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HomeMy WebLinkAboutMP25-163 QyF BR 4. ti �Cwo �J . 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 January 5,2026 Yolanda Paulino 32 Roanoke Avenue Rye Brook,New York 10573 Re: 32 Roanoke Avenue,Rye Brook,New York 10573 Parcel ID#: 141.35-1-40 This document certifies that the work done under Mechanical Permit#25-163 issued on 11/18/2025 for the installation of a new above-ground oil tank has been satisfactorily completed. Sincerely, Steven E. Fews Building&Fire Inspector /to O 2� cu � 1962 BUILDING DEPARTMENT ❑BB LDING INSPECTOR ASSISTANT BUILDING INSPECTOR VILLAGE OF RYE BROOK ❑CODE ENFORCEMENT OFFICER 938 DING STREET• RYE BROOK,NY 10573 (914)939-0668 FAX (914)939-5801 www.ryebrook.org - - - -- - - - - - - - - - - - - - - - INSPECTION REPORT - - - - -- - - - - - - - - - -- - - - ADDRESS:-3Z—:�o- A 'V O�r-� , y- - . DATE: Ot�S- PERMIT# 1 Z lssu> D:/L./S__1sti1 CT:__/!VZ 45'BLOCK:_1_LOT: LOCATION: _ t" S( e 1�Qy�,.P • OCCUPANCY• ❑ VIOLATION NOTED THE WORK IS... F A(;CEPTED ❑ REJECTED/ REINSPF.CTION ❑ SITE INSPECTION REQUIRED ❑ FOOTING ❑ FOOTING DRAINAGE ❑ FOUNDATION ❑ UNDERGROUND PLUMBING NOTES ON INSPECTION: ❑ ROUGH PLUMBING ❑ ROUGH FRAMING ❑ INSULATION , �• ❑ NATURAL GASNe A. S / 2L1/V ❑ L.P. GAS Q Ai ,R-ruEL TANK ❑ FIRE SPRINKLER ❑ FINAL PLUMBING ❑ CROSS CONNECTION FINAL WQ e r, 0 M • L. ❑ OTHER l r � . •--1► �..--•ter - 1 Ln h� m N 00 00 A W E 4 ►� W aa, Cf, x� 0 V� W vi yC z 0•4 0-' � LZ ~ eh ai o o �a o g x [ Ln dr 0 40Lin / „ Ho o ao , Le v ) I i� Oa o b W 00 �j O 4 � W Q u ° aD. Q �i cn O Q A IS v J. O z v p ° ° Ln o W U ,., p ,r IUD0-4b v t7 v a 00 o a W c°� z° .fib 0.0 Z 1 M M Q c7 m A � z Now U WCN C 0 apq V r..� 00 W z a! M M W W a — 1� CN � � ull M�1 (+1 w P-4 P" W A O z z c 014 z u. p; 0 w O v v () � O O F p„ ',� .a u O Ln N z w O0-4 w � * � a M q a Z ¢ o � 8 0 �I a a a w x � � b BUILDkNG D9PARTMENT NOV 17 2025 V1LLA E OF RYE rOK 938 KING ST ET RYE BR NY 10573 (4) -06 8,<f Application for Permit to Install Fuel Storage Tank ("Storage Tanks in excess of I,100 gallons require registration with the County of Westchester)l/ ,,, Approval Date: PP Permit Fee:$ _ Approval Signature:_ Other Disapproved:- (fees are non-refundable) kkA#A+R*k*A***#A+kA**#R#*#**kR##AA ##k*kR**RA*RRkRR*RRRlA*#AR#ARkkkAiA**##*##**R*AAkRR/k#kk**Rk k*##RA*# DO NOT START WO1 or C:O«1'RUCTION L�N'Cll,-�NEitlll'f HAS BEEN ISSCF;D Bl'THEB1 Il,l)I\!; INSIIFC'f()R.'TILE:ARMINISTRATIN'L FEE,FOR WORK PROGRESSED OR t'ONIPLE I'ED WITHOUT,� 11F,IINICl IS 12%0L I'll t;TOTA1,COST OF CONSTRUCTION N'ITFI A aNIINi,'*11 :NI FEE OF S750.00 REOUIREMENTS 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)A--- 3. Your contractor's valid proof of workers compensation insurance. v (Form#C 105.2 or Form # U26.3 or NY State Workers Compensation Waiver) 4. Fee per Tank: Installation: S 185.00 per Tarn). 5. Dig Safely New York (dial 81 1): 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, 11/17125 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 Tyne: Above Ground(X)R Buried in Ground( ) I. Address: 32 Roanoke Ave, Rye Brook SBL 141.35-1-40 zone. JZ0- 2 Property Owner&Address: Yolanda Pa tlino 32 Rnanak Avt-, R e-B ok,-NY 10573 Phone#: 914-830-21 9,9 Cell�: _ Y email: =Ianrlanai iliool011_��il.corn 3. Contractor&Address: FINS 61 Phone#: 845-255-4900 Cell email: erhodes@e2g.us a. Applicant: C2G Environmental Cons. LLC/ 83 SPutt Corners Rd, New Paltz, NY 12561 Phone#:$45- 55-4c100 Cell tt: email:-6tktiode�9 uS 5. Indicate Fuel Type- Fuel Oil()o•L P. Gas( )•Gasoline( )•Other I ) #2 heating oil 6. Number and CapacitN of each Tank old - 275/new 275 ?. Lxact Location(s)ofeach Tank:OUtSide_lunder-deck I 6 1 202-11 STATE OF NEW YORK,COUNTY OF A v ) as: Chrissy Rhodes/Agent C2G ,being duly sworn,deposes and states that helshe is the applicant above named. (print name of tndttiduat signing as the applicants and further states that(s)he is the Tank Installation Contractor for the)egat 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 Code of the Village of Rye Brook and all other applicable laws,ordinances and regulations. q✓� Sworn to before me this B 0 Sworn to before me this f day of�t'2fl_.��t�s.� 20 day of A)_d V41t i .20 2,�— S natur of Property Owner Signatur�co Aplican�t fi, ___t1 _� __.._ Chrissy Rhodes/Agent C2G Pratt Name of Prop mer Print Name of Applicant Ton Notary Public 111oL an N07ARYpU817C,S q ?ublic Coulmissioplf o)iItA9932973 Registration t o.01H 294662 PORK Notary PtlblicStttte of New York Quat+ged in Ukler ccau`y My Commission Expiration:01/17/2029 C—iss+on Exaves i�ecomber 28.201.4 This application 1111aSt he pre pQrly completed in its entirety and mttst inc a notarized si<,nature(s) of the legal ouncr(s)of the subject property.and the applicant of record in the spaces provided.An}, application not properly completed in its entirety and/or not properly signed sllall be deelr,d mall and void and %vIII be returned to the:applicant. 2 6'1 f2424 INSTALLATION AND MAINTENANCE 4.2. Condensation GUIDELINES FOR CondensaSTEEL TANKS FOR OIL-BURNER FUELS AND OTHER processes•Aft water and on can form 'ice tisho should removed fro during the m the tank storing COMBUSTIBLE LIQUIDS installation. prior to 4.3. General location of the tank Manufactured by: Fuel oil storage tanks can either be installed inside or outside of a building, improedstallation is preferable for service, Increased effieency, reduc'edariisksaand increased life GranbyIndustries 1020 Andrd-Una Granby, expectancy of the tank. Quebec,Canada,J2J 1Jg. Tank location should be chosen in accordance with the following Telephone:450-378-2334 requirements: Fax:450-378-5202 The tank should be placed in an area where it Is unlikely to be adversely affected by normal household activities; �( ry The tank should be placed in an area where it can be visually inspected from all sides; §ervice(o�oranbvtanks com The tank label should be visible: L1STEl1 Websfte. If possible,tanks should not be located directly under house eaves 1112//wxv✓oranby�tanks com where they may be subject to falling snow and ice or dripping water. I. SCOPE Protection should be provided if there are no other placement alternatives; These guidelines apply only to the Installation and maintenance of Tanks should not be placed in intimate contact with wafts or domestic,aboveground fuel oil tanks manufactured by Granby Industries structures since leaves and other organk matter can accumulate and to UL80,Steel Tanks for Oil-Burner fuels and Oilier Combustible Lwulds. cause external corrosion of the tank;and These tanks have an otxond shape, are of a single walled or double- - Tank location shall respect the local code for distance to property bottom design,and available In capacities ranging from 120 to 330 gallons. Ines,o other energy sources or to other storage systems. These tanks must be installed in accordance with NFPA 31.Standard for 4.4. Foundations jhe_ Installation of OIL-B imlm c ent and in compliance with any The tank should be appi;cable local codes or regulations. Properly supported a level, rigid and non- combustible base. The base should be designed to prevent uneven the instructions in this document are intended as recommended settsing founatiand t no minimize corrosion of any part of the tank resting on the guidelines only for tank installation. For more specific installation while other Optionsred a are also vtailable basement floor Provides the best option Instructions,please refer to your local code enforcement agency. 