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HomeMy WebLinkAboutMP25-086 yC_4 . 19 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 July 11,2025 Mary Dillon&Nancy Echausse 245 Tree Top Crescent Rye Brook,New York 10573 Re: 245 Tree Top Crescent, Rye Brook,New York 10573 Parcel ID#: 129.76-1-76 This document certifies that the work done under Mechanical Permit #25-086 issued on 6/5/2025 for the installation of a new above-ground oil tank has been satisfactorily completed. Sincerely, Steven E. Fews Building&Fire Inspector /to O Q � .1 ui LDING DEPARTMENT ,❑�BUILDINC.I.NNI-E roR klANNISTANT RLn1.1,ING INSPECTOR VILLAGE OF RYE BROOK ❑COI»4 IiNk(1xc1tm.1'.NT Okklf 131t 938 KING;STRI?FT •RYI?BROOK,NY 10573 (91.4) 939-0668 FAx (914) 939-5801 www�. 01 ro()lr--Q-rg - - - - - - - - - - - - -- - - -- - - - - INSPECTION REPORT - - - - - - - - - - - - - - - - - - - - ADDRESS: R.�Q, � l �J DATE' J D PERMIT# P as- c7 8(o Issu1:D:�,,S—Z�51aCT• o� (. BLOCK: LOT: 7 !c LOCATION: __ —�Ct6./� d _ OCCUPANCY' ❑ VIOLATION NOTED 1.I3E WORk IS... 9/'ACCI?I►TEI) ❑ REJECTED/REINSPECTION ❑ SITE INSPECTION REQUIRED ❑ FOOTING ❑ FOO' ING DRAINAGI ❑ F017NDA-110N ❑ UNI)laR(aRc)UNJ)PLUMBING NOTES ON INSPECTION: ❑ ROUGH PLUMBING ❑ ROUGN FRAMING ❑ INSULATION ❑ NATURAL GAS - Tom, .t rI N P.c�7 ❑ Lit GAs jall"FUI(L TANK - �� � � ❑ FIRE SPRINKLER ❑ FINAL I ❑ CROSS CONNECTION /1 '.�._ � ro�-7 !� • � /,,,� ❑ FINAL A i►1 /�y� /U t� S / ►r ❑ OTI ER ----�-- ' x , x s = a a � � = QQ n ■ OI N CK N a ■ N O Neq Ln t( v U CAP° � y ' Cw� 0 W a = H a a� .a � N Er ■ Fq 'C �-- W y o � � U A � ,� 0 3 y ❑. � h M R Z g b a a C� ?d e "' y Q o00 w c W y a ai a w A _ z�./ W � C13 '� 2 ° 4 [ w E a (� W ap Cl) w A O ca U - V � U 0. = Z W ° z a o c� O cC, U w to f,7 v] 'b Q e M _ z o o �° , 00 s. zbo (77 YII"+Vgl � o V � � p w r-1 09 Z O C b G" � a W - E� O w 00 H �o -E .- u u? C7 H A p A O N A w Cl) � � od cn v a ° I OA �� BUILD MENT D VIL OF ItY OOK 938 Kr1vG ET RYE BR ,NY 10573 MAY 2 9 2025 a 40 -� ov VILLAGE OF RYE BROOK BUILDING DEPARTMENT Avpficafion for Permit to Install Fuel Storage Tank (*Storage Tanks in excess of 1,100 gallons require registration with the County of Westchester) FOR OFFICE USE ONLY: PERMIT#: Approval Date: t,`} Permit Fee: $ Approval Signature: Other: Disapproved: (fees 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: 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: $185.00 per Tank. 5. Dig Safely New York#(dial 811):_ 111A 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, �,2 y J 2 Sr , 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 ice}•Buried in Ground ( ) 1. Address: S� " 1f 'P��/I Cr CSC P -t` SBL: 1 a /, 7/a "/— & Zone: JOUb 2. Property Owner&Address: C q Er-HijuSfe en�- /' P /ybk v Phone#: Cell#: ti / email:I'lAc v ry C kAuSt e 1 3�a�,(•&I-/ 3. Contractor&Address: Phone#: (Fw-)rb l- /S"!2 Cell#: Noma-, C-4s 77`7- email: (W llglfeAV. �,vf 4. Applicant: I(/ _n o re-kaoS 4e- Phone#: Cell#: (r6 y/o/ email: I �c�avSS� C„�fitrr`•c�-f 5. Indicate Fuel Type:Fuel Oil a-L.P. Gas( )•Gasoline( )•Other( ): 6. Number and Capacity of each Tank: r — ;z 7S �r Tan w�1/ot 7. Exact Location(s)of each Tank: IN i�7>o r le✓lyon-( U ukt tR_ on Ooit c r e-�e Ot d t 6/1/2024 STATE 1;NEW YORO JNTYJNTY 0—- CHESTER } as: `, t e g duly sworn,deposes and states that he/she is the applicant above named, t name of i uat siding as the applicant) and furthers (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 trace 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 Z Z Sworn to before me this Z _ I ay of—��— 20 pt 1~ day of__.._. 