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HomeMy WebLinkAboutMP24-115 �yE I3R t L�(C o YV j Ji4L V v J VILLAGE OF RYE BROOK MAYOR 938 King Street,Rye Brook,N.Y. 10573 ADMINISTRATOR Jason A. Klein (914)939-0668 Christopher J.Bradbury www.ryebrookny.gov TRUSTEES BUILDING & FIRE INSPECTOR Susan R. Epstein Steven E. Fews Stephanie J.Fischer David M.Heiser Salvatore W.Morlino CERTIFICATE OF COMPLIANCE December 18,2024 Irwin Simkin,Leomi Simkin&Eric Simkin 93 Brush Hollow Close Rye Brook,New York 10573 Re: 93 Brush Hollow Close,Rye Brook,New York 10573 Parcel ID#: 129.84-2-82 As per the Certification letter from Castlton Environmental Contractors, LLC dated December 2024, the removal of an underground oil tank under Mechanical Permit #24-115 issued on 9/3/2024 has been satisfactorily completed. Sincerely, Steven E. Fews Building&Fire Inspector /to �yE BRCuk, 1932 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 : 1 �RIJ�_`�� D LLUO DATE: PERMIT# 1 1`1 2 LI` ISSUED: 7 -3 Z;,SECT: /0?9• d� BLOCK: LOT: 92- LOCATION: `C �'(�Jl �! C� OCCUPANCY: ❑ VIOLATION NOTED THE WORK IS... ZACCEPTED ❑ REJECTED/ REINSPECTION ❑ SITE INSPECTION REQUIRED ❑ FOOTING ❑ FOOTING DRAINAGE ❑ FOUNDATION ❑ UNDERGROUND PLUMBING NOTES ON INSPECTION: ❑ ROUGH PLUMBING ❑ ROUGH FRAMING ❑ INSULATION / _ ❑ NATURAL GAS L L, _ti) [,/. S /is t k ❑ L.P. GAS A' FUEL TANK ❑ FIRE SPRINKLER ❑ FINAL PLUMBING I ❑ CROSS CONNECTION '"y 4 , c ''" ❑ FINAL ❑ OTHER QyE 4Rcb, cu � t7 >>/�' �9b2• O 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 ' !-J f ��` ; '� L '✓c. J l� ���.-F DATE' / L " 1 7 ) U Z '/ PERMIT# ISSUED: SECT: IZ ? U BLOCK: - LOT: cJ Z LOCATION: 4 G-, A OCCUPANCY: ❑ VIOLATION NOTED THE WORK IS... ❑ ACCEPTED ❑ REJECTED/ REINSPECTION ❑ SITE INSPECTION REQUIRED ❑ FOOTING ❑ FOOTING DRAINAGE ❑ FOUNDATION ❑ UNDERGROUND PLUMBING NOTES ON INSPECTION: ❑ ROUGH PLUMBING ❑ ROUGH FRAMING ❑ INSULATION ❑ NATURAL GAS ❑ L.P. GAS ❑ FUEL TANK ❑ FIRE SPRINKLER / ❑ FINAL PLUMBING f� 1 CI -� ❑ CROSS CONNECTION ❑ FINAL / S S( ( Q c' ❑ OTHER 'r i f ti �F r 3��,"�(yyVp�� T� ! l •1.T• J� ✓ A' . .Y -.1 1, t ,,a;• p 0 �. W t � W da F Ln w N 4 N p N eq c a p = eq y . en w W z A L] A'r � V V °� O w N a �• fl- 04 z LO 00 M iy y c ~ O N d .mil o o cn c � w Is. Q LnON w 0 Cal � G o O z O wo � � 0-4 5 p a 00 a w s w W �i Q tli fl 14 0-0 5 � p .v ° b _ ., V Nw ! j Q d O Qa G Egg15 & x U "" V 2: v o � 0v W p w0 d v W �+ C z z a QI H O w " u � °� 2 v O v (30 o o - M Z W CZo. Z P. _ Bum � MENT Vu, OF Ry OOK 938 KING Q ET RYE BR ,NY 10573 AUG 3 0 2Q24 -0 . . ov VILLAGE OF RYE BROOK BUILDING DEPARTMENT Application for Permit to Remove or Abandon Fuel Storage Tank (*Storage Tanks in excess of 1,100 gallons require registration with the County off Westchester) FOR OFFICE USE ONLY: PERMIT#:�"P / —. Approval Date: . 'r 3 — 2,0 2.1 Permit Fee: S Approval Signature: ,_ ��!`---� Other: Disapproved: (fees are nun-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 REOUIREMEN'TS 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 or Abandonmea S I 85.QQ per Tank. 5. Dig Safely New York#(dial 811): QO — = c1 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, ,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: �R�ejnov*a*l }•Abandonment( )/Above Ground( •Buried in Groun ) 1. Address: 9 2,> aY g\v VOUV" C t 0!