Loading...
HomeMy WebLinkAboutPP24-146 a t a = s a t N � N = a O a t N cZj a O C/l a O by x O r^ _ w Q In t ~ a W � FBI p 00 ,n V r-r ° L � e� o 8A V) � � \ 0 �o A t O W M z �i o W A t 010 c t 00 a � w U W �" C� A U Q °O 4 w H O ° � o cr' ci � x z Cn = 0-4 a C.7 A z rr hh in PLO I- 00 wz = V V 04 t � w t nD QL °RCi� F 18 ZOZ4 BUIL E MENT VIL OF RYE OOK VILLAGE OF RYE BROOK 93$Knv ET RYE B ,NY 1057 BUILDING DEPARTMENT W fl Off' PLUMBING PERMIT APPLICATION FOR OFFICE USE ONLY BP #: PP#: i 7 -� Approval Date: SEP 2 0 Permit Fee: $ II Approval Signature: Disapproved: �1 �C 1)['j (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 Application dated, 9/10/2024 is 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 that said plumbing work will be in conformance with all applicable Federal,State,County and Local Codes. I.Address: 42 Talcott Road, Rye Brook, NY 10573 sBL: 135.50-1-10 zone: R-12 2.Proposed Work: Install Sewer Liner from main sewer to house trap; no changes; legalization 3.Property Owner: _QQLi 609 S (_O,v rZ A lD Address: 42 Talcott Road, Rye Brook, NY 10573 Phone#: Cell#: email: lOLt&6)Dr-(6/►RA0 CPA,Goll 4.Master Plumber: Thomas Webber Jr. Address: 3365 Route 9, Cold Spring, NY 10516 Lic.#: 1489 Phone#: (845)265-1400 Cell#: (845)666-0258 email: Permits@TWebber.com Company Name: T. Webber Address: 3365 Route 9, Cold Spring, NY 10516 INDICATE FIXTURES& LINES TO BE INSTALLED AS PER THE FOLLOWING SCHEDULE: Location Water Urinals Drinking Sinks Showers Bath Laundry Domestic Fire Sanitary Natural/ Other* Total Closets Fountains Tubs Tubs Service Service Sewer LP Gas Basement Ist Floor 2nd Floor 3"d Floor 41 Floor 5ch Floor Exterior 1 1 5.*List Other Equipment/Provide Details: Hammerhead sewer liner (Notarized Signatures Required Next 2 Pages) -1- 6/1/2024 SUILD.L• .{�-����']��iEIVT { � .Y, 1�� A Vmt E OF RY\` �OOK 9.3.9 KIN . Ex RYE B ,NY 105 S�� 1 B 2024 -0 OF RYA BROOK WVV if c v VILL.AGE F T1'+lI�ENT 1 BUILDING wwwxxwwr.xxxwwx+rxx**w*wx*wwwxwxwx*xxwarx*rr*wxe:wwwwww*wwwwwx+wwwwwxrwwxrxwwwx�wxxxxw+.xxx*t,rx,rwwwtw,rwwxxxxx AFFIDAVIT OF COMPLIANCE VTLLAGE CODE §216 • S,rug i SEWERS AND SANITARY SEWFRS THIS AFFIDAVIT MUST BEAR THE NOTARIZED SIGNATURE OF THE LEGAL PROPLRTY 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 ) as: IJ, _DDLk6_L-A S C-C)" f] , residing at, y,:P 7,iLCO7_ f Print narocl ;Address where you libel -- 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; IA�CO( go � , Rye Brook,NY. f!ob Address) 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 conceruiug eil.her the stoma 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. NgUKIC of'Propem,Owlicr{s) Y - ---- — --- —— Coluem {print Kinic of Prorcrt} %%-nett­i Swom to before me this_ /Z day of � rrt \;+,arp uhhcl ITT JUDITH CAMPBELL NO"Public,Slale of New York No.01CAS073100 Qualified in Westchester County -3- Commissron Expires Feb.18.2027' r 1;'_02 STATE OF NEW YORK,COUNTY OF WESTCHESTER ) as- Thomas Webber Jr being duly sworn,deposes and states that he/she is the applicant above named, !print name of individual signing as tiro appiieanp and further states that(s)hc is the Master Plumber for the legal owner and is duly authorized to make and file this application. That all statements contained herein art;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 Unifomi 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 Z_ Sworn