location Unnals ihinki Sinks Sismvers Bath Laundry Donustic Fire Sanitary ]vattrali Other' iotd -water_ L.—.—._ .— n8 Y rY Closets Fountaima Tubs Tubs— Service Service Sewer LP Gas_ _ Basement Ise Floor 310 Floor — -- _- --- 0 Floor 5 Floor 5. List Other l'.quiprnent/Provide Details, (Notarized Signatures Recruilred Nftt 2 Pages _ r- 3ntny STATE OF NEW YORK,COUNTY OF WESTCHESTER ) as C;((,{C� Yj rO�1� _ txing duty su aru,deposes and siatG�that he/she iit.fie upplicant above nameq, (prin:nameorta wdwilligmng its the rpptieUN mid further states that(s)he is the legal owtta of the property to which this application pertains,or that(s)he is the for the legal owner and is duly etuthorized to make and filc this application. (indkete rtcMitcet•connecter,agek.&UwTier,etc.) That all statements con tained herein are true to the best ofhiv./hor knowledge and heiied;and that any work performed,or use conducted at the above captioned lxoperty will be in confonnance with the details as set forth and contained in this appl icatiO n and in any accornpanying approved plaits and specifications,as well as in accordance with the New York State Uniform rite Prevention&Building Code,the Code of the Village of Rye Brook and all other applicable laws,ordinances and regulati'M& Sw W bell, c lie iI is _ 129 Sworn to before me(his �Q ,, 1 rf Sigaatrrre of MSerty Owner Siptnatttrc n. nl ,r ro =Print Name of t roparty Owner , Print NarneofApplicant C sty Public -- NOTARY PUBLIC,STATE OF NEW YORK Ndary Firblic -- NO otuvGtn-ra.-A QItAUFK-'V IN WESTCHESTERCCXJt4TY (_..melt: GSIGN FXPIgES APAIL 12,A)24 ELIZABETH SABLES NOTARY PUBLIC-STATE OF NEW YORK Alo. 1 SAt3392045 Tit; appliczl:10�nit!st be proptriy cotuhtcte3 itt i:s otI;irety laud tort a Include t ua he r�tI'l No,Pl SA63big4bltitty ihr lc�Ln!otvnor(s)ni the,abject piuls�ly.- aM the applicant of record in the s :P M1+fAftl! 114�:A�;�ia"2023 not properly eompletM in its entirety aiWor not properly signed shall he deenic-d null and voirt and tiv+ll h retuntedd to die applic:attt. .2. p EC ENE NC Bull APR 14 2021 DD V I L 'A'GA,.01;R i,il;l31tooi( 938 NY 10573 VILLAGE OF RYE BROOK (914)93941668 FAX (914)939-5801 BUILDING DEPARTMENT AFFIDAVIT OF COMPLIANCE VILLAGE CODE, S2 l6 • STORM SEWERS AND SANITARY SEWERS THIS AFFIDAVIT MUST BEAR THE NOTARIZED SIGNATURE OF THE LEGAL PROPERTY OWNER AND BE SUBMITTEb 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 G ,residing at, o(G _Grp -.-_-- (PI int manic) (Addre"rchaC!)ou li"c) 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; CZ0 C I�U�C,�>LlC L ,���'�'� --_--_-- - _ , Rye Brook,NY. (dub r\ddrrs) Further that all statements contained herein are true, and that to the best of his/her knowledge and belies; 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. / (Prins Name of Propcay Ow ner(s)) — --- Sworn to-before me this l day of _iYjl-v (G _ i 01 - ---- \ot1�y Pu:YI ic) NOTARY PUBLIC, SA"EOF NEW YORK QUALIFIED N WESTCHE TER COUNTY COMMISSION EXPIRES APRIL 12,2024 3/21/19