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Home My WebLink AboutMP16-119 +b ,'t44 y1.yy 19 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. lzzo David M. Heiser Jason A. Klein CERTIFICATE OF COMPLIANCE December 13, 2021 760-800 Owner LLC / 800 Westchester Avenue LLC PO Box 349 White Plains, New York 10605 Re: Illy Cafe, 800 Westchester Avenue, Rye Brook, New York 10573 Parcel ID#: 135.82-1-2 This document certifies that the work done under Mechanical Permit #16-119 issued on 9/16/2016 for the installation of a new air handler and a new condensing unit has been satisfactorily completed. Sincerely, Michael J. Izzo Building&Fire Inspector Ag BUILDING DEPARTMENT ❑BUILDING INSPECTOR AASSISTANT 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 : =� ' v` DATE: 1 �� -X , PERMIT - I ISSUED: k , SECT: BLOCK: LOT: LOCATION: '� �J 1 i n ` 4 F 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 I F'C' "��_1 {� • ( ( f, ❑ NATURAL GAS ❑ L.P. GAS ❑ FUEL TANK ❑ FIRE SPRINKLER ❑ FINAL PLUMBING ❑ CROSS CONNECTION FINAL OTHER �E BR(��, O� tim 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 : �J� kp DATE: 1 \ I � � PERMIT# f / V a 1� ISSUED: SECT: BLOCK: LOT: LOCATION: `T`�- OCCUPANCY: }J VIOLATION NOTED THE WORD IS... ❑ ACCEPTE jECTED/ REINSPECTION �V'FoOTING ITE INSPECTION REQUIRED 1 ❑ FOOTING DRAINAGE ❑ FOUNDATION ❑ UNDERGROUND PLUMBING NOTES ON INSPECTION: ❑ ROUGH PLUMBING ❑ ROUGH FRAMINGD INSULATION ❑ NATURAL GAS 1 - ,C r ❑ L.P. GAS ❑ FUEL TANK ❑ FIRE SPRINKLER ❑ FINAL PLUMBING ❑ CROSS CONNECTION ❑ FINAL ❑ OTHER M-SERIES 24,000 BTUIH WALL-MOUNTED AIR-CONDITIONING SYSTEM A111i ELECTRIC aa Job Name: System Reference: Date: Blower Motor(ECM) FLA. 0.76 I Blower Motor Output W 55 Indoor Unit:MSY-GL24NA-U1 SHF/Moisture Removal 0.75!5.1 pt./h Wireless Remote Controller Outdoor unit.MUY-GL24NA-Ul Field Drainpipe Size O.D. In(mm) 518(15) ACCESSORIES: Indoor Unit Compressor DC INVERTER-driven Twin Rotary Condensate Pump(BlueDiamond X87-711/721;115/230V) Fan Motor(ECM) F.L.A. 0.93 Condensate Pump(Sauermann S130-115/230,115/230V) Anti-Allergy Enzyme Filter(MAC-408FT-E) * • • Super ., Drain Pan Level Sensor(DPLS2) Indoor DRY 388-469-544-628-738 Outdoor Unit (Cooling) WET CFM 347-420-487-562-661 -, Outdoor Mounting Pad(ULTRILITEI) Outdoor 1,769 11,701 Drain Pan Heater(MAC-642BH-U) n 3-114"Mounting Base[Pair](DSD-400P) Sound Pressure Level(Quiet-Lo-Med- Hi-Super Hh ❑ Drain Pan Socket(MAC-8510S) ❑ Air Outlet Guide(MAC-886SG-E) Indoor Cooling 34-41-45-49-53 n Wall Mounting Bracket(OSWB2000M-1) dB(A) Outdoor Cooling 55 Controls Wireless Controller(MHK1) External Dimensions r, Wired Remote Controller PAR-31 MAA(Requires MAC-3331F-E) 12-13116 x 43-5/16 x 9-3/8 n Wireless Interface for kumo cloud1m(PAC-WHS0IWF-E) Indoor(H x W x D) (325 x 1,100 x 238) n Thermostat Interface(PAC-US444CN-1) In.(mm) 34-5/8 x 33-1/16 x 13 Outdoor(H x W x D) SPECIFICATIONS: (880 x 840 x 330) Rated Conditions(Capacity Cooling' BtumrW 22,500/ 1,800 Net Weight IIndoor 37(17) Lbs.