fore e this day of �t-o -e / .204:q day of /20 _nano e of Property Owner Signature of Applicant PO-�61_R-S Thomas Webber Jr Print Name of Property Owner PuU rin Name of Appl nt o Public Notary Puble M.ttnney JF H CAMPEEtI Public,State of New Vbrk . -. Notary Puck,State o Now Yak -- - No.OICAS073100 RepeMon No.:01TI604S0M Qualified in westchester County QU~in Dut&sm cw" Cornmisslan ExpLms Feb.tb.2027 Cpf dnW0 p Expires: It*206 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. Applications not properly completed in its entirety and/or not properly signed shall be deemed null and void and will be returned to the applicant, ri/t r2024 �yE BRcb- O�` Zm cu � • 19t32 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.orz; - - - - - - - - - - - - - - - - - - - - INSPECTION REPORT - - - - - - - - - - - - - - - - - - - - ADDRESS : DATE: PERMIT# ISSUED: SECT: BLOCK: LOT: LOCATION: 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 ❑ CROSS CONNECTION ❑ FINAL ❑ OTHER � t d 4 9 6 AL— ........ ._. i- ._ w_ t .."wool fir �� � ��\\�}�� § \� � \ \ � \ � �� ^ @ °�C\ \ \� . \ � � . . .� \�\` / \ � � ^ �f\r : «, � � °�� \ < . . . . . � . � y� »^ y . : � ^ . � \ . 2» w © ` � � . �»l . » i�\/ � � \�� �� .. c©��- ©«. , . �. .ee, . . -y . - w . . 2 . . � . . � 7 < © �� � - \ % < \ / . \ � � � �f \ . _ ^ , , � 1 � r r ' T, WEB i A 4 � #V"WN 16 2�"�Y.• t �� ��. ;. y ���:., ;<�- �Y ' fit, � Ili 1 't� II ..��''�I <,;r =f ,; `6 . ( �. } Y � Yt s •it • � yr` -_'�>'/y # �� . 4,1 Jw lk .. h". ~7 4 G�. ! ` �����\ _ y22��� : _ ®��2� w�2�� -�� : . : . .x�� > . °��©< : . � °y« �: «. . ^ ®� . . » �a. ©%:2 ; mw . � _ � : �t. � . ?: \��y> . . � . � � , . y> � � . , < 2/�<�:/� <� . . . 2��2��¥ § ��®� ��?? . ?2 ` \���\�\����2 . . : ��/. . < � »��!t ��,� ,,:: dui ;•, 1"'�-�, .�� .�� .__F., _ �':-�: r•� ::.i_.�..�y i� .y,� - ✓ J6 � *� a. N' f �i;,': ,. ;I. t ]1� ? .� � .�� :. V t,• � ��!�{.�� n F .._.��s.. .. le `ice ♦•�r � i .� r �i �• Ahr p If t .Olt% .. ..... ...... .. .... . Ir U ` t -A • ` 'Oroi ,i r •. ?.4 ice►' fY <4 3 .� ow + AX fir WIE 5-265-1400 kPr l- � `e , v l - x a • - ems,,, -,' - - R7 w _ . ct��. �•►� �. ��,. -,� ,�"'' w!e �� � . ,.:_ - � j �_ - , •��- � � � Yyt�_ i s � ', ' ��. � � - �� it ', � I t �.. _ Y , • � +• ^��� � �. � �; �'� s� ', ; • � i� I! r a x,5 I� 0 is s, � Westchester County Board of Plumbinn Examiners Westchester County Consumer P-notection Master Plumbing Lice bR. 4 3 I Thoriias C U', ebhr-< D.0,�J: 1017fI �K Height: Hair: Br o-r,.►n Compar,; ;. 1'. Webber 3365 Cold Spring, N License No. 1489 Expires on:12/31/2024 Josef-,-' , / • �ACORN CERTIFICATE OF LIABILITY INSURANCE DATE(MM/OD/YYYY) 1 11/28/2023 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME:-- Jane Kinsella _ Higginbotham Insurance Agency, Inc. PHONN -502-244-1343 FAX e 1700 Eastpoint Parkway EWC.-MAIL (AIC,No1: P.O. Box 23790 ADDRESS: JKinsella@higginbotham.net Louisville KY 40223 INSURERS AFFORDING COVERAGE NAIC0 _ INSURER A:Safety National Casualty Corporation 15105 INSURED ESSESER-01 INSURER B:HOmeSlte Insurance Company Of Florida 11156 T Webber Service Corporation —T. Webber Plumbing, LLC INSURERC: 3365 Route 9 INSURER D: Cold Spring NY 10516 INSURERE: INSURER F: COVERAGES CERTIFICATE NUMBER:1471627847 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADDL SUER POLICY EFF POLICY EXP LTR TYPE OF INSURANCE POLICY NUMBER MM/DD/YYYY MM/DD LIMITS A X