HomeMy WebLinkAboutMP19-209 DR
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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
Stephanie J. Fischer
David M. Heiser
Salvatore W.Morlino
CERTIFICATE OF COMPLIANCE
July 31,2024
Min Sik Pang&Gui Suk Pang Yeon
7 Maple Court
Rye Brook,New York 10573
Re: 7 Maple Court, Rye Brook,New York 10573
Parcel ID#: 135.66-1-79
This document certifies that the work done under Mechanical Permit#19-209 issued on 11/25/2019 for the
installation of a new gas fired boiler has been satisfactorily completed.
Sincerely,
Steven E. Fews
Building&Fire Inspector
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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 : / 4/- 6P t:1 .i/L 7 DATE:
PERMIT# MP ` '7 1 ISSUED: SECT: BLOCK: LOT: %
LOCATION: �� _ 1 OCCUPANCY:
❑ VIOLATION NOTED THE WORK IS... El' 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
❑ FUEL TANK
❑ FIRE SPRINKLER
❑ FINAL PLUMBING
❑ CROSS CONNECTION
❑ FINAL
❑ OTHER
WATER HEATERS / BOILERS
---- GW B8-E
I ENN[IX
Gas-Fired Hot Water Boiler
0651
PRODUCT SPECIFICATIONS Bulletin Maarchrch 201018
Supersedes July 2016
4
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Yts�4Tm�Fn«�<,� 1 a
AFUE up to 83.9%
Heating Input - 50,000 to 299,000 Btuh
MODEL NUMBER IDENTIFICATION
_ 6WB8 - 075E - 3
W Series T Revision Number
GB=Gas-Fired Hot Water Boiler 3=3rd Generation
AFUE Ignition
Mininum Efficiency-8=82% E=Electronic Ignition
Capacity(Input)
050=50,000 Btuh
075=75,000 Btuh
100=100,000 Btuh
125=125,000 Btuh `
150=150,000 Btuh
170=170,000 Btuh
200=200,000 Btuh
262=262,000 Btuh
299=299,000 Btuh
FEATURES
CONTENTS WARRANTY
Circulating Pump Flow Rate........................................8
Cast iron boiler assembly -Limited twenty-year
Dimensions..................................................................7 warranty in residential applications only.
Features....................................................................... 1
High Altitude Derate.....................................................6 All other covered components -Limited five-year
warranty in residential applications.
Installation Clearances................................................6
Model Number Identification........................................ 1 Refer to Lennox Equipment Limited Warranty certificate
Specifications...............................................................5 included with equipment for details.
FEATURES
APPROVALS Automatic Gas Control
Low pressure, sectional cast iron boilers are design Silent operating gas controls provide 100% safety shut
certified by CSA for use with natural gas or LPG/ off.
Propane. 24 volt redundant combination gas control valve
Annual Fuel Utilization Efficiencies are based on US combines automatic safety pilot, manual shut off option
DOE test procedures and FTC labeling regulations. (On-Off), pilot filtration, automatic electric valve (dual)
Units are certified by AHRI. and gas pressure regulation into a compact combination
Boiler heat exchanger assemblies are constructed and control.
hydrostatically tested in accordance with American Dual valve design provides double assurance of 100%
Society of Mechanical Engineers (ASME) Boiler and close off of gas to the pilot and main burners on each off
Pressure Vessel Code Section IV Standards for cast cycle.
iron heating boilers.. Stainless Steel Burners (050 to 200 Models)
APPLICATIONS Each burner has rows of continuous ports which result
Heating inputs of 50,000 to 299,000 Btuh. in quiet and clean combustion.
AFUE's of up to 83.9%. Titanium Burners(262 and 299 Models)
Natural gas or LPG/Propane (LPG with optional Titanium composite burners resist corrosion and
conversion kit). oxidation.
Boiler applications include radiant floor heating, Slotted port design results in quiet, clean combustion.
baseboard heating and zoned heating systems. Superior strength and longevity.
