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HomeMy WebLinkAboutMP25-004 < t3R3 C. -V O� 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.gov TRUSTEES BUILDING& FIRE INSPECTOR Susan R. Epstein Steven E. Fews Stephanie J. Fischer David M. Heiser Salvatore W. Morlino CERTIFICATE OF COMPLIANCE March 7,2025 Gerardo Hernandez&Juliana Maria Hernandez Nunez 557 Westchester Avenue Rye Brook,New York 10573 Re: 557 Westchester Avenue, Rye Brook,New York 10573 Parcel ID#: 135.83-1-13 This document certifies that the work done under Mechanical Permit#25-004 issued on 1/22/2025 for the removal of an above-ground oil tank has been satisfactorily completed. Sincerely, Steven E. Fews Building&Fire Inspector /to QyE BRC��, BUILDING DEPARTMENT ❑BJdILDING 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 : -s YV L� l�P��C.� N"f DATE: PERMIT# ISSUED: % L SECT: BLOCK: LOT: S LOCATION: 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 12ec e.�ve, Cl,o��I,�o P� Po .-3 3— a vat D. lc- Ac) i ssL.-t c 0/4 1 1 e, ' �' � � •� �' it ' 1 u WOWS r r ;�.�' ..� �'� <~!'�yi•'�s�'�.lt-;fir ._ � ,' r a i ry: ar t I 1r so a -� �•>7 10 a LDS ` ;�^ , ��!•,�,1'� _ '~� L = o N 00 1� N N ON ~ v a N \ ►[) y a '"4 Ln AW •--� P Q.1-4 e=, �:) A z � � O � � �� � W to00 W Ln W -• Lr) 0 � � tl'y � O ��7 bq � ►-� I� W � p O � �� � ,. o F p o �7 MM � C " cnw �. - w0.^ z G O y 2 a Cad «0 `� °� a A t U a\0 u^Z I`'' 0 V z V 0 rn e w " Q oe u w Z �z z A CR ,O to x , o 00 .a a� Alo, � P oz w O rn � . O ° 00 o � 19 -Do v U � W � � � o � �. �. N vn w A W. u V l a a° w xV u BuiLDING DEPARTMENT VILLAGE OF RYE BROOK 938 KING SftFET RYE BR4oK,NY 10573 JAN 2 2 2025 DD (9t4)939-0668 www.ryebrookny.gov VILLAGE OF RYE BROOK BUILDING DEPARTMENT Application for Permit to Remove 2r Abandon Fuel Storage Tank (*Storage Tanks in excess of 1,100 gallons requ' a registration with the County of Westchester) FOR OFFIC'I: I ISF ONL1 : I'I P:ti[ : +��C�D6:_7i_oaq_ JAN 2 ZUZS , ,� 5 Approval Date: Permit Fee: $�,� Approval Signature: _ '� Other: Disapproved: — - -- (fees are non-refundable) DO NO-1 START WORK or CONSI RUC I ION UN-1 IL A FL:ICNII I. HAS 131"EN ISSUED BI THE iiUil-DIM. INSPECTOR. THE ADMINISTRATIVE FEE FOR WORK PROGRESSED OR COMPLETED WITHOUT A PERMIT IS 2% OF THE TOTAL COST OF CONSTRUCTION WITH A MINIMUM FEE OF S750.00 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#C 105.2 or Form# U26.3 /or NY State Workers Compensation Waiver) 4.Fee per Tank: Removal or Abandonment 5.Dig Safely New York#(dKiI X I I): 6. Inspection by Building Department for removal or abandonment. 7. Submit all Manifests&Reports(after work has been completed). 8. Certificate of Compliance will be provided when all requirements are fulfilled. Application dated, hklkjCkv ,is hereby made to the Building Inspector of the Village of Rye Brook for a permit to remove or abandon a Fuel Tar c as herein described.The applicant and property owner,by signing this document agree that the subject fuel tank(s)will be removed or abandoned in conformance with all applicable Village,County,State&Federal laws,codes, rules and regulations. Indicate Permit Type: Removal•Abandonment{ }/Above Ground • Buried in Ground ( ) I. Address: � � 1�1> e►' �11 l �kL yb() N4 SBL: (3S.'