HomeMy WebLinkAboutMP20-031 VILLAGE OF RYE BROOK
MAYOR 938 King Street, Rye Brook,N.Y. 10573 ADMINISTRATOR
Jason A. Klein (914) 939-0668 Christopher J. Bradbury
www.ryebrook.org
TRUSTEES BUILDING& FIRE INSPECTOR
Susan R. Epstein Michael J. Izzo
Stephanie J. Fischer
David M. Heiser
Salvatore W. Morlino
CERTIFICATE OF COMPLIANCE
January 4,2023
Philip Brock
79 Greenway Close
Rye Brook,New York 10573
Re: 79 Greenway Close,Rye Brook,New York 10573
Parcel ID#: 129.84-2-68
This document certifies that the work done under Mechanical Permit#20-031 issued on 2/19/2020 for the
installation of a new oil fired boiler has been satisfactorily completed.
Sincerely,
Michael J. Izzo
Building&Fire Inspector
/to
QyE BRC�v�.
1982 BUILDING DEPARTMENT
❑BUILDING INSPECTOR
SSISTANT 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 - - - - - - - - - - - - - - - - - - - -
c, ' -1c)-13
ADDRESS:- uV DATE:
PERMIT# ( -2 D 0 ISSUED:- ECT: la ��B�OCK: LOT:
LOCATION: Ln� �� ( W-kk� V) 1 �� 1�S� �l OCCIJppNCY: ?�
❑ VIOLATION NOTED THE WORK IS... ACCEPTED ❑ REJECTED/REINSPECTION
❑ SITE INSPECTION \^/!REQUIRED
❑ FOOTING c-, _
❑ FOOTING DRAINAGE 203- 2� 1 C) Q/ V (-/
❑ FOUNDATION _
❑ UNDERGROUND PLUMBING NOTES ON INSPECTION: 3 - Z
❑ ROUGH PLUMBING
❑ ROUGH FRAMING
❑ INSULATION
❑ NATURAL GAS �(1' I- b C '^'�C f �� oQ(1<:Q
❑ L.P. GAS
❑ FUEL TANK
❑ FIRE SPRINKLER
❑ FINAL PLUMBING
�ROSS CONNECTION
FINAL
❑ OTHER
QO
a
o
O
i C4 N N
i w; M 0 C
> a
f y ^ M NO Et F f
`�. ti
T"
E'er" en
Z o 0 � Aw WOWaSa = i
;;60 W >' 3 Q � Q � 3
A
> o
oil
�,
96 co
pxp Z w asZ
� � n cn O
z a U
w
U :496
z u
W Z O
� t
�a n
BUIL E'�' MENT MAR — 2 2020
VIL E OF R v,E OK
938 KINq `PJEE r RY1:B ,NY 1057 VILLAGE OF RYE BROOK
(914)9c(91 939-5801
BUILDING i-EPARTI'�IENT
v;3� do .org
ELECTRICAL PERMIT APPLICATION
Westchester County Master Electricians License Required �)� (
FOR OFFICE USE ONLY BP� D O3 J EP#: Q U`T )
Approval Date: �AR — Permit Fee: $
Approval Signature: V Other:
Disapproved:
(fees are non-refundable)
Application dated, :t0 is hereby made to the Building Inspector of the Village of Rye Brook NY, for the issuance of
a Permit to install and/ r reniove 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: jc! QL+O SBL: IQq. `-r—l— 66 Zone:
2.Property Owner: Lj-- k/t� !AJ A!; 73
Phone #-90.36ag Cell#: email:Pf}/G , urn,
3.Master Electrician: Address: C673
Lic. #:gVl
gePhone#(QJI Cell#K717 g 7,08 email: �.�on �1L17h�9�L
Company Name: AddresT/tST—04re -
4.Proposed Electrical�W rk/Fixture Count:
kkkkkkkkkk�*�l:A:liF*AA :I•:Fk:�Ai7h**':*��l k*kkkk:l-kkkk'.c#'.ctkkkRxi:-si:a-iR**k�R*7F:':Y:�*kk',ckkkkk kk#t#kk:t k:h*:Y-�**9l•kAAkk*�kk:F
SZTE N�W YORK,COUNTY OF WESTCHESTER ) as:
being duly sworn,deposes and states that he/she is the applicant above named,and does further