Compact size allows easy installation in a basement or Circulating Pump
utility room. Heavy duty pump is constructed of cast iron.
All units are completely factory assembled with all Pump motor is impedance protected.
controls installed and wired.
Each unit is factory test operated to ensure dependable Motor and impeller is removeable as a single unit for
performance. servicing.
Pump is shipped separately for field installation.
HEATING SYSTEM
Cast Iron Boiler Assembly Relief Valve
Boiler sections and push nipples are constructed of long Furnished as standard and factory installed on 50 to
life cast iron. 200 models. Field installed on top of cabinet on 260 and
299 models.
Boiler sections and push nipples expand and contract Valve provides for pressure relief of heating system in
together, providing positive watertight seal. case of abnormal operating conditions.
Boiler components are easily accessible for cleaning Valve opens at 30 psig and is approved by ASME.
and servicing.
Electronic Ignition Combination Temperature/Pressure Gauge
Electronic spark igniter provides positive ignition of pilot Gauge monitors system for safe and reliable operation.
burner on each operating cycle. Brass Drain Valve
Pilot gas is ignited and burns during each running cycle 3/4 in. brass drain valve is furnished as standard and
of the boiler. factory installed in drain outlet on side of cabinet on 50
Main burners and pilot gas are extinguished during the to 200 models. Filed installed on 260 and 300 models.
off cycle. See dimension drawing for location.
Ignition system permits main gas valve to open only Optional Accessories
when the pilot burner is proven to be lit.
Should flame fail to ignite, control will continue to re- LPG/Propane Conversion Kit
attempt ignition. Conversion kit required for field changeover from
natural gas.
Pilot operation is fully automatic on demand for heat.
Kits available for standard and high altitude operation.
Should a loss of flame occur, the main valve closes,
See Specifications
shutting down the unit. tables.
GWB8-E/Page 2
FEATURES
IGNITION CONTROL MODULE LED Status Lights
Control module provides ignition sequence, flame Status lights on top
monitoring and safety shutoff for intermittent pilot spark of control continually
ignition heating system. indicates which functions
are active and if the
BOILER CONTROL MODULE control is holding the
On-board microprocessor burner off for any reason. m
saves fuel by adjusting boiler TEMP
temperature based on heating !
ACTIVE—Indicates the control is powered and the
demand.
temperature function is active.
Easy dial-in settings for low/high HI TEMP—Illuminates any time the burner is off as
temperature limits and economy settings. a result of the boiler reaching the high limit setting.
Installed external to the boiler LWCO
cabinet in durable protective ACTIVE— Illuminates when the control is providing
housing with display window. low water cut-off protection.
• LOW WATER—Indicates a low water condition in
Thermal Targeting the boiler.
Microprocessor-based algorithm monitors thermostat
activity and continually evaluates how much heat the ECONOMY
house requires. When it is very cold outside, heat • ACTIVE—Indicates that the Economy dial is turned
demand is high and the control raises the boiler Target on and that Thermal Targeting function is active.
Temperature to provide needed heat to the house. • TARGET—Illuminates any time the burner is
When the outside temperature is milder, heat demand is off as a result of the boiler reaching the Target
lower. During these periods, the control lowers the boiler temperature determined by Thermal Targeting.
Target Temperature-saving fuel-while continuing to • TEST SETTINGS BUTTON—Automatic or Manual
provide comfort to the house. reset mode. and test settings for initial control setup.
Thermal Pre-Purge ADDITIONAL CONTROLS
Enhances boiler efficiency by supplying latent heat that
may remain in the boiler from a previous run cycle to the Flame Rollout Switch
heating zone requiring heat. The control activates the Temperature sensitive fusible-link device is furnished
burner only when it determines that the latent heat will and factory installed on the boiler base just outside of
not be adequate to satisfy the heating demand. the burner box.
Enhanced Condensing Protection (Optional Setting) Prevents unit operation in the event combustion
Allows the boiler to heat to 125°F before energizing the products passageway through the flueway is reduced or
circulating pump, reducing the potential for condensing. blocked.
