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HomeMy WebLinkAboutMP24-152 �.C�Gy JJJy 190 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.Qov TRUSTEES BUILDING& FIRE INSPECTOR Susan R. Epstein Steven E. Fews David M. Heiser Donald T. Krom,Jr. Salvatore W. Morlino CERTIFICATE OF COMPLIANCE July 17,2025 William Stamm&Irene Stamm 124 Brush Hollow Crescent Rye Brook,New York 10573 Re: 124 Brush Hollow Crescent, Rye Brook,New York 10573 Parcel ID#: 129.76-1-136 This document certifies that the work done under Mechanical Permit#24-152 issued on 11/14/2024 for the installation of an above-ground oil tank has been satisfactorily completed. Sincerely, Steven E. Fews Building&Fire Inspector /to BUT D' N-GD.uljA.'.I0.'lMENT Pik 01-711A1IN44 INSPECTOR V*11,1,.A.G.V, 01! RYE BitoOK 938 KING SIRE-11T-ItYli-BROOK,NY.10573 (91.4) 939-0668 F'AX (914) 939-5801 - - INSPEC.'r.10N REPORT - - - - - - - - - - - - - - - - - - - - - ADDimss BLOCK:—.- LOT: OCCUPANCY: ❑ L VIOLATION NOTED lux WOItiC is... REJECTE'D/REINSPE'CTION 11 ST'VE INNII.WITION RL.-QUIRED 11 V'oO,.I.j.N(4 1:1 1'001-ING 'UN"141tGROTTKO PLIMUING ONINSUCHON: 0 ROUGH l'TIJM)t)Ti(. 1:1 RoMill-FRAMING I'l INSITTATION D FINAll Clams co".. .Itc-noT.4 OTI.I.Mit .___._. . ._ _ ` �v 4-. . -- 4 ��•� � ___ ... F� .__ �-'� r+ . ���' ,, i - I� i r 1 r 1 f� � �f �-.. �II � l, '� _ � -- ... _`. �' �- �\�\ �W-iE Mcui-• •Fb '982 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 : ' L� 1� �� _• ' 1�L7 L UU �A DATE: I - 15 Z O PERMIT# 1 ' 1 P Z 1 I J L- ISSUED:_' "Z "'SECT: L 7 L, BLOCK: LOT: /36 LOCATION: ✓� "I CGA `� -` OCCUPANCY: ❑ VIOLATION NOTED THE WORK IS... [LI ACCEPTED ❑ REJECTED/ REINSPECTION ❑ SITE INSPECTION REQUIRED ❑ FOOTING ❑ FOOTING DRAINAGE ❑ FOUNDATION ❑ UNDERGROUND PLUMBING NOTES ON INSPECTION: ❑ ROUGH PLUMBING ❑ ROUGH FRAMING ❑ INSULATION ; ❑ NATURAL GAS T!Nj 6 o �e ❑ L.P. GAS 20 u 'o FUEL TANK ❑ FIRE SPRINKLER ❑ FINAL PLUMBING ❑ CROSS CONNECTION /n� ❑ FINAL /`f Gtil U G, (���� A ❑ OTHER A D a �{ I 1 i � I f ' I I oft JIM h r ' law • T ' r , a s m LO _ � N N N N v N i a 0 W �"+ r°n W a � t � W by cn x g g a bI5 vi 0.3 'O r. a o " Qj ■ �G p r"� r� w O �, d o o � � o QI a (T1 ( h �•+ N W w F oq ed Gd T4 �./ p L p r 1 .�-� H h r y ca p. w A Q ,noo cn 3 vw O U E i P�" � QW W j. o ata© 00 14 H � Q V 2 C) t o H p v • �a E" O ZImw v _ i BUILDING DEPARTMENT VIL�VGE OF RYE BROOK 14 938 KING STREET RYE BRO0K,NY 10573 NOV2024 VILLAGE OF RYE_ BROOK r -fro i ov gal_III-i yli'•i^ DEPARTNIENT Application for Permit to Install Fuel Stora;!e Tank (*Storage Tanks in excess of 1,100 gallons require registration with the County of Westchester) FOR OFFICE USE ONLY: PERMIT#: Approval Date: N Permit Fee: $ / Approval Signature: Other: Disapproved: (Pecs are non-refundable) DO NOT START WORK or CONSTRUCTION UNTIL A PERMIT HAS BEEN ISSUED BY THE BUILDING INSPECTOR.THE ADMINISTRATIVE FEE FOR WORK PROGRESSED OR COMPLETED WITHOUT A PERMIT IS 12%OF THE TOTAL COST OF CONSTRUCTION WITH A MINIMUM FEE OF$750.00 REQUIREMENTS FOR RELEASE OF PERMIT&CERTIFICATE OF COMPLIANCE: I.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: Installation: $185.00 per Tank. 5. Dig Safely New York#(dial 811): 6.Inspection by Building Department for installation. 7. Submit all Manifests&Reports(if applicable,after work has been completed). 