�e- SBL: / 4/.O T—o)`P'�'Zone: tows 2. Property Owner&�ddress: e Vl C S 4V1�y1 qNSVl b)kt ,l/b C(VC U Phone#: l� Z )01V Cell;#. email: 3. Contracto��rjj,&Address: t A — r" h } Phone#:&AYN y(Q Zq �3 Cell#: 7-d1' Ckl) UI��Z email: r�CObs� a CAS � � 4. Applicant: � k y),Q J 14 Phone#: CZATQ TJ , L • Cell#: email: 5. Indicate Fuel Type:kgel Oi )•L.P.Gas( )•Gasoline( )•Other( ): 6. Number ar�\Capacity of each Tank: 7. Exact Location(s)of each Tank: Y 1 6/1/2024 STATE OF NEW YORK,COUNTY OF WFSTCHESTGR ) as: Caslilon Environmental ,being duly sworn,deposes and states that he/she is the applicant above named, (print name or individual signing as the applicant) and further states that(s)he is the icgal Owner of the property to which this application pertains,or that(s)he is the Contractor for the legal owner and is duty authorized to make and file this application.(indicate architect,conlnleior,agem.,auorncy,erc.) That all statements contained herein are true to the best of his/her knowledge and belief,Ind 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 we this Sworn to before me this Q day of_1�ilj 20 '1--�� day of 20 Signature of P,5-pcny Owner Si t1 t re of Applicant Print Narne of Property Owner Print ine of A phcant Notary Public TIANNA MAJOR Not" i' Notary Public-State of New York C d�,i+ {,�p iii ti' NO.01)AA0005867 Y iLLIAMI I Quotibed in Westchester County �Y Public®f fev�Jersey My Commission Expires Apr 19,2027 NOWY V-f''1res This application mast be proper y e co'mp e in its entirety aiz must include the notarized signature(s) of the legal owners)of the subject properly, 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 G/l/2020 App State Click to restore the map extent and layers { Visibility WIICFc you Icft off. t Of I Roo of 1'tom J c t 1 t aa� I i l t � CASTLTON ENVIRONMENTAL CONTRACTORS, LLC "Creating Balance between Industry and Environment" Dram-' December 2024 ID Village of Rye Brook DEC 17 2024 Building Department 938 King Street Rye Brook NY 10573 VILLAGE OF RYE RPOOK ' BUILDING DEP/,, "ENT Ra_1Jtr ground Storage Tank Removal Homeowner: Eric Simkin 93 Brush Hollow Close,Rye Brook,NY 10573 To the Village of Rye Brook Bldg. Dept., Castlton Environmental Contractors, LLC (CEC) was contracted to remove one 330-gallon fuel oil Underground Storage Tank (UST), from the above referenced property on September 191h, 2024. Castlton cut open the tank and thoroughly cleaned out the interior with absorbent pads and a squee-gee. The tanks contents were removed and properly disposed of at Clean Water of NY, Inc., a licensed disposal facility located in Newburgh, NY, with a NYSDEC permitted vacuum truck. CEC did not detect any holes in the tank and did not observe any fuel impaction to the surrounding area. A photo-ionization detector (PID) was utilized to screen the soils below and around the tank for any contamination—no readings found. The tank was removed and properly