(kg) RangeCapacity Outdoor 119(54) Cooling' Btulh 8,200 31,400 External Finish 'Cooling I Indoor 801 F(27°C)DB 167*F(19°CIW9,Outdoor 951 F(35°C)D81751 F(24°C)WB' Rating Conditions per AHRI Standard. Indoor Munsell 1.OY 9.2/0.2 Operating •nditons(Indoor Intake Air Temp.)(Max./Min.) Outdoor Munsell No. 3Y 7.8 1 1.1 Coolingz 9O'F(32e C) DB/67°F(19°C)DB R410A;4 Ib. 3 oz. Operating Conditions(Outdoor Intake Air Temp-)(Max I Min Refrigerant Piping(Flared) Cooling2 115-F (46°C) DB/14°F(-10-C) DB Liquid(High Pressure) 3/8(9.52) In.(mm) 'Applications should be restricted to comfort cooling only:equipment cooling applications are not Gas(Low Pressure) 5/8(15.88) recommended for low ambient temperature conditions. - Max.Total Refrigerant 50(15) Pipe Length(Height Diff.) Ft.(m) — SEER 20.5 Max.Total Refrigerant Pipe Length(Length.) 100(30) Energy Star," Yes ENERGY STAR products are third-party certified by an EPA-recognized Certification Body ElectriGal •-. Power 208 1230V, 1-Phase, 60 Hz Minimum •, lndoorIOutdoor A 1 117.1 Specifications are subject to change without notice. 0 2016 Mitsubishi Electric US,Inc. 1 ► I ► Ul MSY-GL24NA-Ul Unit:in.(mm) 7116XI Oblong hole 7/161,13/16 Oblong hole 115 NlIalic p1gic 5-1/16 8-7/8 8-718 4-5116 Iddoor nif 43.5116 — -� d : ■ b —- — — 42.718 _ _ — �. t I 4 2713 -2713 aO 1-15/16 19-314 11-S116 4.318 Air in Hall hole 13 3116 9-318 V Installai'an plaf, Pi in 2-112 �- Oraie hose �170`I Z-9/16 3 33 I18 7-1/8 Air oat 2-5/1� la 4 7/8 6-5116 II„pJ+II 314 7 114 LL1 - Iasui iou o2 0.0 .. Li uSd live '318 19-1111b IF tar ed ronutlian 13181 6w lie' 'IR Id-151 Ib:Flared toeoetlran#5ial 1 3116 4 pr oin Moss Inntol ae o1-I18 tone't led pairi e518 O.p 2-9116 2-9116 MUY-GL24NA-Ul REQUIRED SPACE Unit:in.(mm) v '1 20 in.(500 mm)or more when front and sides of the unit are clear 16 706 1 Drain hole 01-S18 m Air 1-9176 4 pM•�,e 'o Air in Air - y ;;2..'es 13132X13116 1�"T0 676 19-1 ot m rhJ '2 When any 2 sides of left,right and rear of the unit are clear 33-1116 3- 16 sn Service panel Liquid refrigerant ptpe3oint Refngerant pipe(flared)o 114(GL18) k y Refrigerant pipe(flared)o 318(GL24) _ MITSUBISHI fft ELECTRIC COOLING & HEATING - Gas refrigerant pipe joint ui Refrigerant pipe(Flared)a 112(GL78) 7-v Refri eranl )e(flared)a 5/8{GL24) 1340 Satellite Boulevard.Suwanee,GA 30024 Toll Free:800-4334822 www.mehvac.com a c I us FORM#MSY-GL24NA-Ul I MUY-GL24NA-Ul-201603 Intertek Specifications are subject to change without notice. 0 2016 Mitsubishi Electric US,Inc a f a a N tin G L. tn : C 9 Kt Q v w W MID e U �► � U b r� IF wo 00 A O W co 00 vD • m 00 U r' cn w W z a Z O IZ z 6R _ � U fir„ Q C Q V C a Q z a a a a F t�� D D BUILDING DEPApjMENTRL V[L GE OF RYE OK FMAY 2 2 2017938 KINd ET RYE B ,NY 1057(914)4 939-5841 VILE GF RYE BROOK of BUILDING DEPAR`TMEN�T ELECTRICAL PERMIT APPLICATION Westchester-County Master ,Electricians License Required FOR OFFICE USE ONLY fi '1 : lL f EP#: 1 �/ '- Approval Date: J U 2 Application Fee: S Approval Signature: C/I( Permit Fee: $ ) ZC, Disapproved: Other: (fees are non-refundable) Application dated, / 'T 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 electrical equipment, wiring, fixtures,or to perform other high or low voltage electrical work as per the detailed statement described below. The applicant & property owner, by signing this document agree that all electrical work performed will be in conformance with all applicable Federal, State,County and Local Codes. 