�-3 - 1 Zone: 2. Property Owner&Address:`[yliC.u' y►1cti►�Cf Z - S51 (r� `S�C �'tZ✓ ftV P4Z i� CUY�N ti�S-1'j Phone#: Cell#: q 14—StoS- qa 6"1 email• TuS cL,ne- . 1\d-±lyT, I (c rvm 3. Contractor&Address: ,, -m At 1. Y\v e_ k a. Phone#:(ZIq- ASS 1 -aa-1 S Cell#: email: t,hfu- (' c _� u S 4. Applicant: av 1 t G.v\.o-_ kk v v x&r ck-e L Phone#: Cell#: t�-S to S-�l �? �'3 email: >. Indicate Fuel Type:Fuel Oil L.P.Gas( )•Gasoline( )•Other( ): 6. Number and Capacity of each Tank: 6) zi s co -Crvovr�d n, l �C�v\IL 7. Exact Location(s)of each Tank: �c�v,n�.� t NI/2024 ATE OF NE YORK COUNTY OF � 5 r ) as: S U 1 ,being duly sworn,deposes and states that he/she is the applicant above named. (print name of illidividual signing as the applicant) and further states that(s)he is the Tank Removal/Abandonment 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 hislher 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 Sworn to before me this day of ,20 day of 20 2 S Signature of Property Owner t tue of li t Print Name of Property Owner Print'Name-of Appli can Notary Public - or Pub is 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. 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. Toni L Hokanson NOTARY PUBLIC,STATE OF NEW YOr;K I Registration No.01H06294662 Qualified in Ulster County rr ttt Commission Expires Decemttw 23,20,1 2 6/l/2024 STATE OF NEW YORK,COUNTY OF WESTCHESTER ) as., 7I&C�-ykLi 4kyy�c,e"CLLZ .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 Removal/Abandonment 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 .1 L Sworn to before me this day of rTo.,asry S day of rT�n�.4r v 20 0 3 u� v', w ,o c gn ture of Pro er C tS*pa of Appl'i V\Ck Y� .l C� CiV Print Name of Property O m - Print Name of Applicant z Z. y z ° Notan, " Notary 1'it - his_ai�l cation must be properly completed in its entirety and must include the notarized �l ` signatures) of the legal owner(s) of the subject property, and the applicant of record In the snag. provided. Anv application not properly completed in its entiretv and/or not nroneriv sil'ned shah oZ deemed null and void and will be returned to the annlicant. z 6/1!20.''" D H MAR - 3 2025 i VILLAGE OF RYE BROOK BUILDING DEPARTMENT 642 Ateel SIT k.331Jton?v,1�:401 (645) ' N.Y.S O.M.V 7105074S ,JAM::: C,G C INvaICE4 206178 C l o.s,ed to Cash Pij rchase 1" 'jATiIITRME100i09r?-025 2:41:36 PM ;rATION: 01 Cllslomer Info ^usAomer C2ra C7.G ; 1-:STEEL (UnpreEn�red)-i�?.7 �i79.E0 -�..; �� $0.11 1;579.60 Subtotal G��A?ID �C►T�l. Cash $579.60 Mon-F r iNO TA)(ONE SCRAP tSE ff AL am-2pm SIGNATURE U ILM o c� 3 N C) 70 j (n : N G V .• O > � (n c 3: �- 0 o C: Q n j N O O � L 0 N Z U) Q� O 0) O a (A Y o N a 0 O O Z Z a � OEM" r -0 m � — W w > w N Z N o o — cn z Q O O � U C: Z J 0 Lf 1 - O m W w " > ° 00 m C) CN � Y w " 4-0 +- W o t c U) o ago WQ cN opt 3 = � E c N N O J N > c i U N C/) O V Q fa m f6 > m w z �.