(print name of individual signing as the applicant)
state that(s)he is the legal owner of the property to which this application pertains,or that(s)he is the f'joxZl y&4
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 before me this Sworn to before e this 7�5'
day of 20 day of _ . 20,2o
Signature of Property Owner Signa of AX#nt
Print Name of Property Owner Print Name of Applicant
Ricardo M. DOS Anjos
�f
taty Public t 1 VVECtry f"Publicy State Of Now York Notar y Public
No. 01 D06237942
Qualified in Commissi WestcheSter County
on EXpireS March 28, 2023
3/21/19
V�estch`ester Rockland Electrical Inspection Services, Inc. s, Phone: 914-347 3595
DO NOT&ITE HERE-FOR OFFICE USE ONLY 43 North Lawn Avenue Fax: 914-347-3596
Elmsford, NY 10523r f i '
BUILDING PERMIT NO. (/
TEMP H DATE,
CITY OR VILLAGE ZIP CODE T IP COUNTY
46
STREET AND NO.Op ROhD POLE NUMBER
K
BETWEEN WHAT TWO CROSS STREET411S PREMISES LOCATED? SECTION BLOCK LOT
OCCUPANTS BUILDING OCCUPANCY
OWNER'S1AME AND ADDRESS /� ME LEP NE NUMBER 9C
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 FLUORE NO. H.P EACH NO. WATTS EACH INSPECTION
OUTSIDE
BASEMENT
1'FL.
AM
2-FL.
3'FL. ILLAGI, OF Ric- Bid�'-I
OFF
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❑ ADDITIONAL❑ EXPOSED❑ CONCEALED❑ MUST ENTER APPLICANTS
IDENTIFICATION NUMBER
SERVICE ENTERS BUILDING OVERHEAD L.1 UNDERGROUND') .J!
r '
AVOID DELAYS BY GIVING FULL AND ACCURATE INFORMATION.ALL SPACE MUST BE FILLED IN OR APPLICATION MAY BE RETURNED.
NAME OF COM DATE OF
/APPLICATION SIGNATURE AP NT -""-
STREET ADDRESS
TELEPNONE�/•1V
CRY POST OF ZIP S7 CODE LICENSE NO,WHEN APPLICABLE
5 �
. ...... .. ... .
WESTCNESTE
` -'• ROCKlANB
REI ELECTRICAL DEC 2 9 2022
INSPECTION
SERVICES.IN . VILLAGE OF RYE BROOK
BUILDING DEPARTMENT
BY THIS CERTIFICATE OF COMPLIANCE THE
Westchester Rockland Electrical Inspection Services
43 North Lawn Ave, Elmsford, NY 10S23
914-347-3S9S (Office) 1914-347-3S96 (Fax)
CERTIFIES THAT
i
Upon the application of: Upon premises owned by:
j
REI Property Mgmt Inc Philip Brock
78 SOUTH REGENT STREET
PORT CHESTER NY 10573
Located at: 79 Greenway Close, Rye Brook, NY 10573
Certificate Number: 689301
Section: 129.84 Block: 2 Lot: C8 BDC: Permit Number: EP:20-048 BP:20-031
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: 79 Greenway Close, Rye Brook, NY 10573
❑Basement 01st Floor ❑2nd Floor ❑3rd Floor ❑Garage ❑Attic ❑X Outside
Other:
Inspection was conducted in accordance with the NYS and NFPA 70-2017 International Electrical Code and
I
detail of the installation, as set forth below, was found to be in compliance therewith on 4/27/2020
Name Quantity Rating Circuit Type
Boiler 1
I
I
(
I
i
I
I
i
I
This Certificate has been approved by Westchester Rockland Electrical Inspection Services.
