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HomeMy WebLinkAboutMP25-040 (QyE DR L° 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 David M.Heiser Donald T.Krom,Jr. Salvatore W.Morlino CERTIFICATE OF COMPLIANCE October 9,2025 Rodrigo Malzyner&Monica Malzyner 16 Bayberry Lane Rye Brook,New York 10573 Re: 16 Bayberry Lane, Rye Brook,New York 10573 Parcel ID#: 129.84-2-5 This document certifies that the work done under Mechanical Permit#25-040 issued on 3/24/2025 for the removal of an above-ground oil tank and the installation of a new above-ground oil tank has been satisfactorily completed. Sincerely, / q Steven E. Fews Building&Fire Inspector /to E �k��� 7982 BUILDING DEPARTMENT ❑RVIL1>ING INSPECTOR VtiSISTAN'1'I;1.111MING INSPECTOR VILLAGE OF RYE BROOK ❑COM: I{NFORc:EMENT OFFICER 938 King Street • Rye Brook, NY 10573 (914) 939-0668 FAX (914) 939-5801 www.rycbrook.org - - - - INSPECTION REPORT - ADDRUY, BA Y 6&^A--e DATE: /O — S- 2-024-- PERMIT# 2,5' — 0H<D ititil i ��:3-Ly-L��1(t:'I : �Z l• J(BLOCK: Z LOT: .. _ LOCATION: Real OCCUPANCY: _ ❑ Violation Noted T111". wolm Is... PASSIiU ❑ FAILED / REINSPECTION ❑ SITE IN.sm-- riON REQUIRED ❑ T00.1•ING ❑ TOOTING DRAINAGE. ❑ FOUNDATION ❑ UNDERGROUND PLUMBING NOTES ON INSPECTION: ❑ ROUGif PLUMBING ❑ ROUG11 FRAMING ❑ INSULATION ❑ Natural Gas �••� g �ra 1�e New Z'Zs 4 S?` .-4 ❑ I..P. Gas $�.Q.d B"FUF.I.TANK ❑ TIRI:SPRINKLER ❑ FINAL PLUMBING ❑ CROSS CONNECTION --- ❑ FINAL E BRC10� W l.7 197? BUILDING DEPARTMENT VAss LpING INWE'C OR ISTANT BUILDING IN%PIi(:'1'4)11 VILLAGE OF RYE BROOK ❑CODE ISNU(►R(:U.MUN'1'OFFICUR 938 King Street . Rye Brook, NY 10573 (914) 939-0668 FAX (914) 939-5801 www.rycbroo,k.org - - - - - - - - - - INSPECTION REPORT - ADDRESS : o -up`Y 6tA^. "Je- DATU: 10 PERMi'1'# ZSrQLI ::) 1SSUGD:3-2y-2)11c1 : 1Zq.3q BLOCk: I.00ATION: T-za� OCCUPANCY: ❑ Violation Noted '1'111: WORK 1 ti... 21 PAS8141) ❑ FAILED I REINSPECTION ❑ SUIT, INSPECTION REQUIRED ❑ TOOTING ❑ FOOTING DRAINAGE: ❑ FOUNDATION ❑ UNDERGROUND PLUMBING NOTF'S ON INSPECTION: ❑ ROUGH PLUMBING ❑ ROU(ai FRAMING ❑ INSULATION t ❑ Natural Gas _ _ T" ? ^ 1,J9144 ❑ 1..M Gas /ff-I'Ulil.TANK - ❑ FIRE SPRINKLER ►� ❑ FINAL PLUMBING ❑ CROSS CONNE•.CTION — — ----- FINAL 4 AU- wo v- c n,4 uld k JO ❑ 01'11UR -... �E BRC�k. ym cu � 1982 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 : DATE: ( � Z"� (� 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 i ❑ INSULATION ❑ NATURAL GAS ❑ L.P. GAS ❑ FUEL TANK ❑ FIRE SPRINKLER ❑ FINAL PLUMBING ❑ CROSS CONNECTION ❑ FINAL ❑ OTHER : s ■ r N N y 7 a eq ■ � O a � a.� a W = �+ U v . O 4-4W v o a _ ,ay x a O W 00 W O U ^ �' p O b a b U A. WZ rY�• z " W V z � a z a A O > Q tea-+ � (' � � x c� A � � o a c `� � U � ■ a I� 04 50 00 G\ �l O CA or) W >y CN U � w � E— O w v u � N z � v 064 � W H c R 's H A a. z ,. 44 s t D `� E LE BULL p MENT MAR 2 0 2025 V[L E'OF R OK 938 KING ET Rv�,BR ,NY 10573 VILLAGE OF RYE BROOK (914)9 39-5801 BUILDING DEPARTMENT I' U C A lication 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#: �L Approval Date: _ —�- — Permit Fee:$ Approval Signature: i Other: Disapproved: (fi4 ii#non-re*r,d*N,Cr).