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HomeMy WebLinkAboutMP25-174 a O Ln v m � N N _ cr0. 4t a Ln CIO W Lei U A a� W � w �, .� ; , v � `� rW►�rtt h�l a a W as H W � H (� �--+ Via} �° p ° ' ° y � 1 PLO 101. 0-4 o0 2 w a A W Ln in p mo o ° 'to _ V M M O W U z ,� .� c, w I v Q v Z zs eq il A W A A A �z y -e0-4 �4 0 cy CY v � V 0 V A a A 110, 'S o �� a�a a a w � x � � �� � DEC 0 2025 BUILDIN,' __V ARTMENT VILLA E OF �il'F,011t3UK 938 KING S�` ET RYE But�ciK,NY 10573 -0668 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 OFFICE USE ONLY: .-DEC 1 6 2025 PEA.M- 11 #: � - Approval Date: Permit Fee:S Approval Signature: Other: Disapproved: (fees are non-refundable) DO NOT START WORK or CONSTRUCTION UNTIL A PERMIT HAS BEEN ISSUED BY THE BUILDENG rNSPECTOR. THE ADMLNISTRATIVE FEE FOR WORK PROGRESSEI)OR COMPLETED WITHOUT A PERMIT IS IZ%OF THE TOTAL COST OF CONSTRUCTION WITH A MLNIMUNI FEE OF$750 Oil REQUIREMENTS FOR RELEASE OF PERMIT&CERTIFICATE OF COMPLI41ACE: 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#U26.31 or NY State Workers Compensation Waivcr) 4. Fee per Tank: Removal or Abandonment S225.00 per Tank. 5.Dig Safcly New York#(dial 811): - Or-r - -1-1 1 6. Inspection by Building Department fo for abandonment. 7. Submit all Manifests&Reports(after work has been completed). 8.Certificate of Compliance will be provided when all requirements are fulfilled. Application dated_DL.t- L iQ.ZDLS ,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 LUS: Removal(4°Abandonment( )/Above Ground( )•Buried In Ground W I. Address: �ACRE �� �- ' SBL:1, i�j` Zone: �K -1D 2. Property Owner&Address: :hR Phone#: `�� R3�1 - 1 Cell#: email: 3. Contractor&Address: 2 fah Sioux, 5 p''zD Phone#: 0�-63 3gti ��t`I Cell#: 4. Applicant: ram i'r"' �,tt s52£ tris�o %? '1S Phone#: o'Zb3 3`� Sb"r Cell#: email: � ' t-' t,:w2st+r .L✓W+ 5. Indicate Fuel Type: Fuel Oil(-•L.P.Gas( )•Gasoline( )•Other 6. Number and Capacity of each Tank: 7. Exact Locations)of each Tank: ~' +�' `L 1.S 1. 413 c" i-l'r- S�'ab- off' ' 61 i/2025 F- ACOR& CERTIFICATE OF LIABILITY INSURANCE DATE 12Ml9i2d25 ODIYYYY} '14l 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 rnay require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). CONTACT PRODUCER NAME. RSC Insurance Brokerage, Inc PHONE P O Box 818035 •617-330-5700 AN: No Cleveland OH 44181 Al o ssu art nsk-strate ies corn INSURERS AFFORDING COVERAGE NAIC0 _ INSURERA:Nautilus insurance Company 17370 INSURED NOVOi1CCI INSURER8:Great Divide Insurance Company 25224 Novoli, LLC DBA: Enviroshield 250 Moffitt St INSURERC: Stratford CT 06615-7132 WSURERD: INSURER E _ INSURER F COVERAGES CERTIFICATE NUMBER:1615942502 REVISION NUMBER: THIS :S TO CERTIFY THAT THE POLICIES OF INSJRANCE 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 POUC1ES LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIM$. INSR, - ADDLi UBR -_- POLICYEFF PCILICYW � LTR TYPE OF INSURANCE POLICY NUMBER MM! D A X COMMERCIAL GENERAL LIABILITY ; ECP2047633-10 712412025 7124*026 REACHOCCURRIENCE $1.000.000 �CLAIMS-MADE I A IOCCUR ocairrsnte $100,000X Po1e one person) $5.000 X Pfasuxmail PERSONAL AADVINJURY 31,000.000 GENT AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE S 2,000.000 4PACTX POLICY LOC PRODUCTS-COMPIOP AGG $2.000,000 X OTH Clams Marla Cor S 8 AUTOMOBILE LIABILITY BAP2047626-10 712412025 7/2412-026 COMBINE-5INGLE Lill S1,00%0D0 ANY AUTO BODILY INJURY(Per person) S OWNED )( SCHEDULED BODILY INJURY(Par acc'denr) S AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTYDAMAGE S X AUTOS ONLY X AUTOS ONLY JPer acc dern S A UMBRELLA LIAR X OCCUR FFX2047834-10 7/2412025 7/2412026 EACH OCCURRENCE f 1.000,000 X EXCESSLIAS CLAIMS-MADE AGGREGATE f 1'000,000 DEO RFTENTICN S S B WORKERS COMPENSATION WCA2047627-10 7/24/2025 7/24/2026y I PIN - AND EMPLOYERS'LIABILITY - ANYPROPRIETORIPARTNERIEXECUTIVE Y STATUTE_= NIA E.L_.EACHACCIDENT 51,000,0DO OFI`ICER7MEIl EXCLUDED? If (Mandatory In ll E.L.DISEASE-EA EMPLOYEE $1,000.000 II yy.s5s describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $1,000.000 DESCRIPTION OF OPERATIONS 1 LOCATIONS!VEHICLES iACORD 101.Additional Remarks Schedule,may be attathatl if mare space is regw l CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN I Village of Rye Brook ACCORDANCE WITH THE POLICY PROVISIONS. Building Department 938 King Street AUTHO Rye Brook NY 10573 United States ©1988-2015 ACORD CORPORATION. All rights reserved- ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD roRx 1 Workers' CERTIFICATE OF INSURANCE COVERAGE SoSl. Compensation `i- Board NYS DISABILITY AND PAID FAMILY LEAVE BENEFITS LAW PART 1.To be completed by