20 ^tip S'i Signature o operty Owner Signature of cant I e�ck&-�If, Print Nam of Property Owner Print Name o pplie t / t v of ryry Publtc Notary Pu lie vivi F i DEGE*!!'�4DT WMPAu[ nEGEMH ?^T laotafy ac,Statoof New York '.atary Public,State u,F No. 97135 I,pu.4997— C,:ali'.'ird in Westcl e or oun� qualified i` ' 6/eIriyZeornpleted This applicaMil Fmust be prc� 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 retumed to the applicant. IAIC a ,,/ 2 6/l/2024 The Arbors Homeowners' Association 173 '/2 Ivy Hill Crescent Rye Brook, NY 10573 RJuly 10th, 2025 ' JUL , O 2025 Ma Dillon VILLAGE OF RYE BROOK Mary BUILDING DEPARTMENT Nancy Echausse 245 Treetop Crescent Rye Brook, NY 10573 Re: Above Ground Oil Tank Dear Mary and Nancy. The Architecture and Grounds Committee (A&G) and the Board have reviewed your application for the above-named work. The application is approved and might require screening or painting of your tank. The paint color would match the house color. This will be determined after installation. An inspection of your tank location reveals no screening is required based on location therefore no paintinq of the tank is required. 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 QyE BRC�u,� O� tim 1982 BUILDING DEPARTMENT DILDING 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 : Z "15' 2 / V P m , DATE: ( - zo- ZO�jS PERMIT# m` 2s--O cS ISSUED: b S-- SECT: Z�BLOCK: LOT:2� 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 ❑ INSULATION n / ❑ NATURAL GAS ❑ L.P. GAS Lon 11 F I Gc C+ 4e-'•j yC t 1 FUEL TANK ` ❑ FIRE SPRINKLER .� ono.,se cb L6, ❑ FINAL PLUMBING / n S D /• n . ^' \ ❑ CROSS CONNECTION �1 .) ❑ FINAL ❑ OTHER Jim I IN ; � e l e - _ noun Mona. 4 1N 1 S '• I 111 _W-4 i ��('� � � .,. �(, �,f . -t .! ' , .�_ �.. ,_ . � � � ; 4, 1 6 � ti ��� � � � , :n f "✓' �,� � 4 `��,j,J �. � ��� .��:T. r .' r: .I�" �. '`: jJ � � .� ', v1}� .`Alf ♦, �^ , i , �• � �. • � �. �n.,; � f�s_ �.� -_2 �` /. 3t if'f �, �1 '�'1. �, '� �y `� . ��, j• �1 �\ 1 i'!: ►_ ,,,� �� I � O s J ti U - fl( 0 V Z p ECEIWE JUN - 5 2025 T e Arbors Homeowners' Association LVILLAGE OF RYE BROOK I BUILDING DEPARTMENT173 1/2Ivy Hill Crescent �__ _ Rye Brook, NY 10573 i May 28th, 2025, Mary Dillon Nancy Echausse 245 Treetop Crescent Rye Brook, NY 10573 Re: Above Ground Oil Tank Dear Mary and Nancy, The Architecture and Grounds Committee (A&G) and the Board have reviewed your application for the above-named work. The application is approved and requires screening or painting of 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 C, Roth Worldwide Downloads Rc3+h Home Products Oil Storage Tanks Double-Wall Heating Oil Tanks r t� } J .�: W--Tani lhrl►I!llb�"t'iiri�����l:+►� IIIII�I. �..i1 �... Double-Wall Heating Oil Tanks Oil heating is still an economical and environmentally-friendly heating technology and,above all,it is unsurpassed in safety and inexpensive.Economical,space-saving,and unproblematic storage of the fuel is also one aspect of the complete heating system. Roth heating oil tanks are designed for this purpose.Roth heating oil tanks are a safe solution for all situations:in detached houses or multiple dwelling units,in apartment blocks or business premises,in new buildings,extensions,or renovations.Click here to find a Roth Certified Installer in your area. TANKS The Roth Double Wall Safety Fuel Oil Storage Tank(DWT)is made with a r seamless blow-molded polyethylene inner tank and a 19 