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HomeMy WebLinkAboutMP18-076 (Cr Q is cw wy, VILLAGE OF RYE BROOK MAYOR 938 King Street,Rye Brook,N.Y. 10573 ADMINISTRATOR Paul S. Rosenberg (914) 939-0668 Christopher J. Bradbury www.ryebrook.org TRUSTEES BUILDING& FIRE Susan R. Epstein INSPECTOR Stephanie J.Fischer Michael J. Izzo David M. Heiser Jason A. Klein CERTIFICATE OF COMPLIANCE March 29,2022 Kevin McNamara&Lillian McNamara 6 Tamarack Road Rye Brook,New York 10573 Re: 6 Tamarack Road, Rye Brook,New York 10573 Parcel ID#: 135.67-2-42 This document certifies that the work done under Mechanical Permit #18-076 issued on 6/12/2018 for the installation of a new gas fired boiler has been satisfactorily completed. Sincerely, Michael J. Izzo Building&Fire Inspector /tg �E BRC�j�• 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 :' A DATE: Z PERMIT# V417 I -, -' O�Z V ISSUED:SECT: L 11�� BLOCK: LOT: LOCATION: S' ��� �I 1 N l� �� OCCUPANCY: ❑ VIOLATION NOTED THE WORK IS... ' ACCEPTED ❑ REJECTED/ REINSPECTION ❑ SITE INSPECTION REQUIRED ❑ FOOTING ❑ FOOTING DRAINAGE ❑ FOUNDATION ❑ UNDERGROUND PLUMBING NOTES ON INSPECTION: ❑ ROUGH PLUMBING ❑ ROUGH FRAMING ❑ INSULATION ❑ NATURAL GAS ❑ L.P.GAS z ❑ FUEL TANK ❑ FIRE SPRINKLER ❑ FINAL PLUMBING ❑ CROSS CONNECTION ❑ FINAL OTHER 1 t DRC�j� w m -1. 1932 BUILDING DEPARTMENT ❑BUILDING INSPECTOR VILLAGE OF RYE BROOK ❑ VILLAGE ENGINEER 938 KING STREET RYE BROOK,NY 10573 ❑ASSISTANT BUILDING INSPECTOR (914)939-0668 FAX(914) 939-5801 - - - - - - ---------- - - --- INSPECTION REPORT - - - - - - - - - - - - -- - - - - - -- ADDRESS: �- ` C`L 1'� ' DATE: I PERMIT 1� 1� ISSUED: +�t 2'! SECT: BLOCK: LOT: LOCATION: � �' \ �+ C"� 1` � # F OCCUPANCY: Z 1� ❑ VIOLATION NOTED THE WORK Is... ACCEPTED ❑ REJECTED/REINSPECTION ❑ SITE INSPECTION REQUIRED 0 FOOTING 0 FOOTING DRAINAGE 0 FOUNDATION ❑ UNDERGROUND PLUMBING NOTES ON INSPECTION: ❑ ROUGH PLUMBING 0 ROUGH FRAMING 0 INSULATION ❑ NATURAL GAS ❑ L.P. GAS ❑ FUEL TANK 0 FIRE SPRINKLER ❑ FINAL PLUMBING 0 FINAL ❑ OTHER Village of Rye Brook BUILDING DEPARTMENT 938 King Street, Rye Brook, New York 10573 TeL (914) 939-0668 Fax(914) 939-5801 CERTIFICATION THIS CERTIFIES THAT THE GAS PIPING WORK IN THE BUILDING BELOW HAS SUCCESSFULLY PASSED A LEAKAGE TEST: NAME ADDRESS SECTION I BLOCK LOT DATED: BUILDING INSPECTOR DATED: 4. PLUMBER PLUMBING CONTRACTOR: ®NavieN NCB Series Combination Boilers Condensing Gas Specification Sheet Combination Boiler •Certified design according to ANSI Z21.13-CSA 4.9-2014 standards for indoor residential applications •Gas Input Ranges(Space Heating/DHW) •sn4 small NCB-150E-60,000(120,000 for DHW)to 12,000 BTUh NCB-180E-80,000(150,000 for DHW)to 14,000 BTUh NCB-210E-100,000(180,000 for DHW)to 18,000 BTUh NCB-240E-120,000(199,900 for DHW)to 18,000 BTUh •Domestic Hot Water Flow Rate Capacity(-based on 77•F temperature rise) NCB-150E-2.6 GPM NCB•180E-3.4 GPM NCB-210E-4.0 GPM NCB-240E-4.5 GPM •Dual Primary and Secondary Stainless Steel Heat Exchangers for optimum efficiency and durability •Stainless Steel Flat Plate Heat Exchanger*for DHW — (•certified to IAPMO PS 92.2013 standards) •Domestic Hot Water Priority ._, •Compatible with 2"PVC vent