8.Certificate of Compliance will be provided when all requirements are fulfilled. Application dated, 10/24/2024 ,is hereby made to the Building Inspector of the Village of Rye Brook for a permit to install a Fuel Tank as herein described.The applicant and property owner,by signing this document agree that the subject fuel tank(s) will be installed in conformance with all applicable Village,County,State&Federal laws,codes,rules and regulations. Indicate Permit Type: Above Ground(X)-Buried in Ground( ) I. Address: 124 BRUSH HOLLOW CRESENT SBL: A) , 76—/ /3&zone: IOU6 2. Property Owner&Address: IRENE STAMM 124 BRUSH HOLLOW CRESENT RYE BROOK NY 10573 Phone#: 914-261-8396 Cell#: email: 3. Contractor&Address: HUDSON VALLEY PETROLEUM&ENVIR PO BOX 364 YORKTOWN HEIGHTS NY 10598 Phone#: 914-302-2320 Cell#: email:OFFICE@HUDSONVALLEYFUELOIL.COM 4. Applicant: DONALD DESANDRE-OWNER/PRESIDENT HUDSON VALLEY PETROLEUM&ENVIRONMENTAL CORP. Phone#: 914-302-2320 Cell#: email: OFFICE@HUDSONVALLEYFUELOIL.COM 5. Indicate Fuel Type:Fuel Oil 0(,)•L.P.Gas( )•Gasoline( )•Other( ): 6. Number and Capacity of each Tank: 1-ROTH DWT 1000L 275 GALLON ABOVE GROUND FUEL OIL STORAGE TANK 7. Exact Location(s)of each Tank: REAR OF HOME ON A 4-INCH CONCRETE PAD AGAINST SHED 6/1/2024 STATE OF NEW YORY,COUNTY OF WESTCHESTER ) as: 0©NALn nFRANURE ,being duty 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 Tank Installation Contractor 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. \ Sworn to be rc Me this � �� <, Sworn to before me this day of 20 �`� day o ,202.4 i � r G ,.=.-- Signature of Property Owner Sig Lure of Applicant / Print Name of Property Owner P--bt Name of Applicant ,4�`� (� L 1r E C sirs Notary Public N Pub c' : F o Fq o,L'. fit/ 264L!F0�9i 0 'U rcHESS�ED 1N This application must be properly completed in its entirety and must include the notarized N cofV1} 06125 Za x COU P. signature(s)of the legal owuer(s)of the subject property, and the applicant of record in.the spaces��=.,AVs 2 t provided Any application not properly completed in its entirety an&or not properly signed Shall b��,� ....... y© ,• deemed null and void and will be returned to the applicant. ���,,! 2 b/1/2024 a� c a� ' T L_ d) « C O a � m � - - - O U •Q ' + L M _... e- J to Co (j J G s Nr-- U 0 ° � co � � N c cY O N O `'= s s U �? C .`O. .`O. LL cn 0 0 C Z N ti � Q L ` o o 0 m M r U) a .o .� �' z E _z' ca o = Cf) O L . Z O. M -O j Y C 4-4 J � 0. fQ 7 � � .I--_. - - •1� f O d m F- c0 N CO oi pCL O Z O Cc c a r N V - - - v� mwF-- ca mN 'D Y Y .Y Y 'D C - ---- - C C C C C O n/ 0 F- F- F- F- 2 V c W _ LL J 60 N ch Rt lf> F- LL M c N z co T t0 ❑ �'.. aj{O M r i The Arbors Homeowners' Association 173 1/2 Ivy Hill Crescent Rye Brook, NY 10573 October 18, 2024 I NOV 14 2024 Irene & William Stamm V'` 124 Brush Hollow Crescent R� --- — Rye Brook, NY 10573 Re: Above Ground Oil Tank Dear Irene and Bill The Architecture and Grounds Committee (A&G) and the Board has reviewed your application for the above-named work The approval requires that you screen off or paint your tank. The paint color would match the house color. This project requires a permit from The Village of Rye Brook. You are approved to get a permit from the Village of Rye Brook. You are directed to submit this letter to the Village along with your permit application. Once the permit is obtained, a copy must be provided to A&G. Work on the project may not begin until you receive written notice of receipt of your permit from A&G. If any changes are made to the original plans submitted to A&G, due to input from the Village or arising during construction, the Committee must be notified in writing. Work cannot proceed until you receive written approval for those changes. Failure to comply with these procedures will result in fines and/or work stoppage. If you have any questions, please contact me at. Property Manager. Sincerely, Nicholas Salzarulo Property Manager _ __�__ ___ Ys �� __ .y,. �hr.