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HomeMy WebLinkAboutMP24-118 Qy t4�4P V JJ J (to VILLAGE OF RYE BROOK MAYOR 938 King Street, Rye Brook,N.Y. 10573 ADMINISTRATOR Jason A. Klein (914)939-0668 Christopher J.Bradbury www.tyebrookny.gov TRUSTEES BUILDING & FIRE INSPECTOR Susan R.Epstein Steven E. Fews Stephanie J. Fischer David M.Heiser Salvatore W.Morlino CERTIFICATE OF COMPLIANCE October 3,2024 Christopher Lee&Annie Ma 40 Hillandale Road Rye Brook,New York 10573 Re: 40 Hillandale Road,Rye Brook,New York 10573 Parcel ID#: 130.77-1-5 This document certifies that the work done under Mechanical Permit #24-118 issued on 9/19/2024 for the removal of an underground propane tank and the installation of a new underground propane tank has been satisfactorily completed. Sincerely, Steven E. Fews Building&Fire Inspector /to QyE BRC�k• cu � 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 :- lJ -I i L L P% : A L F DATE: PERMIT# ` ` 2_ S Z" ISSUED: 'ZS- 7.SECT: BLOCK: LOT: LOCATION: I Cam C� 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 �E BRC��, 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.orss - - - - - - - - - - - - - - - - - - - - INSPECTION REPORT - - - - - - - - - - - - - - - - - - - - ADDRESS : LI O H I L L N-\Z P� L-F J? 0 A '> DATE: - PERMIT# /! b r L �1- ISSUED: 9-19- LI SECT: /39' 7'7 BLOCK: LOT: S LOCATION: 15'a V `r T S I �� ' 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 k ❑ FIRE SPRINKLER ❑ FINAL PLUMBING ❑ CROSS CONNECTION ❑ FINAL ❑ OTHER ASSl . �E BRC�uk o`` tim 1932 BUILDING DEPARTMENT ❑BUILDING INSPECTOR Er�1SSISTANT 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 : O 1-1 t LA fy -,�>A 1 DATE: ! 9.3" Z 02 PERMIT# m P a y- / I [} ISSUED: /- /7"Z SECT:,/50-2) BLOCK: / LOT: LOCATION: j"ied NT L FK T S / C. e ! lqz % 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 r ❑ NATURAL GAS `f l A L L E I F A L Z p't.P. GAS 7'� 70 ❑ FUEL TANK ❑ FIRE SPRINKLER ❑ FINAL PLUMBING ❑ CROSS CONNECTION 3 U 2 6 F1 ER v Pit¢S.ScQ ❑ FINAL 1- t (� i ❑ OTHER :a �f e. A „ M fig.�• r�. ,.Ap�t.. to • i''i A J�ti I 1, Y •'Y .dv �;� tU:� r..•� �••�• t 4`�T' ♦• ram'�►• r.�hti. ��,��a�tiJ•w "�'_S, ��_.+'LILT ,`•�':'. . .. .. .t r � .,+�gip;,�?t,.t�,r�y�• _,_..- I Y �• ' Ilk' y�_. = N N fq C o. hl N Ln ev W � A W a� � � R. i••i = U a w W W .0 w w Q) - _ 2 �0 0 v b O �J Q H Q o a4j Q m - 0-4 LO cn © W Ln O Z Q w oc _ E 0 C� W � `n O z Q " � ° � � U - d A 1-4 c - V = im CA H x o v� z zo � a vw w wPC; O v V C F Ow Q ZO O M r. x v u �• W 1.4 �I oa a a 04. w x � v 41 �11 BUIL 1 16 ��'MENT 0 VIL �' .E:aF Iz.Y OOK RSEP 1 7 2024 938 KING ET RYkB.R NY 10573 VILLAGE OF RYE BROOK (914)9 6 2 39-5801 BUILDING DEPARTMENT W" o or Application for Permit to Remove, Abandon and/or Install Fuel Storage Tank (*Storage Tanks in excess of 1,100 gallons require registration with the County of Westchester) FOR OFFICE USE ONLY: PERMIT It: Approval Date: SEP Permit Fee:$ / +v Approval Signature: Other: Disapproved: ti (fees are non-rerundable) 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 If C 105.2 or Form # U26.3 1 or NY State Workers Compensation Waiver) 4. Fee per Tank: Removal, Abandonment, or Installation: $185.00 per Tank. 5. Dig Safely New York #(dial 81 1): 6. Inspection by Building Department for removal/abandonment and/or installation. 