i
I
This certificate may not be altered in any way. I This certificate is valid for work performed before date of inspection only.
i OOA)
FO.
o+�
STREET
A ffM Et Auf4
�S EET
T-
l�
0tiri e 1 0
DIMENSIONS
tou t
.
ru Nr• aa olcl M STANDARD EQUIPMENT:
°x ■ Factory Tested and Assembled
—ra r
a E � ""M D'0' Cast Iron Section Assembly
4W CM (jacket and collector hood are
ft
3' bw w not assembled on 7,8 and 9
section blocks)
} sM• llil ■ Insulated Steel Jacket
r�. 2u•' ,M HJ Aluminized Steel Flue Collector
v-WGOr pot sla. A.wGOFmnt Brack iet.rwrtli.t. Hood with Flue Cap on Top
44 Outlet (convertible to rear
ayo 0 p.P/ %�A outlet)
a
h~8 °�'� ■ Swing-Away Burner Mounting
Door
B� tv2 Alternate return-"A"units only ■ Refractory Blanket and Target
Ea V2 Pressure/temperature gauge Wall in Combustion Area
H 3/4 Drain vale ■ Circulator(Taco 00711-When
L 3/4 � High limit/circulator control Ordered
N 1/2 Piping to expansion tank or automatic air vent ■ High Limit Control with Circulator
R1 3/4 Relief valve`` Relay and LWCO Function
■ Electrical Junction Box with
/ supply"C"(inches) Dimension(inches) Wiring Harnesses
0 0 m ■ Junction Box Cover Plate with
�• �,�' 30 r4 r Service Switch
d AW m ■ Two Vent Pipe Brackets
WGO-2 1 1/4(circulator flange) 11/2 11/2 10 V2 13 3/4 ■ Pressure/ Temperature Gauge
■ 30 PSIG ASME Relief Valve
WGO-4 1 1/4(circulator flange) 11/2 11/2 13 5/8 16 7/8 (boiler sections tested for 50
PSIG working pressure)
WGO 20 ■ Drain Valve
WGO-6 11/4(circulator flange) 11/2 11/2 20 23 V8 ■ Barometric Damper
WGO-7 not applicable ■ Built-in Air Separator
WGO-8 not applicable 11/2 11/2 26 1/4 29 3/8
WGO-9 i not applicable 1112 29 3/8 1 32V2 OPTIONAL EQUIPMENT:
■ High-Efficiency Flame-Retention
RATINGS Burner AHRI Minimum Oil Burner(Beckett AFG, Carlin
/ �'
Input Certified Chimney EZ or Riello).Specify 2-Stage Fuel
Rating Ratings A Size o, Unit(optional) if Required.
Xo \� ra a ■ Vent Damper Kit
,y^ q�� ` oyv 4� ■ W-M 5&10 Year Homeowner
_� • r e?1 Q0Z 4i e� •c D °}
a s s Q J A o �� �4 Q`m Protection Plan
�' �° n� �� �•�+� 2•� a`m Qe� Q° s• �3 ■ W-M Indirect-Fired Water Heaters
WGO-2RD 10.70 98 86 1 75 187.0 1 .010 8X8 6 11 15 1 540
WGO-2 0.70 98 86 75 1 86.4 I ,010 8X8 6 I 15 i 540
WGO-3RD 0.80 112 98 85 87.0 .010 8x8 6 15 595 NOTES:
WGo-3 0.95 133 115 100 X8 I 15 I 595 Add "P"for packaged boiler(WGO-2
WGo-4RD 1.:'0 140 123 107 87.0 l010 8X8 6 15 645 through WGO-6 only).Add"A"for
wGo-4 1.20 168 145 126 .0 15 645 boiler only(WGO-2 through WGO-9).
