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HomeMy WebLinkAboutMP15-133 QyE DR 0 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 May 14,2025 Matthew Rosen&Alyse Rosen 175 Ivy Hill Crescent Rye Brook,New York 10573 Re: 175 Ivy Hill Crescent, Rye Brook,New York 10573 Parcel ID#: 129.76-1-38 This document certifies that the work done under Mechanical Permit #15-133 issued on 9/2/2015 for the installation of a new boiler has been satisfactorily completed. Sincerely, Steven E. Fews Building&Fire Inspector /to QyE BRC��• 1982 BUILDING DEPARTMENT ❑BUILDING 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 : { 1 V lIl�/ DATE' 3 2 02� PERMIT# NN C - � ` ISSUED: lam_SECT: I Z S.7L,-) BLOCK:_LOT: .3t� LOCATION: Vl.�� S C:! ` Lo5- OCCUPANCY: ❑ VIOLATION NOTED THE WORK IS... eACCEPTED ❑ REJECTED/ REINSPECTION ❑ SITE INSPECTION REQUIRED ❑ FOOTING ❑ FOOTING DRAINAGE ❑ FOUNDATION ❑ UNDERGROUND PLUMBING NOTES ON INSPECTION: ❑ ROUGH PLUMBING ❑ ROUGH FRAMING ❑ INSULATION ❑ NATURAL GAS ❑ L.P. GAS ❑ FUEL TANK ❑ FIRE SPRINKLER ❑ FINAL PLUMBING ❑ CROSS CONNECTION FINAL ❑ OTHER • F� F�������� P is���� F� F+��� W��� W��� � Fa �������������� ' i i M � a a� N M r'q a 04 to ti i O W o � avi,6u i W C A - coO W U 3 v � �., Z °" b a p� zO 76-4 b d w kn Ooo � U O U05 .. A : � U p� U � �•.�' o 0 BUILENR!.- � I� VIL * 938 KiN C E � �/ E (914) DD wche, e � , Ph ERMIT APP I RYE BROOK PARTMENT *MUST BE FILED B A LICENSED MAS L UMBER ON Y* Date: G t r Iztumhing.Permit#• HP )5_1 33 Fee: Approval Signature: (fees a on-refuAdab F� Application is hereby made to the Building Inspector of the Village of Rye Brook NY,for the issuance of a Permit to install Plumbing as per detailed statement described below, and in accordance with all applicable Federal, State, County and Local Codes,at the following location: Address: ( ly �yY �'� C�, SC,�,'v� Phone#: �e t Owner:W AnLYf'A ��'`� Address&Phone: ('7S �y�� Kt� C S G��" Use/Occupancy: , '� Parcel I.D.#: 12�1 -Zone: 3g LICENSED MASTER PLUMBER'S INFORMATION: Name(please print). Phone#: ZiY Signature: Westchester County License#: S�� Company Name: _TN'U(S(:5 > Company Address: L/�Zyi�-UW Avt City/Town: S L'y State: ' Y Zip Code: / S`�] Phone#: al j Z` i '7 � ...................................................................................... FIXTURES&LINES ARE TO BE INSTALLED ACCORDING TO THE FOLLOWING SCHEDULE: Location Water Urinals Drinking Sinks Showers Bath Laundry Domestic Fire Sanitary Natural/ Other* Total Closets Fountains Tubs Tubs Service Service Sewer LP Gas Basement Ist Floor 2nd Floor Outside *Other: t" b I L.C1L, Detailed Description of Appliances etc...: I FA Cub-� W r(.%0—� 2015-08-3109:21 Tim Fernandez 8452251098>> A8/10 Y i .r • r � WTGO- Gold Series Oil Boiler Weil-McLain NOR 4 Water u# Tankless Heater Chimney Vent { MBH:115-295 Avg.Efficiency:85% i i' x 'a T.. OO HIGH EFFICIENCY O EASY TO INSTALL AND SERVICE O MADE WITH WELL-MCLAIN QUALITY aim APPLICATIONS INCLUDE: Residential Light Commercial ` Multiple Boilers Indirect-tired Water Heating Radiant HeatingY ...And Much More _ III Now ZW W17110 LAIN MADE 111111 THE Ir a lngs DOE USA )=B�RChimneySize �. Model*' I 1.6-R I %DOE IDGEHeatiriI fleaI I Tankless I Draft Loss I Rectangular Round Height Approx Notm Sumer Seasonal Capacity Water Rating Heater Through (in) (in) 00 Shipping - Pdd P'forpadmgedbolterCWTGO-3thoughWTGe-6oI Cap,(GPH) Efficiency (MBHWater) (MBH) Intermittent Boiler(in.w/c) Weight(Lbs) Add W for bater only MTGO-3tlriWrGO-g) (1) (AFUE) (2)(3) (3)(5) Draw"(6) (7) (1)No.2 fuel oit-CormenialStadad Specification I Heating value of dF-140,000 BTU/Gal :PiWTGO-3' 1 0.95 1 85.3 1 115 100 1 3.25 1 .020 1 8 x 8 6 15 540E•-(2)Based on standard test procedures prescribed by the ftedStates P­WTGO-3Ll 0.95 1 84.5 1 114 1 99 3.00 .020 Sx8 6 15 595 Department arnergyacombusua,rmditionof13112%CO2ard-oo2� WC.draft WTGO-4' 1 1.20 1 85.0 1 145 1 126 1 3.75 1 .010 1 8 x 8 1 6 1 15 645 (3)M BH refers W thousands of 131U per tax (4)1-8-R gross ouW WTGO-5' 1 1.45 1 85.0 1 175 1 152 1 4.00 1 .015 1 8 X 8 1 7 1 15 760 (5)Net I-B-R ratings are based on net installed radiation adoquate for the requirements of the building,including a piping and pickup WTGO-6' 1 1.75 1 85.0 1 212 184 1 4.25 1 .015 1 8 x 8 7 1 15 860 allowance of 1.15-sufficient for normal conditions.Provide WTGO T 2.00 85.0 242 210 5.50 .015 8 x 8 8 15 930 additional allowance only for unusual piping and pickup loads. (6)Tankless heater rating is in gallons of water per minute,heated from WTGO-8 2.30 - 266' 231 1 5.75 1 .025 1 8 x 12 1 8 1 20 1030 40°F to 1401F with 200OF boiler water temperature-tested in accordance with I-W-H Testing and Rating Standard for Indirect WTGO-9 2.55 - 295 257 6.00 .030 1 8 x 12 1 8 1 20 1135 Tankless water Heaters Test with Boilers. (7)Listed draft losses arc for standard bumor settings. Dimensions SupaN'13*6n I Rehm I Dimensbris�in)_I Tankless Heater I Tapping size I Control Model I P-WG0 (n) 1 B I L I Ntmber inlet&Wtk(NPT)(n) Ttutt'm Cordrd(tD(n) Location on) ..�WTGO-3 11/4pa I,ro nanpel 1 1/2 1 t 1/2 13 1/2 1 16 7/8 1 WT-14 1 1/2 3/4 B2 1 1/2 Alternate return-"A'units only E3 1/2 PressureJtemperaturegaugeWO3 11lapcUlawillati 1 11/2 1 11/2 101lz 133la WT-14 1 tl2 3/4 WTGO-4 1t/4pu,Ialonarga)1 11/2 1 11/2 1 135/e 1 167/8 1 WT-14 1/2 3/4 H 31a Drain valve WTGO 5 11/2prcuato nm ge) 1 1(p 1 1/2 16 7/a 20 WT 14 1/2 3/4 L 3/4 High timtt/circulator control WTGO-6 11/2p„�torrange) 1 1/2 1 1/2 20 231/8 WT-14 1/2 3/4 N 1/R1 3/4 Relief valve Piping to expansion tank or automatic air vent WTGO-7 notapplicable 1 t 112 1 11/2 231/a 261/4 1 Wi-20 1 1/ 3/4 WTGO-8 I notlicable 11/2 1 t/2 261/a 293/8 1 WT-20 11/2 3/4 WTGO-9 I Trot applicable 1 1/2 1 1/2 29 3/8 321/2 WT 20 112 r 3/a Crate Dimensions: Height-39" Width-23" Length('WTGO-3,-4)-27"/('WTGO.S,-6)-33" 20'/'— L t 4'apOrex. Nis 7:N 2Y. N -_1 soopitcl PN S(C)1Y i 7"diameter nrl I faFor i' Q I L vent pipe ° '+- R .. . a. 35Ye' burner ............>.. opening 29�46 B f Return 1 15 h, Return 14'/e B2 _....__. 9h 3Yrs' c� H Llr -- P-VVTGO Front Side A-VVTGO Front Brack Intermediate Standard and optional Equipment Standard Equipment: Optional Equipment: Limited Lifetime Warranty on Boiler Sections Circulator(Taco 007)-Supplied wi0i High-Efficiency Flame-Retention Oil Burner Factory Tested "Packaged"Units Only (Beckett AFG,Carlin I or Riello).Specify Factory-Assembled Cast Iron Sections with Comb.Temp.Controls,LWCO&Circulator Relay 2-Stage Fuel Unit(optional)if Required. the Following Parts Installed(not assembled (all P-units/A-units ordered with W-M 5&10 Year Homeowner Protection Plan on 