7. Submit all Manifests& Reports(after work has been completed). S. Certificate of Compliance will be provided when all requirements are fulfilled. Application dated, is hereby made to the Building Inspector of the Village of Ryc Brook for a perniit to remove,abandon,and/or install a Fuel Tank as herein described.The applicant and property owner,by signing this document agree that the subject fuel lank(s)will be removed,abandoned and/or installed in conformance with all applicable Village,County, State& Federal laws,codes,rules and regulations. ******#**###d**ia.a.+r#*i.***#****########Nw►rr****##�ii##*1F**#*****i.#h*f1.Ir##*i#ir#*#*ie##*####*###*#**#*#### Indicate Permit Tyne: Installation (1/�• Removal(% • Abandonment( )/Above Ground ( )• Buried in Ground (V) 1. Address: y o �.,-�� q�,� C SBL: /,3Q; 7 7—�— _"Lone: 2. Property Owner&Address: k6le Mp. - 4D Wt1LQja q1?- lRtaA• tZYe L ,INY 105-13 Phone#:=593 - 51S5 Cell#: email: V16f—(1)t1_9T5PRt17A.11•CQM 3. Contractor&Address: Stibudogn ,fopue-- 25 Kin S1Co bnsi - MOun--ki C0- q_ Phone#: --bleb ` Cell#:_ email: e 4. Applicant: Phone#: WU Cell k: email: 5. Indicate Fuel Type: Fuel Oil{ )►L.P.Gas NJ•Gasoline( )•Other 6. Number and Capacity of each Tank; 7. Exact Location(s)of each Tank; e gjbm� r 1 6/1!2020 WTE OF NEW YORK,COUNTY OF WESTCHESTER ) as: n'n \e f11 C\" ,being duly sworn,deposes and states that he/she is the applicant above named, (print name of individual signing as the applicant) and krther states that(s)l}e4s the legal owner of the property to which this application pertains,or that(s)he is the e �']��(- _`C�,G�A(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 arc 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. q� Sworn to before me this Sworn to before me this day of�, ^'1—'-,Cr 20� day of S' ,20 2q Si a ure of Property Owner ure of Applicant gent Name of Property Owner Print Flame of Applicant � •� �1nP11+iEB � � 1110"yVIIIIIIIII State of New York Notary Publit; DAVID C SLOAN No.OIME6160063 Notary Public-State of New York Qualified In Westchester County NO.OISL6318303 Qualified in Putnam County CorrinnIssion Expires January 29,2 /� My Commission Expires Feb 28, 2027 This application must be properly completed in its entirety and must includC the r of'tlic legal owner(s) of the subject property, and the applicant of record in thespaces.-provided. Any application not properly completed in its entirety and/or not properly signed shall be deemed null and void and Neill be returned to the applicant, 2 6/l/2020 wr t2 jitgar, co it Ir uj CL 0 LL U-1 IL iL < 0 au, 01 0�11 ",V.4� 20 40 FOR ME PuRposEs()NLy SURVEYED CRTTIOROUG'OPEU—S-VIOES.UL ORIGINAL SCALE: 1' = 20' MO DrLy ION Tilt PERSONS ION MOM 11 i NOT'�.FOR Wr OnR]i PURPOSM DR FOR AWOIlL 0-lt MAP OF PROPERTY SMATED AT VILLAGE OF RYE BROOK—VVESTCHESTER COUNTY,N.Y. TOWN OF RYE TAX SECTION:130 77 TAX BLOCK-1 TAX LOT:5 Qp is go os oJ-1 IAIM 25cC4C-4 '05 Y44 G -011 cn =WC7. pko P. 7 WEW MCM .Ox9cvfm Nr FTNLr N 87*57'45* W 23.00' DATE DESCRIPTION kvTESj 71"L'w UUMV, PE;60N FOR VM THE 9JRWY 6 PRVAkM AW,ON In 80 F r'T"L AW 0 aAwm)R ca-FcAncws mDrATED HV"h swi inm O�V Im Tic truMic WpuTok.011WAtMES OR CTWW, -Al OW AK Wn MAY AMNY AHO LDow,w,-TMMN Lt5TrD ICIEW AMD TO rrIE ASN�OF CQ UASMAK O*M015 F1111WITY CC46"UO"ENTS Wff NOI MACEM AS IAr.OF N5 SAWY. OR AWMOH TO TM SLRAY IS A WAARU(x'SECTION 7209 W M W-4'A We STATE WVrAMN W. SM"".j_TIE AWWAM&TWA of jJ46 SURWY"RKM WrIll AN WANK 0:ME L"PlMt'(W5"TT,SEK Oil ME ELMM0 I.my DOPES FROM THE Oww''a.'cs -UO IF AN k��71IACr OF!IME!S illft?f—FD'0 9k:5`,RyLyDR 6310M OF REPRO%<GWY ae*M LALSA LAND SURVEYIN PLLC GUARANTEED TO: '-'f-,,)FLSSl0NhL LAND SURVEYOR. TH.r'HOUGHGRC') VI-f SERVICES, LLFL, LICENSE No. 050936 14 2 RADVN TITLE INSURANCE INC, 112-24 93rd AV04K. 