2. TANK INSPECTION AD tanks are at risk from base movement; especially new outside Installations placed on recently disturbed ground.A wolt4ralned sub grade Inspect the tank mmediately upon receipt.Minor dents and scratches ma should be provided for proper drainage. Six Inches of crushed, Gear, be acceptable.Do not Install the tank if damages are thought to affect the mechanically catty compacted stone is recommended.The site should have all ct your distributor. organic materials such as sod or bark removed and the soil mechanically integrity and performance of the tank. Conta compacted. 3. TANK HANDLING 4.5. Tank legs The tank must be lifted without dragging or dropping to prevent damage. Our domestic obround tanks are provided with four threaded leg supports. tanks are to kited using the handles Provided on the tank heads. The tank Legs that fit into these supports are Schedule 40 1V threaded heads. black iron pipes with a maximum length of 12'.The leg supports installed Do not move a tank unless it is empty. on the tank should: • Provide enough clearance for the tank accessories;and 4. TANK INSTALLATION • provide for proper drainage slope.The tank should be pitched Authorities having jurisdiction should be consulted before the installation of longitudinally,towards the drain,at least 114 inch Per foot of tank length. the tank. The use of tank cradles is not recommended on any of our tanks. The installer shalt ensure that all applicable Codes are met canon o installation. 4.6. Tank piping Fill.vent and supply In must jurisdictions, installation by a technician recognized by the be designed so tthatping tphe tank si renot ubjectedmupect allcob vacuumorp ng shall authority having jurisdiction is mandated.Do-h-yorself installations are not exceeding 1 PSIG measured at the top of the tank. Pressure recommended and must be inspected by the authority having jurisdiction prior to placing In service. 4.7. Overfill Protection Only labelled tanks bearing the UL listing mark with a serial number are An overfill-protection device should be provided on every fuel oil supply eligible for warranty and installation.Under no circumstances shall a used tank.When a vent whistle is installed as an overfill-protection device. to tank of any design be installed. person should deliver fuel oil the supply tank when the vent whistle does not function properly.The use of a 6 in.long whistle is recommen 4.1. Removal of temporary tank closures obround tank models. ded for All tank openings are shipped from the factory with temporary shipping 4.8. Plugging of remaining tank openings caps.These caps must be removed prior to tank installation. AB unused openings on the tanks must be adequately plugged and sealed with liquid-tight closures before the tank is put in service, G W E t ® 2013 GRANBY INDUSTRIES LIMITED PARTNERSHIP Page 1of 2 SI-00'S rev Ca R—sad 20'C-0S-04 4.9. Cross-connected Tanks Two oil tanks may be cross connected in accordance with the installation s• OIL TANK MAINTENANCE requirements and limits specified in NFPA 31, of OII-Burning Eouir,mar, Standard for the Installation It is important for the homeowner to understand that the oil tank is their Property and their responsibility. The tank owner should ensure that it is 4.10. Flood Plains and High Wind Areas properly maintained. Proper