HomeMy WebLinkAboutMP24-043 DR.
C ty`i L
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
May 1,2024
Bowman III LLC
111 Bowman Avenue
Rye Brook,New York 10573
Re: 111 Bowman Avenue, Rye Brook,New York 10573
Parcel ID#: 141.27-1-8
This document certifies that the work done under Mechanical Permit#24-043 issued on 3/26/2024 for the
installation of a new above-ground oil tank has been satisfactorily completed.
Sincerely,
Steven E. Fews
Building&Fire Inspector
/to
QyE BRC��.
1982 BUILDING DEPARTMENT
❑yBUILDING INSPECTOR
2 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: ti]OW rn r'-,3 AV F DATE: 7- -,>)C).)-
PERMIT# ISSUED,• (o-Z, SECT: 2 7 BLOCK: LOT: O
LOCATION: 3 i�, w 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 1
❑ Natural Gas `T S{c 1 12 j `�Ou (} ( u.1 p
❑ L.P. Gas (
,FUEL TANK (Lpc - T ���� ' CA RA.,,--AAJO(,J -2 /1� P
❑ FIRE SPRINKLER c'J()1
❑ FINAL PLUMBING
❑ CROSS CONNECTION
.''FINAL `,L `t C (C 135 UL-01
❑ OTHER
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BUILD, CEP MENT D L� F
VILLAGE OF RYE` OOK �,�� 2 2 2��4
938 KING T` ET RVE BR. ,NY 10573
� 1 _Q VILLAGE OF RYE BROOK
BUILDING DEPARTMENT
Application for Permit to Install Fuel Storage Tank
(*Storage Tanks in excess of 1,100 gallons require registration with the County of Westchester)
FOR OFFICE USE ONLY: PERMIT#:
APR 2 20 ) 33
Approval Date: Permit Fee: $ f
Approval Signature: Other:
Disapproved:
(Fees are non-refundable)
DO NOT START WORK or CONSTRUCTION UNTIL A PERMIT HAS BEEN ISSUED BY THE BUILDING
INSPECTOR.THE ADMINISTRATIVE FEE FOR WORK PROGRESSED OR COMPLETED WITHOUT A PERMIT IS
12% OF THE TOTAL COST OF CONSTRUCTION WITH A MINIMUM FEE OF$750.00
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#C 105.2 or Form#U26.3 /or NY State Workers Compensation Waiver)
4. Fee per Tank: Installation: $185.00 per Tank.
5. Dig Safely New York# (dial 811):
6. Inspection by Building Department for installation.
7. Submit all Manifests & Reports(if applicable, after work has been completed).
8. Certificate of Compliance will be provided when all requirements are fulfilled.
Application dated, ,is hereby made to the Building Inspector of the Village of Rye Brook for a permit to
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 installed in conformance with all applicable Village,County, State&Federal laws,codes,rules and regulations.
Indicate Permit Type: Above Ground ( • Buried in Ground ( }
I. Address: 1 BL: �,'Z1 ` — Qj Zone:
2. Property Owner&Address: L
Phone#:9.14 .q` •E�A(DQ Cell#: em11ai--L•
3. Contractor&Address: �q-ti, C' ., ,ne. n N o _c�+�C'L5C ,rf`_fu f! �/1 .
Phone#q� -C }M Cell#: � . j' (�\\ --e__maiil`SerV ic.9 C %Qt-tp a Qa qX,4 ��[tc�U.CpA
4. Applicant: CO, , G. � N���E'�( fit'• C=ctt' ► xN,&N a—��1c-)
Phone#914 --brm Cell#: .9961 • (0$012:> email:50N G l�s�lntit -e rG p��i[ty�t,
5. Indicate Fuel Type: Fuel Oil V. L.P. Gas
nn( )•Gasoline( ) •Other( ):
6. Number and Capacity of each Tank: Lkm ey(A18 1
7. Exact Location(s)of each Tank:
i
10/30/2023
Liz rl n q-e+t'CU'� F ', r \,e�L
STATE OF Nl COUNTY OF as:
tcI e r--t"-- ,being duly sworn,deposes and states that he/she is the applicant above named,
(print name of' dividual signing as the applicant)
and further states at(s)he.s the legal owner of the property to which this application pertains,or that(s)he is the
{��— for the legal owner and is duly authorized to make and file this
application.(indicate a hitect,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 �cr� ,20 day of 1 ``t ,20,L�
'Ult
gnature of Pi erty Owner gignatitred Applicant
Esc-(16uh J6-I ck-1:100 T br ArAm, )c rn
Print f erty Owner Print Name 6f Appl'
Notary Public Notary Public
SEAN LYTLE S AN LYTLE-
h�07"� pf iiZlC NQTARPPt7.STJC
Illy COMM1S$1O:i E.t;,ff68 n 31 Oc. Ny COMMISSIOn EX063 4g,t i,2
T his application must a 4"pbrly completed in its entirety and must include the notarized
signature(s) of the legal owner(s) of the subject property, and the applicant of record in the spaces
provided. Any application not properly completed in its entirety and/or not properly signed shall be
deemed null and void and will be returned to the applicant.
