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HomeMy WebLinkAboutPP19-178 O0 � N N a V1 �: PLOON Lij d r CAC� O rr�r 3 ; 01*4 Ur > = m r W M M N w _ ;D N o 16 �, a z = 1. �RC��jk,, D � l� LE � V LE Bum E MENT VIL E OF RYE OK OCT —2 2019 938 KIN ET RYE B ,NY 10573 (914)9 939-5801 VILLAGE OF RYE BROOK _ oria BUILDING DEPARTMENT- PLUMBING PERMIT APPLICATION FOR OFFICE USE ONLY BP#: PP#: Approval Date: OCT - 3 1019 Permit Fee: $ Approval Signature: Other: Disapproved: C�E__ (fees are non-refundable) Application dated, in1t91i(Ris 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: I Tamarack Road SBL: J OD56g+1 Zone:R_ 2.Proposed Work: 2 separate locations for Street Sanitary Tie-ins 3.Property Owner: PortChester School District Address: 113 Bowman Avenue,Rye Brook NY 10573 Phone#: 914-934-7900 Cell#: email: rrenda@perufsd.org 4.Master Plumber: Steve Pirzinger Address: 57 S Central Ave,Elmsford,NY 10523 Lic.#: 1444 Phone#: Cell#: 914-438-0747 email: Steve@twpplumbinginc.com Company Name: TWP Plumbing& Heating Inc. Address: 57 S Central Ave,Elmsford NY 10523 INDICATE FIXTURES&LINES TO BE INSTALLED AS PER THE FOLLOWING SCHEDULE: Location Water Urinals Drinking Sinks Showers Bath Laundry Domestic Fire Sanitary Natural/ Other* Total Closets Fountains Tubs Tubs Service Service Sewer LP Gas Basement Ist Floor 2nd Floor 31d Floor 4d1 Floor 51 Floor Exterior 5.* List Other Equipment/Provide Details: 2 Sanitary Tie-ins on Tamarack Road (Notarized Signatures Required Next 2 Pages) 3/21/19 A; STATE OF NEW YORK.-COUNTY OF WESTCHESTER ) as: S� t 8(2 t ( ,being duly sworn,deposes and states that he/she is the applicant above named, (print name of individual signing as a applicant) and fitrther states that(s)he is the legal owner of the property to which this application pertains,or that(s)he is the W f" hAw16 ru R e4i"!!�j fvtc- 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 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 aC0 Sworn to before rt)e this day of o Ir e--c. 20 / q day of 20 Signature of Property Owner Signature of Applicant .4'' l' , Steve Pirzinger Print Name of Property Owner Print Name of Applicant I ota y Public Notary Public 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. 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. -2- DIANNE ROJAS 3/21/19 Notary Public-State of New York DONNA L. MARTIN No.01R06127547 Qualified in Westchester county NOTARY PUBLIC,STATE OF NEW YORK My commission Expires May23,2021 Registration No.01 MA6371402 Qualified in Westchester County Commission Expires February 26. 2022 A6 BUILD1�1./- \` MENT F '-_ 1 i VI . EOFRY OOK OCT -2 26j9938KING TREETRYEDR ,NY 10573 (914)939.-0668 F 9 39-5801 GE OF RYE BROOKi ebr 6] . !NG 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 YORK, COUNTY OF WESTCHESTER ) as: 3J, , residing at, r'5-b &,j t-o Ave 6 y e l fbe)k IVY (Print name) (Address where yiw live) 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 thisXt davit of Compliance pertains at; �u►mar.,c/� Ae5 kc /U.S-73 , Rye Brook, NY. Club,Address) 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. (Signature of Property Owner(s)) (Print Name of Property Owner(s)) Sworn to before me this 011 FN01_,ARY NNA L. MARTIN day of , 20 BLIC.STATE OF NEW YORKion No.01MA6371402 (Nota ubhc) in Westchester County Commission Expires February 26. 