COMMERCIAL GENERAL LIABILITY Y Y G L 6676140 12/31/2023 12/31/2024 EACH OCCURRENCE $5,000,000 CLAIMS-MADE -- OCCUR DAMAGE TO RENTED PREMISES Ea occurrence $1,000,000 MED EXP(Any one neon) $10,000 PERSONAL&ADV INJURY $5,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $10,000,000 POLICY PRO- LOC PRODUCTS-COMP/OP AGG $10,000,000 OTHER: $ A AUTOMOBILE LIABILITY Y Y CA 6676139 12/31/2023 12/31/2024 Ea acclidentS N LE L MI $5,000,000 X ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY Per acciderd AUTOS ONLY AUTOS ( ) $ X HIRED X NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY Per acradent B X UMBRELLA LIAR X OCCUR Y Y CXP-001249-02 12/31/2023 12/31/2024 EACH OCCURRENCE $5,000,000 EXCESS LIAR CLAIMS-MADE AGGREGATE $ DED 1 X I RETENTION$rinjum. $ WORKERS COMPENSATION SPER OTH- AND EMPLOYERS'LIABILITY YIN TATUTE ER ANYPROPRIETOR/PARTNER/EXECUTIVE ❑ E.L.EACH ACCIDENT $ OFFICERIMEMBEREXCLUDED? N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below I E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORO 101,Additional Remarks Schedule,may be attached if more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Village of Rye Brook 98 King Street AUTHORIZED REPRESENTATIVE Rye Brook NY 10573 ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD NEW Workers' SATE Compensation CERTIFICATE OF Board NYS WORKERS COMPENSATION INSURANCE COVERAGE I a. Legal Name&address of insured(use street address only) I b.Business Telephone Number of insured T Webber Plumbing LLC 3365 US 9 Cold Spring, NY 10516 lc.NYS Unemployment Insurance Employer Registration Number of Insured Work Location of Insured(Only required if coverage is specifically Id.Federal Employer Identification Number of Insured or Social Security limited to certain locations in New Yo)*State, i.e.a Wrap-Up Policy) Number 85-3910296 2.Name and Address of the Entity Requesting Proof of Coverage 3a. Name of Insurance Carrier (Entity Being Listed as the Certificate Holder) Safety National Casualty Corporation Village of Rye Brook 98 King Street Rye Brook, NY 10573 3b.Policy Number of entity listed in bo8x"la" LDS4066109 3c. Policy effective period 12/31/2023 to 12/31/2024 3d. The Proprietor,Partners or Executive Officers are X included. (Only check box if all partners/officers 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"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"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 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: Gus E. Aivaliotis (Print name of authorized representative or licensed agent of insurance carrier) Approved by: 0-u . 12/21/2023 (Signature) (Date) Title: Chief Underwriting Officer Telephone Number of authorized representative or licensed agent of insurance carrier: 1-888-995-5300 Please Note: Only insurance carriers and their licensed agents are authorized to issue the C-105.2 form. Insurance brokers are NOT authorized to issue it. C-105.2(9-17) www.wcb.ny.gov Workers' Compensation Law Section 57. Restriction on issue of permits and the entering into contracts unless compensation is secured. 