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HomeMy WebLinkAboutMP20-132 DR << 1, - t ja444,..W V �Y 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 February 20,2025 Philip La Destro&Gloria La Destro 68 Rock Ridge Drive Rye Brook,New York 10573 Re: 68 Rock Ridge Drive,Rye Brook,New York 10573 Parcel ID#: 135.36-1-19 This document certifies that the work done under Mechanical Permit#20-132 issued on 9/17/2020 for the installation of a new oil fired boiler has been satisfactorily completed. Sincerely, Steven E. Fews Building&Fire Inspector /to � oE 4R tim Fo w � 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 : DATE: .ry PERMIT# L ISSUED: SECT: BLOCK: LOT: LOCATION: (� '` 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 ❑ FUEL TANK ❑ FIRE SPRINKLER ❑ FINAL PLUMBING ❑ CROSS CONNECTION ❑ FINAL ❑ OTHER 4; e. N r: M ' e� (' o x clq � � O .. 16 -,0 T ° +n °�' ° E Fes• ' S _Cs ue > y m o . _ Q as ne A !� E ; vu ar ON x J ram--x �Cr r 00 z a A 616 � � (' w z o E.. Q 06 Q oo � OCa .a C. i 1 BUILD MENT 11 v VIL E OF RY OK ID 938 KING ET RYE BR; ,NY 10573 SEP 2020 (914)9 39-5801 VILLAGE OF RYE BROOK A or BUILDING DEPARTMENT APPLICATION FOR PERMIT TO INSTALL AND/OR REMOVE HEATING, VENTILATION AND/OR AIR CONDITIONING EQUIPMENT FOR OFFICE USE ONLY: PERMIT#: /yr c)o 1. SEP 1 7 2020 Approval Date: Permit Fee:$,/pl'L Approval Signature: Other: Disapproved: (fees are non-refundable) REQUIREMENTS FOR RELEASE OF PERMIT&CERTIFICATE OF COMPLIANCE: 1. Properly completed& Signed Application. 2. Site/Staging Plan if Required by the Building Inspector. 3. Copy of Licensed Contractor's Liability Insurance.(Village of Rye Brook must be listed as certificate holder)&Workers Compensation Insurance on a NYS Board form(Foram#C 105.2 or Form#U26.3/or NY State Workers Compensation Waiver) 4. Payment of Fees/Unit: RESIDENTIAL=$100.00/unit•COMMERCIAL=$350.00/unit. 5. Inspection by the Building Department for removal and/or installation. (48 hour notice required) 6. Electrical work requires a separate Electrical Permit&Electrical Inspection. 7. Plumbing/Gas work requires a separate Plumbing Permit& Plumbing Inspection. Application dated, Z !1 a0 is hereby made to the Building Inspector of the Village of Rye Brook for a permit for the installation and or removal of the 11VA7C equipment as listed below.The applicant and property owner,by signing this document agrees that said equipment will be installed and/or removed in conformance with all applicable Local,County,State&Federal laws,codes,rules and regulations. 1. Address: o C_kYnl SBL:15t Zone: w 2. Property Owner: Inr*. a I Address: � 7 �dC&i4e- 10rJ✓e- Phone#:���9�7 24G Cell#:D ,S}r� email: 3. Contractor: R I.Z-d Djdh IV iQ4 e so.?�.S I-Lg Address: a lg Q)Lnn 1 -zj Phone#: o.20 3--�(0 9—,3�,a C) Cell#: email: u+q t l IO�wry�,in ac,l�c a+'r+ •� 4. Applicant: Ldd h >4 iC's ;-,j-,f'oj.+J Address: P. a d ox 77o2J G"Cc,7"4 J 7 Phone#: ;7-0 J —�(i —t7o��0 Cell#: email: 5. Scope of Work:New Installation( )•ReplacemenLK Removal( )•Other( ): 6. List Equipment: ge ee 6�X+j4/n r 12, 6 � 13o,)e,, �✓,�'� 190.*"c_s 1,c Ca, L 7. Location of Equipment: 8. Method of Installation/Removal(list all equipment needed to perform job): d�A �/f_1 GjL t 3/21/19 STATE OF NEW{YORK,COUNTY OF WESTCHESTER ) as: ,C,/eai^ #Aiz 1-t y ,being duly sworn,deposes and states that he/she is the applicant above named, (print name of individual signing as the applicant) and further s ates that(s)he is the legal owner of the property to which this application pertains,or that(s)he is the ch 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. Sworn to before me this Sworn to before me this day of ,20 day of ,20 -��; ,,� y�fl iJ1�"- Signature df Property Owner Sig a of plicant Print Name of Property Owner Print Name of Applicant Notary Public Notary