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HomeMy WebLinkAboutMP25-148 DR, S.iL'L 1 l7 . 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.,ggov TRUSTEES BUILDING& FIRE INSPECTOR Susan R. Epstein Steven E. Fews David M. Heiser Donald T. Krom,Jr. Salvatore W. Morlino CERTIFICATE OF COMPLIANCE November 17,2025 Jason St.John&Maggie St.John 2 Winding Wood Road Rye Brook,New York 10573 Re: 2 Winding Wood Road, Rye Brook,New York 10573 Parcel ID#: 129.83-1-1 This document certifies that the work done under Mechanical Permit#25-148 issued on 10/14/2025 for the removal of an above-ground oil tank has been satisfactorily completed. Sincerely, Steven E. Fews Building&Fire Inspector /to BRC�� o �m '9a2 BUILDING DEPARTMENT ❑BmfLDING 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: Gam._ w I V_ ?aqt. DATE: 13 ` 2.02S. PERMIT» fV".? ZS_ l y �_ ISSUED:_jO`IV-L$SECT: 129.e3 BLOCK: LOT: LOCATION: ko's-e - OCCUPANCY: ❑ VIOLATION NOTED THE WORK IS... ACCEPTED ❑ REJECTED/ REINSPECTION ❑ SITE INSPECTION REQUIRED ❑ FOOTING ❑ FOOTING DRAINAGE ❑ FOUNDATION ❑ UNDERGROUND PLUMBING NOTES ON INSPECTION: ❑ ROUGH PLUMBING ❑ ROUGH FRAMING ❑ INSULATION (� / ❑ NATURAL GAS „E-CQ I M(� � (� S "g 1 to-po-L ❑ L.P. GAS FUEL TANK ❑ FIRE SPRINKLER U— ,V olel m ❑ FINAL PLUMBING ❑ CROSS CONNECTION S isl ❑ FINAL �- ❑ OTHER E BRC�� O ym BUILDING DEPART MENT VI$AssUSTAN-j- 'I-DING INSPECTOR BUILDING INSPECTOR VILLAGE OF RYE BROOK 0 Com:ENFORCEMENT OFFICER 938 King Street • Rye Brook, NY 10573 (914) 939-0668 FAx (914)939-5801 www.rnbro_ ok ors - - - - - - - - - - - - - - - - - - - - INSPECTION REPORT - - - - - - - - ADDRrss : - om. 2 fV 114 G WOO 17 `TgOlwwkl _ DATE:__.I0" ZQ Z O ZT-- PERMIT# _ �? s _�. ISSUED: I�/-ArSEC'I-:IZ9. -1 BLOCK: 1,OT:,--..�.___ LOCATION: � ^044.A _ _ OCCUPANCY: ❑ Violation Noted THE WORK IS... PASSED ❑ FAILED / REINSPECTION ❑ SITE INSPFC-I'ION REQUIRED ❑ FOOTING ❑ FOOTING DILA 1 NAG1: ❑ FOUNDATION ❑ UNDERGROUND PLUMBING NOTES ON INSPECTION: ❑ ROUGH PLUMBING ❑ ROUGH FRAMING ❑ INSULATION �- ❑ Natural Gas .s • �UL(„ pl L, ❑ L.P.Gas —`� �� +'TUEL TANK ❑ FIRE SPRINKLER ❑ FINAL PLUMBING -- ❑ CROSS CONNECTION l ---- ❑ FINAL ❑ OTHIiR annS- I/VPi i 4OW!. - - 1' 00 0 o w I' 1 IN1 y M Vl O W a � F 0 4 CA x a '-U .r a P W ZO 3 & U aid V� o4 o U a o to a b 0 `° -d Q+ A rl E" 3 , a0i v 'y QI ~ V O DE o a Q' a � zb � � 4. v ' (� oo f� z °, w O A v b v v v W H O C1 z C UZ Z � tiQ ° z M logo M a ti pG O zzb vW o z w k q o .o � � � H o z z o OS09 -8 a Z W p o o o V Acn c od H z o O w ono H 8 ° V V O A °` '° y� w ' � ° r z W O A 0 d :� -44 cV q w z H O '.g o b U �, CU H. O U U W W � a. �I ra a � 4 W.( x � � � I3UILll. N '� �t.. MIJNTFFueltoraj!e VIL ,E✓ or'RX ' OOK1938KING T ET ItY>✓BR; :T NY1 025• ' _�dr-o ov RRT�r,00TApplication for Permit to Remove or Abande Ta (*Storage Tanks in excess of 1,100 gallons require registration with the County of Westchester) FOR OFFICE USE ONLY: - PERMIT 4: 1'� � '�� _� Q Approval Date: OCT 142M Permit Fee: $ Approval Signature: Other: Disapproved: (fees are non-refundable) r,t****,t,r**,t,t,t,t,t,t**,t,t*,t*,r,r,t***,t*,t*,t,t*,t*,t*�,t******,t*,t,t**,t,t****�*�**,t**,t*******�,t,t,t,t,►**,t**a,t,t,t+r,t,t**,t***,r** 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 MINI MUNI 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 # C 105.2 or Form# U26.3 /or NY State Workers Compensation Waiver) 4.Fee per"Tank: Removal or Abandonment$185.00 per