+ U L o +r O oC/) w J N 0 a LO � O a O L D Ln O V cL) LL o � m • O L c O (o 0- 0).c Q Z m c v O C - -o aY O J M••M U LO 0 L � a 0 < cn CU CU � a W c ~ oa > U E a� -o " W U � �a 0 m C CO - `I O 0 — >, W Y � LL C)N a) fv C co ) ' U m C) U —A I Lb,WU!',Nye n,WI•USA•(800)327-6868•pkeller.com•Printed in the United States WASTE MANIFESTJ��'Dtunber mergim Response p►one4.Waste Tracking Number NON-HAURDOUS2- 1 d 3.E - 5 Generators Name and Marling Address Generators Site Address(if differentt than marling address) 5S7 c S�ct.�si� ►A� C' Generator's Phone: 2,/2 � —S s .--- 6.Transporter 1 Co/m+pa�ny Name U.S.EPA ID Number 7 Transporter 2 Company Name U.S.EPA ID/umber/ 1 8.Designated Fadlity Name and Site Address - - - -- - — -- �� U.S.EPA ID Number 4P 4c,,IlPhone:Shipping Name andWaste pesctipdpt 10.Containers 11.Total 12 UnitNo- Type Quantity WLNnI cc - - O J / ir W 13.Special Handling Instructions and Additional Information 442,4 / 01 ) 14.GE NERATOR'S/OFFEROR'S CERTIFICATION:I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,and are classified,packaged, marked and labeled/placarded,and are in all respects in proper condition for transport according to applicable international national gDpagental regulations. Gene (s/OffemrSPrinted/Typed Name y Signature Month Dayr, Year J 15.IntemationalionalShipments 2 ❑Import to U.S ❑EVort from U.S. Port of entry/exit: TraqsErter Signature for eqqrts only): Date leaving U.S.: Ir 16.Transporter Acknowledgment of Receipt of Materials —- - — -- —-- ------ Transporter 1 Print Name U signature 'j- Mont J a o Transporter 2 Printed/typed Name Signature - - F Month Day Year I 17 Discrepancy 17a.Discrepancy Indication Space - - -- - —----- Quantity El Type El Residue El Partial Rejection u Full Rejection - -T 17b.Alternate Facility Reference Number lity(or Generator) U.S.EPA ID Number J U L Facility's Phone: F 17c Signature of Alternate Facility(or Generator) - - - - - -- 1 Month Day Year Z t7 ---- ---- -- -- - y W ' 18.Designated Facility Owner or Operator Cerli6catlon of receipt of materials covered the manifest--------------_-- by except as noted in IOeln 17a - -- — Printed/Typed Name ---- ---- --- if I Signature I Month Day 169-BLS-C 6 10497(Rev.9/09) - _._ ._-._--_ _.- `— LYear Published by J.J.KELLER&ASSOCIATES.INC m,Neenah,WI•USA•(800)327-6868•ljkeller.com•Printed in the United States Nowmamm 1 Generator ID Number Pa 1 of 3.Emergency Response Phone 4.Waste Tracking Number I y WASTE MANMT r / -���{1 ev > 1 S'3 1 5 Generators Name and Mailing Address / /n � Generators Site Address(rf different than mailing address) S 5-7 GHQ SEcL�SI "Q J A Generators Phone ye Brtz k, lU5'77 �_ ----------------- --- 6 Transporter 1 Company Name U.S.EPA ID Number 7 Transporter 2 Company.Narne U.S.EPA ID Number 8.Designated Facility Name and Site Address /' X-T u) Se,. U)CkJ U.S.EPA ID Number Facility's Phone 10.Containers 11 Total 12.Unit 9.Waste Shipping Name and Description No. Type Ouanlity Wit N ¢0 1.N o n qib /n a. A^ tf�t�j\v Ulte�l ply t 1 - 1 Z p W C7 ' 4. 