Public This application must be properly completed in its entirety and must include the notarized signature(s) of the legal owner(s) of the subject property, and the applicant of record in the spaces provided. Any application 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 3/21/19 r4 clq I'- P4 5n 16 Z 0 Ci. ► ^ a A 00 00 CA LIJ — 00 CA% C6 C6 a kn < 96 z • yE DRC�v� FRFSEP C E � �/BUILDAI6ARTMENT VILLAGE OF RYE BROOK 17 2020 938 KING STREET RYE BROOK,NY 10573 (914)939-0668 FAX(914)93 9-5 801 VILLAGE OF RYE BROOK www.ryook.org BUILDING DEPARTMENT ELECTRICAL PERMIT APPLICATION Westchester County Master Electricians License Required FOR OFFICE USE ONLY BP'#* /' � I �" EP#: SEP 1 8 1010 �J Approval Date: Permit Fee: $ el 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 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: � h � 6D SBL: f 35t 3 �—)9 Zone:R IO 2.Property Owner: i— M S Q ddress: Phone#: Q(t{ 7 3 2�(0( Cell#: email: 3.Master Electrician: 4 Address: Lic.#: 17(Phone#:Jj3 537 (SSSZ Cell#R(5/ S,5Y AL$S email: f$jr*j[ts Cc?(kU q . Ca vy Y Company Name: Address: 4.Proposed Electrical Work/Fixture Count: �SU �p wiz STATE OF NEW 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 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. J Sworn to before me this Sworn to before me this S�t l day of ,20 day of �20 Signature of Property Owner ignature of Applicant Print Name of Property Owner Print Name of Applicant Notary Public Notary Public 3/21/19 Westchester Rockland Electrical Inspection Services, Inc. Phone: 914-347-3595 DO NOT WRITE HERE-FOR OFFICE USE ONLY 43 North Lawn Avenue Fax: 914-347-3596 • Elmsford, NY 10523 IT- BUILDING PERMIT NO. TEMP# DATE CITY VILLAGE ZI CODE TOWNSHIP COUN vS STR.ET AND N7 ROAD POLE NUMBER cc,\c �� Sp p �-• BETWEEN WHAT TWO CROSS STREETS IS PREMISES LOCATED? SECTION BLOCK LOT OCCUPANT'S NAME BUILDING OCCUPANCY OVA SQ Q j ; c S i S C.- OWNER'S NAME AND ADDRESS, HOME TELEPHONE NUMBER 5 G„t,. 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 1s'FL. C Z—FL. ILLAGE OF RY BROOK 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 RAVE 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 t SERVICE ENTERS BUILDING OVERHEAD❑ 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 APPLICATION SIG.NATUR P L C 1h 't ( cuy c6fl STREET ADDRESS TELEPHONE NO. iLl ;tt S4 21C3 S iSSZ CRY POST OFFICE LP LICENSE NO.WHEN APPLICABLE R WESTCHESTER ROCKLANO ELECTRICAL INSPECTION &ARE1 SERVICES,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: Weigold Electric Philip &Gloria La Destro 101 Mill Street Greenwich CT 06830 Located at: 68 Rock Ridge Dr, Rye Brook, NY 10573 Certificate Number: 735806 Section: 135.36 Block: 1 Lot: 19 BDC: Permit Number: EP:20-176 BP:MP20-132 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: 68 Rock Ridge Dr, Rye Brook, NY 10573 ❑X Basement ❑1st Floor ❑2nd Floor ❑3rd Floor ❑Garage El Attic ❑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 9/23/2020 Name Quantity Rating Circuit Type Boiler 1 This Certificate has been approved by Westchester Rockland Electrical Inspection Services. This certificate may not be altered in any way. This is valid for work oerformed before date of insDection onl . Boilers I` Ll ■ ■ T M rr., Seneas Peerless8oilers.com If� G� .a :sue Classic Jecket Premium Jacket . 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A limited, lifetime warranty is provided for the cast iron sections of Peerlessa residential hot water boilers.A limited,ten-year warranty is provided on the cast Iron sections of residential steam boilers. Visit Peerless Boil ers.corn for complete details. 