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HomeMy WebLinkAboutMP25-147 DR J �• 190 t ct v 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 November 3,2025 Rohit Sharma&Lovleen Sharma 64 Rock Ridge Drive Rye Brook,New York 10573 Re: 64 Rock Ridge Drive, Rye Brook,New York 10573 Parcel ID#: 135.36-1-17 This document certifies that the work done under Mechanical Permit #25-147 issued on 10/3/2025 for the removal of an above-ground oil tank has been satisfactorily completed. Sincerely, Steven E. Fews Building&Fire Inspector /to �QyE[3RC�� O Z� w � 1982 BUILDING DEPARTMENT ❑BUILDING INSPECTOR �MSSISTANT 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 :_J2 -- � R'►� Q,_ 't. - -- — DATE: PERMIT# -WS- 1 '17 BLOCK:_. LOT:1— LOCATION: � S t V--(A-J • OCCUPANCY: ❑ I Violation Noted HE WORK IS.... PASSED FAILED REINSPECTION ❑ SITE INSPECTION REQUIRED ❑ FOOTING ❑ FOOTING DRAINAGE ❑ FOUNDATION ❑ UNDERGROUND PLUMBING NOTES ON INSPECTION: ❑ ROUGH PLUMBING ❑ ROUGH FRAMING ❑ INSULATION ❑ Natural Gas ❑ L.P. Gas P.-TUEL TANK • ❑ FIRE SPRINKLER ❑ FINAL PLUMBING W I •C` `C �,,, e ��/ ❑ CROSS CONNECTION ❑ FINAL we- r ❑ OTHER �/✓� QyE DRC�v� w � 1982 BUILDING DEPARTMENT PBDING 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 : (40 ?0cl-- �1 �e �V`C/ DA1'E:,42 -3-- - - PERMIT# �' •� �U / 7 ISSUED: $ECT:__ �J�� BLOCK:_ LOT: LOCATION: ze '� S/('� c'... OCCUPANCY: ❑ Violation Noted THE WORK IS... rJ PASSED ❑ FAILED REINSPECTION ❑ SITE INSPECTION REQUIRED ❑ FOOTING ❑ FOOTING DRAINAGE ❑ FOUNDATION ❑ UNDERGROUND PLUMBING NOTES ON INSPECTION: ❑ ROUGH PLUMBING ❑ ROUGH FRAMING ❑ INSULATION I ElNatural GasZ C.•.G 1 V4 C s & ` UEL TANK ❑ FIRE SPRINKLER ❑ FINAL PLUMBING L ❑ CROSS CONNECTION f� W ❑ FINAL La I Gy ❑ OTHER ° N '0 Cq N N \ .ti y ++ a c w F cnONO 9:6 VJ °gs fsr � h W M P. O v �� O ^ z 72 v F+■1 w o o 0 i ° C o0 �, F L=r 3 a �+ cn � b O Q O 1 Q w �] cn d V o o f0.VU D QI `a w wa Vov W W oc 0 F . O r1; W i Ln In - - a O W<, Z PG 00 O O y p vy `0 a ao C 'O a�i V U Qy W z b A COD�..,.r � ~ O M z OWL" z G� W U v. O oOE Q � O aPC, o MM .� .a.� ° IN 1�•1 � Q! Q � I� r� WA � 0 O V z � � ►�"i �O v w (.� H A z A Oj a ° N ° z w W d O � � c � q b A O W aC:W5104 �I � a a a w 0 � � �� BUILDING DEPARTMENT VILLAGE OF RYF BROOK 938 KING Sm.F:r RYF.BR()OK,NY 10573 (914)939-0668 Ww N.r�eb rookn}.Ltty Application for Permit to Remove or Abandon Fuel Storage Tank (*Storage Tanks in excess of 1,100 gallons require registration with the County of Westchester) FOR OFFk-T..tISF ONLY: I'I R1%I1 1 0: MP Pd" 5-1 Approval Date: 10 �\ Permit Fee:S Approval Signature: Other: Disapproved: ((«a m ooa rettadadla) ►aAaAalar►raaAafAAAAAAAAAAAAAA►f•1AAAA►►►•AAA►►►►•ArraaAr►1A►►►AA•►►a1AAlraa►lA►a AAAAaf AAa►►fAAAa►A►►•• DO NO] SIARl'WORK or CONS1RUCTION UN Ill,A PERMIT IIAS BEEN ISSI ED RN'THE Nl'II.DING 1Ns1'FC IOlt. HIE ADMINISTRATIVE FF.F FOI(WORK PROGRESSED OR COMPLETED WFF1101 I .%PERMI I IS 12%OF THETOFALCOS-1 OF'CONS IRI ("IION WI111 z% MININII'%I I•FF OF S150.011 REOVIRFMENTS 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: Removal or Abandonment S??