2
10/30/2023
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Part#2335002642
Submittal Data Information
Rod-,
Roth DWT 1500L
YOUR ENVIRONMENT IS OUR BUSINESS.
Effective Se temder 2007 Su ercedes
Job: Engineer: Contractor: Rep:
ITEM PART NO. ITEM DESCRIPTION MANUFACTURER
#2335002642 400 Gal.(1500 Liter)Double Wall Tank Roth
comes with a detached saddle base which the tank is
placed on at the time of installation.
s The tank shall be placed into service in accordance
with local codes and the listed use(indoor or outdoor)
on a flat, level and stable surface,away from heat
sources,corrosive atmospheres or fluids,potential
mechanical damage or rapid temperature changes.
The final location must have the tank label visible
after installation. A minimum of 2"(50 mm)from
all walls or obstructions is recommended for normal
` tank expansion and visual inspection. The integral
base support shall not be removed and raising the tank
height is not allowed except on a continuous concrete
platform at least 6"(150 mm)wider than the tank
base at all sides.All local fire code set-backs for fuel
The Roth Double Wall Safety Fuel Oil Storage Tank oil storage tanks must be observed.
(DWT)is made with a seamless blow-molded
polyethylene inner tank and a 19 ga.galvanized outer Tanks installed indoors shall not be exposed to direct
tank.The outer tank is formed by joining cold rolled sunlight on any plastic parts. Tanks installed outdoors
sheet steel,used to form the sides and bottom from a shall be assembled with the required cover,Roth
single piece,with two stamped metal end pieces. The #2335002054 for the 1500L. All tanks must be
edges between the sides and ends have sealant applied installed with an approved vent alarm(Roth Vent
to them and are then rolled to create leak-proof seams. Alarm#235000999,or equivalent sized UL listed
A stamped top is then pressed and riveted into place to whistle vent)in order to maintain warranty
complete the assembly of the DWT. The DWT is ULo requirements.
listed in the United States and Canada under SU2258
and approved under NFPA 31 (2001)and CSA B-139- Tank Model DWT 1500L
04 as non-metallic fuel oil storage tanks. Nom.Capacity US gal(liters) 400(1500)
Length inches(cm) 64(163)
Width inches(cm) 30(77)
Both inner and outer tanks are pressure tested at the Height Inches(cm) 68(173)
factory during assembly according to UL®standards Min Height Req'd inches(cm) 66(193)
and do not require further field testing. The DWT also Tank Weight lbs.(kg) 333(151)
Shipping Weight lbs.(kg) 358(162)
Your Environment is Our Business.®
ROTH Industries, Inc,268 Bellew Avenue South,Watertown. NY 13601 Telephone: (315)755-1011 Fax (315)755-1013
ROTH Industries, Inc, 1607 rue de I'Industrie. Beloeil,QC J3G 4S5 Telephone: (800)969-7684 Fax:(450)464-7950
Visit our website at:www.roth-america.com Copyright 2007
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ROTH Industries,Inc,268 Bellew Avenue South,Watertown,NY 13601 Telephone:(315)755-1011 Fax:(315)755-1013
ROTH Industries,Inc, 1607 rue de I'Industrie, Beloeil,QC J3G 4S5 Telephone:(800)969-7684 Fax:(450)464-7950
Visit our website at:www.roth-america.com Copyright 2007
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AG�a DATE(MM/DD/YYYY)
�- CERTIFICATE OF LIABILITY INSURANCE 04/19/2023
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE
DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.THIS CERTIFICATE OF
INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE
CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED, the policy(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 NAME CT CLIENT CONTACT CENTER
FEDERATED MUTUAL INSURANCE COMPANY
HOME OFFICE: P.O. BOX 328 IA/CNNo,Eat):888-333-4949 FAX No):507-446-4664
OWATONNA, MN 55060 ADDRIESS:CLIENTCONTACTCENTER FEDINS.COM
INSURERS AFFORDING COVERAGE NAIC tl
INSURER A:FEDERATED MUTUAL INSURANCE COMPANY 13935
INSURED 330-130-6 INSURER B:
WESTMORE FUEL COMPANY INCORPORATED INSURER C:
86 N WATER ST
GREENWICH,CT 06830-5886 INSURER D:
INSURER E:
INSURER F:
COVERAGES CERTIFICATE NUMBER:35 REVISION NUMBER:0
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.
NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE
ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF
SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR ITR TYPE OF INSURANCE ADDL SUBR POLICY NUMBER POLICY EFF POLICY E X P LIMITS
X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $1,000,000
CLAIMS-MADE rX OCCUR AM AGE TO ENTED PREMISES $100 000
MED EXP(Any one person) $5,000
A N N 9062815 06/01/2023 06/01/2024 PERSONAL 6 ADV INJURY $1,000,000
M.LAGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE 2 000 000
POLICY �ECTLOC PRODUCTS&COMPIOP ACC $2,000,000
THER:
MB/
AUTOMOBILE LIABILITY O d n SINGLE LIMIT $1 000 000
Ea accident
X ANY AUTO EE�� BODILY INJURY(Per Person)
A OWNED AUTOS ONLY AUTOSULED N N 9062815 06/01/2023 06/01/2024 BODILY INJURY(Per Accident)
HIRED AUTOS OWNLY AUOT�ONLDY PROPERTY DAMAGE
X UMBRELLA LIAB ICLAIMS-MADE
OCCUR EACH OCCURRENCE $7,000,000
A EXCESS LIAB N N 9062816 06/01/2023 06/01/2024 AGGREGATE $7,000,000
DED I RETENTION
WORKERS COMPENSATION X I PER STATUTE I OTHER
AND EMPLOYERS'LIABILITY
ANY PROPRIETOR/PARTNER/EXECUTIVE E.L EACH ACCIDENT $500,000
A OFFICER/MEMBER EXCLUDED? pJ/q N 9917566 06/01/2023 06/01/2024
(Mandatory in NH) E.L DISEASE-EA EMPLOYEE $500,000
If yes,describe under
DESCRIPTION OF OPERATIONS below E.L DISEASE•POLICY LIMIT $500,000
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101.Additional Remarks Schedule,may be attached if more space is required)
CERTIFICATE HOLDER CANCELLATION
0-6 35 0
VILLAGE OF RYE BROOK SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED
VILLA
938 KING ST BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN
RYE BROOK, NY 10573-1226 ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED REPRESENTATIVE e
O 1988-2015 ACORD CORPORATION.All rights reserved.
ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD
YO K Workers' CERTIFICATE OF
STATE Compensation NYS WORKERS' COMPENSATION INSURANCE COVERAGE
Board
Ia.Legal Name 8 Address of Insured(use street address only) 1b.Business Telephone Number of Insured
203-531-6800
Westmore Fuel Company Incorporated 330-130-6
86 N Water St
Greenwich,CT 06830-5886 1c.NYS Unemployment Insurance Employer Registration Number of
Insured
Work Location of Insured(Only required if coverage is specifically limited to 1 d. Federal Employer Identification Number of Insured or Social Security
certain locations in New York State,i.e.,a Wrap-Up Policy) Number
06-0739367
2.Name and Address of Entity Requesting Proof of Coverage 3a.Name of Insurance Carrier
(Entity Being Listed as the Certificate Holder) Federated Mutual Insurance Company
Village Of Rye Brook #35 3b.Policy Number of Entity Listed in Box"la"
938 King St 9917566
Rye Brook NY 10573-1226
3c.Policy effective period
06/01/2023 to 06/01/2024
3d.The Proprietor,Partners or Executive Officers are
❑ Included.(Only check box if all partners/officers included)
�X all excluded or certain partners/officers excluded.
This certifies that the insurance carrier indicated above in box"3"insures the business referenced above in box"1a"for workers'
compensation under the New York State Workers'Compensation Law. (To use this form, New York(NY)must be listed under Item 3A
on the INFORMATION PAGE of the workers'compensation insurance policy). The Insurance Carrier or its licensed agent will send
this Certificate of Insurance to the entity listed above as the certificate holder in box"2".
The insurance carrier must notify the above certificate holder and the Workers'Compensation Board within 10 days IF a policy is canceled
due to nonpayment of premiums or within 30 days IF there are reasons other than nonpayment of premiums that cancel the policy or
eliminate the insured from the coverage indicated on this Certificate.(These notices may be sent by regular mail.)Otherwise,this
Certificate is valid for one year after this form is approved by the insurance carrier or its licensed agent, or until the policy
expiration date listed in box"3c",whichever is earlier.
This certificate is issued as a matter of information only and confers no rights upon the certificate holder.This certificate does not amend,
extend or alter the coverage afforded by the policy listed, nor does it confer any rights or responsibilities beyond those contained in the
referenced policy.
This certificate may be used as evidence of a Workers'Compensation contract of insurance only while the underlying policy is in effect.
Please Note: Upon cancellation of the workers'compensation policy indicated on this form,if the business continues to be
named on a permit,license or contract issued by a certificate holder,the business must provide that certificate holder with a
new Certificate of Workers'Compensation Coverage or other authorized proof that the business is complying with the
mandatory coverage requirements of the New York State Workers'Compensation Law.
Under penalty of perjury, 1 certify that I am an authorized representative or licensed agent of the insurance carrier referenced
above and that the named insured has the coverage as depicted on this form.
Approved by: Elizabeth Petersen
(Print name ofauthorized representative or licensed agent of insurance carrier)
Approved by: 04/19/2023
(Signature) (Date)
Title: Authorized Representative
Telephone Number of authorized representative or licensed agent of insurance carrier: (888)333-4949
Please Note: Only insurance carriers and their licensed agents are authorized to issue Form C-105.2. Insurance brokers are NOT
authorized to issue it.
C-105.2(9-17) www.wcb.ny.gov