2022 3/21/19 A ® DATE(MM/ Y) CERTIFICATE OF LIABILITY INSURANCE os/17/2019 2o1s 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 Donna Jordan NAME: Keevily Spero Whitelaw,Inc. PH ONE (914)381-5511 FAX (914)381-1134 (AlC No Ext: __ _ AIC,No): 500 Mamaroneck Ave E-MAIL djordan@keevily.com ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC p Harrison NY 10528 INSURERA: Merchants Mutual Insurance Co 23329 INSURED INSURER B: Travelers Indemnity Cc 25658 T W P Plumbing&Heating Inc INSURER C: 57 S.Central Avenue INSURER D: INSURER E Elmsford NY 10523-3513 INSURER F: COVERAGES CERTIFICATE NUMBER: 19-20 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 POLICY EFF POLICY EXP LTR INSD WVD POLICY NUMBER MMIDDIYYYY MM/DD/YYYY LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE S 1,000,000 DAMAGE TO RENTE CLAIMS-MADE � OCCUR PREMISES Ea occurrence $ 500,000 MED EXP(Any one person) S 15,000 A Y BOP1079157 05/01/2019 05/01/2020 PERSONAL BADVINJURY $ 1,000,000 GEN'LAGGREGATE LIMIT APPLIES PER. GENERAL AGGREGATE s 2,000,000 POLICY ig JEl° LOC PRODUCTS-COMP/OPAGG $ 2,000,000 R OTHER. Contractual $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000.000 Ea accident X ANY AUTO BODILY INJURY(Per person) S A OWNED X SCHEDULED CAP1062915 05/01/2019 05/01/2020 BODILY INJURY(Per accident) S AUTOS ONLY AUTOS HIRED NON O MED PROPERTY DAMAGE X AUTOS ONLY X AUTOS ONLY Per acatlent S $ X UMBRELLA LIAB X OCCUR EACH OCCURRENCE S 5,000,000 A EXCESS LIAB CLAIMS-MADE CUP9146777 05/01/2019 05/01/2020 AGGREGATE s 5,000,000 DED I X RETENTION S 10,000 S WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY YIN STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? N/A E.L.EACH ACCIDENT S ❑ (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE S If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT S A ZUP-81N14165-19-NF 05/09/2019 05/01/2020 $5,000,000 Excess Liability $5,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached If more space Is required) Village Of Rye Brook is included as an additional insured with respects to the General Liability when required by written contract. 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 10573 :7^ r ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD NYSIF Now York State Insurance Fund 199 CHURCH STREET, NEW YORK,N.Y. 10007-1100 I nysif.com CERTIFICATE OF WORKERS' COMPENSATION INSURANCE a ,o ^^^^^ 133507613 KEEVILY,SPERO-WHITELAW INC. 500 MAMARONECK AVENUE 0 HARRISON NY 10528 SCAN TO VALIDATE AND SUBSCRIBE POLICYHOLDER CERTIFICATE HOLDER TWP PLUMBING& HEATING INC VILLAGE OF RYE BROOK 57 SO. CENTRAL AVENUE 938 KING STREET ELMSFORD NY 10523 RYE BROOK NY 10573 POLICY NUMBER CERTIFICATE NUMBER POLICY PERIOD DATE G 936 365-6 261378 05/01/2019 TO 05/01/2020 9/17/2019 THIS IS TO CERTIFY THAT THE POLICYHOLDER NAMED ABOVE IS INSURED WITH THE NEW YORK STATE INSURANCE FUND UNDER POLICY NO. 936 365-6, 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:/M/WW.NYSIF.COM/CERT/CERTVAL.ASP.THE NEW YORK STATE INSURANCE FUND IS NOT LIABLE IN THE EVENT OF FAILURE TO GIVE SUCH NOTIFICATIONS. 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 DIRECTOR,INSURANCE FUND UNDERWRITING VALIDATION NUMBER: 18566625