�.00 her I ank. 5.Dig Safely New York#(dial 81 1): '`,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. •arraaaaAr+uruurAAAaaa♦ra►♦►AAuura+ruarararraraaauuu•auarrarrrura+araaar+auauarurraaaAr• Application dated, SF-r,-r61` Z`�,Z��.is hereby made to the Building Inspector of the Village of Rye Brook for a permit to remove or abandon 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 or abandoned in conformance with all applicable Village,County,State&Federal laws,codes, rules and regulations. aa•r♦r•+araur•araara ur••arrrurarruaaraaaarrarauarauraraatrarraaarrrrurararar•►rurraraaraaaurr Indicate Permit Type: Removal(vf-Abandonment( )/Above Ground(Buried in Ground( ) I. Address: �t SBL:155,�>40 ie/ Zooe: � o 2. Property Owner&Address: - ' Phone#:I Au�(`f"I Q Imo _ Cell C (A0 4qQ(A 600 email: (0 K. l( C7 MI 3. Contractor&Address: Phone#:;)--3-3�s� Cell#: email` ��oC=�-��,2�Sl,«.w. 4. Applicant: ,Rc 6,&-J Phone#: 3 38c Cell#: email: 5. Indicate Fuel Type:Fuel Oil(vyeL.P.Gas( )•Gasoline( )'Ocher( ): 6. Number and Capacity of each Tank: a ofeadrTank: 7. Exact Location( ) t 6f IR02S l - ..ter--•. STATE OF NEW XORK,COUNTY OF WESTCHESTER ) as: Leron(Af� Ch%CGV)'o ,being duly sworn,deposes and states that he/she is the applicant above named, (Prim erne of' qi�M 60 swum) and further states that(s)he is the Tank Removal/Abandomnent 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 dt Building Code,the Code of the Village of Rye Brook and all other applicable laws,ordinances and regulations. l Sworn to before me this .,1 Sworn to before me this .2 day o f 202_ 20 a 7 Signature of Property Owner Signature of Applicant Leor,oro< /RQCh.c 10 �Nl ame of Prope Owtxr Print N e of AppliaotY NOVOLI-SANTOS No b ry?GU x,State of Connecticut u c,State of New York No.OIME6160063 My Commission Expires May 27,2026 Qualified In Westchester County CotI his rUsaappltcation must try v9 rog4 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. I 611f s i A. ENVIROSHIELD Clean. Preserve. Protect. October 29,2025 Mr.Joseph Amelio Encore Development Ltd. Re: 64 Rock Ridge Drive D EC(i;� ��R n Rye Brook,NY 10573 v Re: Aboveground Tank Removal,October 24,2025 OCT 3 12025 Sharma Residence 64 Rock Ridge Drive VILLAGE OF RYE BROOK Rye Brook,New York BUILDING DEPARTMENT Dear Mr. Amelio: On October 24, 2025, Enviroshield completed the removal and disposal of one 330-gallon aboveground fuel storage tank located in an enclosure on the exterior of the residence at the subject site. The former location of the tank and progression of the tank removal process is shown in Site Photographs enclosed with this letter. Prior to the removal of the tank,the enclosure and tank were cut open for access to the interior of the tank.All remaining liquid,sludge sediment and rinse water were pumped and cleaned from the tank for disposal by Enviroshield,a State of New York licensed waste transporter at Safety-I{leen Systems, Inc., 120 Forbes Avenue, New Haven, Connecticut. Attached is a copy of the waste transport bill of lading. The tank was cut up and disposed of at P.C.Metals,270 Central Avenue,Bridgeport,Connecticut in a manner consistent with industry standards and in compliance with all Local, State and Federal Codes and Regulations. Attached is tank disposal scrap ticket. If you have any questions concerning this work,please contact me at your earliest convenience. Sincerely, Enviroshield T"o;1-Q'a1Lr-d Bochicchio Senior Project Manager Enclosure CC: Village of Rye Brook Building Department via email IpctersciiQrycbrook.org,and adivitto@1�:ebrook.org Permit #MP 25-147 250 Moffitt St. Stratford,CT 06615 Q(203)380-5644 Q info0a enviroshietd.com ® w wv.enviroshietd.cor ENVIROSHIELD Clean. Preserve. Protect. Site Photographs Sharma Residence,64 Rock Ridge Drive, Rye Brook,New York ID as OCT 31 2025 VILLAGE OF RYE BROOK BUILDING DEPARTMENT 1.0cation of 330-gallon aboveground tank(AS'1)in enclosure. .