#**##*### RE DIRE ENT FOR RELEASE OF PERMIT CERTIF CATS 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 Stage Workers Compensation Waiver) 4. Fee per Tank: Removal,Abandonment,or Installation: S 185.00 per Tank. S. Dig Safely New York#(dial 811): 6.Inspection by Building Department for removal/abandonment and/or installation. 7. Submit all Manifests&Reports(after work has been completed). 8. Certificate of Compliance will be provided when all requirements are fulfilled. Application dated, 3/10/2025 is hereby made to the Building Inspector of the Village of Rye Brook for a permit 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 tank(s)will be removed,abandoned and/or installed in conformance with all applicable Village,County,State& Federal laws,codes,rules and regulations. I di a Permit T e: Installation (`' • Removal(Abandonment( }!Above Ground (�j• Buried in Ground( ) 1. Address: 16 Bayberry Lame __ SBL- 129.84-2-5 Zone: 2. Property Owner&Address: Rodrigo 8� Monica Malzyner Phone#: 914-291-4727 cell#: email: monicamalzyner@gmail.com 3. Contractor& Address: Robison oil 1 Gateway Plaza,4th FL, Port Chester, NY 10573 Phone#: 914-847-0295 _ —Cell#: email: jweir@robisonoil.eom 4. Applicant: Robison Oil Phone#: 914-847-0295_ —Cell#: email: iweir@robisonoil.com robisonoil.com 5. Indicate Fuel type:Fuel Oil O(-L.P.Gas( )-Gasoline( }•Other( ): _ 6. Number and Capacity of each Tank: Removal and replacement of 275 gallon above ground oil storage tank in Utility Shed. 7. Exact Locations)of each Tank: Outside-rear of home in Utility shed. U C V jOAS t 6/1/2020 od OF NE) }CORK,COUNTY OF WESTCHESTER ) as: �/' being duly sworn,deposes and states that he/she is the applicantm above naod, m(print nae of individual s g mg as the applicant) and further states that(s)he is the Heating,Ventilation and/or Air Conditioning 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 Cade of the Village of Rye Brook and all other applicable laws,ordinances and regulations. Sworn to before me this 11 Sworn to before me this 106 A day of f gQGh ,20.25 day of 20 .7 Signature o roper•ty O ncr gn re of Ap cant Print Name Prope Owner nt N pl' t C" "'0' - Q—�— Notary Public — N lic IGY. AMANDA K OL MSTEAD PxPMae flEl�.� NOTARY pniJC,nAn OF NEW YORK �,w Rcgiatra im No.01OL6417632 Quhf, d in Weatchester comfy Comm aam F Wim 0$f3Q M 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. 2 611/2024 GRANBY RESIDENTIAL OIL TANKS STORAGE TANKS SIMPLY THE STRONGEST MADE TANKS ON THE MARKET A LOGICAL AND RESPONSIBLE CHOICE SAFETY AND RELIABILITY PEACE OF MIND Granby Industries offers the most complete line of oil tanks With 65+years of experience, Granby Industries is known with secondary containment systems. for its quality and proven track record in innovation and design. Whether it be our ECOPLUS and ECOGARD double-bottom tanks GREAT WARRANTIES or our 2-in-1 tanks with a 110%secondary containment, you will Warranty of up to 30 years. not find safer and more reliable oil tanks on the market. GUARANTEED DURABILITY Granby Industries offers oil tanks made of non-corrosive material such as HDPE plastic on its 2-in-1 tanks and fibreglass. Tanks built of non-corrosive material provide greater durability. OptiFue DD THE . OPTIFUEL GRANBYINDUSTRIES.COM DE-AERATOR RESIDENTIAL OIL TANKS / UL 80 1� ,r Gauge Dimensions Weight ., „ , 209101 120 vert. 12 47' 23' 30' 170 208101 138 vert. 12 44' 27' 30' 160 208601 138 horiz. 