disposed of at Teplitz Scrap Recyclers of Nanuet, New York. All UST removal activities were performed in accordance with the NYSDEC, Westchester County, and the Village of Rye Brook regulations. In summary, all contaminated material, from the tank, was removed from the property and properly disposed of. If you have any questions do not hesitate to call me at (845)624-1312. Sincerel Greg Spadaccini Environmental Scientist Castlton Environmental Contractors, LLC 121 KOCH WAY • PEARL RIVER,NY 10965 • (845)624-1312 9 FAX:(845)6244275 �QyE BRC�� o ti 1932 BUILDING DEPARTMENT ❑ ILDING 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.or, - - - - ---- - - - - - - - - - - - - INSPECTION REPORT - - - - - - - - ----- - - - - - - - ADDRESS : Ll__4Yw� _ DATE: PERMIT# ISSUED:l-d ECT: AR _BLOCK: Z LOT: �Z LOCATION: OCCUPANCY: ❑ VIOLATION NOTED THE WORK IS... ZACCEPTED ❑ REJECTED/REINSPECTION ❑ SITE INSPECTION REQUIRED ❑ FOOTING ❑ FOOTING DRAINAGE ❑ FOUNDATION ❑ UNDERGROUND PLUMBING NOTES ON INSPECTION: ❑ ROUGH PLUMBING ❑ ROUGH FRAMING ❑ INSULATION ❑ NATURAL GAS ?e►n a vC 4 3 30 ❑ L.P. GAS ,�' FUEL TANK ❑ FIRE SPRINKLER ❑ FINAL PLUMBING �( (w� I L � i S.S r � ❑ CROSS CONNECTION 11- . C 4P ❑ FINAL e v p ❑ OTHER ` L ~ i "4eq 7 _ C d a A R B MNI M M b g O i N N F W tgCq MCI OF N o b00 w Cl rA 19 � ^ � M rat °' a 'ts '_^• G ° �, -4 iL 0-0 J-4 00 co W W ai o R ' cf) � � z W � o Woyo � Wa , � w � Z O °� z H $ 0 -auv � ' A ' M r� 0-4 o WSW oo O z G1 W W (A o 0 pp M�1 O �W Z a M1 1 O O Z b v s V a zcnv k o E-- W Q O z14 � � � a a •N � c 40 14 o ° p �o 5 o a ,..,, �� u i i I fi I SCALE PURCHASE TICKET Teplitz Metal Processing 108 West Nyack Road Nanuet, NY 10954 845-623-0040 DMV#7104668 Ticket: 429934 Weigh In: 09/20/2024 14:39 Customer: 1030 Weigh Out: 09/20/2024 14:54 Castlton Environmental Services 121 Koch Way Pearl River, NY 10965 White Rack Body PO Commodity Gross Tare Net Price TOTAL$ Unp.Tanks 10280 10060 220 /GT ------------ ------ ------ - - - - -- - - ------------ SCALE PURCHASE TICKET Teplitz Metal Processing, 108 West Nyack Road Nanuet, NY 10954 845-623-0040 DMV#7104668 Buyer: 9 i 1 hereby certify that I have the right to possess and sell this scrap. This is a Bill of Sale to the above described scrap, I hereby acknowledge payment in full. This is to certify that I deliverd the above material for the named supplier. This will also certify that I, on behalf of the above named supplier, am familiar with Teplitz's list of unacceptable/prohibited materials,and that the above load does not contain any unacceptablelprohibited materials, including any Class I (chlorofluorocarbons) or Class 2(hydrochloroflourocarbons) refrigerants(Freon),which under the federal Clean Air Act must be reclaimed not vented. Customer Signature Please do not lose this ticket. Ticket required for payment. TEPLITZ METAL PROCESSING NYSDMV#7104668 1 PRODUCT 6558 CASTLTON ENVIRONMENTAL CONTRACTORS, LLC JOQ �II ORK ORDER P.O. Box 609 4%S NANUET, NY 10954 22220 1-800-25-TANKS FAX (845) 624-1325 OATS OF ORDER CUSTOMEq'S ORDER NO PHONE MEOHANIC HELPER STARTING DATE BILL TO - _`.— -_. --_ ! 