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HomeMy WebLinkAboutMP24-120 DRY c� . 19 O VILLAGE OF RYE BROOK MAYOR 938 King Street, Rye Brook,N.Y. 10573 ADMINISTRATOR Jason A. Klein (914) 939-0668 Christopher J.Bradbury -,A-ww.ryebrookny.gov TRUSTEES BUILDING& FIRE INSPECTOR Susan R. Epstein Steven E. Fews David M. Heiser Donald T. Krom,Jr. Salvatore W. Morlino CERTIFICATE OF COMPLIANCE August 19,2025 Joseph D'Ambrosio&Pamela D'Ambrosio 34 Talcott Road Rye Brook,New York 10573 Re: 34 Talcott Road, Rye Brook,New York 10573 Parcel ID#: 135.50-1-6 This document certifies that the work done under Mechanical Permit #24-120 issued on 9/19/2024 for the installation of a new above-ground oil tank has been satisfactorily completed. Sincerely, Steven E. Fews Building&Fire Inspector /to QyE BRC�k ID ��• �9a2 `� BUILDING DEPARTMENT ❑BBUILDING INSPECTOR 19 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 : Ot, DATE: 9 / ✓`���J PERMIT# ISSUED: 2 /SECT: 1 J. -D BLOCK: LOT: LOCATION: OCCUPANCY: ❑ Violation Noted THE WORK IS... Cj., PASSED ❑ FAILED REINSPECTION ❑ SITE INSPECTION REQUIRED ❑ FOOTING ❑ FOOTING DRAINAGE ❑ FOUNDATION ❑ UNDERGROUND PLUMBING NOTES ON INSPECTION: ❑ ROUGH PLUMBING ❑ ROUGH FRAMING ❑ INSULATION ❑ Natural Gas l ❑ L.P. Gas 2 , L) 0 FUEL TANK 11 ❑ FIRE SPRINKLER /�� S �' -� ti 1C �,.� A-R, ❑ FINAL PLUMBING 7 n n ❑ CROSS CONNECTION 0 FINALS ❑ OTHER L GJL) Co , -, Ce.� D Ic is� �yE BRC�uk Q,x . . 19l32 BUILDING DEPARTMENT ❑$UILDING INSPECTOR E 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 : S L 1 DATE: / J Z 1 PERMIT# MP Z ISSUED: j " c1"Zj SECT: 3�. Sn BLOCK: LOT: CU LOCATION: Ah * P„�P Q� OCCUPANCY: ❑ VIOLATION NOTED THE WORK IS... CCEPTED ❑ REJECTED/ REINSPECTION ❑ SITE INSPECTION REQUIRED ❑ FOOTING ❑ FOOTING DRAINAGE ❑ FOUNDATION ❑ UNDERGROUND PLUMBING NOTES ON INSPECTION: ❑ ROUGH PLUMBING ❑ ROUGH FRAMING ❑ INSULATION w, 1 ❑ NATURAL GAS ❑ L.P. GAS ❑ FUEL TANK ❑ FIRE SPRINKLER ❑ FINAL PLUMBING J n 1 � ❑ CROSS CONNECTION `'`-�c ' C } ❑ FINAL , J 1 ►. 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U x O ,rj Q O 0q UD v o9 Q W cu 4 lu u Cl di A. _ ■ e m x ED BUILD INq DEPARTMENT D [E C E M VILLAGE OF RYE BROOK SEP 17 2024 938 KING STREET RYE BROOK,NY 10573 (91.4)939-0668 VILLAGE OF RYE BROOK %iw-A.riebrookuy.gov BUILDING DEPARTMENT Application for Permit to Install Fuel Storage Tank (*Storage Tanks in excess of 1,100 gallons require registration with the Countyy�of Westchester) FOR OFFICE USE ONLY: PERMIT#: /"/ l'd 7"'� 0 Approval Date: SEP 2024 Permit Fee: - Approval Signature: I Other. Disapproved: (fees are non-refundah1t) DO NOT START WORK or CONSTRUCTION LNTIL A PERMIT HAS BEEN ISSt.ED 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: 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: Installation: 5185.00 per Tank. 5.Dig Safely New York h (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, oer ww4 ,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 Buried in Ground 1. Address: 34 TALCOTT ROAD SBL: 135.50-1-6 Zone: R-12 2. Property Owner&Address: PAMELA D'AMBROSIO 34 TALCOTT RD RYEBROOK NY 10573 Phone#: 914-636-0022 Cell#: 914-522-9214 email. PAM.BUDDYAMBROSIO@GMAIL.COM 3. Contractor&Address: Northeast Environmental Inc 225 Valley Pl Mamaroneck NY 10543 Phone#: 914-777-1930 Cell#: email: dmonaco@neenviro.com 4. Applicant: Dwayne Monaco for Northeast Environmental Inc. Phone#: 914-777-1930 Cell#: email: dmonaco@neenviro.com 5. Indicate Fuel Type:Fuel OiRJ L.P.Gas( )•Gasoline Other( ): 6. Number and Capacity of each Tank: ONE (1) 275 DOUBLE WALLED AST {�,VS " SC (e DVS 5 QC Q ,-\CR 7. Exact Location(s)of each Tank: EXTERIOR RIGHT HAND SIDE OF RESIDENCE t 6/l/2024 STATE OF NEW YORK,COUNTY OF WESTCHESTER ) as: DWAYNE MONACO ,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 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 before me this 5- V- I Sworn to before me this l day of 2.0 ' }20 g day of ,20 J � JA;Y�N�E tgnature of Property Owner Applicant 05 o MONACO Print Name of Property Owner :Print Namea pp an Notary Public �,Esateof New YorkKATHLEEN KILLINGBACK Registration No.01BA6171381 (Votary Public, State of New York Qualified in Westchester County Qualifi:. in Westchester County Corrrmission Expires July 23,20 0� 7 ID # 01 K 5071 This applicatlfdmppu7;�af �jltcSfiiagfntirety and must include the notarized signature(s) of the legal owner(s) of the su jec property, 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. z 6/1/2024 Double-wall Heating Oil Storage Tanks Utilizing double-wall construction for ultimate safety and reliability for all your home heating needs. -Unique double-walled construction Rc3 Our uniquely designed oil tanks are the safest and most reliable on the +h market. The outer tank is made of leak-proof,weld-free galvanized steel and rollseamed with an oil and fire-resistant seal. It can contain at least 110 percent of the capacity of the inner tank for maximum protection.The inner tank is made of blow-molded, high-density,seamless polyethylene that is leak proof and will never corrode. Roth tanks are easier and faster to fill thanks to their unique expansion system, all but eliminating the possibility of spills - by home heating oil professionals.And,our compact tanks are available in several different sizes, providing more flexibility for placement in any home. - Built with safety and the environment in mind Roth oil tanks exceed the industry standard safety regulations.They are rust resistant inside and out and are designed to prevent spills, leaks and fires i caused by defective pipes, couplings or fittings located underneath the tank. In fact,it is the only tank on the market with no fittings below the oil line. Each tank undergoes thorough testing,including ultra-sound and pressure testing,to ensure optimal thickness and sealing. Roth DWT Features ' i Weld-free galvanized steel outer tank that can hold 110 percent of the primary tank 5 2 Seamless high-density polyethylene inner tank 3 Highly visible optical leak alarm a 4 Up to 50 percent lighter than a 12-gauge steel tank with larger storage capacity 2 . . 5 Non-corrosive steel filling system that provides an even level in each tank when installed in groups 1 6 Burner feeding system with a duplex bushing installed directly into the opening. Available with 3/8"or 1/2"slip-thru compression fittings for copper tubing. Fittings can be removed for a threaded opening of either 3/8"or 1/2". \ 7 Cover for outside use _ �r �S o0 NF. CAN MAN NEAT ASV%'IATNIN effortGREAT NSUMER WEBSITE FREE INSTALLATION TRAINING In an Einstallation more aware of the safety and reliability training sessions on a regular basis. providea micro website specifically for this trainees,we are available to product. It is loaded with valuablelocation. , information and can be found at or arrange a training session,cat(your �, -n,....a .. www.heatingoitstoragetanks.com sales representativeRoth Key Benefits Tank Dimensions • Leak-proof and will not corrode Tank ModelDWT ' WT • Outer tank holds 110 percent of inner tank for maximum protection Nom.capacity US gal(liters) 110(400) 165(620) 275(1000) 275(1000) 400(1500) • Up to 50 percent lighter than Length inches(cm) 29(74) 29(74) 43(110) 51(130) 64(163) conventional steel tanks Width inches(cm) 28(72) 28(72) 28(72) 30(76) 30(77) Can use for heating oil,diesel and Height inches(cm) 44(112) 61(155) 61(155) 54(137) 68(173) bio fuels,motor oil,DEF and ATF Min.height required inches(cm) 49(125) 66(168) 66(168) 60(152) 76(193) • Compact,economical design Tank weight lbs.