7-,8-and 9-section blocks.) tankless heater) W-M Indirect-Fired Water Heaters Tankless Heater(P-units)or Tankless Electrical Junction Box with Wiring Harnesses Opening Cover Plate(A-units) Junction Box Cover Plate with Service Switch Insulated Steel Jacket Two Vent Pipe Brackets Aluminized Steel Flue Collector Hood Pressure/Temperature Gauge - I with Flue Cap on Top Outlet 30 PSI ASME Relief Valve(boiler sections tested Swing-Away Sumer Mounting Door for 50 PSI Working pressure) N_ - Refractory Blanket and Target Wall in Drain Valve Combustion Area Balanced Draft Damper ["AAWEIL-McLAIN , In the interest of corortnual improvements in prod and performance,Weil-McLain reserves the rightto change sp pificatiI without notice. C-751(1009) '_' _ _ N a : � w Ill 0 N _ : s N M ON CG i O, k N M a, [6-4 w tn r- co t N o : ;T4 W v� d W z V,) a U � g - z W W O Q BUILDING DEPARTMENT D E C E H E VILLACIt OF RYE D[D BROOK � ' 20 938 KING STRI�F:i RN'l: BR()oK,NY 10573 (914)939-0668 OX(914)939-5801 VILLAGE OF RYE BROOK BUILDING DEPARTMENT ELECTRICAL PERMIT APPLICATION This application must be filed in person at the Building Department by the Licensed Electrician of Record and must be accompanied by the completed Electrical Inspection Agency application form. Office Use Only: Date: / Approval Signature: Inspection Agenc Electrical Permit M Fees: paid x f due( Buttc Mg+ermit#: xxwaw+x+++rx+x++xww+w++x++x+x++x+x+xxa+a+++x++xx+xxaaw++x++x++x+w+a++++xxx+x+xxxawwxxaa+w++a+x++x+xwxxxwxxx++++++x+xxxwww++xx++xx+rawx+xwa Application is hereby made to the Building Inspector of the Village of Rye Brook NY, for the issuance of a Permit for the installation/removal/repair of Electrical Equipment as per detailed statement described below,and in accordance with the Code of the Village of Rye Brook, NYSUFP&BC, NEC, NFPA and all other applicable State, County and Local Laws. Address: - C / Phone#: — 7 Owner: ,4- SC- Address& Phone: 74 �ieG S e12-N Use/Occupancy: -Rc s Parcel l.D.#: /-19.74 -- — Zone: 1 Proposed Electrical Work: /v 01 le LICENSED ELECTRICIAN'S INFORMATION: , Name(Please PriFit) Phone# �f Cif 92 3-2 Signature: estchester County License#: Comp� Na — _�//v --- — �`�� /1 C 6— - Company Address: / � 1iL� — City/Town: Y� State: Zip Code: f OS 9-O _ Phone#: Field Con ct& Phone: Revised 9/6/1 1 Westchester Rockland Electrical Inspection Services, Inc. Phone: 914-347-35 DO NOT WRITE HERE-FOR OFFICE USE ONLY 43 North Lawn Avenue Fax: 914-347-3596 Elmsford, NY 10523 BUILDING PERMIT NO. TEMP# DATE" I ' -- — ; , ,/ Z I 1z bip)-!5- !`13 CITY OR VILLAGE ZIP CODE TOWNSHIP Co � (rit/ �S �— STREET AND NO.OR ROAD`-+�/� i _ ee �(. POLE NUMBER BETWEEN WHAT TWO GROSS JSTREETS IS PREMISES LOCATED? SECTION BLOCK LOT OCCUPANT'S NAME IJ BUILDING OCCUPANCY OWNER'S NAME AND ADDRESS HOME TELEPHONE NUMBER ]� �: CURRENT SUPPLIED BY FROM THEIR OFFICE ORK TE TONE NUMBER LIST BELOW ALL EQUIPMENT WHICH YOU INSTALLED NUMBER OF OUTLETS NO.OF FIXTURES& MOTORS HEATERS OFFICE USE LOCATION LAMP RECEPTACLES ONLY SIDEWALL SWITCH INCADE FLUORE NO. H.P.EACH NO. WATTS EACH INSPECTION OUTSIDE BASEMENT 1"FL. 2' FL. 3'FL. REMARKS:LIST OTHER ELECTRICAL DEVICES NOT SET FORTH ABOVE: THIS APPLICATION IS INTENDED TO COVER THE ABOVE LISTED ITEMS TO BE INSPECTED.IF AT ANY TIME OF INSPECTION ADDITIONAL ITEMS HAVE BEEN