Tank. 5. Dig Safely New York# (dial 81 1): NA 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 firlfilled. Application dated, 09119f2025 ,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. Indicate Permit Type: Removal Abandounent❑/Above Ground 0 Buried in Ground❑ I. Address: 2 WINDINGWOOD ROAD NORTH SBL: 129.83-1-1 Zone: R-15 2. Property Owner&Address: JASON ST. JOHN Phone#: 914-400-5092 Cell#: email: JASON.D.STJOHN@GMAIL.COM 3. Contractor&Address: Northeast Environmental Inc. 225 Valley pl Mamaroneck NY 10543 Phone#: 914-777-1930 . Cell 4: email: dmonaco@neenviro.com 4. Applicant: Dwayne Monaco for Northeast Environmental Inc. Phone#:914-777-1930 Cell#: email: dmonaco@neenviro.com 5. Indicate Fuel Type:Fuel Oil • L.P. Gas( )• Gasoline❑•Other( ): 6. Number and Capacity of each Tank ONE 275-GALLON HEATING OIL AST 7. Exact Location(s)of each Tank: ENCLOSURE BENEATH REAR PORCH t 6/112024 STATE OF NEW YORK,COUNTY OF WESTCHESTER ) as: DWAYNE MONACO , being duly sworn,deposes and states that he/she is the applicant above named, (print name of individual signing as the apl)licant) and further states that(s)lie is the Tank Installation 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 contauied 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. �Fh Sworn to before nie this 2(o+h_ Sworn to before me this day of 5cor ber ,20 z s 20 L SigtKature of Property 0Wrier l Zitature of Applicant GJN .c.J ICo \Prrintt'Name off Property Owner Print Name O ��PPHC� York �Notary Public i--'4'N ubc k IVIADERA No.O1LE6143W8 State of New York Qualified in Bronx County Registration No.01 BA6171381 Certificate Filed in New York County Qualified in Westchester County Commission Expires 03/27/2026 Commission Expires July 23,2002 7 This application niust 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 6/I/2024 Removal of a 275-gallon heating oil AST and install a 275- gallon AST in same location. Mobilize equipment on site and set up perimeter of work area with proper cautionary devices to ensure public safety while work is being conducted. 275-GALLON AST IN ENCLOSURE BENEATH PORCH All piping (i.e. vent, fill, suction and return, etc.) will be flushed leading back to the tank then removed from the AST. The AST will be properly vented, then be cut opened, cleaned of its contents, and deemed gas free. The tank contents will be transported to a permitted disposal facility. The AST will then be cut into manageable pieces and disposed of offsite at a metal recycling facility. The sub-level will be surveyed for the proper placement of the AST keeping in mind the required distance from any open flame. Utilization of 2"schedule 40 steel pipe with NPT fittings for the vent and fill pipe. Vent and fill to be piped to the exterior of the structure with weather tight terminations. Exterior vent and fill pipe terminations will be at least two(2)feet away from any openings. An audible vent overfill alarm will be installed at the tank. ''Y2" coated copper tubing will be used to feed fuel oil to the burner with the required in line safety valves. Any foundation penetrations will ■ be repaired in a manor to prevent ground/surface water from entering building. Proper documentation of the tank replacement will be provided to the client and local governing agencies. Generalized Site Plan; Not To Scale; For reference Only OIL FIRED FURNACE SITE: St.John Residence 2 Windingwood Road North Rye