tank maintenance should include, but is not limited to,the following: Additional stability should be considered in flood plain areas or areas of ' Subscribing to a maintenance program performed by a heating oil high wend.This would require some form of shatter and/or anchoring that system licensed service technician; does not adverseiv affect the operation of the tank. Visually inspecting the tank(s) at least once a year. Careful visual inspection will uncover traces of oil on the tank surface; 4.11. Tank anchoring Asking a service technician to check, at least once a year, for the presence of water inside the tank and to remove it, A tank must be anchored to its foundation(as shown below meets one Of the following conddions: )if it Immediately correcting an unstable foundation or when the tank is • It Is intended for outside installation;or likely to topple.The services of a licensed installer should be used; • It is intended for inside installation and will not be connected to Maintaining the tank's exterior surface,at least once per year,by: ete wall or Gentry brushing the rusted areas on file tank's exterior with secured fill and vent pipes passing through a concr foundation. sandpaper; 2. Cleaning the sanded surface;and Anchoring method: 3. Applying a coat of rust proof metallic paint(readily available at any hardware store). If needed, Granby Industries has color matched touch-up paint canisters. Contact the order desk for more details. Maintaining the tank's exterior surface is a good Practice and the • application of touch-up paint will not void the warranty of the tank Gi Maintaining the tank liquid level as high as Possible during the summer months to limit water condensation within the tank;and Verifying the status of a double bottom tank model,at!east once per year,by performing the following: 1. When the tank is full,took into the monitoring opening on top of the tank; 2. If the red"FAIL'indicator can be seen,rl indicates a problem; -- — a DETNL B contact Granby Industries. GOV (16x)'Wdia.x 13/4"long Concrete Tapeon®Screws / (4x)11V NPT floor flanges l (4x)11,:'Schedule 40 pipes of appropriate length 5. TESTING All tanks that leave the factory have been tested twice for leakage.The oil tank could have sustained unforeseen damage during handling, transportation, installation and connection. The installer, oil company representative or a designated person shall be In attendance at the initial filling of the tank. This person shall visually inspect all tank seams and fittings for leakage once the tank is full WITHOUT APPLYING PRESSURE INTO THE TANK. Tanks that are not filled immediately after installation shall have all lines blocked and the fill pipe shall be marked to Prevent inadvertent filing to ensure that the first fill inspection is performed. GPA BY C 2J10 GRANBY INDUSTRIES:_IMITED PARTNERSHIP Page 2of 2 SWO15 r6v Ca Revved:201n&04 C2G Environmental Consultants, LLC 83 South Putt Corners Rd Tel: (845)255-4900 New Paltz,NY 12561 Fax(845)255-4909 November 17,2025 Yolanda Paulino 32 Roanoke Ave Rye Brook,NY Scope of work: Cut,clean,and remove(1)275 gallon aboveground oil tank from the backyard. Install(1) 275 Granby Ecoguard double bottom tank on the opposite wall to include fill piping,vent, vent alarm and gauge � c Ask " Y •+� • Y •+ K) • t' y •+ v • s AM �x.._. - �c•salt)>?'" . .a �. . . . . . . . . .... . . . . . . ... a BSc c . 06. LLJ CD y C 0 I^ram z w «t CD �. 4 Y r ; N b i-. ✓!r' V Q W O w LIJ N �� fi a ckion uj pui I (dais) ; W O w C� n w o ►- c+t�.> it � = N � c� .✓ (rj '9"� Q� CO Q �p W G > x o z CN c. •�r 4� ���11 z a� o I �� •�'" a w ca 'c� a� .