i WGO-SRD 2, 168 148 129 87.0 .015 8x8 7 15 760 (1) No.2 fuel oil-Commercial Standard
wG0-5 1,45 203 175 1 152 .0 8X8 ..15 760 Specification CS75-56. Heating value
of oil-140,000 BTU/Gal.
wGo-6Ro 1 40 96 173 150 87.0 I .015 18X8 7 15 ( 860 (2)Based on standard test procedures
WGO-6 1.75 245 212 184 85.0 '015 8X8 7 15 860
prescribed by the United States
• WGO-7RD ' 224 197 17, 87.6 8X, e <(:
- Department of Energy at Combustion
1 wGo-7 2.00 280 242 210 85.3 .015 8x8 t5 930 condition of 13 1/2%CO2 and-0.02"
WGO-B 2.30 322 266 231 .025 8x12 8 20 1030 1 W.C.draft.
l WGO-9 .1 357. 95 j 257 - }, 8X12 20 (3)MBH refers to thousands of BTU
*ENERGY STAR'compliant with Version 3.0 Boiler Specification of 87%AFUE only when installed at per hour.
the reduced burner rate(R)and with the optional vent damper kit(D).Burners shipped with standard (4) Net AHRI ratings are based on net
rate nozzle,reduced rates achieved through nozzle change-refer to burner instructions or boiler's installed radiation adequate for the
rating label for correct selection. k requirements of the building,
In the interest of continual improvements in product and performance,Weil-McLain reserves including a piping and pickup
allowance of 1.15-sufficient for normal
the right to change specifications without notice.
rw.e�T.e conditions.Provide additional
AA
WM1410_BR0_018_WG0 " E I * allowance only for unusual piping
and pick up loads.
'. n y.iiyw�t+..�•'�ir .A 17M -A y�."��r.--. A h•>"' "'�r� ...w �A'• - #� �
Fir
fll� -1 ,a*is AM;1 Fii,� Y !tI • 1�N I +i v/�'Yjl (1•♦I) Y Y
_ Y����E�ax ♦ �1 1'i' 4'� ��'1+ii''' fo- \'illii' i-s
fi
• • E _. x N
y
c L" ctst.
cn
` Jq «o)>�
Goo —_.co uj
�, • s
0 CD
x
CD
In W r ce
ui
cu
oftmo
c =
I �� V � O j-i•.j. .;
y y OO , F
W CCU`
• r0 N r�.
? O y �J N Q i
c+ a cn N
±.��•��s=' �pr j/i'1'1; 1 fNh c:.,i Ifll r�'1 14` z r+OIr ��{w�'i} ''i;+;i:' ¢a,ii� :�+y+++i' �fe i}= ��'�+f++1' 'i� - ;'i'++1�'i S '�'++1+51'�
err • l.% ��.•x�,�1++ ,+++,t �'ii�} t++4a-
�l y�i� 1yv� ti� A f�yy�tip" f njytfy y M n *41- i'q
�' ��.. �-. .� uMV_• p a'},�G•i'S;'�"_ Tp� tj`�N'L�` �p 1�1�' II. `�"Y
'iy H v. � v auw/ u,t "�v]� b �F•++'?CGv�I,: ,eV yr ` �"•
CO® DATE(MWDD/YYYY)
A
C" CERTIFICATE OF LIABILITY INSURANCE 12131/2019
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:
Arthur J. Gallagher Risk Management Services, Inc. PHONE 888-273-8155 FAXNo:856 273-3663
4000 Midlantic Drive Suite 200 E-MAIL
Mount Laurel NJ 08054 ADDRESS:
INSURE 3 AFFORDING COVERAGE NAIC 0 _
License#:BR-724491 INSURER A:New York Marine And General Insurance Company 16608
INSURED SINGHOL-02 INSURER B:
Singer Holding Corporation
One Gateway Plaza, 4th Floor INSURERC:
Port Chester NY 10573 INSURERD:
INSURER E:
INSURER F:
COVERAGES CERTIFICATE NUMBER:1780150934 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 DDL VD POLICY NUMBER POLICY EFF POLICY MID00 EXP LIMITS
LTR2111111
A X COMMERCIAL GENERAL LIABILITY PK201900020101 12/31/2019 12/31/2020 EACH OCCURRENCE $1,000,000
CLAIMS-MADE I-XL OCCUR DAMAGET RENTED
PREMISES Ea occurrence) S 100,000
MED EXP Any one person) $5,000
PERSONAL&ADV INJURY S 1,D00,000
GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $2,000,000
POLICY❑ PRO JECT ❑LOC PRODUCTS-COMP/OP AGG $2,000,000
X
OTHER: $
A AUTOMOBILE LIABILITY AU201900017525 12/31/2019 12/31/2020 CEaOMacciINBdeED nt SINGLE LIMIT $1 000 000
X ANY AUTO BODILY INJURY(Per person) $
OWNED SCHEDULED BODILY INJURY(Per accident) $
AUTOS ONLY AUTOS
HIRED NON-OWNED PROPERTY DAMAGE $
AUTOS ONLY AUTOS ONLY Per accident
$
A UMBRELLA LIAB X OCCUR EX2019D0001405 12/31/2019 12/31/2020 EACH OCCURRENCE s 5,000,000
X EXCESS LIAB CLAIMS-MADE AGGREGATE $5,000,000
DED RETENTIONS $
WORKERS COMPENSATION ER TH-
AND EMPLOYERS'LIABILITY Y/N STATUTE I I ER_
ANYPROPRIETOWPARTNER/EXECUTIVE ❑ E.L.EACH ACCIDENT $
IOFFICER/MEMBEREXCLUDED? NIA
(Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $
If yes,describe under
DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $
i
j
7-
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space Is required)
Village of Rye Brook Building Department is named as an additional insured with respect to the above General Liability Policy,if required by a written contract
executed prior to services performed.
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 Building Department
938 King Street
Rye Brook NY 10573 AUTHORIZED REPRESENTATIVE
01988-2015 ACORD CORPORATION. All rights reserved.
ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD
NEW Workers'
RK
STA E Compensation CERTIFICATE OF
Board NYS WORKERS' COMPENSATION INSURANCE COVERAGE
1a.Legal Name&Address of Insured(use street address only) 1b.Business Telephone Number of Insured
ADP TotalSource FL XVII,Inc. (914)345-5700
10200 Sunset Drive
Miami,FL 33173
UC/F 1c.NYS Unemployment Insurance Employer Registration Number of
Singer Holding Corporation DBA Robison Oil Insured
1 Gateway Plaza 4th Floor 45045108
Port Chester, NY 10573
1d.Federal Employer Identification Number of Insured or Social Security
Work Location of Insured(Only required if coverage is specifically limited to Number
certain locations in New York State,i.e.,a Wrap-Up Policy) 133121491
2.Name and Address of Entity Requesting Proof of Coverage 3a.Name of Insurance Carrier
(Entity Being Listed as the Certificate Holder) New Hampshire Ins Co
Village of Rye Brook Building Department 3b.Policy Number of Entity Listed in Box"1 a"
938 King Street WC 080394906
Rye Brook,NY 10573 3c.Policy effective period
12/23/2019 to 07/01/2020
3d.The Proprietor,Partners or Executive Officers are
®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"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"T'.
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"30,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,1 certify that 1 am an authorized representative referenced above and
that the named insured has the coverage as depicted on this form.
Approved by: Adriana Sanchez
(Print name of authorized repr tat or licensed a of insurance carrier)
Approved by: 1 1/9/2020
(Signature) (Date)
Title: Account Specialist II
Telephone Number of authorized representative BF WORSed HgelFlt Of 800-743-8130
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