-r It l Fnelosure cut open,tank Pumped,cleaned and removed. I umcr location of aboveground tank and enclosure. D 250 Moffitt St,Stratford,CT o6615 43(203)380-5644 0 info(genviroshield.com 8 w wv.enviroshield.co Clean, Preserve...Protect Environmental Specialists BILL OF LADING OCT 3 12025 DESCRIPTION: VILLAGE OF RYE BROOK Check applicable waste ID: BUILDING DEPARTMENT "\(NA1993) Fuel oil /diesel/waste oil _ (UN1203) Gasoline (UN1223) Kerosene Off-Specification commercial chemical product fuel (applicable in CT only) _ Waste, NON-RCRA, Liquid, N.O.S. (Oil/Water mix) Non-Haz, None (applicable in NY State) Water only(no fuel waste). Date: G L Total Quantity: -� gallons Generator Name: 1 cr --r rf-1 111j"Site Address: `'`1 or City: I _ ` �` ���` State: , Z. . I Telephone: �/ -� VV.O#: Generator/Agent for Signature: Transporter: Enviroshield, Inc., 250 Moffitt Street, Stratford, CT 06615 203-380-5644 Connecticut: CT-HW-495; New York: CT-095; Westchester County NY: WC-27310-1-114; Connecticut H.I.C. 05&259-91) Driver Signature: Destination/Facility: Tradebe Treatment and Recycling of Bridgeport, 50 Cross Street, Bridgeport, CT 06610 ,OSafety-Kleen Systems, Inc.. 120 Forbes Avenue, New Haven, CT 06512 Tradebe Treatment and Recycling Northeast. 136 Gracey Avenue, Meriden. CT 06451 Approval Code: (SEE BACK FOR HAZARD/SAFETY/RESPONSE DETAILS) F JemplatesMisbBill of-ading Liquid docx CT Home Improvement Contractor HIC.0582591 - Westchester Home Improvement License WC-27310-H14 250 Moffitt Street, Stratford, CT 06615 (203) 380-5644 FAX ("203) 378-8736 www.enviroshield.com - info(c�.enviroshield.com ENVIROSHIELD Clean. Preserve. Protect. D EEcVVE OCT 31 2025 GE OF RYE BROOK BUILDING DEPARTMENT V a*75 SCALE PURCHASE TICKET P.0 Metals, Inc. 270 Central Avenue Bridgeport, CT 06607 203-367-9328 Ticket: 614399 Weigh In: 10/29/2025 10:01 Customer: 1034 Weigh Out: 10/29/2025 10:04 ENVIRO SHIELD Bridgeport, CT RED DUMPTRUCK Commodity Gross Tare Net Price TOTAL$ UNP TANK 13740 12220 1520 /GT Buyer: 0 1 hereby certify that I have the right to possess and sell this scrap. This is a Bill of Sale to the above described scrap. I hereby acknowledge payment in full. Customer Signature Please do not lose this ticket. Ticket required for payment. 0 250 Moffitt St,Stratford,CT o6615 Q (203)380-5644 0 info(a enviroshietd.com 0 ww w.enviroshietd.con BUILDING DEPARTMENT OCT 3 1 2025 I VILLAGE OF RYI:,BROOK 938 KING SIW.FT RYE BRO(K NY 10573 VILLAGE OF RYE BROOK (914)139-0"6 BUILDING DEPARTMENT %s-*N',r>#br(rpkny.Eov Application for Permit to Remove or Abandon Fuel Storage Tank ('Storage Tanks in excess of 1,100 gallons require registration with the County of JWestchester) I OR O11'1('l I'SI ONI )': PI RMII li: / � r/ ✓s ✓_-/�� r)rApproval Date: 1 O \ Permit Fee:S :7c Approval Signature: l?thcr: Disapproved: (tees in now rsrtaaftbio) DO\01 ti l AR I WORK or(ON%I RIW 11OV 1 \111 4 1'1•10111 I11S IIEFN I1,S1 Fl)BY ]lit B1 11 DI\(. I\til'I('11Oft I IIF M)MI\NI Kt l IN-1.UFF I-Oft'WORK PRO 1(F1St 1)OR('0MPL.I.TI.1)%"11-I101 1 .t 1'1:1t%ll l_ Is Cto OF l'IIE 10YAJ.('O%f OF CONS I RIVI ION %%I 1 I-I-V 01- %750.on gEotilgE ENTS Fog RELEASE OF pER,41T do CERTIFICATE OF COMPLIANCE; Application Completed by Bonded.Lieerued 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 Forth#U26.3/or NY State Workers Compensation Waiver) 4.Fee per Tank: Removal or Abandonment$225.00 per I ank. 5.Dig Safely New York#(dial R 1 1): $ 1 A 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 requir=cnts are fulfilled. fifffffffifffffffffff.fflffffffffff ffff.f•ffffffffflfff iffff ffff iff fiff ff fff/f fffffff fflffflffffff f/.