up to 60 ft**and 3"PVC vent up to 150 ft** (*•with neelbow) Sleek Design•Compatible with 2"PVC Vent •Backlit Front Panel-allows adjustment of hot water temperatures and boiler functions including Outdoor Reset Curve settings,heating setback, Integrated Low Water Safety Control,water fill pressure,and output capacity •Ready-Link Cascade Compatibility with Navien water heater models-can be connected with up to 15 tankless water heaters for increased DHW output & ■ •Compatible with NMi k.Wi-Fi Control •Internal Circulation Pump-comes included with a primary circulation pump and air vent for added value and convenience •Low Voltage Terminal Strip-contacts for thermostat or zone controller, outdoor reset,24 VAC device relay,air handier interrupt,and LWCO •Temperature Options-two boiler setpoints:hydronic heating temperature settings range from 77*17 up to 194e17 and from 86e17 to 140e17 for DHW temperatures •Outdoor Reset Sensor(included)-when installed with an NCB Series model, the unit controls will sense outdoor ambient temperatures and adjust the boiler INCLUDED Illuminated Front Panel with operation for maximum comfort and efficiency Advanced Hydronk and DHW Operation •AFUE Ratings NCB-150E/-180E/-210E/-240E-95.0%(NG/LPG) Ir Most Efficiela •Compatible with Natural Gas(NG)and Propane(LPG)*** E2017 I—requires Installation of Included Field Conversion xlt by a qualified gas servicer) 0u. •Certified by CSA,ASME,NSF/ANSI 372 for Low Lead(DHW only), SCAQMD(Rule 1146.2 Type I-Complies with 14 ng/J or 20 ppm NOx @ 3%02) A of S o,y •CRN-2002.9YT(NCB-150E),2003.9YT(NCB-180E),01-16835.4 and S 2004.9YT(NCB•210E),OH6835.4 and 2005.9YT(NCB-240E) ME oFR�ry �ri�e •10-Year Heat Exchanger and 5-Year Parts Warranty**** H (**•*see Navlen Limited Residential Warranty) NSFIANS1 372 •Optional accessories are available(see below) y.: For 3/4' O / �'•, ', Valves Only Plumb Easy Valve Set Condensate Neutraliser SmartZone*Pump ControMr NCB Primary Manifold (30010950A-1 arve$ard) (GXXX001322-SNtgk Unk) Ready-Link Cascade (PFMZ 02P-001.Fa 2 Zones) 3'Vent Termination NaviLink'WI-F(Control (GFFM-MCOZUS-0Ol) (30009323A-3/4'Lead Fred (G)00=1324•Upto6 Units) Communiatlon Cable (PBCM-AS-001) (PFMU3P-001 F.3Zonesl t Caps and Wall Flanges 7 (30012581A-3/4•for Pipe Cover) (GXXX001325-Up to 16UMts) (GXXX000546) Ii Z06P-001 F.az (GXXX38739) (PFKZ.NP-001 F ,Z smaviem NCB Series Combination Boilers Condensing Gas Specification Sheet Combination Boiler Dimensions Navien Combination Boiler Other Specifications Space Heating Ratings Heating Input, o ;3B inn,; 143'1361 mm, Model MBH Heating Capacity', Net AHRI Rating,Water;, AFLI Water Water Connection Numbers Min Max MBH MBH % Pressure Size(Supply,Return) E NCB-150E 12 60 56 49 95.0 NCB-180E 14 80 75 65 95.0 12-30 1In NPT 4s�q'Olsmm) 6rp7omml NCB-210E 18 100 94 82 95.0 Psi NCB-240E 18 120 112 97 95.0 1 Rahngs are the same for Natural Gas models converted to propew use. 1 Based on U.S.Department of Energy(DOEI test procedures. 