1. The head of a state or municipal department,board,commission or office authorized or required by law to issue any permit for or in connection with any work involving the employment of employees in a hazardous employment defined by this chapter,and notwithstanding any general or special statute requiring or authorizing the issue of such permits,shall not issue such permit unless proof duly subscribed by an insurance carrier is produced in a form satisfactory to the chair,that compensation for all employees has been secured as provided by this chapter. Nothing herein, however,shall be construed as creating any liability on the part of such state or municipal department,board, commission or office to pay any compensation to any such employee if so employed. 2. The head of a state or municipal department,board,commission or office authorized or required by law to enter into any contract for or in connection with any work involving the employment of employees in a hazardous employment defined by this chapter,notwithstanding any general or special statute requiring or authorizing any such contract,shall not enter into any such contract unless proof duly subscribed by an insurance carrier is produced in a form satisfactory to the chair,that compensation for all employees has been secured as provided by this chapter. C-105.2(9-17)Reverse BUIL E �HTMENT SEP - 6 2022 VIL/r E OF RYEROOK 938 KING ET RYE BROOK,NY 10573 VILLAGE OF RYE BROOK BUILDING DEPARTMENT org PLUMBING PERMIT APPLICATION FOR OFFICE USE ONLY is , PP#: n Approval Date: Permit Fee: $ Approval Signature: Other: Disapproved: (fees are non-refundable) ************************************************************************************************** Application dated, hbo Z is 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 that said plumbing work will be in conformance with all applicable Federal,State,County and Local Codes. 1.Address: 9 Z TA LM P-Q.81D SBL: V:�s, So- i — I U Zone: 2.Proposed Work:_S EALEE� b.-t.I•/V J F (&JL f2-_ :J�U HWS r� 3.Property Owner: %Le�-C-'r uJac>1 V- Address: u Z'T-AL(,(}'TT )Z-6PrD Phone#:1)Ll t4a) 7LI 23 Cell#: email: 4.Master Plumber:TVO M�� WVc5?5E.f2. Address: Lic.#:Ni 9 Phone#: 2549-4Z�4(L6 Cell#: Company Name: Address:- INDICATE FIXTURES& LINES TO BE INSTALLED AS I �pTl� WIG Ccx 0LULE: Location Water Urinals Drinking Sinks Showers Bath Laundry D( Nam) i Other* Total Basement Closets Fountains Tubs Tubs Se G}� 0>R3rrQT* 1 st Floor 2nd Floor 31°Floor 41h Floor 5 m Floor �� V` �� �- ►'J a t �J7 Exterior )v C' 5.*List Other Equipment/Provide Details: der,? (Notarized Signatures Required Next 2 Pages) -1- 8/12/2021 STATE OF NEW YORK,COUNTY OF W TCHESTER ) as: C�� M &f{� lMA0-V kt4I 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 CLAMm f IU L 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 0� 5 Sworn to fore me this J� day of ,20 a a day of 20 Sign a re of Property Owner Sign o Applicant ,TOQ N kra-5-0 e ti V Print Name of Property �Owner % Print Name of Applicant W � Nota tc STEVEN w COHEN Notary Public jt Maury Public,State of New Ybt No.01 CG!�OE9bOS M'n f N Ouelifma in We--Achester C � StanStano of Now rbrlt Oe nkeron Expose NpvQmber 2f, --I d1noLutmecaunty 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. Applications 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- 8/12/2021 BUILDII -6�t"*.RTMENT D [E c F�Y E D VILLW E OF RY OOK NOV - 7 2022 938 KING ET RYE BR NY 10573 4 , VILLAGE OF RYE BROOK BUILDING DEPARTMENT AFFIDAVIT OF COMPLIANCE VILLAGE CODE §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 ) as: 1, A /V r,EAS,N residing at, L4 L T A L( y T T R-o A p (Prin(naive) (Address