� i .:l ���1 ��J �r ��r ��� ��1 ��� �, �� �� e �y��..� �' - 7�,Y2 LL y, — —_ _ ._ .:� __ l ••• �� �F !` u I t I, i i ! i I L� 3 T � fJ 1 Co i i T� FEB - 7 2025 Hudson Valley Petroleum 4T ILLAGE OF RYE BROOK BUILDING DEPARTh.4ENT Environmental Corp. DBA /Tanksoilutions Wehsite: www.tanksollutions.com Email: ofrce(atanksoilutions.com PO BOX 364 Westchester License WC-33112-H2O Yorktown Heights,NY 10598 Putnam License #794-12 914-352-0500 (office) Yonkers License #7963 914-980-9513 (cell) Yonkers Fire Dept. #5960 New Rochelle License #22-102 Mi. Vernon Fire Dept #8811 City of Poughkeepsie # 193 City Of Rye #23-OHE-01 NYSDEC Waste Hauler #3A-1350 US-EPA NYR000266924 February 3, 2025 Irene Stamm 124 Brush Hollow Cresent Rye Brook,NY 10573 914-261-8396 Irenebi ll7 l O@gmail.com Permit#MP 24-151 and#MP 24-152 Dear Ms. Stamm, We have completed the removal of your 330-gallon underground fuel oil storage tank from under the rear deck of the home. All waste oil and tank bottoms were transferred to Waterworks, 77 Stewart Ave, Newburgh, NY 12550 and the oil tank that was removed was recycled at Expressway Recycling, Cold Springs, NY. Our visual inspection showed no perforations or leaks of the tank. We also installed a Roth DWT 10001, 275-gallon tank at the rear of home against the shed. erely, Donald DeJ 4M�2' NON-HAZARDOUS WASTE MANIFEST Please print or type (Form des,gned Ior use on able(12 pilch)typewriter) NON-HAZARDOUS 1 Generator's US EPA In rl' _ Manifest 2 Page i WASTE MANIFEST CESQG Nc77 0_;', of 3 Generator's Name and MailirV Address 121j ru sh t-�c;���w CfeSCen�- 4 Generators Pno w I, ) � � 10 '�73 5 Transporter 1 Company Name 6 US EPA ID Number A State Tfansurter's ID 3A-1350 TANK SOILUTIONS i NYR000266924 a Transporter t Phone 914-352-0500 7 Transporter 2 Company Name 6. US EPA ID Number C.Stale Transporters ID D Transporter 2 Phone 9 Designated Facility Name and Site Address 10 US EPA 10 NurnDer F State Facility's ID WATER WORKS 3-3346-00020/00003 77 STEWART AVENUE NYR000236349 F Facility's Phone NEWBURGH, NY 12550 845-803-1519 11.WASTE DESCRIPTION 12 Containers 13. 14. Total Unit No Type Oisfitlly WllVol. a PETROLEUM CONTAMINATED OILY WATER AND SLUDGE. NOT REGULATED. NOT US DOT HAZARDOUS MATERIAL. N/A, NONE, 001 DM ,-'1 G NONE CJ G b E N E R c A T O R d W I— N QG Addknnai Descriptions for Materials listed Above Fi Handling Codes for Wastes Listed Above N 0 0 Q Q '5 Special Hardling Instructions aid Additional Information Z 0 Z -AIIIIIIIIIIIIff-i AV AV A 16 GENERATOR'S CERTIFlCATION:I Mreby Certify alai me COntNtts of thls sMPment are fully and acwraleiy described and are M all respects in prope,-ndition br transport The matedals described on this manifest am ro'subtec'to federal hazardous waste ierfulat ons Data PnnledTyped Name Siynaluie Monfh Uay yYar Donald DeSandre For Generator Above ( 1 a TR 17 Transporter 1 Acknowtedgement of Receipt M htatenals Data A P,mted'ryped(dame Signatwe Month Day 1fler s Ryan Connolly 4 P b 16 Transporie,2 Acknowledgement of Receipt of Materials Date R PnntedT d Namc Signature E YPr Month Day leer R F 19 Discrep 3n1;7 indication Space A C L20 Facility OWner or Operator.Cend!cation of receipt of the waste materials covered by this malfesl.except as noted in item 19. I Date T PnhtedTyped Names Signature Monti DM, year Y PAYMENT RECEIPT E PRESSWAY M 845-809-5633 �� d 3455 RT 9 Cold Spring N.Y. eceipt: 133909 Date:1/21/2025 comer:100729 Time:2:12.31 PM *Solutions VIN MCGEE FIELDSTONE LN )RTLANDT MNR, NY 10567 Number. 