'MBANK NA 'A"CA. N.Y, 114,i3 V0 CHRIST OPHFR LEE _WW"HONE (917)W 7)" 4 ANNIE MA ANC "t rt)i rmm &. SEIFF ot 1 1x 17 C C IV h e o a2 aqq it 4 m CD 2 cu ; rV if lu to l4r3 to W � CA -► A io O � E 06 No N O \L.1 N Q to t.i C� \i 4 � N. > t a c = F G io io g 1ovSwti ai rod, : Is ° r-- ': O c i� ice► v in in �o . t r I � r _ _ .P. LZ 1-4 O� (10 GO iY -LYi. tl ~ c p of L fi a °D oNo v v r�i rn }�� d W O C'1 in J S N r= 00 N N M 0o .--i .� 3 C aVa$ O C iY v OD � � ip Vl N 10=Lz L w w w .1 tD N Q N M b j E' 0 O �-TRC Q N � '•~ C � vJ .lS O O O O v a�4 y C. CO V O ly LL �f u P ri N v to A Vi r_ v�i�it a 44 v ,•_ N in O w 2 x LI- v a1 - s s c o a N N N fN � w z Ulj cn c A W = as s a i.r H , = O z s FBI WP � 00 ►- O M. 0 ►-� ■ Z W I Z CN _ ace wc p Z J V z ix u w O W Z c can ocon o z x �, f BUIL; F ENT E, WE VtL , OF JOK SEP 2 5:2024 938 KIN iTRFm R 'FBRNY10573 ] DDD(914) 939-06f 8,," VILLAGE OF RYE BROOK %k%IV\VANC.h1'Q_qk:ny.gov BUILDING DEPARTMENT PLUMBING PERMIT APPLICATION FOR OFFICE USE ONLY PP#: C; Approval Date: Permit Fee: $ Approval Signature: a�\I jRJ J*(-r LION Disapproved: (fees are non-refundable) 10) NO T START NkORK or CONI I-ION UNTIL A PERMIT HAS BEEN ISSUED BY THE, BUILDING INSPECTOR.THE ADMINISTRATIVE'FEE FOR WORK PROGRESSED OR COMPLETED N41THOUT A PERMIT IS 120,,(, OF THE TOTAL COST OF CONSTRUCTION 11 ITH A MINIMUM FEE OF$750.00 Applicatirin dated, 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:-40 SBL: 130.-7 7 Zone: 2.Proposed Work: ftMy- ON 3.Property Owner: NK&AVhU_ LtL Address: L40 Phone#: Cell#: email:_UMOJAV� 14t-a aowt4 teof 4.Master Plumber: IXi L U"S Address: Lic. #: Phone ;5 Cell#: q1 4 't" I N+L'f email: r 1p fj� PVIV�-Company Name: Address: INDICATE FIXTURES& LINES TO BE 1 NSTALLED AS PER THE FOLLOWING SCHEDULE: F Location Water Urinals Drinking Sinks Showers Bath LaUlidi-v Domestic Fire Sanitary Natural/ Other* Total Closets Fountains Tubs Tubs Service Service Sewer LP Gas Basement I M Floor 2iid Floor I____ - _ I 3"Floor L4"Floor Floor ---------_ Ext crior 5.*List Other Equipment/Provide Details: We4v kti�S Ch AIRC-W /114f, (Notarized Signatures Required Next 2 Pages) STATE OF NEW YORK,COUNTY OF WESTCHESTER ) as: _1``At V� L JWS ,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 Master Plumber for the legal owner and is duly authorized to make and file this application. 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. ;k- Sworn to before me this 1'S Sworn to before me this J 4� day of �'�ct�,bp,- ,20 Q(-t day of . 20 Signature of Property Owner Signature of App Print Name of Property Owner Print Name of Applicant Ac�llh &-Yzza- $74"A&--2�!(�) -t-C) ota u lie Ufa DCbe* Wotary Public - GREG RY M.RNERA Nd ry t ubYa,Stale of New York No"Public,State of New York Replstratlon No.01 D14819030 No.01 R16441398 Qualified In Westchester County . Qualified In Westchester County Camussim Expires 07/31/20 mis Comsion Expires September 26, 1 hi., application must be properly completed in its entire° , ,rid mu it include the notarized signature(s) of the legal owner(s) of the subject properly, and (lie 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. 6/1/2024 . BUILP1fi ERTMENT D VILE OF RY'�OOK 938 KING ET RYE BR raid,NY 10573 SEP 2 5 2024 �t«'s� �'��--`-"1` �•�°`' 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 YO//RK, COUNTY OF WESTCHESTER ) as: 31,_ ;S� ► a� C�Q , residing at, __40 Z j . N16111 n,,ntc} where <ou lixe) 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; --- 10 1 a^ �� �F �� . , Rye Brook, NY. 