1.Address: M& "/f S 7-c 'e. 'f--e SBL: Zone: 2.Property Owner:_ Address: Phone#: `�Iy�D25 — 7 1 Z3 Cell#: email: 3.Master Electrician: Gj 4_-10 Za ofc ;t,f i1 a Address: Lic.#: 7!�5-Phone#- Cell#: ,e/m,,ail: eth, -c t 4 2 GCct rt, ,/wIr Company Name:�CG0. h (y �G,t/'f G Address: /�� 4.Proposed ,El-ecctrriic,,al�W,pork/Fixture Count: C C-.��1.t� �1 ""� STATE OF NEW YORK,COUNTY OF WESTCHESTER ) as: kAA (/ being duly sworn,deposes and states that he/she is the applicant above named,and does further print nkme of individual signinj as the applicant) I - �/ � state that(s)he is the legal owner of the property to which this application pertains,or that(s)he is ther^.� it J A) for the legal owner and is duly authorized to make and file this application. (indicate architect,contractor,agent,attorney,etc) The undersigned further states 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. Sworn to be ore me this CL Sworn to be r e t is fa d 20 day of AP/7 Sign a of Prop it Owner Si a of#fplicant Print Name of Property Owner Print Name of Applicant CC N STEVEN J GAGNON Notary AR Pub ATE NEW YORK NdfAWYPI*11 ATE C NEW YORK T No. 1 00238 No �38 Auollti In Chester Countr,/ Aual d I stc ester County My Co lf5lo'+ Expl ctobar 14, 2fl_ -r buy ommisston Expdr October 14, 20_� dot Westchester Rockland Electrical Inspectiop Services, Inc. ` ,, r Phone: 914- 47-3595 DO NOT WRITE HERE-FOR OFFICE USE ONLY 43 North Lawn Avenue Fax: 914-347-3596 Elmsford, NY 10523 a Pq IT M TEMP# CrAOR VILLACf. ZIP G DE_ TOWNSHIP CO TY STR ET AND Nq.OR ROAD POLE NUMBER 1, -r �( �S]� AGE BETWEEN WHAT TW�9ZAOSS STREETS IS PREMISES LOCATED? SECTION BLOCK LOT OCCUPANT'S NAM f BUILDING OCCUPANCY OWNER'S NAME AND ADDRESS Lf Z A /V V C HOME TELEPHONE NUMBER CURRENT SUPPLIED BY FROM THEIR OFFICE WORK TELEPHONE 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 FLUGHE NO. ECT10N i -- IN OUTSIDE J BASEMENT If FL VIL RYE 2—FL PAR, ENT 31 FL, REMARKS:LIST OTHER ELECTRICAL DEVICES NOT SET FORTH ABOVE: C[ C Ll THIS APPLICATION IS INTENDED TO COVER THE ABOVE LISTED ITEMS TO RE INSPECTED. —. ANY TIME OF INSPEC7I 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 I] ADDITIONAL i I EXPOSED Fl CONCEALED r7 MUST ENTER APPLICANTS IDENTIFICATION NUMBER SERVICE ENTERS BUILDING OVERHEAD L7 UNDERGROUND AVOID DELAYS BY GIVING FULL AND ACCURATE INFORMATION.ALL SPACE MUST BE FILLED IN OR APPLICAT(ON MAY,#E RETURNED. 