7 ORDER TARN BY ADDRESS CITY DAY WORK ❑ CONTRACT ©� ❑ EXTRA JOB NAME AND L pTION JOO PHONE DESCRIP'nON OF W&gK; O h� I TOTAL MATERIALS — TOTAL LABOR 1.5% per month interest will be a lied to ac counts ccounb osar 30 ePmu.and court fees will the news' — DATE COMPLETED limns this TAX COMPLETED nYAY mac, TOTAL AMOUNT f ��❑No one home ❑ Total amount due ❑ Total billing to for above work:or be mailed after I hereby acknowledge the sensfaao 00 — completion satisfactory mPletlon of work �_, of the above described work ` Clean Water of New York, Inc. LEAN WATER O 3249 Richmond Terrace Staten Island NY 10303 of New York, Inc, Phone: 718-981-4600 Fax: 718-981-5213 RECEIPT Job Number Date Time Job Type JOB0208477 10/4/24 10:29 am Truck Job Generator rans orter VARIOUS GENERATORS CASTLTON ENVIRONMENTAL CONTRACTORS,LL NY P.O.Box 609 80 West Nyack Road Nanuet,NY 10954 EPA Permit# Customer EPA Permit#: NJR000001180 NYS DEC Permit#: NJ-636 CASTLTON ENVIRONMENTAL CONTRACTORS,LLC P.O.Box 609 80 West Nyack Road Transport/Vessel: VAC#17 Nanuet,NY 10954 #of Tanks: 1 PO#: Job# Total Capacity: 3,800 Profile Sheet Yes Approval Code:219-001 1 U of M: Gallons VARIOUS GENERATORS-VARIOUS GENERATORS NEW YORK 219-001 Received 1,750 Gallons Of Oily Water For Proper Treatment and Disposal. Products& I Category Code Description Quantity UoM a!L____j D N018 Oily Water 1,750 Gallons Compartment %Water %Oil %Solid Halogens(ppm) Flash Point(oF) PH Value 1 47.00 50.00 3.00 100 >= 110 6.00 Other Tests Pefonned:No Did this load or any portion of this load orginate at a utility? No Receivers ignature and Date Generators Representative Signature and Date 10/4/2024 10:31 am Page 1 of 1 NQN.HpjpgppS 1.Gerreretor ID Ntsrrber 2.Papa 1 of 3 Emerperucy Respol PMne 4 W esla Traddnp Number WASTE MANIFEST 6.GenereWfs Name and Matling Address e ,`r Gerrerebfs Site Add(I ditlerent than g address) h1 CloSe Geraral Phone: 8, or 1 Name U S �Numbor�1n v,®7.Transporter 2 Comparry Name 8.D�nated Fail�/j��r/� , U.S.E � , U.S.EPA ID Number F s PMne 9.Waste Shipping Name and Description 10.Containers 11.Total 12.Unit No. Type omility MNd. g a UJI W 2• a 4. 3. 1�Special Handlingfl�fristruictione and Addtiorrel Irdonnation Q r 401ill r /Z.22,' O C/ 2 14.GENERATOR'S CERTIFICATM:I rxrtity the materials described above on this rrreni(est are not subject to federal regulations for report ng proper dusposai of Hazardous Waste, Gen9Wofs/Offerofa Pdntr Marrrp S� K Month Day Year J 15.International Shipments r n ❑Irtpat io U.S ❑Export from U.S. Port of entry/ext T der S nature for-ports ol Ir 16.Transporter Aduwwledgmerrt of Recall of Materials Date leaving U.S Transporter 1 Printsd?yped(Jame Signature Month Day Year z TranspoAer2Pri Signature Month Day Year 17.Discrepancy 17a.Discrepancy Indication Space ❑Quaf ty Type ❑Residue ❑Partial Refection ❑Full Rejection 176.Alternate FadBty(or Generator) _Mongol Reference Number. U.S.EPA ID Number Facility's Plane: 17c.Signature of A senate Fall(or General Z Month Day Year �7 W O 18.Designated Facility Owner or Operator.Certifcation of MOW of materials covered by the manifest except as rated in Item 17a toll00, Signal Name ! MOM Day Year i 169-BLS-C 6 10497(Rev.6/06) TRANSPORTE #1 ° yy !Y.r'(r.» •� W 00 •♦ R � ed —• y Ii WD CA ' p N o � U) a �. I U5 o M� 4 � U � � 00 + x � a Lf) )N. Jam_ -�oa Z Q (M ° 04 a Qt section • ems{ o as Q } Ei O •v - Z W corJ o. W p rays 4. - + O Z NO wpBQ �e I % Z X 4. ; Ll1 O X c0 Z m + sue• �.