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. r,ii.un+c , I'i�,l>crty f?ti� Cr�ti)) il'nui ''.an. : I1'rr;it Ut.'n'r(stl Sworn to before me this 2 S clay of S�PI n, ,�Q� , 20Jm 'REGORY M.RNERA N*"ary Public,State of New York ivo.01 RI6441398 ,rud In Westchester County �nrrm.'sslvn FYNires September 26,2t1 6/t iznz4 �` : �. '�.�i; 11►�fl ,: '►'�i U� ��� u;���4i'.' 1 lJj xa �,.. f: ti 4�IH' �r, - ���-..Ni1'1',!':<..,. i..,1► �'-. L�`..�ua.;.:•=Y_--_ems N N c ... = y G n O O Oxl } a y c uis» CAPoo C �r^ tr >► .•zj i.i V r< G� r„•, Z w w o section �` LLJ � . ram' m `n o 04�• fn m X �° Z i = :� �� � Cr y J U � �, • 11 1�j� •�ta-^1JTa �I.f 1�.1 sai*.....� i_r'{11'�iiiT��it^I-�nl^•L ESQ-'^r. Ar 1.0 r ���r,�,1�1 si�'FIS i,'1� �11',1,'1' < 1 „ : .. rri .. „ s'ati;� ,a. Nr •.�1 � �1,•,•,1 . ltrr ti:':' 1 A r r � �g{•I.� _ 4� ��{�1;Dp`�'� �!�'' 1 iI ..i�/��5�. �vRF'." - ���!R vAiY ,�VM DATE(MMIDD/YYYY) ACCW? CERTIFICATE OF LIABILITY INSURANCE �� 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 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 MARSH USA,LLC NAME: PHOE FAX 445 SOUTH STREET (A/CNNo.Exti (A/C,No): MORRISTOWN,NJ 07960-6454 E-MAIL Attn:Momstown.CertRequest@marsh.com Fax:212.948.0979 ADDRESS:.__ _ INSURE S AFFORDING COVERAGE NAIC# SP LP CLIE INSURER A:Liberty Mutual Fire Insurance Company 23035 INSURED INSURER B:LM Insurance Corporation 33600 SUBURBAN PROPANE PARTNERS,L.P. 240 ROUTE 10 WEST INSURER C:N/A N/A WHIPPANY,NJ 07981 INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: NYC-009138921-46 REVISION NUMBER: 4 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 TYPE OF INSURANCE ADDL UBR POLICY EFF POLICY EXP LIMITS LTR POLICY NUMBER MM/DD/YYYY MM/DD/YYYY A X COMMERCIAL GENERAL LIABILITY TB2-631-507975-083 10/01/2023 10/01/2024 EACH OCCURRENCE $ 2,000,000 DAMAGE TO RENTED CLAIMS-MADE FxI OCCUR PREMISES Ea occurrence $ 250,000 MED EXP(Any one person) $ 10,000 PERSONAL&ADV INJURY $ 2.000,000 GEN'L AGGREGATE LIMIT APPLIES PER. GENERAL AGGREGATE $ 2,000,000 PRO X POLICY a ECT LOC PRODUCTS-COMP/OPAGG $ 2,000,000 OTHER $ A AUTOMOBILE LIABILITY AS2-631-507975-073 10/01/2023 10/01/2024 COMBINED SINGLE LIMIT $ 2,000,000 Ea accident X ANY AUTO BODILY INJURY(Per person) $ X OWNED X SCHEDULED AUTOS ONLY AUTOS BODILY INJURY(Per accident) $ X HIRED X NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY Per accident UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB HCLAIMS-MADE AGGREGATE $ DED 1 1 RETENTION$ $ B WORKERS COMPENSATION WA5-63D-507975-093(AOS) 7MTU=10I01/20 4 X PER OTH- AND EMPLOYERS'LIABILITY STATUTE ER B ANYPROPRIETOR/PARTNER/EXECUTIVE YIN WC5-631-507975-113(WI) 10/01/2023 10I01/2024 E.L.EACH ACCIDENT $ 1,000,000 OFFICER/MEMBER EXCLUDED? N NIA (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ 1,000.000 If es,describe under 1,000,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT E DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached If more space is required) VILLAGE OF RYEBROOK IS SHOWN AS AN ADDITIONAL INSURED SOLELY WITH RESPECT TO GENERAL LIABILITY COVERAGE AS SHOWN HEREIN AND SOLELY IN THE EVENT THIS STATUS IS REQUIRED BY WRITTEN CONTRACT BETWEEN SUBURBAN PROPANE,L.P.OR ITS SUBSIDIARIES OR AFFILIATES AND CERTIFICATE HOLDER, CERTIFICATE HOLDER CANCELLATION VILLAGE OF RYEBROOK SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE ATTN:BUILDING DEPARTMENT THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 938 KING STREET ACCORDANCE WITH THE POLICY PROVISIONS. RYEBROOK,NY 10573 AUTHORIZED REPRESENTATIVE ©1988-2016 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD Workers' PORK CERTIFICATE OF STATE Compensation Board NYS WORKERS' COMPENSATION INSURANCE COVERAGE 1 a.Legal Name&Address of Insured(use street address only) 1 b.Business Telephone Number of Insured Suburban Propane Partners, L.P. 973-887-0500 240 Route 10 West Whippany NJ 07981 1c.NYS Unemployment Insurance Employer Registration Number of Insured 892-18602 Work Location of Insured(Only required if coverage is specifically limited to 1d. Federal Employer Identification Number of Insured or Social Security certain locations in New York State,i.e.,a Wrap-Up Policy) Number 22-3410353 2.Name and Address of Entity Requesting Proof of Coverage 3a.Name of Insurance Carrier (Entity Being Listed as the Certificate Holder) LM Insurance Corporation Village of Rye Brook 3b.Policy Number of Entity Listed in Box"la" 938 King Street Rye Brook NY 10583 WA5-63D-507975-093 3c. Policy effective period 10/1/2023 to 10/1/2024 3d.The Proprietor,Partners or Executive Officers are Z 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 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: Susan Martinez-Dolman (Pri"----- -•- .`--'--''--------­ - --"-}}�� 'nsurancecarrier) Approved by: M J,-A//M4V 9/19/2023 (Signature) (Date) Title: Client Service Coordinator II Telephone Number of authorized representative or licensed agent of insurance carrier: 1-914-606-5181 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 76362852 1 3-507975 1 10/23-10/24 C105.2 I Marshall Johnson 1 9/19/2023 7:50:54 AM (CST) I Page 1 of 2 Laura Petersen From: UDig NY Exactix <tickets@exactix.udigny.org> Sent: Thursday, September 19, 2024 1:36 PM To: Steven Fews Subject: Message from UDig NY ****REGULAR**** DIG REQUEST from UDig NY for: VIL RYE BROOK Taken: 09/19/2024 13:36 To: VIL RYE BROOK PRIMARY Transmitted: 09/19/2024 13:36 00007 Ticket: 09194-001-536-00 Type: Regular Previous Ticket: ------------------------------------------------------------------------------ State: NY County: WESTCHESTER Place: RYE BROOK Addr: From: 40 To: Name: HILLANDALE RD Cross: From: To: Name: Offset: ------------------------------------------------------------------------------ Locate: RIGHT SIDE OF PROPERTY AS FACING NearSt: KING ST Means of Excavation: SHOVEL Blasting: N Site marked with white: N Boring/Directional Drilling: N Within 25ft of Edge of Road: Y Work Type: REMOVAL OF PROPANE TANK Estimated Work Complete Date: 09/24/2024 Depth of excavation: Site dimensions: Length 4 FEET Width 4 FEET Start Date and Time: 09/24/2024 00:00 Must Start By: 10/08/2024 ------------------------------------------------------------------------------ Contact Name: EVA PALMAFFY Company: SUBURBAN PROPANE, MOUNT KISCO Addrl: 25 KENSICO DRIVE Addr2: City: MOUNT KISCO State: NY Zip: 10549 Phone: 914-666-5174 Fax: Email: epalmaffy@suburbanpropane.com Field Contact: EVA PALMAFFY Alt Phone: 914-666-5174 Email: epalmaffy@suburbanpropane.com Working for: REMOVING A 500 GALLON PROPANE TANK ------------------------------------------------------------------------------ Comments: Lookup Type: PARCEL ------------------------------------------------------------------------------ Members: ALTICE USA CONED SUEZ WTR WESTCHESTER TEN GAS-HDS VLY VIL RYE BROOK WESTCHESTER CTY SWR 1