12 27' 44' 30' 160 207201 220 stubbies/vert. 12 44' 27' 48' 220 203201 230 thin/vert. 12 44• 22' 60' 235 203701 230 thin/horiz. 12 22' 44' 60' 235 202201 240 narrow/vert. 12 47' 23' 60' 265 202701 240 narrow/horiz. 12 23' 47' 60' 265 204201 275 vert. 12 44' 27' 60' 255 204203 275 vert./UL-142 12 44" 27" 60" 255 204701 275 horiz. 12 27' 44' 60' 255 211201 275 vert. 10 44' 27' 60' 330 211701 275 horiz. 10 27' 44' 60' 330 205201 330 vert. 12 44' 27' 72' 290 205203 330 vert./UL-142 12 44" 27" 72" 290 205701 330 horiz. 12 27' 44' 72' 290 External finish: BLACK electrostatic powder paint of if you desire GREY Warranty*: 10 years add a G at the end of the item number. Touch up paint: PE0030C "BLACK" PE0032C "GREY" CYLINDRICAL MODELS HORIZONTAL Capacity Gauge cover Dimensions Weight Product # (US gal.) Model thickness Shell Dia. Height .. 005224 138 horiz. 12 12" 26' 60' i 165 External finish: BLACK electrostatic paint Warranty*:3 years I- UL J UL-80 ' 20PLUS 2 � PLUS Residential oil tanks with polyurethane coating Product# Capacity Model Gauge Dimensions Weight .. 204201P 275 vert. 12 44' 27' 60' 257 204701P 275 horiz. 12 27' 44' 60' 257 205201P 330 vert. 12 44' 27' 72' 290 205701P 330 horiz. 12 27' 44' 72' 290 �. 211201P 275 vert. 10 44' 27' 60' 334 UL 142 also available(275 and 330 gal.) External finish: BEIGE polyurethane coating Warranty*:20 years Touch up paint: PE0056C "BEIGE" KR0001 (repair kit) ECOGARD Residential oil tanks with double-bottom protection system ECG Product# Capacity Model Gauge Dimensions Weight .. r`-0°M0 244201 275 vert. 12 44. 27' 60' 290 241201 275 vert. 10 44' 27' 60' 370 h- 245201 330 vert. 12 44' 27' 72' 334 External finish: BEIGE powder paint coating Warranty*: 25 years A Touch up paint: PE0055C "BEIGE" ECOPLUS ECOPLUS Residential oil tanks with ECOGARD + 20PLUS with polyurethane coating Product# Capacity Model Gauge Dimensions Weight .. �wt 244201P 275 vert. 12 44' 27' 60' 295 241201P 275 vert. 10 44' 27' 60' 375 245201P 330 vert. 12 44- 27' 72' 340 External finish: BEIGE polyurethane coating Warranty*:30 years Touch up paint: PE0056C "BEIGE" KR0001 (repair kit) 02- 02- 02- 02' TECHNICAL SPECIFICATIONS �-12+12+12+12-d •Steel ASTM A1011 •Female threaded openings •Pressure tested at 5 to 7 PSIG H — ——————— • UL 80&UL 142 listed Foj •Operation at atmospheric pressure �L -I MHH U L-80 *See warranty certificate for additional details 2-in-1 Double-wall tanks I HDPE plastic tanks inside a galvanized secondary containment supplyModel # Top opening Burner oil .. openingqty 961225 4 3/8"and 1/2"/top duplex bushing 720/158/190 48•28-44 150 Indoors/outdoors 961226 4 3/8" and 112"/top duplex bushing 1000/220/265 63 - 28 - 44 185 Indoors/outdoors Visual leak indicator TANKS COME FULLY PACKAGED AND EQUIPPED FROM Cast aluminum FACTORY WITH NECESSARY INSTALLATION ACCESSORIES tightening nuts -2" NPT galvanized steel fill pipe adaptor - Low-pressure vent and overfill protection alarm -Oil level gauge -Oil burner supply duplex bushing with tube adaptors -Optimal space utilization I it Primary tank of high-density