762006793 Ticket: 136710 BOL:PO: )perator.Admin Ref: Veigh In: 1212025 2:09'.24 PM Sigh Out: 121/2025 2:12:12 PM AY welg"ts We'n pounds UNess otherwise noted Gross Tare Net Price TOTAL$ nmodity 336.30 Steel!Prep 38,360 34,820 3.540 0.09501LB ---�338-30 ---------------------- Tlckat Total: No.of Tickets:I ayment Method:Cash Total Paid: g338.30 nereby state that I'm the lawful owner of the fad ved ies described ll heron, that I ave a right to sell same and that for o me to: dviowledged,I sell and convey :)qresway Recycling Inc. f1>enk you for your business,Expresway Recydng,Inc. �E BR�� BUILDING DEPARTMENT ❑BUILDING INSPECTOR ASSISTANT BUILDING INSPECTOR VILLAGE OF RYE BROOK ❑CODE ENFORCEMFNT OFFICER 938 KING STREET • RYE BROOK, NY 10573 (914)939-0668 FAX (914) 939-5801 www.ryebrook.org - - - - - - - - - - - - - - - - - - - - INSPECTION REPORT - - - - - - - - - - - - - - - ----- ADDRESS:- I y �e ,AS�N l^+o L[ , DATE: I - PERMIT*ml l J` ISSUED: I-1'4-lSECT: lZZ_(. BLOCK: I LOT: /3( LOCATION: Zoc✓ �')o , OCCUPANCY: ❑ VIOI ATION NOTFD THE WORK IS... 0---ACCEPTED ❑ RE/ECTED/REINSPECTION Cl SITE INSPECTION REQUIRED ❑ FOOTING ❑ FOOTING DRAINAGE ❑ FOUNDATION ❑ UNDERGROUND PLUMBING NOTES ON INSPECTION: ❑ ROUGH PLUMBING ❑ ROUGH FRAMING ❑ INSULATION❑ NATURAL GAS 17" N04 ) x0o �� � 60 ✓ ❑ L.P. GAS ,FUEL TANK Cl FIRE SPRINKLER ❑ FINAL PLUMBING I� /5`-s L e q ,N [I CROSS CONNECTION � A (,� �V !J TLI Tz [3 FINAL ❑ OTHER WE- WILL i SS v-P Cv-n/6 e C G-- K N o •q U Li .� LLJ 1ti r • rt w z pl�Ct{OR od � �� w LLL w ~0-3 y�•� �'GQ J r� -J o t� 1 LU a w H O w o M z o aa �N ONO >- _ CLLLJ xOCl) .Y i� - % c ALeeCDORO® CERTIFICATE OF LIABILITY IN U RA N C E OATS(MM/pD/yyyy) THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NOR 07/192024 HTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER T COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETW EN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the poll:00s)must have DDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WgIVED,subject to the terms and conditions of the policy,certain polio es may require an endorsement A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s) PRODUCER Marshall&Sterling,Inc. NAME.CT Angel -- 110 Main Street PHONE 5 84 454 AIC No Ext ( 0800 AX (845 454-0880 aDRE : anacri marshalistening.com •No: ) ADDREAIL SS Poughkeepsie INSURER(S)AFFORDING COVERAGE INSURED NY 12601 Union Insurance Company NAM x INSURER A: 25844 Hudson Valley Petro;eum&Environmental Corp INSURER B: Aced Ins Company 31325 PO Box 364 INSURER C: Guide ne National Insurance Company 74167 INSURER D; Yorktown Heights INSURER E: COVERAGES NY 10598 CERTIFICATE NUMBER: CL2471968523tNsuRERF; THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE IJSTED BELOW HAVE BEEN ISSUED TO THE IN RED NAMED ABOVE FOR THE POLICY PERIOD REVISION NUMBER: INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CSSUE TO OR IN CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRI ED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID LAIDOCUMENT WITH RESPECT TO WHICH THIS INSR LTR TYPE OF INSURANCE D wV0 POLICY NUMBER OLI Y POL COMMERCIAL