INSTALLED.YOU ARE AUTHORIZED TO MAKE THE INSPECTION AND ADJUST THE FEE FOR THE ADDITIONAL ITEMS INSPECTED AS PROVIDED BY THE APPLICANT.THE APPLICANT DECLARES THAT THERE IS NO OPEN APPLICATIONS FOR THE ABOVE WITH ANY OTHER INSPECTION COMPANY.WREIS, INC. IS NOT LISTING,LABELING.UNDERWRITING OR CERTIFYING ANY EQUIPMENT, MATERIALS OR DEVICES WHICH ARE PERFORMED BY OTHER CERTIFIED TESTING AGENCIES OR INSPECTION COMPANIES.THE APPLICANT.OWNER.OR AUTHORIZED AGENT AGREES TO ALL THE ABOVE TERMS AND CONDITIONS AS SET FORTH FOR THE APPLICATION. SIZE OF SERVICE FEEDERS CHARACTER OF WORK NEW Li ADDITIONAL a EXPOSED❑ CONCEALED 0 MUST ENTER APPLICANTS IDENTIFICATION NUMBER SERVICE ENTERS BUILDING OVERHEAD I. UNDERGROUND❑ AVOID DELAYS BY GIVING FULL AND ACCURATE INFORMATION.ALL SPACE MUST BE FILLED IN OR APPLICATION MAY BE RETURNED. NAME OF COMPANY DATE OF APPL19ATION' / SIGNgyl1STREET ADDREW RE -Ff MA `' Jc� TELEPHONE No. CRY Q06�,^O LICENSE NO.WHEN APPLICABLE �� ` BY THIS CERTIFICATE OF COMPLIANCE THE Westchester Rockland Electrical Inspection Services 43 North Lawn Ave, Elmsford, NY 10523 914-347-3595 Office 914-347-3596 Fax CERTIFIES THAT Upon the application of: Upon premises owned by: Zaccagnino Electric (E) -Angelo Zaccagnin Matt Rosen - 81 Maple Avenue 175 Ivy Hill Crescent Rye, NY 10580 Rye Brook, NY 10573 Located at: 175 Ivy Hill Crescent, Rye Brook, NY 10573 Application Number: 2036464 Certificate Number: 2036464 Section: 129.76 Block: 1 Lot: 38 BDC: 003 Permit Number: 15-214/15-133 A visual inspection of the electrical system at this premise described as a Residential occupancy,wherein the premises electrical system consisting of electrical devices and wiring, described below, located in/on the premises at: 175 Ivy Hill Crescent, Rye Brook, NY 10573 basement was inspected in accordance with the NYS and NFPA 70-08 and the detail of the installation, as set forth below, was found to be in compliance therewith on the 09 Day of September 2015. Name Date Quantih Rating Circuit Type Boiler I This Certificate has been approved by Westchester Rockland Electrical Inspection Services. a This certificate may not be altered in any way. This certificate is valid for work preformed before date of inspection only. Mquillante 24 Thursday,October 22,2015 Page I of I A oRV CERTIFICATE OF LIABILITY INSURANCE DATE(MMlDDIYYYYI 7/28/2015 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(les)must 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 NAMCONE: p TACT Stephanie Payne P e SPAIN AGENCY PHONE (B45)62B-4500 FAX (845)628-1804 N6 No.Ext]: LA-c.No: 625 Route 6 a pl.Ess spayneBspainins.com INSURERS)AFFORDING COVERAGE Mahopac NY 10541 INSURERAAmerica Fire and Casualty Co. 24066 INSURED (NsuRERsOhio Casualty Insurance Co 24074 Thuesen Mechanical Corp. INSURER Rochdale Insurance ComiDanv 12491 345 Lexington Ave. INSURER D: INSURER E Mt. Kisco NY 10549 INSURERF: COVERAGES CERTIFICATE NUMBER:15-16 Master 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 1S SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE N. S ti POLICY NUMBER MOUCY EFF MMM�Y£XP LIMITS LR �.—.