polyethylene(HDPE) Warranty: 30 years` Exterior tank of two-sided galvanized steel sheet 2-IN-1 SAFETY TANK SYSTEM OPTIONAL Integral galvanized stand AND/OR SPARE ACCESSORIES GENERAL CHARACTERISTICS 2-IN-1 DOUBLE-WALL OIL TANKS ULC-S670/UL-2258 960000 Rain cover—mandatory for outdoor installations •Primary tank made of blow-molded high-density polyethylene(HDPE) 962245 Installation tie-down kit for 720 L/190 USG • Internal tank is fluorination treated for odor and chemical resistance, 9622" Tie-down kit for 1000 L/265 USG which is unique to the Granby 2-in-1 tanks' 962247 Leak indicator assembly for 720 L/190 USG •Secondary containment made of galvanized steel on both sides,tightly 962248 Leak indicator assembly for 1000 L/265 USG welded and edged using state-of-the-art manufacturing equipment •Visual leak indicator for the monitoring of the integrity 962266 Sealed fuel oil rope gauge 720 L/190 USG of the primary tank 962267 Sealed fuel oil rope gauge 1000 L/265 USG •Connection fittings made of cast aluminum for greater torque resistance 962280 Metallic cap nut ADC12 and greater peripheral sealing 971040 2"transition fiting for gauge • Rugged floor stand made entirely of galvanized steel E206-0001 Compression fitting 112"x 1/2"tube Suited for basements with headrooms as low as 60" E207F-999S Duplex bushing with 3/8"x 1/2"NPT fitting Ease in maneuverability and access through narrow doorways E208F-999S Duplex bushing with 1/2"x 1/2" NPT fitting only 28"wide E209-0001 Compression fitting 1/2"x 3/8"tube • Easy carrying due to light weight and welded handles E250-999S Threaded 2" NPT fill pipe adaptor •30-year limited warranty E540-999 2"NPT low-restriction vent and overfill alarm •B100 bio-fuel ready JE03002 Gauge gasket 3.275 x 2.725 x 0.125 UL157 •Optional rain cover mandatory for outdoor installation JE15020 Metallic cap nut 0-ring seal CDPM GRANBY "Consult warranty documents for details. ' 00 For more information, please contact the head office 'Fluorination is used to make specific w modifications to the surface properties of n 98,des Industries ^ u1 �.7c plastics such as wettability and permeation w Cowansville,(Quebec) J2K 0A1 Canada ® ` resistance.It is a process that has been used in the automotive industry for more m y sales@granbyindustries.com ULC-S670 than ten years way of reducing the permeation of fuel vapors from the tanks Z W granbyindustries.com UL-2258 of motor vehicles. ROBISON h "THE HOUSE THAT SERVICE BUILT" Executive Office. One Gateway Plaza, 4' Floor, Port Chester, NY 10573 i ) �✓ (914) 613581 FAX: (914)4) 345-5793 WASTE OIL DISPOSAL FORM www.robisonoil.com Hastings-on-Hudson (914) 478-5700 Mount Kisco Date of Disposal: 3/27/25 PERMIT ID MP25-040 (914) 666-5107 Peekskill 1 (914) 736-0043 Account #: MALBA04 Scarsdale OCT U 8 202-5 � (J- (914) 723-8000 Name/Address Rodrigo Malzyner VILLAGE OF P"F Yonkers BUILDING= (914) 963-1108 16 Bayberry Lane Follow us: Rye Brook, NY 10573 tacebook com/Robison0il _ No. of Gallons: 8 `.� twitter.com/RobisonEnergy1 �I Place of Disposal: Robison Oil — Port Chester Terminal Comments: Pick up from Port Chester Terminal by Enviro Waste t 1 Sign/ature Print Name & Title Heating Oil • Natural Gas • Electricity • Heating and Air Conditioning Service • Installations- Oil Tanks ROBISON f HE HOUSE THAT SERVICE BUILT" Executive k01N!!