Once activated, the control continues to monitor boiler Junction Box
temperature and interrupts the pump if it drops below Furnished in Control Module housing for easy field
115°F. wiring.
Display LEDs Limit Sensor
Three, seven segment LEDs continually displays Factory installed immersion type limit sensor provides
boiler temperature. Instantly changes to display control protection against abnormal operating conditions.
settings when any dial is adjusted. Indicator light for
heating call. Transformer
Fahrenheit or Celsius display. 40VA transformer furnished for control module
operation.
Optional Accessories
Thermostat
See Thermostat bulletins in Controls section and
Lennox Price Book for a complete list of thermostats.
GWB8-E/Page 3
FEATURES
VENTING CABINET
Blocked Vent Shutoff Sensor Constructed of heavy gauge steel with a baked-on
Temperature Switch prevents unit operation in case of enamel paint finish.
flue blockage. Cabinet is fully insulated with fiberglass insulation,
Sensor is furnished as standard and factory installed at keeping cabinet surface temperatures low.
the relief opening of the draft diverter. Hole for drain valve (furnished) is furnished on left side
Integral Draft Hood of cabinet for 262 and 299 models only.
Reduces the overall height and footprint of the Controls are shipped factory installed on right side of
boiler making it ideal for low clearance/space limited cabinet.
installations. Burner access panel is easily removed for servicing.
Vent Damper Integral draft diverter is part of unit cabinet.
Motorized vent damper electrically interlocks with the
gas ignition system to increase efficiency of heating
system by reducing loss of heated air up the chimney
after burner shut off.
Also reduces chimney infiltration during boiler off cycle.
Furnished as standard for field installation.
GWB8-E/Page 4
SPECIFICATIONS
Model No. GWB8-050E-3GWB8-075E-3GWB8-100E-3GWB8-125E-3GWB8-150E-3
Gas Heating capacity input-Btuh 50,000 75,000 100,000 125,000 150,000
Heating Heating capacity output-Btuh 42,000 63,000 83,000 104,000 124,000
Performance
' Net AHRI I=B=R rating-Btuh 37,000 55,000 72,000 90,000 108,000
z AFUE 83.5% 83.1% 83.0% 82.0% 83.0%
Boiler Data Number of boiler sections 2 3 3 4 4
Boiler capacity-U.S.gallons 2.4 4.0 4.0 5.6 5.6
Connections Flue Size diameter(round) 4 5 6 6 7
in. Gas piping Natural gas 1/2 NPT 1/2 NPT 1/2 NPT 1/2 NPT 1/2 NPT
size I.P.S. LPG/Propane 1/2 NPT 1/2 NPT 1/2 NPT 1/2 NPT 1/2 NPT
Water supply and return size 1-1/4 NPT 1-1/4 NPT 1-1/4 NPT 1-1/4 NPT 1-114 NPT
Drain connection size 3/4 NPT 3/4 NPT 3/4 NPT 3/4 NPT 3/4 NPT
Electrical characteristics 120 volts-60 hertz-1 phase(less than 12 amps)
Shipping Data lbs.-1 package 205 253 253 315 315
OPTIONAL ACCESSORIES
See Lennox Price Book For Complete Listing of Optional Accessories
LPG/Propane Conversion Kit 68E01 I 76E01 68E01 71E01 68E01
Net AHRI water ratings indicate the amount of equivalent direct radiation each boiler will produce under normal conditions and thermostatic control.Ratings based on an
allowance of 1.15 in accordance with the factors shown on the I=B=R Standard as published by The Hydronics Institute.Selection of boiler size should be based on'Net
I=B=R Rating"being equal to or greater than the calculated heat loss of the building.
Annual Fuel Utilization Efficiency based on US DOE test procedures and FTC labeling regulations.