♦ Application dated, is hereby made to the Building Inspector of the Villagc of Rye Brook for a permit to remove or abandon a Fuel Tank as berein described The applicant and property owner.by signing this do:umcat agree that the subject fuel tank(s)will be removed or abandoned in conformance with all applicable Village,County,Stare&Fcderal laws,codes. Hiles and rcgulstions fffff fff lffffffffffiffff fff•ff fffffffffif••f•fffffff fff ffff fff•fff ffff fffffffffff fff ff ffffffffff ifffff Indicate Pe It Tvae: Removal(vr•Abandoa:ment( )/Above Ground(Buried in Ground( ) I. Address: x SBL:/65•-�Ip'-)-/-_zuae: 2. property Owner A Address: ddres �1(1�i'1 Phone N: cou N: ( ({(0 4'T�(A L47) _"mail: 1l] J`Li/ �'YLi1�"/ �/ (•e►'1't 3. Contractor&Address:_ , ,zc5ti.tt� "tic J Phone/:�03 3r'd +cct`.1 CCU N: 4. Applicant: Phone A: �� 38c Sbt t�'r Cell M: entail:'Z��u ��•t.o,R S� ��t .�o.r 5. Irulic=Fuel Type:Fuel Oil(v�•/L.P.Gas( )•Gawline t )•Other( Y 6. Number and Capacity of each Tank: 2. Exact Location(s)of each Tank: 33e- -b-".,`CS•�L I"'' �^G-e�ati o. '• ---- �� •.�` t n..r_ �s�. A'�J 6_-_O.r."t"S-:p4-'"H��,. Qua��c+t,-i:-'- 6110.025 STATE OF NEW CORK,COUNTY OF WESI'CHESTER ) as: !t;o(1"f Ol �C h t CGh,o ,being duly sworn,deposes and states that he/she is the applicant above named, (print name of i samn N 66 swims) and further states that(s)he is the Tank Removal/Abandonment Contractor for the legal owner and is duly authorized to make and fik this application. . That all statements contained herein arc 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 tit Building Code,the Code of the Village of Rye Brook and all other applicable laws,ordinances and regulations. Sworn to before me this J Sworn to before me this day of + r ,20 �� da of !+' 20 0�7 _ l'_--- Sagnature of Property Owner Signature of Applicant Cilcefi;a t Name of Prope Owner Print N of Applicant N :•�5;'=LLY NOVCU-SANTOS Noca u c,State of New York No b - �;.ary.,,0. ,-*Late of Connecticut No.01ME8160063 My Commission Expires May 27,2026 Qualified In Westchester County 7 Co sslon Fxplres January 29.20� r �s application must be proper 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. D Ec L VED SUPPORT ONLY pCT 31 2025 DO NOT PAY VILLAGE OF RYG BROOK DEPAR BUILDINGTMENT ttr'l/:02� D ELENE , N O W v N� OCT 31 2025 a� O N N Y \ \ M 03' 0 >� v = M 01 VILLAGE OF RYE BROOK 6. a o W H w BUILDING DEPARTMENT M H � v " � o Gi e� V A o o g a f�loA W en � O ^Cf G� y 0 o T en C w wcoo (� ° fig ° 6 &o A wi O O � > a o •� � `� Ha 0l O r7 ( � M - z o a o (� Z M O A v "o E o r.+ _ vxi M z V z °' b ani V1 V1 b aQi' s Z a Q Uu� ' UO � a � g W z o E -A x 5 o� A � oo ° are) , x pWt%A W a O zZ E -96 A W �., O � ' a, 104E" (� O00 Q H O O O z zo °aabv �^ a.l U � � V Ua o , a w O u v w U CA O OF cn zLn ° o `o Fo '� p •� H U O U -no z H W O A O � � .�,,' o u o w a � 4 0 b-fH D � av � � W xvdi � �� -o s ti c OAS ol '` yA ���`' - fir:"'` 3• %. 