3 The NET AHRI Water Ratings shown are based on a piping and pickup allowance of 1.1 S.Consult Navlen before selecting a boiler for installations having unusual piping and pickup rea.aennenu, Con ction Size such as Intermittent system operation,eae-ve piping systems,etc. Q Pressure Relief Valve Adapter nem314" Specifications 0 Airintake 0 2" Item NCB 150E NCB-180E NCB-210E NCB-240E 0 Exhaust Gas Vent (D 2' Space Heating 12,000-60,000 BTU/H 14,000-80,000 BTU/H 18,000-100,000 BTU/H 18,000-120,000 BTU/H Gas Input Domestic Hot Water 12,000-120,000 BTU/H 14,000.150,000 BTU/H 18,000-180,000 BTU/H 18,000-199,900 BTU/H Flow Rate(DHW) 77eF(43°C)Temp Rise 2.6 GPM(9.8 Um) 3.4 GPM(12.9 Um) 4.0 GPM 0 5.1 1 4.5 GPM(17.0 Um) Dimensions 17"(W)x 28"(H)x 12"(D) 17"(W)x 28"(H)x 12"(D) 17"(W)x 28"(H)x 12"(D) 17"(W)x 28"(H)x 12"(D) Weight 661bs(30kg) 74lbs(34kg) 84lbs(38kg) 84lbs(38kg) Installation Type Indoor Wall-Hung Venting Type Forced Draft Direct Vent Ignition Electronic Ignition Water Pressure(Hydronic/DHW) 12-30 PSI/15.150 PSI Natural Gas Supply Pressure(from source) 3.5"-10.5"WC Propane Gas Supply Pressure(from source) 8.0%13.5"WC Natural Gas Manifold Pressure(min-max) -0,08"WC to-0.34"WC -0.07"WC to-0.66"WC -0.05"WC to-0.36"WC -0.06"WC to-1.2"WC Propane Gas Manifold Pressure(min-max) -0.08"WC to-0.30"WC -0.06"WC to-0.62"WC -0.1"WC to-0.66"WC -0.03"WC to-0.98"WC Minimum Flow Rate(DHW) 0.5 GPM 0.9 Um) Heating Supply/Return 1"NPT DHW Inlet/Outlet 3/4"NPT (eT� Connection Sizes Gas Inlet 3/4"NPT IiJ Auto Feeder 1/2"NPT Condensate Outlet 1/2"NPT E r Main Supply 120V AC,I N Power Supply Maximum Power LE Consumption 20OW(up to 2 amperes) r 3s' 4a• 3' s Casing Cold Rolled Carbon Steel Isom I89mml (I13mm) 96—) (4 17.3'(44 mm1 Materials Primary/Secondary Heat Exchanger:Stainless Steel Heat Exchangers DHW Heat Exchanger:Stainless Steel Connection size QHeating Supply Outlet (D 1" Exhaust 2"or 3"PVC,CPVC,Approved Polypropylene ® 2"or 3"Special Gas Vent Type BH(Class II,A/B/C) Heating Return Inlet (D 1" O DHW Hot Water Outlet (D 3/4" Venting 2"or 3"PVC,CPVC,Polypropylene Intake III Gas Supply Inlet m 3/4" 2"or 3"Special Gas Vent Type BH(Class II,A/B/C) © DHW Cold Water Inlet (D 3/4" Vent Clearances 0"to Combustibles Q Condensate Outlet 0112" O Auto Feeder Inlet (D t/2" Safety Devices Flame Rod,APS,Gas Valve Operation Detector,Ignition Operation Detector,Water Temperature High Limit Switch, Exhaust Temperature High Limit Sensor 'Navien reserves the right to change specifications at any time without prior notice Navien,Inc. 20 Goodyear,Irvine,CA 92618 Ph:(949)420-0420 Fax:(949)420-0430 www.Navien.com Rev.11/16 SR 4;t-t 471(71 C.46 ti,C;t; 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LA z L_ v ;' i L BUILp DEP $TMENT VIL ,_J E OF RYE ROOK JUN 11 2018 938 KING, ET RYE B lc,NY 1057 (914)9�9; )939-5801 VILLAGE OF R`'E. 13R""',K wwivh :org BUILDING DEPARTt:i~:W . PLUMBING PERMIT APPLICATION FOR OFFICE USE ONLY W 1 L) 01(4 PP Approval Date: JUN 1 Permit Fee: $ / i 5,1r)(4 - Approval Signature: Other: Disapproved: (fees are non-refundable) Application dated, is hereby made to the Building Inspector of the Village of Rye Brook NY, for the issuance of a Permit to install and/or remove Plumbing as per detailed statement described below.The applicant&property owner,by signing this document agree that said plumbing work will be in conformance with all applicable Federal,State,County and Local Codes. I.Address: PCB SBL: Zone: 2.Proposed Work: < < G Gk-n 0" , j V l 4 C C+_YL6 I'7 t-"h1 c41L ally,✓ /N&6 - a Ko n 3.Property Owner: V—"Lll '� A),u- l,i y-'l Address: Ic 140-c4• IL Phone#: — -7 7 ' y'3` Cell#: email: 0 v/L? 4.Master Plumber: -Tktjy) , Address: ?