Brook, NY 10573 CONTRACTOR: Northeast Environmental 225 Valley Place Mamaroneck NY 10543 (914) 777-1930 WINDINGWOOD ROAD NORTH Westchester County License No. WC-14361-H03 NYSDEC Transporter No. 3A-500 r'�" NORTHEAST i. ENVIRONMENTALIILLC 225 VALLEY PLACE * MAMARONECK * NEW YORK * 10543 * (914) 777-1930 October 29, 2025 Attn: Inspector Steven E.Fews Village of Rye Brook Building Department 938 King Street Rye Brook, NY 10573 Re: St. John Residence, 2 Winding Wood Rd North Building Dept. Permit #: MP-25-148 & MP 25-149 NE Job #: 4214-25 Dear Inspector Fews: This letter is to inform you that the work at the above referenced site has been completed. WORK COMPLETED: • Cut opened, cleaned out,removed and disposed of one (1) 275-Gallon#2 Fuel AST and associated piping from under rear porch. • Supplied and installed one(1) 275-Gallon Granby horizontal AST in the same location on an owner supplied concrete pad with new fill,vent,vent alarm and new line to inside. DATE COMPLETED: Wednesday, October 29, 2025 Enclosed,please find copies of all paperwork requested by your office. Northeast Environmental's work was performed with its best present judgment and level of effort consistent with professional standards and in compliance with all applicable Federal,State, and Local ordinances and regulations. _Please feel free to contact me at(914) 777-1930 with any questions or concerns. (inel , wa a J. Monaco `2 u u u u u u 1 VILLAGE OF RYE BROOK PERMIT#:MP 25-149 Im Im BUILDING-•DEPARTMENT ISSUED: 10/14/2025 969.K 'fG STRgET, Mng BR-00 • NY40573 ExpmES: 10/14/2026 ffi 9� =939-0G6:8. www.itycbioknt `. '. r, Y-gov r MEN I :yINST GoU, r�,i = `ANK ' f ,ems' J�.-r.�• •?�• :..�:+` :e.. .�v �t �� > AT: 2 WINDING WCO.6dit-OAD:51 BUILDING CLASSIFICATION&�PfARCEL:ID#:-•I -3-rONE�FAmm-i-RESIDENT.AL,/ 129.83-1-1 t& PROPERTY OWNER: ASON ST OHN&MkGGIE ST. .JoflN 914) 400-5092 LICENSED CONTRACTOR:NORTHEAST ENVIRONMENTA,II LLC'.(914) 777-1930 3 LOCATION OF WOM 04DER REAR PORCH,` FEE PAID: $185.00 ` { d1 CONTRACTOR•MUST BE PRESENT ON THE JOBS=FUR ALL INSPECTIONS' HOURS OF OPERATION OF CONSTRUCTION'EQLT b& LL m/VIAGE CODE§158-4:WEEKDAYS—&OOAM TO 6 00P OR DUSK,W.MCHEVER IS E&RUER; SATURDAYS-9:OOAM TOA:00Prs, - 'SUNDAYS&HOLIDAYS-NO'_CONSTRU&.=4 ACTI.W Y.AI:i.OWED This permit is valid for a period aot to exceed t�vielye.�12).imoaths'fi�om.�tlie.dnie of issuance,snd coves galy that work listed,above.Separate permits are requited for any electrical,plumbing,fire suppression,5iresmokt%carlioa monoxide detectors/alums;ox aay_otlier Work not Govated tinder this permit.The approved plans must be kept on the job site&be made;availabkT' r review:by the Biulding Department upon demand Any amendmcats or:ehangessto the approved plans must be designed by your architect/engmi m.aa�d"subsiEtted to,the-Budding Department for review and appmvalycor top"' a work. ffi A Certificate,or'Ctttificate of Compliance is muuemm orde_s:to=z:lose o. this permit. t e. Steven E.Fews Building&Fire InspectorInA ffi THIS PERMIT MUST BE CONSPICUOUSLY POSTED AT THE JOB SITE • Del t I xe�'I 1-8-jo 1'3?i RON, 61351fA213 ----------------------------------------------------------- -------------------------------------------------------------------------------- NORTHEAST ENVIRONMENTAL 11,LLC. NYS DEC #3A-1419 225 Valley Place EPA #NYR-000083766 Mamaroneck,NY 10543 914-777-1930-Fax 914-777-1928 USDOT #4462624 www.northeastenvironmental.com