SPECIFICATIONS
Model No. GWB8-170E-3 GWB8-200E-3 GWB8-262E-3 GWB8-299E-3
Gas Heating capacity input-Btuh 170,000 200,000 262,000 299,000
Heating Heating capacity output-Btuh 139,000 165,000 220,000 251,000
Performance
Net I=B=R rating-Btuh 121,000 143,000 191,000 218,000
2AFUE 82.0% 82.0% 83.9% 83.7%
Boiler Data Number of boiler sections 5 5 8 9
Boiler capacity-U.S.gallons 7.2 7.2 12.7 14.4
Connections Flue Size diameter(round) 7 8 7 7
in. Gas piping Natural gas 1/2 NPT 1/2 NPT 3/4 NPT 3/4 NPT
size I.P.S. LPG/Propane 1/2 NPT 1/2 NPT 1/2 NPT 1/2 NPT
Water supply and return size 1-1/4 NPT 1-1/4 NPT 1-1/4 NPT 1-1/4 NPT
Drain connection size 3/4 NPT 3/4 NPT 3/4 NPT 3/4 NPT
Electrical characteristics 120 volts-60 hertz-1 phase(less than 12 amps)
Shipping Data lbs.- 1 package 377 377 552 616
OPTIONAL ACCESSORIES
See Lennox Price Book For Complete Listing of Optional Accessories
LPG/Propane Conversion Kit 1 71E01 68E01 72E01 74E01
Net AHRI water ratings indicate the amount of equivalent direct radiation each boiler will produce under normal conditions and thermostatic control.Ratings based on an
allowance of 1.15 in accordance with the factors shown on the I=B=R Standard as published by The Hydronics Institute.Selection of boiler size should be based on"Net
I=B=R Rating"being equal to or greater than the calculated heat loss of the building.
Annual Fuel Utilization Efficiency based on US DOE test procedures and FTC labeling regulations.
GWB8-E/Page 5
HIGH ALTITUDE DEBATE
CSA certified units for the U.S. must be derated when installed at an elevation of more than 2000 feet above sea level.
If unit is installed at an altitude higher than 2000 feet, the unit must be derated 4%for every 1000 feet above sea level.
Thus, at an altitude of 4000 feet, the unit would require a derate of 16%.
CSA certified units for Canada must be derated when installed at an elevation of more than 2000 feet above sea level.
If unit is installed at an altitude higher than 2000 feet, the unit must be derated 10%for elevations between 2000 feet
and 4500 feet above sea level.
NOTE—This is the only permissible derate for these units.
INSTALLATION CLEARANCES - INCHES (MM)
Size 050 to 200 262 to 299
Models Models
Left Side 3(76) 6(152)
Right Side Gas Supply/Control Side 9(229) 7(178)
Top 18(457) 6(152)
Front 'Alcove 'Alcove
Rear 4(102 6(152)
Service Clearance(Front and Right Side) 24(610) 24(610)
2 Floor Non-Combustible Non-Combustible
Flue Pipe Vertical 6(152) 6(152)
Horizontal 6(152) 6(152)
Type"B"vent pipe(vertical venting only) 1 (25) 1 (25)
Hot Water Piping 2(51) 2(51)
NOTE-Air for combustion must conform to the methods outlined in the National Fuel Gas Code(NFPA 541
ANSI-Z223.1)or the National Standard of Canada CAN/CSA-B149.1"Natural Gas and Propane Installation
Code'.
NOTE-In the U.S.flue sizing must conform to the methods outlined in the current National Fuel Gas Code(NFPA
54/ANSI-Z223.1)or applicable provisions of local building codes.In Canada flue sizing must conform to the
methods outlined in National Standard of Canada CAN/CSA-B149.1.
Definition of Alcove is a three-sided space with no wall in front of boiler.ANSI standard for alcove is 18 inches(457
mm)from front of appliance to leading edge of side walls.
2 Clearance for installation on combustible floor if combustible flooring base(field supplied)is installed between the
boiler and the combustible floor.