-!2 �\�� Office: One Gateway Plaza, 4"' Floor, Port Chester, NY 10573 (914) 613581 FAX: (914)4) 345-5793 CERTIFICATE OF DISPOSAL www.robisonoil.com SCRAP METAL Hastings-on-Hudson (914) 478-5700 Mount Kisco (914) 666-5107 Date: 3/27/25 PERMIT ID # MP25-040 Peekskill (914) 736-0043 Scarsdale(914) 723-8000 Customer: Rodrigo Malzyner 16 Bayberry Lane Yonkers Rye Brook NY 10573 (914) 963-1108 Follow us: Account #: MALBA04 91 facebook.com/RobisonOil © twitter.com/RobisonEnergyl Removal of (1}275 GALLON from the above premises Date of Removal: 3/27/25 Place of Disposar- M. Miller's Scrap lr—h & Metal Co. Inc. Fleet Signatur The undersigned certifies that the material will be processed for remel ing only and will not be sold as usable as is. / Si ature i Heating Oil • Natural Gas • Electricity • Heating and Air Conditioning Service • Installations • Oil Tanks No. 5625 M MILLER'S IRON•METAL•RECYCLING 914.939.1357 COPPER COPPER BRASS LEAD ALUM SS BATT STEEL CAST LT IRON MAX TARE NET 69 Traverse Ave., Portchester, NY 10573 �►yr �.�1s�s�,rrrtt�, �Irtrrl�l• ;I��.. r-..I��1► 00%t-1'��w►`*'`�` y ihsz�gt. � r dM►`rnS. y' '�,? ld►`�NI� s�1Y�!1 ��1 r.��, __ `�U6 `�N►. I ."ter S c � t�:l�� George Latimer c� y Jama Maisano Westchn O�1ntter County Executive Director,Consumer Protection Department of Consumer Protection ; Home Improvement License � i MEENAN OIL CO.. L.P. Fsi BURKE HEAT/ROBISON OIL 475 COMMERCE STREET A! HAWTHORNE,NY-10532 This license is issued in accordance with Article XVI of the Westchester County Consumer Protection Code and is valid only upon presence of the official department seal.Proof of citizenship or immigration status is not required for issuance of this license. NOT FOR FFDFRAI.PURPOSES s ' tatrw� 4Ir \o`Oonsu/?7P.,o > c License Number � on Date of Expiration 4 r WC-13355-H02 0 10111/2026 ` s�chester Co�� �NOM �+wprs-•-.fie. -•rpR— -R'e.-.:,,n: ( :an---q ATE AcoRO� CERTIFICATE OF LIABILITY INSURANCE D091r2o24D 2 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 endorsemenl(s). PRODUCER CONTACT Max Domes MARSH USA,LLC NAME 1166 Avenue of the Americas FA (aC PHONE EaU: 347-328-3107 � New York,NY 10036 E-MAIL max. Gnmarfh.rJlm ADORES: gqn�. Adn:NowYorK.certs@Marsh.com — -- -- --- INSURER(S)AFFORDING COVERAGE MAIC� CNt01414839-PETRO-ACORD-24- WVJItER A National Union Fxe Ins Cc Pittsburgh PA INSURED INSURER B: AIU Insurance Cc 1t1399 MEENAN OIL CO.,L.P.One Gateway Plaza INSURER C NIA WA 55 South Main St,4th FL INSURER 0: Port Chester,NY 10573 INSURER E INSURER F COVERAGES CERTIFICATE NUMBER: NYC-012044029-03 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 POUCIES 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 ADOL SUER POLIC POLICY EI(P LIMIT$ LTR POLICY NUMBER MIDOYEFF MMI ";% A X COMMERCIAL GENERAL LIABILITY GL 7032483 101012024 101012025 EACH OCCURRENCE f 1.000,0M CLAIMS MADE X OCCUR DAMAGE-0 RENTED PREMISES(Ea ocaw"ge). f 5W,000 X XCU MEDEXP(Anyone person) f 10,000 X Contractual _ PERSONAL 8 ADV INJURY S 1,060,000 GENL AGGREGATE LOST APP_l_DI1 PLR: GENERAL AGGREGATE f 5,000,000 X POLICY X LOC PRODUCTS COMPIOP AGG