ga.galvanized outer -- tank.The outer tank is formed by joining cold rolled sheet steel,used to form _ I the sides and bottom from a single piece,with two stamped metal end pieces. The edges between the sides and ends have sealant applied to them and are then rolled to create leak-proof seams. A stamped top is then pressed and riveted into place to complete the assembly of the DWT. The DWT is UO listed in the United States and Canada under SU2258 and approved under NFPA 31 (2001) and CSA B-139-04 as non-metallic fuel oil storage tanks. Both inner and outer tanks are pressure tested at the factory during assembly according to UL®standards and do not require further field testing. The DWT also comes with a detached saddle base which the tank is placed on at the time of installation.The tank shall be placed into service in accordance with local codes and the listed use(indoor or outdoor)on a flat,level and stable surface, away from heat sources,corrosive atmospheres or fluids,potential mechanical damage or rapid temperature changes.The final location must have the tank label visible after installation. A minimum of 2" (50 nun)from all walls or obstructions is recommended for normal tank expansion and visual inspection. The integral base support shall not be removed and raising the tank height is not allowed except on a continuous concrete platform at least 6" (150 mm.)wid- er than the tank base at all sides.All local fire code set-backs for fuel oil storage tanks must be observed. 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Double-Wall Oil Storage Tank Part# Description Weight lbs.(kg) 2335103401 ROTH DWT 400L-110 Gallon,UL Listed 99.23(45) 2335101861 ROTH DWT 620L-165 Gallon,UL Listed 136.71(62) 2335101862 ROTH DWT 1000L-275 Gallon,UL Listed 198.45(90) 2335103722 ROTH DWT 1000LH-275 Gallon,UL Listed 208(94.4) 2335102642 ROTH DWT 1500L-400 Gallon,UL Listed 312(141.5) Roth Industries 888-266-7684 1 DWT Product Catalog 3.2019 7 5 6 0 2 • • 3 1 i 4 Roth Double-Wall Oil Storage Tanks Residential Oil Fuel Tanks 1.Weld-free galvanized steel outer tank capable of holding 110%of the primary tank. 2.Seamless high-density polyethylene inner tank. 3.Highly visible optical leak alarm. 4.55%lighter than a 12-gauge steel tank with a larger storage capacity. 5.Corrosion-resistant steel filling system with external 2"thread,allowing for an even level in each tank when installed in groups. 6.Burner feeding system consisting of a fusible link valve and check valve incorporated with supply and return port when using the optional Roth suction assembly. 7.Cover for outside use FEATURES: • Up to 50%lighter than conventional steel tanks. • Wide handles on each end facilitates transport and handling. • Removable base facilitates access to tight spaces and offers greater stability. • Compact and economical design.(8 sq.ft.for 1000L) • No fittings below the oil line. • Unique expansion system ensures increase storage capacity and faster,easier fill-ups. • Completely sealed,every one of our tanks is pressure tested and meets exacting quality control standards. • Premier Industry Warranty of 30 years with 10 years insurance,$2 million clean up policy* *Roth double-wall oil storage tanks come with a 30-year warranty when installed by a Roth Certified Installer. Becoming certified is free and easy. For more information on becoming certified,contact us. DWT 400L DWT 620L DWT 1000L DWT 1000LH DWT 1500L Nom.Capacity U.S.Gal(liters) 110(400) 165(620) 275(1000) 275(1000) 400(1500) Length:inches(cm) 29(74) 29(74) 43(110) 51(130) 64(163) Width:inches(cm) 28(72) 28(72) 28(72) 30(76) 30(77) Height:inches(cm) 44(112) 61(155) 61(155) 54(137) 68(173) Min.Height:Inches(cm) 49(125) 66(168) 66(168) 60(152) 76(193) Tank Weight:lbs.