NAME: DATE: 10-29-2025 GENERATOR/LOCATION BILL TO(IF DIFFERENT FROM LOCATION) NAME NAME STJOHN INFORMATIOWATTENTION LINE ETA ONSITE INFORMATIONIATTENTI[ON LINE ADDRESS ADDRESS 2 WINDING WOOD RD CITY STATE ZIP CITY STATE ZIP RYE BROOK NY PHONE NUMBER PURCHASE ORDER NUMBER PHONE NUMBER PURCHASE ORDER NUMBER TIME IN TIME OUT DRIVERS NOTES CUT AND CLEAN 275-GALLON AST; NON-HAZ SOLIDIFIED TANK BOTTOM SERVICE SECTION WASTE CODE DESCRIPTION DRUMS GALLONS UNIT PRICE LINE TOTAL 1993 USED OIL REMOVAL 1993 OILY WATER DISPOSAL 1325 SLUDGE DISPOSAL 1203 GASOLINE WATER DRUM DISPOSAL(NON-KAZ) I DRUM DISPOSAL(HAZ) TANK CLEANING VACUUM TRUCK STOP TRUCK HOURLY RATE SUBTOTAL TAX Terms-Not CONDITIONALLY TOTAL 15 Dpys EXEMPT SMALL QUANTITY GENERATOR CHARGE MY ACCOUNT FOR THIS GENERATOR WARRANTS AND REPRESENTS THAT THE CERTIFICATION TRANSACTION O' UNLESS OTHERWISE MATERIALS PROVIDED NORTHEAST ENVIRONMENTAL INDICATED N.HE PAYMENT SECTION. $ HEREUNDER HAVE NOT BEEN MIXED, COMBINED OR I oeffify that this generator INVOICED REFLECTING CHANGES1 OTHERWISE BLENDED IN ANY QUANTITY WITH MATERIALS generates less than WO kilograms TO CUSTOMER ARE SUBJECT TO AN CONTAINING POLYCHLORINATED BIPHENYLFCCY,OR ANY of hazardous waste per month, INTEREST RATE OF THE LESSER OF 1-1/2%PER MONTH(18% OTHER MATERIAL DEFINED AS HAZARDOUS WASTE UNDER an PER ANNUM)OR THE MAXIMUM RATE ALLOWED BY LAW ON ANY APPLICABLE LAWS,INCLUDING BUT NOT LIMITED TO 40 CFR as defined In 40 C.F.R.261,h d INVOICES THAT ARE NOT PAID WITHIN 16 DAYS.IN THE EVENT OF PART 261 GENERATOR AGREES TO INDEMNIFY AND HOLD does not accumWale more than DEFAULT.NORTHEAST ENVIRONMENTAL 9,LLC.SHALL BE ENTITLED NOFITHEAb-f ENVIRONMENTAL HARMLESS FOR ANY DAMAGES =S 1,000 kilograms of such waste TO RECOVER COSTS OF COLLECTION,INCLUDING REASONABLE COSTS ATTORNEY'S FEES,ETC.ARISING OUT OF OR IN AN� dudrigthemonth. ATTORNEYS FEES.INITLAL tLATED TO A BREACH OF THE ABOVE WARRANTY 13Y THE WAY R GENERATOR. I -- Generator certifies that the waste Is [I used oil IGENERATOR'S SZNATURE I PAYMENT RECEIVED SECTION El city water 0 Other NON CONDITIONALLY El I TOTAL RECEIVED l)ESCFUF-1'04 EXEMPT LARGE aaac In aoowdance The NJ.A.C.726-12.1 at mq.Northeast En-Ammental has the required parrrft to accept the above described waste, QUANTITY GENERATOR 9coordance th NJAC7;28-6.76+40 CFR PART 270.Northeast ronrnwft he notifia the US EPA of IT*used oil management saMbes. CERTIFICATION n P'= PRINT N&ME 7rRE Dexsil CDT Test Results PRINT A i SIGNATURE DATE GENERATOR/CUSTOMER PPM WINATUSE DATE �/NORTHEAST ENVIRONMENTAL REPRESENTATIVE i I PAYMENT RECEIPT Pascap Co, Inc. 4250 Boston Road C Bronx, NY 10475 (718)325,`-7200 (914)725-3300 FACILITY ID NO. 7003010 SCP NYC DCA License#0437184-0764024 ; Receipt: 1551794 Date: 1 OJ2912025 Customer: 1242 Time: 15:15 NORTHEAST ENVIRONMENTAL 225 Valley Place MAMARONECK,NY 10543 In: 10/29/2025 15:08 �-o Ticket: 3526501 Weighs 1 1 Operator: 9 Weigh Out: IW2912025 15:14 Commodity Gross Tare Not Price TOTAL$ #2 Unprep Steel 14500 14240 260 -, - ----- -------------- -------- -------- -- ----- ---------------- ------ Ticket Total #of Tickets: 1 Total Paid Paid by EZCash Rounded to nearest $1.00 I I THERE IS TO BE NO PROCESSING OR CLEANING OF MATERIALS ON PASCAP PROPERTY NO EXCEPTIONS,VIOLATORS RISK BEING BANNED FROM THE YARD BY MANAGEMENT ACo® CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 09/19/2025 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 