�) ,". Lic.#: Phone#: po�i�(-�t to 4'�C Ili( Cell#: email: (-Fj tZti C✓a�l� occ��l Gc�. Company Name: \1 b s+ Address: 20 P h L-� INDICATE FIXTURES& LINES TO BE INSTALLED AS PER 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 I st Floor 2nd Floor 3` Floor 4 Floor 5 Floor Exterior 5.*List Other Equipment/Provide Details: D� (�'7 llr ✓SI �� n cx")v ul 6JA-t r 60 L Lw Notarized Signatures Required Next Page 4- 2/26/18 STATE OF NEW YORK,COUNTY OF WESTCBESTER ) as: t '- i I" R r M e rJ a-,c - a— ,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)he is the legal owner of the property to which this application pertains,or that(s)he is the for the legal owner and is duly authorized to make and file this application. (indicate architect,contractor,agent,attorney,etc.) 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. By signing this application,the property owner further declares that he/she has inspected the subject property,and that to the best of his/her knowledge there are no roof drains,sump pumps or other prohibited stormwater or groundwater connections or sources of infiltration into the sanitary sewer system on or from the subject property. Sworn to before me this r 7 Sworn to before me this day of 20.,i? day of 20 Sign ture of Pro erty er Signature of Applicant Print Name of Property Owner Print Name of Applicant Mobile in �otary Public Y ublic,State of New York Notary 1 NO.01N06094608 TANYA TOLEDO Qualified in Westchester County NOTARY PUBLIC-STATE OF NEW YORK 0034 Commission Expires June 23,20 No. d in Bronx Co Qualified In Bronx County This application must be properly completed in its entirety and must includblYPM si"i na uref j of s the legai 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- 2/26/18 :Y-a _;,'saw: >_..si�.y �i4S<. 'x•big h •} t 'H5 Y i 15 `� 1 i�Pi K. i" }lME 1 }l1S RoGert'P ln Astor41� � �sr �i `l"'' I - �+ i r •5 ••r, i:�1' % 1 + jl�(v Department of Consumer Protection Home Improvement License 1 YOST&„CAMPBELL OF ROCKLAND INC. 20:BROOKD-ALE PLACE r MOLl,NT VERNON,NY-10550 i .• This hcecise is.fssued in aCcordanee wrth'Artrt:le XVl of the Westchester County Consumer Protection Codb and is valid onlyupoh presence ofthe%official dcparhrient seal. Cons �1 Liceusp Date of E cplratinp �rr,`�� ye��t�.� ••'S� �1t(( {fir tl 14�L�4t}r �t �. O �• i ►'�jr;. � � 30/2Q18 5t f: :•/; .':11V1: 52441;t2 07J 1 i ,�'r/r �+ ) 1 ry• Itiei 11 � I 1 .r OI.Y•aVf Ili•-0••.v�` - ,ace CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) �" 9/11/2017 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 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 endorsements . PRODUCER CONTACT Arthur J. Gallagher Risk Management Services, Inc. NAME: PHONE 212-797-9600 FAX 212 994-7047 250 Park Avenue 3rd Floor E-MAILA'C New York NY 10177 INSURERS AFFORDING COVERAGE NAIC 0 INSURER A:Harleysville Insurance Company 