13 Special Handing Instructions and Additiortal Information I 14.GENERATOR'S/OFFEROR'S CERTIFICATION:I hereby declare that the contents of this consignment are fully and accutg1elY described above by the proper shipping name,and are classified,packaged, marked and labelediplacarded,and are in all respects in proper condtlion for transport according to applicable internatioWnd nadorlal gWmental regulations. Generator erors P ted/ryped Name A 7 Signature Month Day Year -J 15 International Shipments Import to U.S Fz ❑ po ❑Export from U.S. Port of entry/exit: Transporter Signature for exports only): Date leaving U.S. 16.Transporter Acknowledgment of Receipt of Materials - - - - -- — - --- Transporter 1 Printed/Typed e / Signature - Month Day Year < Transporter 2 Printed/Typed Name Signature Month Day Year 17.Discrepancy 17a.Discrepancy Indication Space -❑ I l — ;��----- — Quantity U Type ❑Residue ❑Partial Rejection J Full Rejection Manifest Reference Number: r 17b Aftemate Facility(or Generator) U.S EPA ID Number J U a Facility's Phone. WC 17c.Signature of Aftemate Facility(or Generator) ( Month Day Year F Z W rO 18.Designated Facility Owner or Operator Certification of receipt of materials covered by the manifest except as doled In darn 17a Printed/Typed Name Signature Month I Day I Year r r r ei i w w s O W 7 O N N v Ln N N 00 W 8 a N N N w 79 v � r, x N [qC 05 ^ r-W a a _ vu b at � Z �' 3w ■, MCI p .c pot O r M Z W x $ S V 1 W on W oo N rn a o 41 Cam,� C a W r� tn W N z i ca m U T7 H W 7 A � g � � �j L \ ¢ ° 1° O 3 0 v " Q r � M W �■1 Z ',�• H F'' w ear Q � C � G � � r H ^ � a n ' Q � 0 1.0U ago W c,3 p U fzz' oo i W Z A ,a W U ? . ti v c V1 z W W �" > � ° °� t U ►'� V W z Q A z pq O c c V Gz7 ham+ 0�0 G� ✓ , (� u 1,.s u W A a "� cr r M■■■i G1 � d< o ' U E"� V H � q° N w � ° z .� � y � u � � v� z x U W Ca b W W o w c ° � 5 � x � z Zv11 O a � oo NSA° o .. v 0 ■ �I CQ L'� � ►.a L14 A cQn � � .� C2GENVI-01 LGRYCZYNSKA AICORO DATE(MM/DD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 12/11/2024 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 Craig Cecere E. World Insurance Associates,LLC PHONE FAX 226 Madison Ave A/C,No,Ext: 732)228-8236 1805 ac,No Morristown,NJ 07960 AbmpAfiss.CraigCecere@worldinsurance.com INSURERS AFFORDING COVERAGE I NAIC# INSURER A:Admiral Insurance Company 24856 INSURED INSURER B:Selective Insurance Company of the SE 139926 C2G Environmental Consultants,LLC INSURER C: 83 South Putt Corners Rd INSURER D: New Peitz,NY 12661 INSURER E: 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. INSR TYPE OF INSURANCE ADDL SUBR POLICY NUMBER POLICY EFF POLICY EXPLTR LIMITS A X COMMERCIAL GENERAL LIABILITY 6,000,000 EACH OCCURRENCE CLAIMS MADE OCCUR FEI-ECC-36284-00 12/12/2024 12/12/2026 DAMAGE TO tE RENTEDrencel $ 60,000 MED EXP(Any oneperson) $ 10,000 PERSONAL&ADV INJURY $ 6,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE 6,000,000 RPOLICY 71JE� 17 