'Technical Information L FI member M E M III E R fnfertek Premium Jacket Water Classic Jacket Water Classic Jacket FL Steam -.Ulm Boller Dimensions Crated Dimensions & Shipping Weights �,I "Re a'of WPC, WPC, WPC, Len gill I Width Hoijjhl Approximate Shipping WvlUht([b,;.) Boiler laclel, Jacket Jacket c kut to Vent Size Motel Depth Width Height "I ,Vent Diameter Boiler Knockdown P4,eki,11. Number .,A" 1.81, "C" D. �E' Model WPCT, WPCT' WPCT, I SP -1 WU SU WPC WPCT tSPSP4 Nuinbe, WPCO SP-SPT SP-SPT -SPT' W-S S T WOV-03 1 4.1/3': -03 35" 40" 573 58 1 15! 9-1 1 ell 61 WBV*04 18.ill, 22 WGV 288.1 12" 79-3/4" '0 41�1': '1i3 685 696 WV-05 22-1/8" 22-1/8" 35" 11-1/161, 7- WBV-04 43" 40" 2 1/2" 39-3/4" :91) e 't, e"" 'i, WV-05 43" - 28-1 12' 39-3/4" 710 725 805 013 WBV-03 1 115-3/4" 1 35' 8-718'�' - WBV-D4 9-3/4- 22-118" 1 35- 10-7/8 WBV-03 44:33,1: 228 8:33/1:'I47" 1 90 600 85 50D 52 WBV-03 1 1B-31/:. 2233:55//: 4:: 7". 61. WOV-04 48 47' 605 620 70735 735 22 VVV-05 52-3/4" 28-3/4" 47' 725 740 830 340 WBV-04 WV-05 26-3/8" 23.5/5" 39-1/4" 15.1 7" Jackal 01t, Boiler Ratings Series WBV/WV"' Water Minlmu Boiler Input Heating Capacity',MBH Net Ratings' Aruo. Content, S ack % Draft Gallons Model Steam, Sterlm, Water, I Required, Number GPHl MOH Water Steam scift MOH-1 MEW Water Steam Water Steam In Wc, WBV-03 0.60+0 84 75 - - - 65 87.5- - 11.75 - -.03 WBV-03 0.55 119 104 103 321 77 90 86.2 84.6 11.75 12.00 -.04 WOV-03 1.05 147 126 124 388 93 110 85.0 83.6 11.75 12.00 -.05 WBV-04 0.95+ 133 117 - - - 102 87.0- - 14.75 - -.03 WE3V"014 1.25 175 151 161 471 113 101 85.4 85.3 14.75 14,87 -04 W13VO4 1 1.50 1 210 1 180 1 179 558 1 134 1 156 1 85.1 84.3 14.75 14.87 -.05 1 8:'0 WV-051 1 1.71 1 24 212 184 5 7.76 - 1 5 235 - - - 204 8 1 -.06 WV-05t .95 273 17.75 -.06 4 A,*_11i FN;7r;GY STAW Pallet PO I VA.LLG has(1civimiciJ Ilwl Ulm,liritty rale:imm iW LINCKOY 3 0.14!pxkllto;for twr(jy Jfick=-J. , rup vrnwlg unly. +N-jols r thove fiumv nve..not I)ffrm l a-.slwwlnr:J iquilmnent.Cor,ull faclefy lur lAvaiv.1 maili*kty. "Thii foing mio ran oil,Ix!aMk,.vwI wtha PiOn F-3 loArrvir.CommP w for1 13,.�nnfofl,l t-d-No.21,114 NI w111 1 I'lialriv value of WRNM ell,IWN lovinn. 2 NU wal"""Irs bawl on analk-IN"'u:(1.15. 3 Nei steam rali,j-hawd on a,atl-10,a, f.333. 4 comulf 13mry a lit*Uf kx irlsiallatiulls havillf trivjl"011iiOu and(rickkip foQuirtirmils.Stwhas klownifliolk sysilt-opt'alinis•wd.'rve llnovj 4yger'-Me 5 Hemul)Crqmoly aiid Ail-ltyll FOO 1)(AIZAlklil ElOrmicy(AFUE)raivxj5 arH lj3wl on U.S.Gm oinoll Iftis,y0l.133".CO;and-0.02' draft rr-F.,!. 6 Ch.­UY SI"':0'x B-1 15 h P"'Iessevilt's Co. 4"- CUT-%',8VR5(l/I5 7 6P.1) S A. p-,,,j-.Ccy""'ll'P't' PeeriessBoilers.com DATE(MM/DD/YYYY) AC" " CERTIFICATE OF LIABILITY INSURANCE 9/17/2020 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 John M. Glover Agency PHONE Sarah G idoda FAX P.O. Box 700 c •203-956-2458 A/c No):203-857-7848 Norwalk CT 06852 nDoRless: sgjidodaj@jmg.com INSURERS AFFORDING COVERAGE NAIC# INSURER A:United Ohio Insurance Company 13072 INSURED RUDOBIA-01 INSURER B: Rudolph Biagi&Sons Plumbing P 0 Box 7725 INSURERC: Greenwich CT 06830 INSURERD: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:1387323555 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 ADDL UBR POLICY EFF POLICY EXP LTR POLICYNUMBER MM/DD/YYYY MM/DD/YYYY LIMITS A X COMMERCIAL GENERAL LIABILITY Y BP 0020655 07 5/20/2020 5/20/2021 EACH OCCURRENCE $1,000,000 CLAIMS-MADE OCCUR DAMAGE TO RENTErF_ PREMISES Ea occurrence $50,000 MED EXP(Any one person) $10,000 PERSONAL&ADV INJURY $1.000,000 GEN'L AGGREGATE LIMIT APPLIES PER: I GENERAL AGGREGATE $2,000,000 PRO- )( POLICY JECT LOC PRODUCTS-COMP/OP AGG $2,000,000 OTHER: $ A AUTOMOBILE LIABILITY CPPOO17142 5/20/2020 5/20/2021 Ea sBBINEDt SINGLE LIMIT $1,000.000 IxANY AUTO BODILY INJURY(Per person) $ OWNED X SCHEDULED BODILY INJURY Per accident $ AUTOS ONLY AUTOS ( ) HIRED X NON-0VUNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY Per accident A X UMBRELLA LIAB X OCCUR CX 0002107 07 