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" " ENVIINC-01 JSILVP CERTIFICATE OF LIABILITY INSURANCE OATE 1 z14n0I1'2 VYYY) za 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 endorseme B. PRODUCER Cote ACT Mary Tomaselli Gowrie Group PHONE — ---7 FAx -- 70 Essex Road No,Esi: 86 399-2838 Westbrook,CT 06498 .mtomaselli@nsk-strafe ig es.com IN$URERLSj AFFORDING COVERAGE ----__--+ _NAIL INSURER A:Nautilus Insurance Company 17370 _ INSURED Enviroshield Inc.and E.G.Kost Rental,LLC als e I a•Great Divide Insurance Company--_ _125224 -- PO Box 1296 ----- 250 Moffitt Street tR§VRERIt: Strafford,CT 06615 tNSURER 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 Lin TYPE OF INSURANCE - DOL SUER wwo POLICY NUMBER -_ POUCV EFF POLICY EXP UMRS _ A X COMMERCIAL GENERAL LIASIUTY 1,000,000 CLAIMS-MADE X OCCUR ECP01521982-25 12/1/2024 12M/2025 0 Mt TO g TE 100,000 X Pollution Liability X Professional Liab �.M xP ort person) 5,000 PERSONAL 6 ADV I URY 11000,000 GEML AGGREGATE LIMIT APPLIES PER: 2,000,000 Il POLICY r�Y J LOC NERAL PRODUCTS -CO-C A JI OMP/OP AGG S 2r000,000 B AUTOMOBILE LIABILITY COMBINEDi WGLE LIMIT 1,000,000 ANY AUTO SAP1521979-25 12M/2024 12/1/2025 BODILYINJU YiPerversoni OWNED SCHEDULED AUTOS ONLY Ix �,A(UUTOpS E BODILY INJURY_Per nX AUTOS ONLY AUTOS ONLYOAGE X MCS-90 Endt 11 A UMBRELLA LIAR M OCCUR OCCURRENCE 10000,000 X EXCESSLI►M CLAIMS-MADE FFX203675213 12/1/2024 12/1/2025 GATE S 1,000,000 DEC) I X I RETENTIONS 10,000 B AECOMPENSATION XS, PER OTH- NDD WORKERS LIABILITYYIN CA 1521980 24 � ES. PR PRIETORfE IEXECUTIVE12/1/2024 25 1_,0_0_ 0,000 MSER EXCLUDED? N/A ELFACHACCIDENT nNH) E.L.DISEASE-EA EMPLAY _. _ 1,000,000 DESCRIPT ON OF OPERATIONS below E.L DISEASE-POLICY LIMIT S 1,000,000 I DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Addillonal Remarks Schedule,may be attwJwd H more I'm ' Is required) Village of Rye Brook is listed as Additional Insured for General Liability where 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 ACCORDANCE WITH THE POLICY PROVISIONS. Village of Rye Brook AUTHORIZED REPRESENTATIVE 938 King StreetiRya Brook-NY 10573 �rL ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD STATE OF NEW YORK WORKERS'COMPENSATION BOARD CERTIFICATE OF NYS WORKERS' COMPENSATION INSURANCE COVERAGE Ia.Legal Name&Address of Insured(Use street address only) lb.Business Telephone Number of Insured (203)394-2268 Enviroshield,Inc. Post Office Box 1296 lc.NYS Unemployment Insurance Employer Stratford,CT 06615 Registration Number of Insured Work Location of Insured (Only required if coverage is Id.Federal Employer Identification Number of Insured specifically limited to certain locations in New York State, i.e., a or Social Security Number Wrap-Up Policy) 060319014 2.Name and Address of the Entity Requesting Proof of 3a. Name of Insurance Carrier Coverage(Entity Being Listed as the Certificate Holder) Commerce&Industry Insurance Company 3b.Policy Number of entity listed in box"la" BAP1521979-25 Village of Rye Brook 938 King Street 3c. Policy effective period Rye Brook,NY 10573 12/1/24 to 12/1/25 3d. The Proprietor,Partners or Executive Officers are ■ included. (Only check box if all partners/officers included) ❑ all excluded or certain partners/officers excluded. This certifies that the insurance carrier indicated above in box "Y' insures the business referenced above in box "la" 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"T'. The Insurance Carrier will also notify the above certificate holder 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. 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 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: Vincent M.Falcigno (Print name of authorized representative or licensed agent of insurance carrier) Approved by: V i.r►,c e h l-M. E4_itA 4A0- 11/25/2024 (Signature) (Date) Title: Managing!Member Telephone Number of authorized representative or licensed agent of insurance carrier: (203)745-0078 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