where you live) 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; vl Z l" A L. ( o rT VA)'zk- Rye Brook,NY. (Job Address) 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. ISi,nar r of Property Owncr( 30)4N (-2/06N rc (Print Name of'Property Owner(s)) Sworn to before me this t day o , 20 Z y otary Pi -- 0 C T 0 31011 STEVEN W COHEN NOWY Public,State of%etiv Vwk 4 No.01 COSCOC-9606 By i Owhfied in Wdstehesrsr Cow► Or0100"alon Expires Navemhsr 26, 8/12/2021 vvestcnester County Board of Plumbing Examiners Westchester County Consumer Protection Master Plumbing License 2022 Thomas C Webber JR D.O.B: 10/711987 Height: 06*0 Weight:245 Hair: Brown Eyes: Blue Company: T. Webber Plumbing LLC 3365 Route 9 Cold Spring. NY 10516 License No. 1489 Expires on:1213112022 Laura Petersen From: Laura Petersen Sent: Tuesday, September 6, 2022 2:46 PM To: permits@twebber.com Subject: Plumbing Permit Application - 42 Talcott Road Attachments: Affidavit of Compliance 8.2021.pdf Good morning, The Building Department has received in the mail the plumbing permit application for 42 Talcott Road. The application is missing the affidavit e which requires the property owners notarized signature. !//-2C-/V00l A)o V- 7 The Building Department also requires the master plumber to file the application in person to the Building Department. 0,? C The fee for the application is $175.00 (check made payable to the Village of Rye Brook). Thank you `-- Iece l Ky Wov, 7 Laura Laura Petersen Office Assistant Village of Rye Brook 938 King Street Rye Brook, New York 10573 Phone(914)939-0668 1 Ipetersen(&ryebrook.org �^} hl L (L>uO)ASi Gli �ONL�UN� To tLUN VS Vti,ow Tti� P.rvo W� V�' �lL PPS\ UN`-�N�-, 11 s TvvZ5Ak2 IL)M r CV-1tb'Ylkt_ _. r.\/� 1 0'J Ntti O h t�y'�rhN V-LS TL C� DATE(MM/DD/YYYY) A CC CERTIFICATE OF LIABILITY INSURANCE 12/28/2021 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 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 NAME: PHONE NC.NO :502-244-1343 No:502-244-1411 The Underwriters Group, Inc. 4WL 1700 Eastpoint Parkway ADDRE : P.O. Box 23790 _ INSURER(S)AFFORDING COVERAGE NAN:t Louisville, KY 40223 _ INSURERA: Safety National Casualty Corporation 15105 INSURED INSURER S: T Webber Service Corporation - T. Webber Plumbing, LLC INSURERC: INSURER D. 3365 Route 9 - Cold Spring NY 10516 INSURERE: - INSURER F: COVERAGES CERTIFICATE NUMBER: 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. LTRR TYPE OF INSURANCE ��SUBR POLICPOLICY NUMBER MW/DY EFF MWDD EXP LIMA A X COMMERCIAL GENERAL LIABILITY X X GL6676140 12/31/2021 12/31/2022 EACH OCCURRENCE $2,000,000 CLAIMS-MADE X OCCUR AGE REN ED 100,000 �_i PREMISES Ea occurrence $ MED EXP(Any one person) $5,0 0 0 PERSONAL&ADV INJURY $2,000,000 GEN'L AGGREGATE LIMIT AP PLIES PER: GENERAL AGGREGATE $4,000,000 POLICY❑JET LOC PRODUCTS-COMP/OPAGG $4 r 000,000 OTHER: $ A AUTOMoenELIABILITY X X CA6676139 12/31/2021 12/31/2022 COMBINED SINGLE LIMIT $2,000,000 Ea accident X ANY AUTO BODILY INJURY(Per person) E ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS ) HIRED AUTOS AUSNON-OWNED Pt.OPE DAMAGE $ S UMBRELLA LUB OCCUR EACH OCCURRENCE $ EXCESS IJAS CLAIMS-MADE AGGREGATE $ DED I RETENTION S $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY Y/N STA T E ER ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? ❑ N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) CERTIFICATE