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HomeMy WebLinkAboutRB25-0119 N C O 0 N ++ O N o „ v + o a aLn CAvm LL •� E > a, o � o0 Q, a v M v � L- V) m (v m W Ln p � m vta 3 W N E _ X 0z 0) oao w W v C N ` M O- w aJ L > C L � O CO > � �.'' � W \ 3 O a) v F- / o ~ L L LLl u ^ v ) N W O Ln v E O CO W 3 L o CN O N It �` _ N Y O N Y O d 'I ~ Z Cp a Z _ O o O L on o � a T uy W Y Y `� \ W W a o Y O G Y Z N d CO o w y v w W �• U J N m o m a o m u 2 66 c Q a O Y � J a W LU o >oO W co U E O ° � J o aoiTaCL m N 0 Z Q W W U M Ln rj p O W 3 •+ N .� Cl to Y d C. W O oo O E v � 'j m ei U O E CO `ri o v E O 0% •i �, � a z z Xt o v E a a, o �, W ` -j 410 uQ r o0 v _ � E oNu m o -0 m u , =v' o - > > -um' ov � U C � 0 cv�i vYs c �-1 L � 7 C W >- Ln CIO00 n �O N O as v E 3 m ca � 2 c D Q O � .It C14 a C O � L V W V1 N '� L r-I c-I Q W J N Ln J H Q C I , C O Ln r-I N o ,� o a r C. R o n n a C a E o o a 0 LL W V vY � ` � 0 or-C. r `o_ c72 _ E �,Ew yoR Q . a F, r cii C ' > E - '`- N ~ W J LLI W O N a} *' n�i a�i cc O coCC Q - Q co p. L U H o C u ^ u a/ ClC Yd W � C u °s d Q a a 0 :E v Y Fuel Storage Tank Permit Application Village of Rye Brook 938 King St Rye Brook, NY 10573 Phone: (914)939-0668 1 www.ryebrook.gov Building Department Storage Tanks in excess of 1,100 gallons require registration with the County of Westchester Project Information Permit Type Fuel Type Buried in Ground Fuel Oil #of Fuel Tanks Capacity of each Tank: Exact Location(s) of each Tank: 1 300-Gallon Removal The tank is located in the rear of the unit. Fuel Storage Tank Permit Application,page 1/1 �y DR(�j� VILLAGE OF RYE BROOK 938 King 5t Rye Brook,NY 10573 Q Y Phone:(914)939-0668 1 www.ryebrook.gov b2• Building Department Fuel Tank/Buried In Ground(Removal) Permit Permit Set 140 BRUSH HOLLOW CRIES P#RB25-0119 R#129.76-1-120 PERMIT INFORMATION Address Permit number Date issued 140 BRUSH HOLLOW CRIES RB25-0119 11/14/2025 REVIEWED BY If you have any questions regarding the review of these drawings please contact: Application in general Alfredo(Freddy)DiVitto adivitto@ryebrook.org INSTRUCTION AND ATTENTION It is the responsibility of the Applicant to print full size the entire approved permit package and provide at the time of inspection. TABLE OF CONTENTS Cover page 1 Building Permit 2 Required Inspections 3 Contractor's Liability Insurance,Contractor's Workers Compensation Insurance(Showing Rye Brook 4-9 Cert Holder Property Owner/Homeowner Government ID,and/or Proof of Ownership 10-11 Site plan 12 Certificate of Occupancy,Certificate of Compliance,and Certification of Final Costs Application 13 Fuel Storage Tank Permit Application 14 Building Department.938 King St Rye Brook,NY 10573/Phone:(914)939-0668 BR(�uk VILLAGE OF RYE BROOK O 938 King St Rye Brook,NY 10573 W :E Q Y Phone:(914)939-0668 1 www.ryebrook.gov > �O ��• b2• f Building Department INSTRUCTIONS THE PERMIT HOLDER AND/OR PROPERTY OWNER IS RESPONSIBLE FOR ENSURING THAT ALL REQU[RED/APPLICABLE INSPECTIONS ARE SCHEDULED AND THAT THE PERMIT IS COMPLETE � ❑� 6ill REQUIRED INSPECTIONS Name Description Final