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HomeMy WebLinkAboutMP24-039 E BRS 0 t4%4`:s OIL J�V 4 G q � � L 19 VILLAGE OF RYE BROOK MAYOR 938 King Street,Rye Brook,N.Y. 10573 ADMINISTRATOR Jason A.Klein (914) 939-0668 Christopher J.Bradbury www.aebrook.org TRUSTEES BUILDING & FIRE INSPECTOR Susan R.Epstein Steven E. Fews Stephanie J. Fischer David M.Heiser Salvatore W.Morlino CERTIFICATE OF COMPLIANCE April 29,2024 Saverio Fiorino&Stephanie Fiorino 42 Valley Terrace Rye Brook,New York 10573 Re: 42 Valley Terrace, Rye Brook,New York 10573 Parcel ID#: 135.59-1-40 This document certifies that the work done under Mechanical Permit #24-039 issued on 3/21/2024 for the removal of an above-ground oil tank has been satisfactorily completed. Sincerely, Steven E. Fews Building&Fire Inspector /to QyE BRC��. '9a2 BUILDING DEPARTMENT ❑BUILDING INSPECTOR QB/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 : / Z DATE:_ 7 - Z 3 - Z O Z PERMIT# ISSUED: 3'2 J'Z/SECT: S I BLOCK: LOT: % 6) LOCATION: OCCUPANCY: ❑ Violation Noted THE WORK IS... 2 P/ASSED ❑ FAILED /REINSPECTION ❑ SITE INSPECTION REQUIRED ❑ FOOTING ❑ FOOTING DRAINAGE ❑ FOUNDATION ❑ UNDERGROUND PLUMBING NOTES ON INSPECTION: ❑ ROUGH PLUMBING ❑ ROUGH FRAMING ❑ INSULATION ❑ Natural Gas ,< _ Yy'1O 2 Q^L ❑ L.P. Gas ,FUEL TANK �� t ❑ FIRE SPRINKLER L l , IV ort p✓+'1 P ❑ FINAL PLUMBING ❑ CROSS CONNECTION ❑ FINAL ❑ OTHER s (k y G* _ y w � h+l N w � � � z � a•� a °' � a r~ A o o og H F+_I o F, U O o ° ~ o O M 30 9z u p a w v 7! - w �i 11 ° p""d cn � ti w a p o lu oo, w p %wo' ao a = O H W w w p ZIo ° ovw V = V v o z LC) 9 LW � z � vao _ � � -o 'er' ' z a z $ a� o a v MM 00 wA v yy y 1. U F U v o -IVo � -°N �� w H F y w a ai W z o °a U � o ? � •�ov _ o u z F Vl : ►-� w o o � � � � x OZ o o E.y .49 *4 Vol 70 O a .n a vxl -- BUILD MENT VIL E OF RY OOK I " ' MAR 2 `on E 938 KING � ET RYE BR NY 10573 OK -0 , Application for Permit to Remove or Abandon Fuel Storage Tank (*Storage Tanks in excess of 1,100 gallons require registration with the County of Westchester) FOR OFFICE USE ONLY: PERMIT#: cQ4— 0 Approval Date: Z�12 Permit Fee: $ Approval Signature: Other: Disapproved: (Ices are non-refundable) DO NOT START WORK or CONSTRUCTION UNTIL A PERMIT HAS BEEN ISSUED BV 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: Removal or Abandonment$185.00 per Tank. 5.Dig Safely New York#(dial 811): 6.Inspection by Building Department for removal or abandonment. 7. Submit all Manifests&Reports(after work has been completed). 8.Certificate of Compliance will be provided when all requirements are fulfilled. Application dated, 3/12/2024 ,is hereby made to the Building Inspector of the Village of Rye Brook for a permit to remove or abandon 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 or abandoned in conformance with all applicable Village,County,State&Federal laws,codes, rules and regulations. Indicate Permit Type: Removal (x) • Abandonment( )/Above Ground(x)•Buried in Ground( ) I. Address: 42 Valley Terrace, Rye Brook, NY 10573 135.59-1-40 SBL: Zone: 2. Property Owner&Address: Saverio Florino 42 Valley Terrace, Rye Brook, NY 10573 Phone#: 914-720-5053 Cell#: 914-282-2243 email: fiorinosam@gmail.eom 3. Contractor&Address: Burke Energy 475 Commerce St, Hawthorne, NY 10532 Phone#: 914-919-3507/3545 Cell#: email: burkepermits@meenanip.com 4. Applicant: Burke Energy Phone#: 914-919-3507/3545 Cell#: email: burkepermits@meenanip.com 5. Indicate Fuel Type:Fuel Oil(x)•L.P.Gas( )•Gasoline( )•Other( ): 6. Number and Capacity of each Tank: Remove (1) 275 gallon AG Oil tank 7. Exact Location(s)of each Tank: Right front corner Of garage 1 2/21/2024 STATE OF NEW YORK,COUNTY OF WESTCHESTER ) as: Kelly Redlon/Burke Energy ,being duly sworn,deposes and states that he/she is the applicant above named, (print name of 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 Contractor 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 M%r 11 20 2- day of N_ 'I rV�� .20 � Signature of Property Owner Sig atu WAplicant'P'L— SR\lRf� o F-;v�, 1 � ,4 Kelly Redlon/Burke Energy Print Name of Property Owner Print Name of Applicant .4 I A OTT W.CRAIG Notary Public Notary Public of New York N ZABETH SARLES REG NO. 01CR6390567 NOTARY PUBLIC,STATE OF NEW YORK COMMISSION EXPIRES O4115/2027 Registration No. 01 SA6392045 led in utnar�County This application must be properly completed in its entirety and mu � ay 20,2027 signature(s)of the legal owner(s)of the subject property, and the ap 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 ip -- � 1� �,kt l(.o�,j l e.rr�. I�ye��. R0111 1)OLINC-W1 1II l Iii;iI Oil Sfmiq-c Vank� M:tnufac(urcr hit: Oil 'l ank Rcl)1;lrcIIw. Page 1 <11 1 /Slam /Produ�ls r Dcub1c-Wa 1 01I Sloragr Tangs Roth Double-Wall Oil Storage Tanks(DWT) ilk Roth's state-of-the art double-wall tanks are the best you can find. More for the environment More for your safety More quality More than 4 million installed —NEW 30-YEAR PRODUCT WARRANTY— Follow the links below for more information. Overview Characteristics / Specifications ( I� Dimensions for Individual tanks Tank Model DWT OWT OWT DWT DWT 400L 620L 1000E 1000E 1500L i Nom.Capacity US gal 110(400) 165(620) 275(1000) 275(1000) 400(1500) (liters) Length inches(cm) 29(74) 29(74) 43(110) 51(130) 64(163) Width inches(cm) 28(72) 28(72) 26(72) 30(76) 30(77) Height Inches(cm) 44(112) 61(155) 61(155) 54(137) 68(173) Min Height Req'd inches 49(125) 66(168) 66(168) 60(152) 76(193) (cm) Tank Weight Ibs (kg) IOr,(48) 132(60) 167(76) 208(94) 333(151) Shipping Weight lbs (kg) 115(52) 143(65) 185(64) 230(104) 358(162) Dimensions for grouped tanks Tank Model 400 OWT 620L DWT 1000L DWT 1000LH DWT 1500L 2 Tanks 29 x 60 29 x 60 43 x 60 51 x 63 64 x 63 (side by side) (74 x 152) (74 x 152) (110 x 234) (130 x 160) (163 x 160) 3 Tanks 29 x 92 29 x 92 43 x 92 51 x 96 64 x 96 (side by side) (74 x 234) (74 x 234) (110 x 234) (130 x 244) (163 x 244) 4 Tanks 29 x 124 29 x 124 43 x 124 51 x 129 N/A (side by side) (74 x 315) (74 x 315) It 10 x 315) (130 x 329) 5 Tanks 29 x156 29 x156 43 x 156 51 x 162 N/A (side by side) (74 x 397) (74 x 397) (110 x 397) (130 x 411) 2 Tanks (and to end) N/A NIA (72 x 229) NIA NIA Accessories 7 ft. x 4 in. Round Top On-Diameter 16-Guage Concrete Filled Painted Grey Bollard (5 Per Pallet) Portland Stone Ware 7 ft. x 4 in. Yellow Powder Coated O. D. "`�--�- 16-Gauge Bollards are visible barriers used to protect vaivable areas.Common placement of bollards are in commercial/industrial settings to block areas such as parking lots, sidewalks,storefronts and utility equipment.They are also often used to restrict access to specific areas. Portland Stone Ware bollards are made from minimum 3,000 psi concrete batches and specified pipe or tubing to withstand R -C significant impact. (J� Y Specifications a LL Dimensions Product Diameter On.) 4 in Product Height(in.) 84 in Details Base Plate Depth(In.) 0.00 Base Plate Width On.) 0.00 Color Famlly Yellow Material Concrete Product Welght Ob.) 113 lb { Reconditioned No Returnable 90-Day Safety&Traffic Control Type Bollard https://www.hamedeput.com/p/7-ft-x-4-in-Round-Tup-On-Diameter-I6-Guage-Concrete-Fi Iled-Painted-Grey-Bollard-S-Per-Pallet-BL407/320126938#ov... 3/7 BurkeEn MAY - 9 2024 Your local home service experts. 