—___ X COMMERCIAL GENERAL LIABILITY i 1,000,000 EACH OCCURRENCE S A f— CLAIMS MADE EX OCCUR PREMJ$F5(Ea occurtence] S_ 300,000 X I BKAS5S58075 7/31/2015 7/31/2016 MED EXP(Any one person) $ 15,000 PERSONAL d ADV INJURY S 1,000,000 �GENI-AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE s 2,000,000 POLICY SEC- LOC PRODUCTS-COMPIOPAGG $ 2,000,000 OTHER: Empl Bene Liab-Each Claim S 1,000,000 AUTOMOBILE UABKJTY I M 1 ED SINGLE LIMIT $ 1,000,000 a accident) A X ANY AUTO BODILY INJURY(Per person) S ALLOOWNED SCHEDULED RAA55558075 i 7/31/2015 7/31/2016 BODILY INJURY(Per acadont) S NON-OWNED ++ PROPERTY DAMAGE S HIRED AUTOS AUTOS t e<accidor,0 PIP-Additional S X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 4,000,000 El EXCESS UAB CLAIMS-MADE ( AGGREGATE 6 4,000,000. DED X (RETENTIONS 10,000 IUS055556075 7/31/2015 7/31/2016 I g WORKERS COMPENSATION j XJgTATU�, ER AND EMPLOYERS'LIABILITY ANY PROPRIETORIPARTNERIEXECUTIVE YIN E.L.EACH ACCIDENT S 1,000,000 C (Ma��In EMNµ)EXCLUDE07 r NIA RWC3369804 5/1/2015 5/1/2016 iE.L.DISEASE-EA EMPLOYEE S 1,000,000 i It Ees, IPTION OF OPERATIONS below under D SCRIPTI EL.DISEASE-POLICY LIMIT $ 1,000,0100 I i I DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Addltionai Remarks Schedule,may be attached R more space Is regWred) Certificate holder is named as Additional Insured as their interests may appear subject to policy terms and conditions. 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 10580 AUTHORIZED REPRESENTATIVE Michael Spain/MP ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD INS025 nmjnn 'Certificate-of NYS Workers'Compensation Insurance Coverage Page 2 of 3 STATE OF NEW YORK WORKER'S COMPENSATION BOARD CERTIFICATE OF NYS WORKERS' COMPENSATION INSURANCE COVERAGE la.Legal Name and address of Insured(Use street address only) lb.Business Telephone Number of Insured Thuesen Mechanical Corp&Thuesen Management Corp 914-241-7499 345 Lexington Ave Mt Kisco,NY 10549 le.NYS Unemployment Insurance Employer Registration Number of Insured Id.Federal Employer Iudentification Number of Insured Work Location of Insured(Only required if coverage is specifically limited or Social Security Number 061405021 to certain location in New York State,i.e.a Wrap-Up Policy) 2.Name and Address of the Entity Requesting Proof of Coverage 3a.Name of Insurance Carrier (Entity Being Listed as the Certificate Holder) Rochdale Insurance Company Village of Rye Brook 938 King Street 3b.Policy Number of entity listed in box"la": Rye Brook,NY 10580 RWC3369804 3c.Policy effective period: 5/1/2015 to 5/1/2016 3d.The Proprietor,Partners or Executive Officers are: included(Only check box if all partnerstofficers 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 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 Certification of Insurance to the entity listed above as the certificate holder in box"2". 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'?c",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: Henry C.Sibley (Print name of authorized representative or licensed agent of insurance carrier) Approved By: l ✓ 5/1/2015 (Signature) (Date) Title: Underwriting Manager Telephone Number of authorized representative or licensed agent of insurance carrier:CarrierPhone Please Note:Only insurance carriers and their licensed agents are authorized io issue the C-105.1 form.lruurance brokers are NOT authorized to issue a C-105.2(9-07) https://ao.amtrustgroup.com/anawc/PolicyNYCertifiicateOf Wclns.aspx?IndexId=110472&1... 5/1/2015