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HomeMy WebLinkAboutPP26-002 STATE OF NEW YORK,COUNTY OF WESTCHESTER ) as: V YIC� 11 I. t ,being duly sworn,deposes and states that he/she is the applicant above named, (print name of individual signing as the applicant) and further states that(s)hc is the Master Plumber 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&Building Code,the Code of the Village of Rye Brook and all other applicable laws,ordinances and regulations. DEOUNA BARON-DANIEL NOTARY PUBLIC,STATE OF NEW YORK Registration No.01BA0032946 Qualified in Westchest r 'My Commission Expim ' Sworn to before me this om to before me this day of ,20 day of 20 Sign ture of Property Owner Signa a of Applicant iNAnLtu L,4ecz, i i6E t "D rL4 ri Print Name of Property Owner Print Name of Applicant b&uw9a(61- D3hrei bona QA r6h -00A1?,4 tiotar} Public Notary Public This application must 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. Applications 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/vaa24 10:11 AM Mon Nov 24 .d LTE 84% M tergusonhome.com Log In OFERGUSON HOME V",-41 are you shopping for? Q Projects Orders& Returns .. All Departments .. Appliances Clearance Black Friday Early Access Learning Center FREE Standard Ground Shipping on Orders over S49 A Brands Kingston Brass View All Kingston Brass CC8320.X 161 INIKINGSTC7N Kingston Brass Kingston Brass 1/2" Sweat x 3/8" OD Comp Angle Shut Off 4,W� � Valve with 5" Extension Model CC83202X f Item.bci1505014 �, 1 Review $48.72 Finish Polished Brass - 127 In Stock t r- fY � t i Free Shipping on orders over S49.00! Leaves the Warehouse in 1 to 3 Lousiness days - Shipping to 10598 — 1 + Add to Cart Key Specifications • Water Water Connection Connection: 112" Type: Sweat • Material: Brass See More Details Recommended for You s Y� 4 > q ni, t �tr. ACORL?X CERTIFICATE OF LIABILITY INSURANCE onrE IMMf00nmY) Illl.�r 1 1019/2025 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 NAME: Certificate Unit Edgewood Partners Insurance Center PHONE FAx 100 Montgomery Street IAlC.No.Eat1:404-781-1700 No Floor 20 Suite 2000 EADDREss: apexrerts@epicbrokers.com San Francisco CA 94104 INSURER(S)AFFORDING COVERAGE NAICt _ Lioansep:OB29370 INSURER A:AIU Insurance Company 19399 INSURER APEXSER' INSURERS:Upland Specialty Insurance Company 16988 Bruni 8t Campisi, Plumbing,LLC IN 100 Grasslands Road suRERc:National Union Fire Ins Co of Pittsburg19445 Elmsford, NY 10523 INSURERD: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:1615477053 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 TYPE OF INSURANCE ADOL-$UBR POLICY NUMBER MMLDDY EFF POLY EXP LIMITS CTR B X COMMERCIAL GENERAL LIABILITY Y USPCL0284125 8/10/2025 8/1012026 EACH OCCURRENCE $2,000,000 CLAIMS-MADE OCCUR PREMISES Ea occuE once $100,000 MED EXP(Any one person) S Excluded PERSONAL&ADV INJURY $1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE $4,000,000 _ X POLICY 7] PRO- JECT LOC PRODUCTS-COMPfOPAGG $4,000,000 OTHER $ C AUTOMOBILE LIABILITY Y 9812741(AOS) 411/2025 41112026 rE�MBI�Nd.) NGLE LIMIT 5 5.000,000 X ANY AUTO BODILY INJURY(Per person) S OWNED SCHEDULED BODILY INJURY(Per accident)_S AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE S AUTOS ONLY AUTOS ONLY Per accident _ S B UMBRELLA LIAR X OCCUR Y USXCLO100925 8/10/2025 8/10/2026 EACH OCCURRENCE S 4,000,000 X EXCESS LIAR CLAIMS-MADE AGGREGATE S 4,000,000 CE 0 RETENTIONS 1 j S A WORKERSCOMPENSATPON 020396018(AOS) 4/112025 4111`2026 X A AND EMPLOYERS'LIABILITY YIN 020396020(WI) 4/112025 411f2026 STATUTE ER ANYPROPRIETORIPARTNER(EXECUTIVE I'—y E.L.EACH ACCIDENT S 1,000,000 OFFICERIMEMBER EXCLUDED? NIA (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $1.000.000 It yes,describe under DESCRIPTION OF OPERATIONS belt a I E.L.DISEASE-POLICY LIMIT S 1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES IACORD 101.Additional Remarks Schedule,may be attached it more space is required) Village of Rye Brook,to the extent required by written contract_is an additional insured with respect to general liability and auto liability. Umbrella is follow form over the General Liability,Auto Liability and Employers Liability. 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 938 King St. AUTHORIZED REPRESENTATIVE Rye Brook NY 10573 _ ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016t03) The ACORD name and logo are registered marks of ACORD Workers' YORK CERTIFICATE OF STATE Compensation NYS WORKERS' COMPENSATION INSURANCE COVERAGE Board 1a.Legal Name&Address of Insured(use street address only) 1 b Business Telephone Number of Insured 914-946-5558 runi&Campisi Plumbing,LLC 100 Grasslands Rd Ste130 1c.NYS Unemployment Insurance Employer Registration Number of Elmsford. NY 10523 Insured 8831360264 Work Location of Insured(Only required if coverage is specifically limited to 1d.FederaR Employer Identification Number of Insured or Social Security certain locations in New York State, i e,a Wrap-Up Policy) Number 92-0299696 2.Name and Address of Entity Requesting Proof of Coverage 3a.Name of Insurance Carrier (Entity Being Listed as the Certificate Holder) AIU Ins Co. Village of Rye Brook 3b.Policy Number of Entity Listed in Box"1a" 938 King St. Rye Brook. NY 10573 020396018 3c.P©Ircy effective period 0410112025 to 04/01/2026 3d.The Proprietor,Partners or Executive Officers are ❑X 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"1 a"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 must notify the above certificate holder and the Workers'Compensation Board 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. This certificate is issued as a matter of information only and confers no rights upon the certificate holder.This certificate does not amend, extend or alter the coverage afforded by the policy listed. nor does it confer any rights or responsibilities beyond those contained in the referenced policy. This certificate may be used as evidence of a Workers' Compensation contract of insurance only while the underlying policy is in effect. Please Note: Upon 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: Don Bailey f Prmt n e o onzed representative or licensed agent of insurance carrier) Approved by: 05/12/2025 (5igna ure) pQate) Title: CEO, North America Telephone Number of authorized representative or licensed agent of insurance carrier: 212-770-7000 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 (9-17) www.wcb.ny.gov