LOC PRODUCTS-COMP/OP AGG $ 6,000,000 X OTHER Pollution Liability POLLUTION LIABI $ 6,000,000 B AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000 X ANY AUTO S 2307223 4/29/2024 4/29/2026 BODILY INJURY Perperson) OWNED SCHEDULED AUTOS ONLY AUTOS pp BODILY INJURY Per accident $ X AUTOS ONLY X AUOTOS ON�V (Per accident)DAMAGE $ UMBRELLA LIAB OCCUR EACH OCCURRENCE EXCESS LIMB CLAIMS-MADE AGGREGATE DED I RETENTION$ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY Y/N aI&IUIE ER ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ (MandatoryOFOFFICER/MEMBER NH)EXCLUDED? N/A E.L.DISEASE-EA EMPLOYE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT A Professional Liabili FEI-ECC-36284-00 1 12/12/2024 12/12/2026 Professional-lability 6,000,000 A Transport.Poll.Liabl �FEI-ECC-36284-00 12/12/2024 12/12/2026 Transport.Poll.Liabi 6,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 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 Village Of Rye Brook THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN g Y ACCORDANCE WITH THE POLICY PROVISIONS. 938 King Street Rye Brook,NY 10673 AUTHORIZED REPRESENTATIVE ACORD 26(2016/03) ©1988-2016 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD /7_0WN*N*1 NYSIF PO Box 66699,Albany,NY 12206 New York State Insurance Fund I nysd.com CERTIFICATE OF WORKERS' COMPENSATION INSURANCE 1 A A A A A 200882662 0 ' ❑� LOVELL SAFETY MGMT CO.. LLC 22 CORTLANDT STREET 33RD FLR 4imm NEW YORK NY 10007 SCAN TO VALIDATE AND SUBSCRIBE POLICYHOLDER I CERTIFICATE HOLDER C2G ENVIRONMENTAL CONSULTANTS LLC I VILLAGE OF RYE BROOK 83 S. PUTT CORNERS ROAD I I 938 KING STREET NEW PALTZ NY 12561 RYE BROOK NY 10573 POLICY NUMBER CERTIFICATE NUMBER POLICY PERIOD DATE Z 1412 798-9 372884 04/01/2024 TO 04/01/2025 04/01/2024 THIS IS TO CERTIFY THAT THE POLICYHOLDER NAMED ABOVE IS INSURED WITH THE NEW YORK STATE INSURANCE FUND UNDER POLICY NO. 1412 798-9. 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://WWW.NYSIF.COM/CERT/ CERTVAL.ASP. THE NEW YORK STATE INSURANCE FUND IS NOT LIABLE IN THE EVENT OF FAILURE TO GIVE SUCH NOTIFICATIONS. THIS POLICY DOES NOT COVER THE SOLE PROPRIETOR. PARTNERS AND/OR MEMBERS OF A LIMITED LIABILITY COMPANY. THE POLICY INCLUDES A WAIVER OF SUBROGATION ENDORSEMENT UNDER WHICH NYSIF AGREES TO WAIVE ITS RIGHT OF SUBROGATION TO BRING AN ACTION AGAINST THE CERTIFICATE HOLDER TO RECOVER AMOUNTS WE PAID IN WORKERS' COMPENSATION AND/OR MEDICAL BENEFITS TO OR ON BEHALF OF AN EMPLOYEE OF OUR INSURED IN THE EVENT THAT. PRIOR TO THE DATE OF THE ACCIDENT. THE CERTIFICATE HOLDER HAS ENTERED INTO A WRITTEN CONTRACT WITH OUR INSURED THAT REQUIRES THAT SUCH RIGHT OF SUBROGATION BE WAIVED. _ 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 �v V 4 lei DIRECTOR. I SURANCE FUND UNDERWRITING VALIDATION NUMBER: 280317536 111i 0 0000000000000 oil III161111111 0 1RdININYI4II�(IIII��� Form WC-CERT-NOPRMT Version 3(08/29/2019)[PVC Policy-1 4 1 2 79891 I 158 100000000000126048834]10001-0000141278881If#ZI[16358-18][Cert NoP-CERT 1][01-00001]