GWB8-E I Page 6
DIMENSIONS - INCHES (MM) - 050 TO 200 MODELS
VENT DAMPER 44 A 27(686) 10
(Furnished) C 3-112 5-1/2 3
(89) (140) BOILER (76)
SUPPLY CONTROL D
WATER MODULE\
n9 RELI�F�;
IGNITION VALVE
BLOCKED J RETURN CONTROL TEMPERATURE/
VENT /WATER MODULE\
v SENSOR DRAIN (78 1) PRESSURE GAUGE
rl
B (
VALVE 781 l
(Furnished) RETURN
14 ROLLOUT WATER
(356) SWITCH A
4-1/4 \GAS VALVE
(108)
LEFT SIDE VIEW FRONT VIEW RIGHT SIDE VIEW
NOTE-Pump is shipped separately with unit for field installation.
Model No. A B C D
in. mm in. mm in. mm in. mm
GWB8-050E-3 11-1/8 283 36-1/4 921 5-1/2 140 5-3/4 146
GWB8-075E-3 15 381 37-3/4 959 7-1/2 191 5-3/4 146
GW138-100E-3 15 381 37-1/4 946 7-1/2 191 6 152
GW138-125E-3 18-7/8 479 37-1/4 946 9-1/2 241 6 152
GWB8-150E-3 18-7/8 479 37-3/4 959 9-1/2 241 6-3/4 171
GWB8-170E-3 22-3/4 578 38-3/4 984 11-1/2 292 6-3/4 171
GWB8-200E-3 22-3/4 578 1 38-3/4 1 984 1 11-1/2 292 7-3/4 197
NOTE-Add 6(152 mm)to height for Vent Damper.
DIMENSIONS - INCHES (MM) - 262 TO 299 MODELS
I I VENT DAMPER SUPPLY
RELIEF 04 />, WATER 26-1/2(673)
I � (Furnished)
VALVE IWATER
TEMPERATURE/ 4-3/4
C� PRESSURE GAUGE (121)
(Furnished,
Field Installed)
� BOILER
CONTROL_
u IGNITION MODULE
r CONTROL
DRAIN BLOCKED MODULE
VALVE VENT /
SENSOR 1 36-3/8
(Furnished) RETURN
29
RETURN (924) �/WATER
+ �(737)
ROLLOUT WATER
SWITCH,,,,,,,
GAS VALVE
(311) 0
11
(13/837)
LEFT SIDE VIEW FRONT VIEW f RIGHT SIDE VIEW
NOTE-Pump is shipped separately with unit for field installation.
1 Minimum acceptable height for low water cutoff probe.
A
Model No.
in. mm
GW68-262E-3 27-1/2 699
GWB8-299E-3 30-3/4 781
NOTE-Add 7(178 mm)to height for Vent Damper.
GWB8-E/Page 7
CIRCULATING PUMP FLOW RATE
AWc?C17 00 CIRCULATORS
FLOW-M3/H
0.0 0.3 0.6 0.9 1.2 1.5 1.8 2.1 2.4 2.7 3.0 3.3 3.6 3.9 4.2 4.5 4.8 5.1 5.4
16 4.8
— 003B
14 Q_. 005 4.2
—Q-- 006
— 006B
12 '—Qs — 007 3.6
6 —�— 008
cr
w 10 3.0 w
w *5 F
LL LU
0
z8 �� � 2.4 w
J ; _
Q
O 6 1.8
4 1.2
t
2 0.6
0 0.0
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24
FLOW-GPM *007 Pump furnished with all boilers
REVISIONS
Section Description
New Added circulator pump flow rate chart.
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Visit us at www,lennox.com
LENVNDX For the latest technical information,www.LennoxPros.com
Contact us at 1-800-4-LENNOX
NOTE-Due to Lennox'ongoing commitment to quality,specifications,Ratings and Dimensions subject to change without notice and without incurring liability.
Improper installation,adjustment,alteration,service or maintenance can cause property damage or personal injury.
Installation and service must be performed by a qualified installer and servicing agency. 02018 Lennox Industries,Inc.