(kg) 106(48) 132(60) 167(76) 208(94) 333(151) (8 sq.ft.for 1000L) Shipping weight lbs.(kg) 115(52) 143(65) 185(84) 230(104) 358(162) • Provides maximum storage safety with minimum space requirements Approximate F•• • for • Installations • Removable base facilitates access to i Tank Model DWT r tight spaces and greater stability 400L • • 0•• 100OLH •• • Wide handles on each end allow you 2 tanks in inches 29 x 60 29 x 60 43 x 60 51 x 63 64 x 63 to transport and handle with ease (side by side) (74 x 152) (74 x 152) (110 x 152) (130 x 160) (163 x 160) • Quality control and testing exceeds 3 tanks in inches 29 x 92 29 x 92 43 x 92 51 x 96 64 x 96 industry standards (side by side) (74 x 234) (74 x 234) (110 x 234) (130 x 244) (163 x 244) 4 tanks in inches 29 x 124 29 x 124 43 x 124 51 x 129 N/A (side by side) (74 x 315) (74 x 315) (110 x 315) (130 x 328) 5 tanks in inches 29 x 156 29 x 156 43 x 156 51 x 162 N/A (side by side) (74 x 397) (74 x 397) (110 x 397) (130 x 411) 2 tanks in inches N/A N/A 28 x 90 N/A N/A (end to end) (72 x 229) All double-walled tanks come with a generous 30-year Rest easy knowing Roth i limited warranty, as well as an insurance policy worth productsenergy storage up to S2 million. reliable,are safe, most durable _ f market and they are guaranteed • ROTH DWT ACCESSORIES w— Roth provides the a1 1 1components you'll -/ to install - 1 operate our oil tanks to their full potential. Duplex Bushing, 1/2"or 3/8" • Fuel Oil Gauge • Expansion Kits(for multiple tank installation) Down (for installation �l l Cover•Tank (for outdoor installation) • c c m >1 a> Y >+ m O F a 0 c n m o � � N t o C O O � _ � � U � � L Q F- U � c n CD N I LC) M J cl ti U , O' s M (D N Y Y Y O 'r- CD 00 ' C C C N ' 4, M M m F- F- Q U O OL m r d N �J N y N f0 7 7 C LL� U) m -Qj U00 $z E N Z m c 0 o t O 0 .0 ` � f0 C N 0 p. V! J E a� E �U (5�y a CD N Z E Z C Q o rn •LCD o4 C f0 f Y _C M VJ `�' C Z C CD � .� U m H � m (6 r-� ao of 2 F- a� N YO d d O c) m W F- CD C ° m N V Y Y Y Y -a C a H H H Fes- 2 U c wtf a BO J N M In F- LL C) fD N tv- r r �P �� Generation Storage Distribution z c� >Solar >Septic >Radiant Floor Heating � RQ f"'"� m >Cistern >Plumbing Systems >Rainwater Collection >Oil Storage Tanks O�SjR1BUZ��� RothRcAh Distributed By: • Roth • Corporate Office PO Box 245 Syracuse, NY 13211 888.266.7684 00 °� L ° � 0 ) c .a) E 3co > N � o ywm > ° cr o m 7 3 m C CO-0 y- 0 C C 0.O p N m O N a p m V 2 7 m N m L U N L U C w a w0 U a) Y y., N U m m'° °U L+ N ce IS U a)L a) O N t0 m 7i E C ° N .O L N a)L 3 —� O I— N... > E m a) a O.N'p C m CO N C.0 m C m d .4 M w o_g -0-0 m rna�io 00-c, m 0�NL) m`° c m�5->'3Q o ° of e o Uz 'O= ° umj� C.0 >O U N p (a ° 0� N- a)'` C O-v a)L a) U c o cmo3 moa °;� D mo' v'�wm ° � � EO °oL' EOc } o o i°0mo� m 3iiEb0'° moyyf� cNmU0' mo > N CL.50 mc�aoo � mYMzm C p L U 0 0 N `.0 O C W m N ° E Q C N N•c Y ..W a p rn 0 U N .�.. ° m a a) N H N L-� w U 0' O C_O c U 0 Q °. 0 C a) C.L0.