NYS disability and Paid Family Leave benefits carrier or licensed insurance agent of that carrier ia.Legal Name&Address of Insured(use street address only) 1b.Business Telephone Number of Insured Envirasnietd 250 Moffitt street 860-380-5644 Stratford,Cr 06615 Work Location of Insured(Only required ifcouerage is specifically limited to 1c.Federal Employer ldent)ficalion Number of Insured certain locahom in New Ytuk State,i.e,Wfig"p Policy) or Social Security Number 33-4944860 2.Name and Address of Entity Requesting Proof of Coverage 3a.Name of Insurance Carrier (Entity Being Listed as the Certificate Holder) Village of Rye Brook AmGUARD Insurance Company Building Department 3b.Policy Number of Entity Listed in Box fa 938 King Street D816508923.1 Rye Brook, NY 10573 3c.Policy Effective Period 09/23/2025 to 07/24/2026 4. Policy provides the following benefits: A.Both disability and Paid Family Leave benefits. ❑ B.Disability benefits only. ❑ C.Paid Family Leave benefits only. 5. Policy covers: R] A.All of the employer's employees eligible under the NYS Disability and Paid Family Leave Benefits Law ❑ B.Only the following class or classes of employer`s employees: 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 NYS disability and/or Paid Family Leave benefits insurance coverage as described above. Date Signed 12/09/2025 By z;e_ (Signature of insurance carrieei authorized representative or NYS Ilcensed insurance agent of that insurance carrier) Telephone Number 800-673-2465 Name and Title Adam Edelstein President IMPORTANT: If Boxes 4A and 5A are checked,and this form is signed by the insurance carrier's authorized representative or NYS Licensed Insurance Agent of that carrier,this certificate is COMPLETE. Mail it directly to the certificate holder. If Box 413,4C or 58 is checked,this certificate is NOT COMPLETE for purposes of Section 220,Subd.8 of the NYS Disability and Paid Family Leave Benefits Law. It must be emailed to PAU@wcb,ny.gov or it can be mailed for completion to the Workers' Compensation Board, Plans Acceptance Unit, PO Box 5200, Binghamton, NY 13902-5200. PART 2.To be completed by the NYS Workers'Compensation Board(only if Box 49,4C or 50 have been checked) State of New York Workers' Compensation Board According to information maintained by the NYS Workers'Compensation Board,the above-named employer has complied with the NYS Disability and Paid Family Leave Benefits Law(Article 9 of the Workers'Compensation Law)with respect to all of their employees. Date Signed By (Signature of Authorized NYS workers'Compensation Board Fmployee) ;Telephone Number Name and Title l Please Note:Only insurance carriers licensed to write NYS disability and Paid Family Leave benefits insurance policies and NYS licensed insurance agents of those insurance carriers are authorized to issue Form OB-120.f. Insurance brokers are NOT authorized to issue this form. DB-120.1 (12-21) 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)380-56" Novoli,LLC DBA:Enviroshieid 250 Moffitt St Ic.NYS Unemployment Insurance Employer Stratford CT 06615-7I32 Registration Number of Insured Work Location of Insured(Only regairedifcoverageisspecifically Id.Federal Employer Identification Number of Insured limited to certain locations in New York State, i,e., a Wrap-Up or Social Security dumber Policy) 334944860 2.Name and Address of the Entity Requesting Proof of 3a. Name of Insurance Carrier Coverage(Entity Being Listed as the Certificate Holder) Great Divide Insurance Company 3b.Policy Number of entity listed in box"la" Village of Rye Brook WCA2047627-10 Building Department 938 King Street 3c. Policy effective period Rye Brook,NY 10573 7124/25 to 7/24126 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 "3" insures the business referenced above in box "la" for workers' compensation larder 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 notes the above certificate holder within 10 days IF a policv 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 maybe sent by regular mail.) Otherwise,this Certificate is valid for one year after thisform is approved by the insurancr 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.Falcieno (Print name orauthorized representative or licensed agent of insurance carrier) Approved by. 101�3 5t natucf (Dater Title: Commercial&Environmental Insurance Specialist Telephone Number of authorized representative or licensed agent of Insurance carrier: Please Note. 0n1s insurance carriers and their licensed agents are aisihori ed to i.sstre Form C-105.2. Insurance brokers are NOT authorized to issue it. C-105.2(9-07) www.wcb.state.ny.us O r 1 - ® 4 sJ