5/20/2020 5/20/2021 EACH OCCURRENCE $2,000,000 EXCESS LIAB CLAIMS-MADE AGGREGATE $2,000,000 DED I I RETENTION$ $ WORKERS COMPENSATION 7PER TH- AND EMPLOYERS'LIABILITY Y/N ISTATUTE ER ANYPROPR I ETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? NIA E.L.EACH ACCIDENT $ (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) 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 Ryebrook 938 King Street 10573 AUTHORIZED REPRESENTATIVE Ryebrook, NY 10573 C �• ,hid ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD <NTEW i Workers' YORK TE Compensation CERTIFICATE OF Board NYS W')RKERS' COMPENSATION INSURANCE COVERAGE 774Hamilton &Address of Insured(use street address, ily) 1 b. Business Telephone Number of Insured IAGI&SONS PLUMBING&HEATING INC 203-869-3220 Ave 1 C.NYS Unemployment Insurance Employer Registration Number of c , CT 06830-3102 Insured N/A Work Location of Insured(Only required if coverage is spec ica/ly limited to certain locations in New York State,i.e.,a Wrap-Up policy) 1d. Federal Employer Identification Number of Insured or Social Security 74 Hamilton Ave, Greenwich, CT 06830-3102 Number 06-1454502 2.Name and Address of Entity Requesting Proof of Covera (Entity Being Listed as the Certificate Holder) 3a. Name of Insurance Carrier The Village Of Rye Brook NorGUARD Insurance Company 938 King St 3b.Policy Number of Entity Listed in Box"1 a" Rye Brook, NY 10573 RUWC135851 3c.Policy effective period 05/20/2020 to 05/20/2021 3d.The Proprietor,Partners or Executive Officers are El included.(Only check box if all partners/officers included) This certifies that the insurance carrier indicated all excluded or certain partners/officers excluded. compensation under the New York State Workerss''Cotov( in box"3"insures the business referenced above in box"1a"for workers'Cot pensation Law. (To use this form, New York(NY)must be listed under Item 3A on the INFORMATION PAGE of the workers'comps this Certificate of Insurance to the entity listed above a Isation insurance policy). The Insurance Carrier or its licensed agent will send the certificate holder in box"2',. The insurance carrier must notify the above certificate older and the Workers' Compensation Board within 10 days IF a policy Is canceled due to nonpayment of premiums or within 30 days IF tl are are reasons other than nonpayment of premiums that cancel the policy or eliminate the insured from the coverage indicated on tf s Certificate. (These notices may be sent by regular mail.)Otherwise, this Certificate is valid for one year after this form is ap:,roved by the insurance carrier or its licensed agent, or until the policy expiration date listed in box "3c",whichever is earl 3r. 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 liste , 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' :,ompensation contract of insurance only while the underlying policy is in effect. Please Note: Upon cancellation of the workers'core iliensation policy indicated on this form, if the business continues to be named on a permit, license or contract issued by a ertificate holder,the business must provide that certificate holder with a new Certificate of Workers'Compensation Coverag or other authorized proof that the business is complying with the mandatory coverage requirements of the New York hate Workers'Compensation Law. Under penalty of perjury, I certify that I am an autho zed 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: Dave Simmons (Print name of authc zed representative or licensed agent of insurance carrier) Approved by: i 09/16/2020 - (Date) Title: Vice President of Sale Telephone Number of authorized representative or licen ad agent of insurance carrier: 800-673-2465 Please Note: Only insurance carriers and their licens d 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