GENERAL LIABILITY MM/DO MMID LIMITS ©OCCUR EACH OCCURRENCE = 1,D00,000 A PREMI S oecurtence S 300,000 Y CPA551984612 MED EXP(Ary one person) $ 10.000 GEML AGGREGATE LIMIT APPLIES PER. 07/20/202 0720/2025 PERSONALAADVINJURY s 1,000,000 POLICY ©JJEEC lOC GENERAL AGGREGATE s 2,000,000 OTHER. PRODUCTS-C(WP/OP AGG $ 2,000,000 AUTOMOBILE LIABILITY Employee Benefits S 2.000,000 ANYAUTO EO�cBI�NeDISIN ELIMI7 S 1,000,000 A OWNED SCHEDLLED BODILY INJURY(Per parson) s AUTOS OILY AUTOS CAA551984712 HIRED AUTOS ONLY NON-OWNED 07/20/2024 07/20/2025 BODILY INJURY(Per acadent) s AUTOS ONLY PRO ERTY DAMAGE (Perapcident) S X UMBRELLA LIAB s OCCU BR EXCESS LIAB CWMSMADE CUA551984812 EACH OCCURRENCE $ 5.000,000 DED RETENTIONS 10,000 07/20/2024 07/20/2025 AGGREGATE $ 5.000,000 WORKERS COMPENSATION AND EMPLOYERS LIABILITY $ ANY PROPRIETOR/PARTNERIEXECUTIVE YIN R TH- OFFICER/MEMBER EXCLUDED? ❑ NIA STATUTE ER (Mandatory In NN) E.L.EACH ACCIDENT If y .da�cnba under s DESCRIPTION OF OPERATIONS below E.L.DISEASE-EA EMPLOYEE t C Pollution E.L DISEASE-POLICY LIMIT $ Pollution Liability Per OCc $1,000,000 ENV56201104302 07/202024 07/20/2025 Pollution Liability $2,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES(ACORD lei,Addnlonal Remarks Schedule. C.Onlractors Professional $2,000,D00 Village Of Rye Brook is an additional Insured if required by written contract `"�be attached If more ce Is roQuwed) See page 3 of Certificate Of Insurance for applicable forms based on the coverage reflected above CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF E ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Village Of Rye Brook THE EXPIRATION ATE THEREOF,NOTICE WILL BE DELIVERED IN 938 ling Street ACCORDANCE WI H THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE Rye Brook NY 10573 { ACORD 25(2016103) The ACORD name and logo are registered marks f ACORD I5 ACORD CORPORATION. All rights reserved. NYSIF New York state Insuranco Fund PO Box 66699,Albany,NY 12206 I nysff.com CERTIFICATE OF WORKERS' COMPENSATION INSURANCE n A A A A A 421749379 FRIEDLANDER GROUP,INC. 2500 WESTCHESTER AVE-#400A PURCHASE NY 10577 a. v SCAN TO VALIDATE AND SUBSCRIBE FHUDSON LICYHOLDER VALLEY PETROLEUMCERTIFICATE HOLDER ENVIRONMENTAL CORP VILLAGE OF RYE BROOK O BOX 364 938 KING STREET RKTOWN HGTS NY 10598 RYE BROOK NY 10573 POLICY NUMBER CERTIFICATE NUMBER G 2574 766-8 794798 POLICY PERIOD DATE 07/01/2024 TO 07/01/2025 07/08/2024 THIS IS TO CERTIFY THAT THE POLICYHOLDER NAMED ABOVE IS INSURED WITH THE NEW YORK STATE INSURANCE FUND UNDER POLICY NO. 2574 766-8, COVERING THE ENTIRE OBLIGATION OF THIS POLICYHOLDER FOR WORKERS' COMPENSATION UNDER THE NEW YORK WORKERS'COMPENSATION LAW WITH RESPECT TO ALL OPERATIONS IN THE STATE OF NEW YORK,EXCEPT AS INDICATED BELOW. IF YOU WISH TO RECEIVE NOTIFICATIONS REGARDING SAID POLICY, INCLUDING ANY NOTIFICATION OF CANCELLATIONS, OR TO VALIDATE THIS CERTIFICATE, VISIT OUR WEBSITE AT HTTPS:17WWW.NYSIF.COM/CERT/ CERTVALASP. THE NEW YORK STATE INSURANCE FUND IS NOT LIABLE IN NOTIFICATIONS. THE EVENT OF FAILURE TO GIVE SUCH THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS NOR INSURANCE COVERAGE UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICY. NEW YORK STATE INSURANCE FUND VALIDATION NUMBER: 918032693 DIRECTOR,I SURANCE FUND UNDERWRITING iq I„'�0000000000=21397gg„1" Form WC-CERT-NOPAINT VenioO l(OV29l2019)[WC Polity-257476681 (0000000000011919/9E21[0001-00002574756g](o/G1(16425-0S)IC"OGLERT_ll(01-00001] U-26.3