�, ° O U 0 C Q 3 w i of c0 O O ��• Wt El (t(asi F' 0 O LO is"'ram••= : v IA 3 a r, is Ow _ ,� A i., �� � A c •��'�r a �w (i�1(�Y.� • )tf�(�. wi� )�)�(� � (�(,(1 � �(/(/(f :. fly / 1 DATE(MM/DD/YYYY) ACO.R" CERTIFICATE OF LIABILITY INSURANCE Ill08/28I2024 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT Jane Begreen NAME: Insurance Solutions 8 Services,Inc. A , o Ext: (732)738-6080 A/C,No): (732)738-6081 619 Amboy Avenue E-MAIL jbegreen@issi-nj com ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC p Edison NJ 08837 INSURER A: Nautilus Insurance Company 17370 INSURED INSURER B: Castlton Environmental Contractors LLC INSURER C: 48 Bi-State Plaza INSURER D: INSURER E Old Tappan NJ 07675 INSURER F COVERAGES CERTIFICATE NUMBER: CL2443007914 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. IPOLICY EXP LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER MMIDD/YEFF MWDD/YYYY LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE TO CLAIMS-MADE 7XI OCCUR PREMISES(EaENTE u occ ence) $ 300,000 MED EXP(Any one person) $ 20,000 A Y ECP2040265-11 05/01/2024 05/01/2025 PERSONAL BADVINJURY $ 1,000,000 GEN'LAGGREGATELIMITAPPLIESPER: GENERAL AGGREGATE $ 2,000,000 JECT ❑ LOC PRODUCTS-COMP/ PAGG $X POLICY ❑ PRO 2,000,000 OTHER Employee Benefits $ 1,000,000 AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY Per accident $ UMBRELLA LAB OCCUR EACH OCCURRENCE $ EXCESS LAB HCLAIMS-MADE AGGREGATE $ DED I I RETENTION$ $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY Y/N STATUTE I I ER ANY PROPRIETOR/PARTNER/EXECUTIVE ❑ NIA E L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? (Mandatory In NH) E.L DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below E L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached If more space is required) Village of Pelham is included as Additional Insured with regard to the General Liability as respects the operations of the Insured. Additional Insured status is subject to written contract requirements. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN Village of Pelham ACCORDANCE WITH THE POLICY PROVISIONS. 195 Sparks Avenue AUTHORIZED REPRESENTATIVE Pelham NY 10803 /y/� ©1988-2015ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD STATE OF NEW YORK WORKERS' COMPENSATION BOARD CERTIFICATE OF NYS WORKERS' COMPENSATION INSURANCE COVERAGE 1 a. Legal Name&Address of Insured (Use street address only) lb.Business Telephone Number of Insured 845-624-1312 Casdton Environmental Contractors LLC 48 Bi-State Plaza 1 c.NYS Unemployment Insurance Employer Old Tappan,NJ 07675 Registration Number of Insured 4700419 ld.Federal Employer Identification Number of Insured Work Location of Insured(Only required if coverage is specifically or Social Security Number limited to certain locations in New York