f 2.000.000 OTHER SIR f 1,000.000 A AUTONONLELIAGLRy 8682607(ADS) 1 010 1 20 2 4 iC1012025 COMBINED SINGLE LIW' s 5000,0m Ea accwem( B X ANYAUTO 862608(MA) 10/012024 10/012025 BODILY INJURY iP*r pe,son) f OWNED SCHEDULED AUtO�ONLY AUTOS BODILY INJURY(PK socJdsm) f "M NON-OWNED PROPERTYDAMAGE -- AVMGONLY AUTOS ONLY (Per accident) f (FELLA LIM OCCUR EACH OCCURRENCE f EXCESS LIAR CLAIMS4AADE AGGREGATE f OED RUENT40N f s B WORKERS COMPENSATION WC 016440129(CT.DE,MA,MO,MI,NH, 1010112024 101012025 X PER OrH- AND EMPLOYERS LIASILITY 4T6TVT1E_ _ER _ ANYPROPRIETORIPARTNERIEXECUTIVE YIN NJ,NY,PA,RI,VA,WV) 1,000,000 OFFICERMEMBER EXCLUDED? [_] NIA E.L.EACH ACCIDENT f (Mandatory In NMI E.L.DISEASE-EA EMPLOYEE f 1.000,000 Ifye�.desmbe under -- - DESCRIPTION OF OPERATIONS balow E.L.DISEASE-POLICY LIMIT f 1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS 1 VEHICLES(ACORD 101.Additional Rsma,"Schedule,may be stU.hsd N murs space Is rsRulndl Certificate holder Is included as additional Insured(except Worker?Compensation)where required by written contract. This insurance IS primary and non-contributory over any existing Insurance and limited to Yabtkry ansng oul of the operations of the named Insl,red sublecl to pofcy terms and conditions Waiver of subrogation Is aopkrable where required by written contract and subleti to policy terms and conditions. CERTIFICATE HOLDER CANCELLATION Village of Rye Brook Building Department SHOULD ANY OF THE ABOVE DESCRIBED POUCIES BE CANCELLED BEFORE 9M King Street THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Rye Brook,NY 10573 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ©1988-2016 ACORD CORPORATION. All rights reserved. ACORD 25(2016(03) The ACORD name and logo are registered marks of ACORD Workers' Y""oaK CERTIFICATE OF STATE Compensation NYS WORKERS' COMPENSATION INSURANCE COVERAGE Board I Legal Name&Address of Insured(use street address only) lb Business Telephone Number of Insured Meenan Oil Co.LP dba Robison Oil 845-782-8161 One Gateway Plaza Port Chester.NY 10573 1c.NYS Unemployment Insurance Employer Registration Number of Insured 8311425-2 Mork Location of Insured(Only required if coverage is specifically limited to 1d. Federal Employer Identification Number of Insured or Social Security jcertain locations in New York State.i e.a Wrap-Up Policy) Number 11-3093408 2 Name and Address of Entity Requesting Proof of Coverage 3a Name of Insurance Carrier (Entity Being Listed as the Certificate Holder) AIU Insurance Company Village of Rye Brook Building Department 938 King Street 3b Policy Number of Entity Listed in Box"l a" Rye Brook. NY 10573 WC 016440129 3c Policy effective penod 10/1/2024 to 10/1/2025 3d The Proprietor.Partners or Executive Officers are inClUded.(Only check box if all partnersiofficers 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 1 a 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 Don Bailey (Print n e of authorized representative or licensed agent of insurance carneo Approved by 9/19/2024 (Signature) (Date) Title CEO, North America Telephone Number of authorized representative or licensed agent of insurance carrier. 212-770-7000 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