1 Village of Rye Brook VILLAGE OF RYE BROOK �uilding Department BUILDING DEPARTMENT 938 King Street Rye Brook, NY 10573 475 Commerce Street Hawthorne, NY 10532 May 2, 2024 914.769.5050 T 914.769.1521 F RE: Saverino Fiorino burkeenergy.com 42 Valley Terrace Rye Brook, NY 10573 Oil Tank Installation Close Out Letter- Permit# MP 24-039 & MP 24-040 April 23, 2024 - Burke Energy removed the existing oil tankO Ind installed a r:ew 275 gallon Roth oil tank. We installed new fill, vent, vent alarm, tank gauge, new coated oil line, fireomatic valve, all necessary pipe and fittings to complete new installation. The new oil tank(s) were installed in accordance with all existing local and state building department codes and ordinances. The old oil tank(s) were removed, cut and cleaned on site and disposed of at a recycling center, scrap manifest provided. The waste oil was disposed of at an approved waste oil recycling center, manifest provided. We deeply appreciate your help with this matter. Any further questions, please don't hesitate to contact Kelly or Dan in our permits department at 914-919-3507/3545. Thank you 01 John Burns / Install Manager / Burke Energy 914-769-5050 jburns@meenanlp.com burkepermits@)meenanlp.com Heating I A/C I Propane I Oil Tank Removal I Generators I Home Security&Automation Crown STANDARD COLLECTION Petroleum ORDER FORM Waste Services 2072 936 Route 6 Mahopac, NY 10541 - 845.803.8253 EPA# NYR000246355 NAME DATE 531 2-LI NAME: GENERATOR/LOCATIONot BILL TO NAME: ATT ETA,, ATT. ETA ADDRESS: % 4 . ADDRE§§:. Ty. LT ZIP:A C STATE: 1, ZIP: CITY' STATE: PHONE: PO: PHONE: TIME IN:,--.)-" q TIME OUT. .) DESIGNATED FACILITY NAME AND SITE ADDRESS U NAML: �]I WATER WORKS 77 STEWART AVE Ip,RFCYCLE OIL COMPANY i 16M SOUTH 25TH ST- ADDRESSS: NEWBURGH,NY 12560 1 845.561.4111 EASTON,PA 18042 1610.250.8747 NYD986908085 PAD980537666 EPA ID 0: DESCRIPTION OTY UNIT PR LINE TOTAL CHARGE MY ACCOUNT FOR THIS USED OIL REMOVAL TRANSACTION UNLESS OTHERWISE INDICATED IN THE PAYMENT SECTION. ANTI-FREEZE REMOVAL INVOICES REFLECTING CHARGES ARE SUBJECT TO AN INTEREST RATE OILY WATER REMOVAL OF THE LESSER OR 1-1/2%PER SLUDGE DISPOSAL MONTH(18%PER ANNUM)OR THE VACUUM SERVICE MAXMIJ RATE ALLOWED BY LAW ON ANY INVOICES THAT ARE NOT PAID �tRVICE HOURLY RAI-E VACUUM S WITHIN 30 DAYS IN THE EVENT OF DEFAULT CROWN PETROLEUM SHAL_ TRANSPORTATION BE ENTITLED TO RECOVER COSS OF COLLECTION,INCLUDING REASON- A ABLE ATTORNEY'S PEES. c. INITIAL -T j f!ME;N TIME OUT US DOT DESCRIPTION USED OIL,NON REGULATED,NOT US DOT HAZARDOUS MATERIAI-S,N/A,NONE,NONE G OILY WATER,NON REGULATED,NON R,C,R.A.N/A,NONE,NONE TT S UG PETROLEUM CONTAMINATED SLUDGE,NOT REGULATED,NO I US DOT HAZARDOUS MATERIALS,NA/,NONE,NONE TT_ G GENERATOR WARRANTS AND REPRESENTS THAT THE MATERIALS PROVIDED CROWN PETROLEUM HEREUNDER HAVE NOT BEEN MIXED,COMBINED.OR OTHERWISE BLENDED IN ANY QUANTITY WITH MATERIALS CONTAINING POLYCHLORINATED BIPFIENYS_t(PCB)CR ANY OTI4FR MATERIAL OFFINEDAS HAZARDOUS WASTE UNDER i CERTIFY THAT MY TOTAL WASTE APPLICABLE 1AWS,INCLUDING BUT NOT LIMITED TO 40 CM PART 261.GENERATOR AGREES TO INDEMNIFY AND HOLD CROWN PETROLEUM HARMLESS FOR ANY STREAMS ARE WITHIN ONE OF THE i)AmAu,s.cosrs.ATTORNEY'S FEES,Cr,ARISING OUT OF OR IN ANY WAY RELATED TO A BREACH OF THE ABOVE WARRANTY BY THE GENERATOR- FOLLOWING CATEGORIES: CROWN PETROLEUM,ITS AGENTS AND CONTRACTORS HAVE THE CAPAGRYAND ARE AUTHORIZED AND PERMITTED IN ACCORDANCE WITH ALL APPLICABLE LAWS AND REGULATIONS,TO TRANSPORT ACCEPT.STORE,RECLAIM OR ANDIETR DISPOSE OF-HF WASTF LISTED ON THIIS DCOUNIENT OTO 2.20 LBS/MONTH INITIALS: GENERATOR CERTIFIES THAT THE WASTE IS U USED OIL Z)USED ANTI-FREEZE Q OILY WATER U OTHER --- _ 220 LBS TO 2,200 LBS/MONTH INITIALS: RRIN-F-3 NAME: GREATER THAN 2,200!