(kg) 106(48) 132(60) 167(76) 208(94) 333(151) Shipping Weight:lbs.(kg) 115(52) 143(65) 185(84) 230(104) 258(162) ENVIRONMENTAL PROTECTION Roth double-wall tanks are designed to offer the highest level of environmental protection.Avoid oil spills and leaks caused by defective pipes,couplings,or fittings which are located underneath the tank. Every inner Roth tank is made out of blow-molded, high-density polyethylene that is seamless,absolutely leak-proof,and corrosion-resistant.In addition,Roth tanks feature top connections to ensure the oil stays where it should.The outer tank is made of leak-proof corrosion resistant steel which is capable of containing at least 110%of the capacity of the inner tank for maximum protection. SAFETY AND SECURITY Roth tanks are completely rust-free,inside and out.Minimize the potential dangers and disasters of oil spills and leaks caused by corrosion.The outer tank is made out of galvanized steel,roll seamed(no welds)with an oil and fire-resistant seal,making it one of the safest and most reliable tanks on the market.Roth uses state-of-the-art technology to ensure maximum storage safety and minimum space requirements. More than 4 million tanks installed Since 1971 more than 3 million Roth tanks have been installed in Europe and North America.Roth tanks last longer than ever before due to the outstanding quality and the unbeatable guarantee.That is why Roth tanks enjoy such an enviable reputation. Find a Rep Find your local Roth sales rep. Any Country Please select your state to find a local sales rep. Roth Products Copyright 2025 Roth. -k w '."�+ w .... `4�3n w •'.•pl• 3a w'• •a+T. 8.'r�S+ w wr-' A it p A i`y{` �j y �ljt+1 ,,���('U xx33`` ,(�(�J� 17 1~�••�/ `g t1 44, ,/ {�Phi �� rJ ,.,�• v `R....'"1' '�r'' .. Xi `. �111i -*j �9j1 11•li' 4 , /, ��.. tiz=:-111 111 +�. a til 111.) 111 Illy s 1/1 1j1.' ; �•. 1 llss> � 4 dam) �l(q)1,- emu._.: .,_�.:_'s�3. 1... ! .s -3.� s.r.._ %i<'11•s�.:iza:i •-�£ 1) 1�'.ea t r•.: 11 1� � •��.I � `s�.� IF N ' tv cuIN 40 i .� �+ U G Q.1 •., j wLO rMo w o � o : V C ZO ui uj w m 3 r o r rQ4 l(o)> �.1 �i Z Z o := �1�p aQ 'i,I ♦"r uj �" O :. Q Xw G� v g f llr a>— '-E L O Q 1 ;ica;rs)i y A cCa pL"` �aeii� OLn y t\ aye 10 A y i a y �p E 00 7 1. 40 v jy s- '.^�3:i.`-,'1►ill. ./1 11 -5*, .: sa`�T-1 1 t ;F =f+s r�•� �-�i�f-•As—•—�=rWltT ,/ yl 11/�111 I+1 dt`t 11� �3e{llpr d 1 h��tlf!/j� a7�� m { ti\ t+�cc�,aty'ity� �'FIl � � 1(�ll !# n 1 /�l N��f ��1 r 7''iIA �R� � r 11� �/�1 ,}.�i�A7i•'{3 ^(lf�Al AC- DATE DATE(MMIDOrYYYY) "R CERTIFICATE OF LIABILITY INSURANCE 05/20/2025 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 Caren Mallianer NAME C&H Agency PHONE (973)890-0900 — AX (973)812-9860 AI s Alt No 55 1 ane Road.Suite 7 111 E-MAIL cmaflhaner"r4chagency com ADDRESS. PO BOX 10003 INSURERS)AFFORDING COVERAGE NAIC a Fairfield NJ U/004 INSURER A. Great Divide Insurance Company 25224 INSURED INSURER 8 Key Risk Insurance Company 10885 Optima Environmental Services,Inc. INSURER C. 92-94 Stewart Avenue INSURER D Newburgh,NY 12550 INSURER E INSURER F COVERAGES CERTIFICATE NUMBER: 25-26 GL.A,U.WC 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 l IMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS INS POLICY FF POLICY P LTR TYPE OF INSURANCE