State, i.e., a Wrap-[Ip 90-0154807 Policy) 2. Name and Address of the Entity Requesting Proof of 3a. Name of Insurance Carrier Coverage(Entity Being Listed as the Certificate holder) Great Divide Insurance Company Village of Pelham 3b.Policy Number of entity listed in boa"la" 195 Sparks Avenue WCA 1549026 Pelham,NY 10803 3c. Policy effective period 5/1/2024 to 5/1/2025 3d. The Proprietor,Partners or Executive Officers are ® included. (Only check box if all partners/offleers included) ❑all excluded or certain partners/officers excluded. This certifies that the insurance carrier indicated above in box "Y' insures the business referenced above in box"la" 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"T'. The Insurance Carrier will also notes the above certificate holder 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 maybe 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 pokey expiration date listed in box"3e",whichever is earlier. Please Note: Upon the 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: Insurance Solutions&Services,Inc. (Print name of authorized representative or licensed agent of insurance carrier) Approved by: ����� 8/28/2024 (Signature) (Date) Title: Frank G.Jacobs,President Telephone Number of authorized representative or licensed agent of insurance carrier. (732)738-6080 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(9-07) www.wcb.state.ny.us Laura Petersen From: UDig NY Exactix <tickets@exactix.udigny.org> Sent: Friday, September 13, 2024 4:55 PM To: Steven Fews Subject: Message from UDig NY ****REGULAR**** DIG REQUEST from UDig NY for: VIL RYE BROOK Taken: 09/13/2024 16:54 To: VIL RYE BROOK PRIMARY Transmitted: 09/13/2024 16:54 00009 Ticket: 09134-001-983-00 Type: Regular Previous Ticket: 08304-000-243-00 ------------------------------------------------------------------------------ State: NY County: WESTCHESTER Place: RYE BROOK Addr: From: 93 To: Name: BRUSH HOLLOW CLOS Cross: From: To: Name: Offset: ------------------------------------------------------------------------------ Locate: CURB TO ENTIRE PROP NearSt: ARBOR DR Means of Excavation: EXCAVATOR Blasting: N Site marked with white: N Boring/Directional Drilling: N Within 25ft of Edge of Road: U Work Type: SOIL REMEDIATION, REMOVE ROOTS, REMOVE BUSHES / SHRUBS, STUMP REMOVA Estimated Work Complete Date: 10/02/2024 Depth of excavation: Site dimensions: Start Date and Time: 09/18/2024 07:00 Must Start By: 10/02/2024 ------------------------------------------------------------------------------ Contact Name: GEORGE PORTA Company: CASTLTON ENVIRONMENTAL CONTRACTORS Addr1: PO BOX 609 Addr2: City: NANUET State: NY Zip: 10954 Phone: 973-207-0931 Fax: Email:jjacobsen@castlton.com Field Contact: GREG SPADACCINI Alt Phone: 973-207-0931 Email:jjacobsen@castlton.com Working for: SIMKIN .............................:------------------------------------------------ Comments: Lookup Type: ADDRESS ------------------------------------------------------------------------------ Members=ALTICE USA BELL-VALHALLA/WSCHSTR CONED SUEZ WTR WESTCHESTER TEN GAS-HDS VLY VIL RYE BROOK i