HOLDER CANCELLATION Village of Rye Brook SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 98 King Street ACCORDANCE WITH THE POLICY PROVISIONS. Rye Brook NY 10573 AUTHORIZED 1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD "�" Workers' S APX Compensation CERTIFICATE OF Boalrd NYS WORKERS' COMPENSATION INSURANCE COVERAGE 1 a. Legal Name&address of Insured(use street address only) I b.Business Telephone Number of Insured 845-809-0064 T Webber Service Corporation 3365 US 9 1 c.NYS Unemployment Insurance Employer Registration Number of Cold Spring, NY 10516 Insured Work Location of insured(Only required if coverage is specifically 1 d.Federal Employer Identification Number of insured or Social Security limited to certain locations in New York State, i.e. a Wrap-Up Policy) Number 85-3689722 2.Name and Address of the Entity Requesting Proof of Coverage 3a. Name of Insurance Carrier (Entity Being Listed as the Certificate Holder) Safety National Casualty Corporation Village of Rye Brook 98 King Street Rye Brook, NY 10573 3b.Policy Number of entity listed in box"la" LDS4066109 3c. Policy effective period 12/31/2021 to 12/31/2022 3d. The Proprietor,Partners or Executive Officers are x included. (Only check box if all partners/officers 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"ta"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 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: Seth A. Smith (Print name of authorized representative or licensed agent of insurance carrier) Approved by: 12/3 0/2 0 21 (Signature) (Date) Title: Executive Vice President Underwriting Telephone Number of authorized representative or licensed agent of insurance carrier: 1-888-995-5300 Please Note: Only insurance carriers and their licensed agents are authorized to issue the C-105.2 form. Insurance brokers are NOT authorized to issue it. C-105.2(9-IT) www.wcb.ny.gov Workers' Compensation Law Section 57. Restriction on issue of permits and the entering into contracts unless compensation is secured. l. The head of a state or municipal department,board,commission or office authorized or required by law to issue any permit for or in connection with any work involving the employment of employees in a hazardous employment defined by this chapter,and notwithstanding any general or special statute requiring or authorizing the issue of such permits,shall not issue such permit unless proof duly subscribed by an insurance carrier is produced in a form satisfactory to the chair,that compensation for all employees has been secured as provided by this chapter. Nothing herein, however,shall be construed as creating any liability on the part of such state or municipal department,board, commission or office to pay any compensation to any such employee if so employed. 2. The head of a state or municipal department,board,commission or office authorized or required by law to enter into any contract for or in connection with any work involving the employment of employees in a hazardous employment defined by this chapter,notwithstanding any general or special statute requiring or authorizing any such contract,shall not enter into any such contract unless proof duly subscribed by an insurance carrier is produced in a form satisfactory to the chair,that compensation for all employees has been secured as provided by this chapter. C-105.2(9-17)Reverse