Cole Lahey NAME: PF Northeast Brokerage Inc P HO NE (845)223-8107 FAX (845)227-8816 A/C No Ext: A/C No 1035 Route 82 E-MAIL clahey@pfnortheast.com ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC# Hopewell Junction NY 12533 INSURERA: Great Divide Insurance Company INSURED INSURER B: Key Risk Insurance Company Northeast Environmental II LLC INSURER C: 225 Valley Place INSURER D: INSURER E: Mamaroneck NY 10543 INSURER F: COVERAGES CERTIFICATE NUMBER: CL2582616985 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 ADDLSUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER MM/DD/YYYY MM/DD/YYYY LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE �OCCUR PREMISES Ea occurrence $ 100,000 X Contractual Liability MED EXP(Any one person) $ 25,000 A ECP01530828-25 06/11/2025 06/11/2026 PERSONAL&ADV INJURY $ 1,000,000 GEN'LAGGREGATE LIMITAPPLIES PER: GENERAL AGGREGATE $ 2,000,000 ❑ POLICY PRO- ❑ JECT LOC PRODUCTS-COMP/OP AGG $ 2,000,000 POTHER: Professional Liability $ 1,000,000 AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000 Ea accident ANYAUTO BODILY INJURY(Per person) $ B OWNED I SCHEDULED BAP1530830 06/11/2025 06/11/2026 BODILY INJURY(Pe raccident) $ AUTOS ONLY AUTOS X HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY Per accident $ UMBRELLA LIAB X1 OCCUR EACH OCCURRENCE $ 5.000,000 A X EXCESS LAB CLAIMS-MADE FFX1530829-25 06/11/2025 06/11/2026 AGGREGATE $ 5,000,000 DED I X1 RETENTION$ 10,000 $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY Y/N STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? N/A E.L.EACH ACCIDENT $ ❑ (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Village of Rye Brook is listed as additonal insured with regard to general liability coverage as per written contract.Coverage is primary and non-contributory. Waiver of subrogation applies,as per written contract.No labor law exclusion applies. 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 l-4— ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD STATE OF NEW YORK WORKERS' COMPENSATION BOARD CERTIFICATE OF NYS WORKERS' COMPENSATION INSURANCE COVERAGE la.Legal Name&Address of Insured(Use street address only) lb.Business Telephone Number of Insured (914)777-1930 Northeast Environmental II LLC 225 Valley Place lc.NYS Unemployment Insurance Employer Mamaroneck,NY 10543 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) 33485701E 2.Name and Address of the Entity Requesting Proof of 3a. Name of Insurance Carrier Coverage(Entity Being Listed as the Certificate Holder) American Fire&Casualty Co. Village of Rye Brook 3b.Policy Number of entity listed in box"la" 938 King Street XWA57980680 Rye Brook,NY 10573 3c. Policy effective period _6/29/25 to 6/29/26 3d. The Proprietor,Partners or Executive Officers are included. (Only check box if all partners/officers included) X 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"2". The Insurance Carrier will also note the above certificate holder within 10 days IF a policy is canceled due to nonpayment ofpremiums 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: Joseph W. Pires (Print name of authorized representative or licensed agent of insurance carrier) Approved by: 9/19/2025 (Signature) (Date) Title: President—PF Northeast Brokerage Inc. Telephone Number of authorized representative or licensed agent of insurance carrier: (845)223-8107 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