� j m O T N y J c mE 0 0 Dom= E NN o o EU) mL m cmi 2 w.LO E m m a o° aCi w m m , (uDLu 3 m �'3ma� yUpyO}C• co o c w _ > > z> JO N N 0 m n.C 3 a)'J C~-° m (Na O N d O z U 0 C C Y m d E ° o Q O O N m U} p U m Q a) >O �a 'p$ a) p vai H �.p.. 0 ° N 7 m C '° U N > m 0 °' L)2 CN z Z m Cu p U) 0 H 0 m.0 m N U)- N C Y O C A T c:E C mU y 0 m"LJ�..'C O V C= m rn'°�� m� 0 Z °-�'D �m.m. m m c N U �-p'U L C - w r.c E m N O C L N 0 7 0 Q N 0 N w > m C1 '° z io nc (>iF- :E 0 c 0 0 w c ac o 0� 0 °-« � NY N `m E•�o�E c) c R�CD o cY m-0-0 a-5 m o m•m 3 o c�o m=- o v a)— uir rnL°avw 10a co 0U a)N moQ :.3 m m o > rno a� T3Q-0 � .- N m cw °� m= cn N c.� m o m e 3 c c v a=� U Co mZ'c CL c a) O 3 a0 3 3 '3 m-0.0 w N C CO °C V) 0 >@_ N O X•V.N E O a) p •p 's C0) >.? O-d= m a)z .0.0 m O 'O } '° . OE= aCi C.0 ` =umONyeErn�a�� � f0a oan� rn3L_-0Aa) E� 2 o 0 p 0 � o E c� a� m am c.oD o c m m E c) rn .@ y a—c E. 0 — 3 a) c a U o a ,c (a. � ) N m c d c a) o m E aXi L� p E O 3 aN c. a 0 E Co E dc~nmvp� >=NUamiowt~n �od� ma) �'= drt~Ama���aQ= p � LL E a) a!n o"§ 0 a 0 w 6 0 cL E.0 a ° 3 s :E m a a- 0— 3 w N D ch W I W z U) U) J Q :D } z z F- O O LLJ J J 0 U (7 0 C O� 0 r LC) N LC) 00 0 Q 0 V M O p z U J f'- jNORTHEAST D ECEWF�j ID ENVIRONMENTALNC. NOV 12 2024 225WleyMace � VILLAGE OF RYE BROOK NbmaroneckbklewYork 10543 BUILDING DEPARTMENT Phone:19141777-1930 ----- -- -. _ _.._.__ Fax:(914)777.1928 October 9, 2024 Steven Fews - Code Enforcement Officer Village of Rye Brook 938 King Street Rye Brook, New York 10573 RE:34 Talcott Road Permit#: MP 24-119 and MP 24-120 Dear Inspector Fews: This letter is to inform you that the work at the above referenced site is complete. WORK COMPLETED: Excavated, cut, cleaned,and properly disposed of one (1)550- gallon UST and its associated piping. Once the tank was removed,one(1)composite CP-51 soil sample was extracted from the excavation: it was then backfilled to a rough grade. This sample was sent to a NYS certified laboratory and analyzed according to DEC protocol. The analytical results are attached and shown to be within NYS DEC guidance. NE Installed one(1)275-Gallon ROTH double wall AST on a concrete pad with a rainshield in the rear of the residence. DATE COMPLETED: October 9, 2024 Enclosed, please find copies of all paperwork requested by your office. NE's work was performed with its best present judgment and level of effort consistent with professional standards and in compliance with all applicable Federal, State,and Local ordinances and regulations. P ease feel free to contact me at(914) 777-1930 with any questions or concerns. Sincere , Dw yne J. Monaco .c. Enc. Haz-Mat Spill Response ■ Soil Remediation ■ Transporting •Tanks Installed/Removed wvvw.noriheastenvironmental.com ACC>4t CERTIFICATE OF LIABILITY INSURANCE 71E MM'DD"YYYI 31 ?024 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 AShlea Tarkazikis NAME PF Northeast Brokerage Inc PAHONE (845)223-8107 No.Exti, IAUC Ne (845)227-8816 1035 Route 82 E-MAIL atarkazlkls@pfnortheast.com ADDRESS INSURERIS)AFFORDING COVERAGE NAIC a Hopewell Junction NY 12533 INSURERA: Great Divide Insurance Company INSURED iak insurance Company INSURER B: �Rrn C p Y Northeast Environmental Inc INSURERC: 225 Valley Place INSURER D: INSURER E' Mamaroneck NY 10543 INSURFR F COVERAGES CERTIFICATE NUMBER: CL2453115862 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 LTR TYPE OF INSURANCE INSD yVVD POLICY NUMBER MMIODNYYY MM/DOIIYYYY UNITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE S 1 000,000 CLAIMS-MADL)AMM*TO RENTED E ©OCCUR PREMISES Ea occurrence S 100 000 X Contractual Liability 25 000 MED EXP An one person)son $ A ECP01530828-24 06 1112024 06/11/2025 PERSONAL&ADV INJURY S 1000.000 GEN'LAGGREGATE LIMITAPPLIES PER GENERAL AGGREGATE $ 2.000.000 POLICY PRO