— � I N Y 3 w c0 04 r � U `t k tT (� 9, f t! _-M e . yl,I4 �,xi 7 t y `r r f Tis. 4 1`n, 0 _. o ";'fit+1 rl )• y1t17�jr kd14�t t '�Pyr, '8,51 / n �.fl +i•1� Ii 1 11i i1/� 1/ Z N /i .�. Ik'}vJ .✓�� �� � ��. '� O'+ ay j�yy�Lr .ry�v�•! .Z1A(h'y.�=t A'' � }�?.:.�=I '^•t�J ¢ :,14 v�°'� 'f� ;~3 �+ !� � 4Y=" k��'UJJJQ J 4vly q��>(fi. 1 ..- C2GENVI-01 EMARTIN A`CO�RO CERTIFICATE OF LIABILITY INSURANCE DAT DYYYY) ___— 5/1 5/1/2/2025 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 Elaine Martin NAME: World Insurance Associates,LLC AI°N o,EXt (973)871-15251813 225 Madison Ave I ,No: Morristown,NJ 07960 E-MAIL elainemartin orldinsurance.com ADDRESS; INSURE 1 AFFORDING COVERAGE _ NAIC i INSURER A:Admiral Insurance Company 2"68 INSURED INSURER 13:Selective Insurance Company of the SE 39926 C213 Environmental Consultants,LLC INSURERC: 83 South Putt Corners Rd INSURERD: New Paltz,NY 12561 INSURER 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. IN8R TYPE OF INSURANCE 'A SUER wftmPOLICY NUMBER POLICY EFF POLICY EXP LIMITS A I X COMMERCIAL GENERAL LIABILITY I EACH OCCURRENCE 5,000,000 CLAIMS-MADE X OCCUR DAMAGE TO RENTED FEI-ECC-36284-00 12H2/2024 12112/2026 50,000 MED EXP oneperson) 10,000 PERSONAL 8 ADV INJURY 9 5,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 5,000,000 X POLICY jpERFf LOC PRODUCTS-COMPIOPAGG 5,000,000 X]OTHER Pollution Liability POLLUTION LIABI 5,000,000 B AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT 1,000,000 ent) X ANY AUTO S 2307223 4/29/2028 4/29=26 BODILY INJURY Pet OWNED SCHEDULED AUTOS ONLY AUTOS yV E BODILY INJURY Per accldeM AUTOS ONLY AUTOS O ��Ee RRTTYnt AMAGE UMBRELLA LAB OCCUR EACH OCCURRENCE_ _ EXCESS LIAR CLAIMS-MADE AGGREGATE -_- DED RETENTION E WORKERS COMPENSATION PER AND EMPLOYERS'LIABILITY YIN A LITE ANY PROPRIETOR/PARTNER/EXECUTIVE QFFICER/MEMSEREXCLUDED? ❑ NIA .L EACH ACCIDENT (Mandatory in NH) If yes,de—be under E.L.DISEASE-EA EMPLOYE DESCRIPTION OF OPERATIONS below L.DISEASE- MIT _ A (Professional Liabili FEI-ECC-36284-00 12/12/2024 12/12/2025!Prof Liability 5,000,000 A Transport Poll Liab FEI-ECC-36284-00 12/12/2024 12/12/2025'(Transport Poll Liab 5,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Village of Rye Brook THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 938 King Street ACCORDANCE WITH THE POLICY PROVISIONS. Rye Brook,NY 10573 AUTHORIZED REPRESENTATIVE ACORD x^' Y ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD N Y S I F PO Box 66699,Albany,NY 12206 New York State Insurance Fund nysif.com CERTIFICATE OF WORKERS' COMPENSATION INSURANCE ^^^^^^ 200882662 LOVELL SAFETY MGMT CO.,LLC 22 CORTLANDT STREET 33RD FLR NEW YORK NY 10007 SCAN TO VALIDATE AND SUBSCRIBE POLICYHOLDER CERTIFICATE HOLDER C2G ENVIRONMENTAL CONSULTANTS LLC VILLAGE OF RYE BROOK 83 S. PUTT CORNERS ROAD 938 KING STREET NEW PALTZ NY 12561 RYE BROOK NY 10573 POLICY NUMBER CERTIFICATE NUMBER POLICY PERIOD DATE Z 1412 798 9 894279 04/01/2025 TO 04/01/2026 02/28/2025 THIS IS TO CERTIFY THAT THE POLICYHOLDER NAMED ABOVE IS INSURED WITH THE NEW YORK STATE INSURANCE FUND UNDER POLICY NO. 1412 798-9, 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:/MIWW.NYSIF.COM/CERT/ CERTVAL.ASP. THE NEW YORK STATE INSURANCE FUND IS NOT LIABLE IN THE EVENT OF FAILURE TO GIVE SUCH NOTIFICATIONS. THIS POLICY DOES NOT COVER THE SOLE PROPRIETOR, PARTNERS AND/OR MEMBERS OF A LIMITED LIABILITY COMPANY. 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,I SURANCE FUND UNDERWRITING VALIDATION NUMBER: 572364289 1100000000000137708753111 Form WC-CERT-NOPRINT Version 3(08/29/2019)1 WC Pohn-141279891 1,26 3 213