23582 INSURED YOST&CA-01 INSURERS:Harleysville Worcester Insurance Company 26182 Yost&Campbell, Inc. INSURER C: 20 Brookdale Place INSURER D Mt. Vernon, NY 10550 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:2096867839 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 I ADDLSUBK POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER MM/DD/YYYY MM/DD/YYYY LIMITS A X COMMERCIAL GENERAL LIABILITY SPP0098990H 9/15/2017 9/15/2018 EACH OCCURRENCE $1,000,000 DAMAGE TO RENTED CLAIMS-MADE X❑ OCCUR PREMISES Ea occurrence $500,000 MED EXP(Any one person) $10,000 PERSONAL 8 ADV INJURY $1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $2.000.000 POLICY lil ECT LOC PRODUCTS-COMP/OP AGG $2,000,000 OTHER: I _759WED SINGLE LIMIT $ B AUTOMOBILE LIABILITY BA 00000026188J 9/15/2017 9/15/2018 Ea accident $1.000.000 X ANY AUTO BODILY INJURY(Per person) $ OWNED OS ONLY SCHEDULED BODILY INJURY(Per accident) $ AUTOS HIRED NON-OWNED AUTOS ONLY AUTOS ONLY Per accident A $ A X UMBRELLA LIAR X OCCUR CMB098989H 9/15/2017 9/15/2018 EACH OCCURRENCE $3,000,000 EXCESS LIAB CLAIMS-MADE AGGREGATE $3,000,000 DED X I RETENTION$10,000 $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY Y/N ISTATUTE I ER ANY PROPRIETOR/PARTNER/EXECUTIVE N/A E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? (Mandatory In NH) E.L.DISEASE-EA EMPLOYE $ If as,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached If more space Is required) Village of Rye Brook is included as Additional insured for general liability as per written contract and as per policy terms,conditions and exclusions. 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 USA AUTHORIZED REPRESENTATIVE 01988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD New York State Insurance Fund 199 CHURCH STREET, NEW YORK,N.Y. 10007-1100 CERTIFICATE OF WORKERS' COMPENSATION INSURANCE .n n n n n 132866714 �i '`Qi YOST&CAMPBELL OF ROCKLAND INC DBA YOST&CAMPBELL INSTALLATIONS 20 BROOKDALE PL MT VERNON NY 10550 0'.. Scan to Validate POLICYHOLDER CERTIFICATE HOLDER YOST&CAMPBELL OF ROCKLAND INC VILLAGE OF RYE BROOK D/B/A YOST&CAMPBELL 938 KING STREET 20 BROOKDALE PL RYE BROOK NY 10573 MT VERNON NY 10550 POLICY NUMBER CERTIFICATE NUMBER POLICY PERIOD DATE G 2261 81 163592 04/01/2018 To 04/01/2019 3/20/2018 THIS IS TO CERTIFY THAT THE POLICYHOLDER NAMED ABOVE IS INSURED WITH THE NEW YORK STATE INSURANCE FUND UNDER POLICY NO. 2261 808-6, 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,AND,WITH RESPECT TO OPERATIONS OUTSIDE OF NEW YORK, TO THE POLICYHOLDER'S REGULAR NEW YORK STATE EMPLOYEES ONLY. IF YOU WISH TO RECEIVE NOTIFICATIONS REGARDING SAID POLICY, INCLUDING ANY NOTIFICATION OF CANCELLATIONS, OR TO VALIDATE THIS CERTIFICATE, VISIT OUR WEBSITE AT HTTPS:/M/WW.NYSIF.COM/CERT/CERTVAL.ASP. THE NEW YORK STATE INSURANCE FUND IS NOT LIABLE IN THE EVENT OF FAILURE TO GIVE SUCH NOTIFICATIONS. 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,INSURANCE FUND UNDERWRITING VALIDATION NUMBER: 803627896 IIII���II��000000000004205p59413�II�jlll��Ill� Form WC-CERT-NOPRINT Version 2(02,29M]t,)[WC Poliq_26 BO861 5 100000000000042055940110001-000022a 18086j[#*G](1 45e2-00pcen_NoP-c ERT_t 1101-o000 I I