_F3S/MON7H SIGNATURE. DATE; INITIALS. PAYMENT RECEIPT Brookfield Resource Management 100 Lamont Street Elmsford, NY 10523 *� 914-592-5250 Receipt:186O366 Date:5/3/2O24 Customer:1915 Time:2 26 17 PM BURKE HEAT 475 Commerce Street Hawthorne, NY 10532 ID Number. Ticket:1916551 Weigh In:5/3/2024 2:17 35 PM Operator:Romy C Weigh Out:5/312024 2 26 15 PM White Ford Utility Commodity Gross Tare Net Price TOTAL$ #2 Unprepared 12.040 11.420 620 5 4000/CW 33.48 ------------------------------------------------------------------------ Ticket Total: 33.48 No.of Tickets:1 EZCash Paid: $33 00 Payment Method:EZCash Round Amt: ($0 48) Total Paid: $33. For current pricing,hours and contact information check us out on the web @brookfieldscrap.com Join Brookfield Scrap on Facebook @webuyscrap T r ), x ♦♦ r i George Latimer X-�l� James MAisanu ems)! Westchester County Executive Director,Consumer Protection c r Department of Consumer Protection I' Home Improvement License MEENAN OIL CO., L.P. �) BURKE HEAT 475 COMMERCE STREET . HAWTHORNE,NY-1 0532 = u { This license is issued in accordance with Article XVI of the Westchester CountyConsumer Protection Code and is valid only upon =d Y Po ,'. presence of the official department seal.Proof of citizenship or immigration status is not required for issuance of this license. NOT FOR FEDERAL.PURPOSES got Consr,�e License NUmher �FO� 'rA Date of Expiration ro WC 13355 c 10/11/2024 -H02 d r ohBBterCo�� Y� if's .own Q�� H 1�1t1'�� •�1))y P��t��i+e � 1�SY'�' ti d��tir�. :, rr��t1 y� �tr • +•U U i�t .y �4Po,�i1 nu.. �3,.t��� ..� �',�J.�tl� +'i...0 � ��',��• �1`.Q �i�.4.'� 1�':�r + �3 g� j( �44 4� ��`4F j� crl'ygn. 0 7a h� k• �ro {4 S0 `1 Sr \t //F / 1 ® DATE(MMIDO/YYYY) ACORO CERTIFICATE OF LIABILITY INSURANCE 1 011 2/20 23 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 WANED, 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 MaxGomes MARSH USA,_LC. NAME' PNONE 347-328-3107 FAx 1166 Avenue of the Americas New York,NY 10036 E-MAIL max. tom NewAttn:Nor,,NY 0036 arsh.com ADDRESS; INSURER(Sl AFFORDING COVERAGE NAIC 2 CN501414830-PETRO-ACORD-23- INSURER A:National Union Fire Ins Co Pittsburph PA 19445 INSURED MEENANOIL CO.,LP INSURERS:N/A NIA D/BiA BURKE HEAT AND BURKE FUEL OIL CO. INSURER c:NIA NIA 475 COMMERCE STREET INSURER D: HAWTHORNE.NY 10532 INSURER E INSURER F: COVERAGES CERTIFICATE NUMBER: NYC-011745459-01 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. S TYPE OF INSURANCE POLICY NUMBER POLICY EFF POLICDi Y UP— LMRS A kXContractuai MERCIAL GENERAL LIABILITY GL7032451 10/01,2023 10/01/2024 EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE �OCCURDAMAGEIO n n 5 500,000 MED EXP An one person S 10,000 PERSONAL&ADV INJURY S 1�� GEN'L AGGREGATE LIMIT APPLIES PER. GENERAL AGGREGATE 5 5,000,000 PRO X POLICY JECT C, LOC PRODUCTS-COMP/OP AGG S 2,000,000 II SIR S 1,000,000 AUTOMOBILE LIABILITY C6M8rNED SINGLE LIMIT S ANY AUTO BODILY INJURY(Per person) S OWNED SCHEDULED BODILY INJURY(Per accdent) $ AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTYDAIMAGE s AUTOS ONLY AUTOS ONLY (Per ecadeall S UMBRELLA LIAR OCCUR EACH OCCURRENCE S EXCESS LIAR HCLAIMS-MADE AGGREGATE S DED RETENTION S S WORKERS COMPENSATION PER O - AND EMPLOYERS'LIABILITY TLITE ANYPROPRIETOR/PARTNER/EXECUTIVE Y E.L.EACH ACCIDENT S OFFICERIMEMBEREXCLUDED? N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE S If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT S DESCRIPTION OF OPERATIONS I LOCATIONS 1 VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) THE VILLAGE OF RYE BROOK is included as additional insured where required by written contract. CERTIFICATE HOLDER CANCELLATION THE VILLAGE OF RYE BROOK SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 938 KING STREET THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN RYE BROOK,NY 10573 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE 7J55o1s 'Na ©1988-2016 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD Yo KR Workers' CERTIFICATE OF STATE Compensation NYS WORKERS' COMPENSATION INSURANCE COVERAGE Board Ia.Legal Name&Address of Insured(use street address only) 1 b.Business Telephone Number of Insured Meenan Oil Co.,LP 845-782-8161 dba Burke Heal and Burke Fuel Oil Co. 475 Commerce Street 1 c.NYS Unemployment Insurance Employer Registration Number of Hawthorne,NY 10532 Insured 8311425-2 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 11-3083408 2.Name and Address of Entity Requesting Proof of Coverage 3a.Name of Insurance Carrier (Entity Being Listed as the Certificate Holder) AIU Insurance Company Village of Ryebrook 3b.Policy Number of Entity Listed in Box"1a" 938 King Street WC 016440041 Ryebrook,NY 10573 3c.Policy effective period 10/01/2023 to 10/01/2024 3d.The Proprietor,Partners or Executive Officers are ✓� included.(Only check box if all partrerslofficers included) all excluded or certain partners/officers excluded. This certifies that the insurance carrier indicated above in box"3"insures the business referenced above in box"1a"for workers' compensation under the New York State Workers'Compensation Law. (To use this form,New York(NY)must be listed under Item 3A on the INFORMATION PAGE of the workers'compensation insurance policy). The Insurance Carrier or its licensed agent will send this Certificate of Insurance to the entity listed above as the certificate holder in box"2". The insurance carrier must notify the above certificate holder and the Workers'Compensation Board within 10 days IF a policy is canceled due to nonpayment of premiums or within 30 days IF there are reasons other than nonpayment of premiums that cancel the policy or eliminate the insured from the coverage indicated on this Certificate. (These notices may be sent by regular mail.)Otherwise,this Certificate is valid for one year after this form is approved by the insurance carrier or its licensed agent,or until the policy expiration date listed in box"3c",whichever is earlier. This certificate is issued as a matter of information only and confers no rights upon the certificate holder.This certificate does not amend, extend or alter the coverage afforded by the policy listed, nor does it confer any rights or responsibilities beyond those contained in the referenced policy. This certificate may be used as evidence of a Workers' Compensation contract of insurance only while the underlying policy is in effect. Please Note: Upon cancellation of the workers'compensation policy indicated on this form, if the business continues to be named on a permit,license or contract issued by a certificate holder,the business must provide that certificate holder with a new Certificate of Workers'Compensation Coverage or other authorized proof that the business is complying with the mandatory coverage requirements of the New York State Workers'Compensation Law. Under penalty of perjury,I certify that I am an authorized representative or licensed agent of the insurance carrier referenced above and that the named insured has the coverage as depicted on this form. Approved by: David McElroy (Print name of authorized representative or licensed agent of insurance carrier) N 09/27/2023 Approved by: Cy (Signature) (Date) Title: Authorized Representative Telephone Number of authorized representative or licensed agent of insurance carrier. 212-770-7000 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