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A OC RO® CERTIFICATE OF LIABILITY INSURANCE DATE 2/1012 18 VI
12/10/2018
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INSR TYPE OF INSURANCE DL SUBR POLICY NUMBER POLICY EFF POLICY EXP LIMITS
LTR INSR NIVD MMIDDIYYYY MMIDDIYYYY
X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $1,000,000
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PREMISES Ea occurrence
MED EXP(Any one person) EXCLUDED
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GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $2 000 000
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OTHER:
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $
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OWNED AUTOS ONLY SCHEDULED
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HIRED AUTOS ONLY NON-OWNED PROPERTY DAMAGE
AUTOS ONLY Per.
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DED I X I RETENTION$10,000
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Y/N ER
TH-
AND EMPLOYERS'LIABILITY X PER STATUTE DER
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AUTHORIZED REPRESENTATIVE
O 1988-2015 ACORD CORPORATION.All rights reserved.
ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD
Workers CERTIFICATE OF
' s-f-ArE'Compensation
NYS WORKERS' COMPENSATION INSURANCE COVERAGE
Board
'•a.Legal Narne A Address rf Insured(use street rddi-PS8 o:liy; lb Surress Teiepti,iu Niirntiyr rf Ir u:,ter!
ARCTIC MECHAMC•AL INCORPORATED #286-468.4 r914'934-8301
460 N MAIN BTREET N
PORT CHESTER.,NY 1 0595-1 31 9
le.NYS'lnamployrnent;nsurarce Emplc✓er kag:stalion tiumoerof
insured
:Mork Location of insured(Only required it cova2i<Ja is SpBCi`C3!I%hrryted to 1 d. sdarai Ernployer idea lifination Number of:n,urer or Social Sa_urity
caRain lccatior.•s rn tiler,•York State...e-a Wrap-Up Pc!icy)
+urn ber
W-159344c3
2.Name and Address of Entity Requesting Proof of Coverage 3a.-Name of insurance Carrier
(Entity Being Listed as the::ettifr:ate Ho:rerj e'.ierated Mutual insurance Corrrpanv
Village Of Rva Brook 90
938 King St 3b.Policy Number•Y Entity Listed in Box"1 a"
Rve Brcok.NY+,0573-„2E a21 985,1r
3c Policy effective period
011i19Q019 to 01!1°'2020
..........---...... .-...................._......_._._. i
3d.The Proprietor,Partners or Executive Officers are
iXl inciuded.;Orly ctlw*brz i;al;�adrars'ofS�,ys.::rluArvl
ail 2rduded of detain p2ttnarsloff•Cers exouder.
This certifies that the insurance carrier'ridicated above in box"3''insures^le business referenced above ii,box"a'for woricers
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). 'f he Insum,nee Carrier or its licensed agent wi::send
this Certificate of Insurance to the sn'-t' •1'•sted above as the certificate holder in box
The insurance carrier must notify the above rwtificats holder and the Workers Compensation Boar;within 10 days:F a policy is ranceied
due to nonpaymer:t of premiums or within 30 days iF there are reasr>ns other thar.nonpavment of rnremiurns that;ancsl the nolicy of
eliminate the insured from the coverage irioic i-ed on this(;erificate.;Thal.^;nr ;C:'"5 may he sent by regular:rail)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 abate 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 tie coverage afforded by the Policy listed,nor does it confer any rights or responsibilities beyond those contained:n the
referenced Policy.
This certificate may be used as evidence of a'workers'Compensation contract of insurance only vinde the urderiyina 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 an this form.
Approved by: Carlie Pal.Berg
(R fit mace u'e:atanzw rep—n;enwl,L o;:icu,rs—J overt w i;isu:arl (kx;;L
App-oved by:
S�rrature i (Oatei
Title:Authorized Representative
Telephone Number of authorized representative or licenser:agent of insurance carrier: (386.1333-4949
Please"Dote: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(9-1'} wwww-wcb.nv.9ov