POLICY NUMBER LPOLIC EFF MW ICY FXP LWFTS yYY COMMERCIAL GENERAL LL#AtrTY EACH OCCURRENCE f 1.000.000 CLAIMS-MAD E ®OCCUR PREMISES Ee ocprrence f 3�'� XCU Included MED EXP(Arty ons parson) f 5.000 A X Contractual Liability ECPOl536097-23 04/01/2025 04/01/2026 PERSONAL S ADV INJURY f 1.000.000 GEN'L AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE f 2.000,0W POLICY ©PRO- ❑LOC PRODUCTS-COMPiOP AGG f 2.000.000 OTHER Pollution Liability f 1,000,000 AUTOMOYIL[LAAMITY LOMBINED SINGLE LIMIT f 1 000 000 Fa a<.cWenl ANYAUTO BOOR INJURY(P.personi S B OWNED S(HLDULED BAP1536099-23 04/01/2025 04/01/2026 HODIIY INJURY leer accaani) f AUTOS ONLY AUTOS TY HIRED NON-OWNED PROPER DAMAGE f AUTOS ONLY ALITOS ONLY Pnr accMenl f UMBRELLA LIAR EACH OCCURRENCE f 5,000,000 A EXCESS LLAS CLAIMS-MADE FFX1536098-23 04/01/2025 04/01/2026 AGGREGATE S 5.000.000 DIED I I RETENTION S 1 f WORKERS COMPENSATION PER OTH. AND EMPLOYERS'LL4JMUTY Y I N TAT ER A ANY PROPRIFTORIPARTNER/EXECUTIVF E.L.EACH ACCIDENT S 1,000,000 OFFICERIMEMNI R EXCLUDED? ❑ NIA WCA2011314-21 04/01/2025 04/01/2026 (Mandatory in NN) E.L.DISEASE-EA EMPLOYEE f 1.000.000 it yes describe under 1�0�0 DESCRPTION OF OPERATIONS bok- E.L.DISEASE-POLICY LIMIT s DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is requited) Re- Permits. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN Building Department Village of Rye Brook ACCORDANCE WITH THE POLICY PROVISIONS. 938 King Street AUTHORIZED REPRESENTATIVE Rye Brook NY 10573 4f rg 1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD S NEW Workers' CERTIFICATE OF YORK ---`'SENATE Compensation NYS WORKERS' COMPENSATION INSURANCE COVERAGE Board 1a.Legal Name 8 Address of Insured(use street address only) 1b Business Telephone Number of Insured 845-561-1512 Optima Environmental Services Inc tc NYS Unemployment Insurance Employer Registration Number of 92-94 Stewart Avenue Newburgh NY 12550 Insured Work Location of Insured(Only required if coverage is specifically limited to 1d Federal Employer Identification Number of Insured or Social Security certain locations oil New York State,i e,a Wrap Up Policy) Number 47-4028616 2 Name and Address of Entity Requesting Proof of Coverage 3a Name of Insurance Carrier (Entity Being Listed as the Certificate Holder) Great Divide Insurance Co Building Department Village of Rye Brook 3b Policy Number of Entity Listed in Box 'I a' 938 King Street Rye Brook, NY 10573 WCA2011314-21 3c Policy effective period 04/01/2025 to 04/01/2026 3d The Proprietor,Partners or Executive Officers are aX included (only check box if ail paitnarsibfhc.eis includedi all excluded or certain partners/officers excluded This certifies that the Insurance carrier Indicated above in box 1"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 f[5fn-M on the INFORMATION PAGE of the workers'compensation insurance policy). 1 he Insurance Carrier or Its licensed agent will send this Certificate of Insurance to the entity listed above as the certificate holder in box"2" l he 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 nlay 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 cunfeis 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, CarerLM ilthaner (Pn name of authowr ep sentative of licensed agent or insurance carrier) Approved b� C-Az-/- QVj 5/20/2025 (Signature) (Dale) Title Account Executive I elephone Nunlbef of authorized representative or licensed agent of insurance carrier 973-890-0900 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