1T NAME OF COMPANY PATE OF APPLICATION SIGNATLJR F A�1//' STREET ADDRESS TELEPHONE NO. a A C(fI- ?,W - 3 �z CITY OR POST OFFICE ZIP CODE LICENSE NO.WHEN APPLICA13LE Ut ke 54 �ESTCNESEE! WKLLN1 ELECTIOL WRE1551111IMS INC BY THIS CERTIFICATE OF COMPLIANCE THE Westchester Rockland Electrical Inspection Services 43 North Lawn Ave, Elmsford, NY 10523 914-347-3595 (Office) 1 914-347-3596 (Fax) CERTIFIES THAT Upon the application of: Upon premises owned by: Zaccagnino Electric Suzanne Schwab 81 Maple Avenue Rye NY 10580 Located at: 800 Westchester Avenue,Suite#440, Rye Brook, NY 10573 Certificate Number: 439286 Section: 135.82 Block: 1 Lot: 2 BDC: Permit Number: EP:17-137 W:16-119 A visual inspection of the electrical system at this premise described as a Commercial occupancy,wherein the premises electrical system consisting of electrical devices and wiring, described below, located in/on the premises at: 800 Westchester Avenue,Suite#440, Rye Brook, NY 10573 ❑Basement ❑1st Floor 02nd Floor ❑3rd Floor ❑Garage ❑Attic ❑X Outside Other: Inspection was conducted in accordance with the NYS and NFPA 70-2017 International Electrical Code and detail of the installation, as set forth below,was found to be in compliance therewith on 6/26/2017 Name Quantity Rating Circuit Type A/C unit 1 Ductless System/Split A/C Condenser 1 Blower 1 I This Certificate has been approved by Westchester Rockland Electrical Inspection Services. This certificate may not be altered in any way. V 'Vif' t7 This certificate is valid for work performed before date of inspection onl . ,1 f f, 11 I j 111111 � � j111j � 1111 7f 111f1 �+ �+� ►` ;�). 11 +1 �. � ,tiy 14 _ r/ + - . a=•,,Ilrl+ ==Fs Iti 11 - `[ . ,. p !' N is fr. •�ey o !Z4 CN 5l �!+,` ' •^.y U) U Ct[+<w)> �f �j+ is ► • 4ma 'w� � � W �,.. �,-, i ,etc =. ?► JLecUon 4tOIt �'1'• i •tro �� rV� Irl ❑ O 1'S y ¢�G� V1 =9 W M c O Z o o ca WU. • v FF • ui 06 10. W LO y CV +\ .0 y N N " n #e_111 f► 1 f g� • . •t,�:.1j t[s > //Il/rlf, /11111i'1' 1+1�1�11 fit. IIIIII�f�� ,ogii'1 31 r4111rIg41 t , yx�'�"•--` v ��."".' it �� e.� � Y '"�, .�Wy r-+,� \47 v�it i' --c 4�Oadr �._•—+. tq��.'i Y' BRUN&CA-01 JFINLEY A �* CERTIFICATE OF LIABILITY INSURANCE DATE 1 2N212 212016 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 CONTACT Jennifer Finley John M.Glover Agency PHONE FAX Insurance Services (,C.No.E,,:(914)909-5320 VC No):(914)909-6321 45 KnDllwood Rd E-MAIL Elmsford, 1 ADDRESS:servlcos@johnmglover.com INSURER(S)AFFORDING COVERAGE NAIC INSURERA:Wesco Insurance Company25011 INSURED INSURER B:Great American Ins Company of New York 22136 Bruni and Campisi Plumbing, Heating 8 Air Conditioning,Inc. INSURER c.Rochdale Insurance Company 12491 199 Ridgewood Drive INSURER0: Elmsford,NY 10523 _ --" 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, ILTRR ADDUS TYPE OF INSURANCE INSO VYVD' POLICY NUMBER MMIUDDY✓YYYY EFF MM QCYDIYYYY LIMITS A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE S 1,000,000 CLAIMS-MADE X OCCUR X WPP1238824 02 02N612016 02116/2017 PREMISES Eao=rrence t 300,00 X WOS,PNC,Blanket Ad MED EXP(Any one person) S 10,000 PERSONAL a ADV INJURY E 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE E 2,000,00 