Inspection Completion of all required items under the permit including the site grading and the surveyor's final grading certificate. Certificate of Occupancy Completion of ALL Work,All fees Paid and Final Survey in if required) 6 vm ENVIINC-01 JSILVA DATE(MM/DD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 12/4/2024 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 Mary Tomaselli Gowrie Group ;PHONE FAx 70 Essex Road (AC.No.Ea*(860)399.2838 (AIC,No):_ _ Westbrook,CT 06498 ADDRESS;mtomaselllWsk-MAIL INSURER(31 AFFORDING COVERAGE _ _AI S INSURER^:Nautilus_Insurance Compaq 17370 INSURED I_wsuaexe:Great Divide Insurance Company 25224 Enviroshleld Inc.and E.G.Kost Rental,LLC INSURER C: _ PO Box 1296 -- — - — 250 Moffitt Street INSURER D: _ Strafford,CT 06615 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. _ I ISR TYPE OF INSURANCE ADDL SU POLICY NUMBER POLICY EFFJJ& POLICY EX 2. O A X COMMERCIAL GENERAL LIABILITY EAACAyH�O�CCURRENCE 1,000,000 CLAIMS-MADE I X OCCUR ECP01521982-25 I 12/1/2024 12M/2025 pl;EM1SE$iOF.RaENoccu�anca 100,000 X Pollution Liability 5,000 MED EXP(Any oneperson iX Professional Liab PERSONAL a ADV INJURY 1,000,000 GENLAGGREGA LIMIT APPLIES PER: GENERAL AGGREGATE S 2,000,000 POLICY LOC PRODUCTS-COMP/OP AGG S 2,000,000 OTHER III B AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT 1,000 000 _{Eap�tylr,D _ '— ANY AUTO BAP1521979 25 12/1/2024 12/1/2025 BODILY INJURY(Per pe 3 OWNED SAUTOS CHEDULED 80 ILY INJURY(Per accident) HHOWNE�S ONLY X SCHEDULED E X AMCSIRS ONLY X.E AUTOS ONNLY A UMBRE"UAe X OCCUR 1 EACH URRENCE_ 1,000,000 OCC X EXCESS LUW CLAIMS-MADE FFX 2036752 13 12M/2024 12/1/2025 AGGREGATE 1,000,000 DED 1 X I RETENTIONS 10,000 B AND EMPLERSOYERS'LIABILITY YIN X I PFJTMIF'i Tµ. i ANY PROPRIETORIPARTNER/EXECUTNE CA 1521980 24 12/7I2024 12/1/2025 1,000,000 OFFICETMJMBEREXCLUDED4 NIA L.EACHACCIDENT S lMa Idatory I NH) _E.L.DISEASE-EA EMPLOY S 1,000,000 if yes,describe unde DESCRIPTION OF OrPERATIONS below EL DISEASE-POUCY UA4T l S 1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 1111,Addklonal Remarks Schedule,may be attached If more space Is required) Village of Rye Brook is listed as Additional Insured for General Liability where required by written contract. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE Village of Rye Brook 938 King Streetl /! __$ye_Btgok NY 10 �► 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 1a.Legal Name&Address of Insured(Use street address only) lb.Business Telephone Number of Insured (203)394-2268 Enviroshield,Inc. Post Office Box 1296 le.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"Ia" BAP1521979-25 Village of Rye Brook 938 King Street 3c. Policy effective period Rye Brook,NY 10573 12/I/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", whicherver 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,1 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 authorzed representative or licensed agent of insurance carrier) Approved by: Vi,vi.GevvF M. ELL_ca n.o 1 1/25/2024 (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