PRODUCTS-COMPrpPAGG S JECT LOC 2.000,000 OTHER Professional Liability S 1.000,000 AUTOMOBILE LNIAILITY COMBINEDSINGLE LIMIT $ 1,000,000 Ea accadeM ANY AUTO BODILY INJURY IPer person) S B OWNED SCHEDULED BAP1530830 06/11/2024 06/11/2025 BODILY INJURY Fer accident) 5 AUTOS ONLY AUTOS HIRED NON OWNED PROPERTY DAMAGE 5 AUTOS ONLY AUTOS ONLY Per acoderrl S X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 5 000 000 A EXCESS LIAB CLAIMS-MADE FFX1530829-24 06'1112024 06/11/2025 AGGREGATE 5 5 000 000 DED 1><RETENTIONS 10,DOO S WORKERS COMPENSATION H. AND EMPLOYERS'LIABILITY YIN TAI SPIER T R ANV PRJPRII T,_,WPARTNER,EXECUTIVE ❑ NIA E L EACH ACCIDENT S OFFICER MEMRER EXCLUDED') (MandataY in NH) E L DISEASE-EA EMPLOYEE S If yes describe under DESCRIPTION OF OPERATIONS below E L DISEASE-POLICY uM,T 5 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101.Additional Remarks Schedule,may be attached it more space is required) Village of Rye Brook Is listed as addltonal Insured with regard to general uaolhty coverage as per written contract Coverage Is primary ana non-contributory Waiver of subrogation applies as per written contract No labor law exclusion applies CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF.NOTICE WILL BE DELIVERED IN Village Of Rye Brook ACCORDANCE WITH THE POLICY PROVISIONS 938 King Street AUTHORIZED REPRESENTATIVE Rye Brook NY 1057.1 ID 1988-2015 ACORD 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 la. Legal Name& Address of Insured(Use street address only) Ib.Business Telephone Number of Insured (914)777-1930 Northeast Environmental Inc 225 Valley Place Ic.NYS Unemployment Insurance Employer Mamaroneck,NV 10543 Registration Number of Insured N1 ork Location of Insured (Only required if coverage is Id. Federal Employer Identification Number of Insured speciftcallt,limited to certain locations in New Fork State, i.e., a or Social Securit% Number IiYap-Up Policy) 133965670 2. Name and address of the Entity Requesting, Proof of 3a. Name of Insurance Carrier Coverage(Emit. Being listed as the Certificate Ilolder) American Fire&Casualty Co. Village of Rye Brook 3b.Policy Number of entity listed in box"la" 938 King Street XWA57980680 Rye Brook, NY 10573 3c. Policy effective period 6/29/24 to 6/29/25 3d. 'i he Proprietor. Partners or Executive Officers are included. 11Inh check bo%if all partners/officers included) X 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,Ness fork(NN')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 will also noth,the above certificate holder within 10 days IF policy is canceled due to nonpayment of premiums or within 30 days IF there are reasons other than nonpayment of premiums that cancel the polic-v or eliminate the insured from the coverage indicated on this Certific•ale. (These notices may he sent by regular mail) Otherwise, this Certificate is valid for one year after this firm is approved by the insurance carrier or its licensed agent, or until the police' expiration date listed in box "3c", 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 conlract issued hs 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 tie%York State Workers'Compensation Law. I rider 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: Joseph W.Pires (Print name of authorized representative or licensed agent of insurance tamer) Approved by: 6/2/24 (Signature) IDate) Title: President—PF Northeast Brokerage Inc. Telephone Number of authorized representative or licensed agent of insurance carrier: (845)223-8107 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