POLICY I"�JECT I J LOC PRODUCTS-COMP/OP AGG $ 2,000100 PRO- OTHER: _ POLLUTION LIAB a 1,000,00 .AUTOMOBILE LIABILITY COMBINEDSINGLELIMIT (Ea accident) s 1,000,000 A X ANY AUTO WPP123882402 02/16/2016 02116/2017 BODILY INJURY(Per person) 5 ALL OWNED SCHEDULED BODILY INJURY Per accident S AUTOS AUTOS ( ) PROPERTY DAMAGE _ HIRED AUTOS AUTOS I Per accident _ S _ $ X UMBRELLA LIAR X OCCUR EACH OCCURRENCE a 5,000,000 B f EXCESS LIAB CLAIMS-MADE XS3717765-01 0211612016 02/16/2017 AGGREGATE 5 6,000,000 DED X I RETENTION$ 10,000 S WORKERS COMPENSATION XPER TF' AND EMPLOYERS'LIABILITY YIN _STATUTE FOR C IANYPROPRIETORIPARTNERIEXECUTIVE � RWC3410499 05MV2016 U5101/2017 E.L.EACH ACCIDENT t 1,000,000 0 FICER/MEMBER EXCLUDED? I NIA (Mandatory In NH) E.L.DISEASE-EA EMPLOYE i 1,000,000 If yes,describe under — DESCRIPTION OF OPERATIONS below T E.L.DISEASE-POLICY LIMIT S 1.000,000 DESCRIPTION OF OPERATIONS 1 LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached If more space is required) Certificate holder is included as additional insured under general liability. 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 ACCORDANCE WITH THE POLICY PROVISIONS. 938 King Street Rye Brook,NY 10573 AUTHORIZED REPRESENTATIVE � O 1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD STATE OF NEW YORK WORKERS' COMPENSATION BOARD CERTIFICATE OF NYS WORKERS' COMPENSATION INSURANCE COVERAGE Ia.Legal Name and Address of Insured(Use Street Address Only) Ib.Business Telephone Number of Insured Bruni and Campisi Plumbing,Heating&Air Conditioning,Inc. (914)946-5558 199 Ridgewood Drive Elmsford,NY 10523 lc.NYS Unemployment Insurance Employer Registration Number of Insured Work Location of Insured(only required if coverage is specifically limited to certain locations in New York State, i.e. a Wrap—Up 1 d.Federal Employer Identification Number of Insured or Social Policy) Security Number 13-2999646 2.Name and Address of the Entity Requesting Proof of Insurance 3a.Name of Insurance Carrier Coverage(Entity Being Listed as the Certificate Holder) Rochdale Insurance Company 3c.Policy Number of Entity Listed in Box"la": Village of Rye Brook RWC3410499 938 King Street 3c.Policy Effective Period Rye Brook,NY 10573 5/1/2016 to 5/1/2017 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 "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"2". The Insurance Carrier will also notes 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 a maximum of 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. 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: John M Glover Agency (Print name of authorized representative or licensed agent of insurance carrier) Approved by: (5`' —A�� February 12,2016 (Signature) (Date) - Title. President Telephone Number of authorized representative or licensed agent of insurance carrier: (800)275-2766 C-105.2(9-07)Please Note: Only insurance carriers and their licensed agents are authorized to issue the C-105.2 form. Insurance brokers are NOT authorized to issue it.