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HomeMy WebLinkAboutMP20-142 �yE BRn,1- J tl��u j JJ V 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.or� TRUSTEES BUILDING& FIRE INSPECTOR Susan R. Epstein Steven E. Fews Stephanie J. Fischer David M. Heiser Salvatore W. Morlino CERTIFICATE OF COMPLIANCE February 21,2024 Cristiano Mello de Almeida&Ana Paula DeLuca Almeida 38 Talcott Road Rye Brook,New York 10573 Re: 38 Talcott Road, Rye Brook,New York 10573 Parcel ID#: 135.50-1-8 This document certifies that the work done under Mechanical Permit #20-142 issued on 10/6/2020 for the installation of two new furnaces have been satisfactorily completed. Sincerely, Steven E. Fews Building&Fire Inspector /to QyE BR(�� o`` tim 0 19b2•1� BUILDING DEPARTMENT ❑BUILDING INSPECTOR bQ,/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: 3 8 � 6-r-T i�10 k(' DATE: 2 " 7 - Z V Z-y PERMIT# M r Z ISSUED: 10 -2O SECT: I BLOCK: ! LOT: LOCATION: i�A W C --)` OCCUPANCY: Z ' J ❑ Violation Noted THE WORK IS... a rASSED ❑ FAILED /REINSPECTION ❑ SITE INSPECTION REQUIRED ❑ FOOTING ❑ FOOTING DRAINAGE ❑ FOUNDATION ❑ UNDERGROUND PLUMBING NOTES ON INSPECTION: ❑ ROUGH PLUMBING ❑ ROUGH FRAMING ❑ INSULATION ) � -{�� i ❑ Natural Gas < - 1. ( 12 ❑ ��� ►.1 CJ(` L�.- � ���S �� L V C, �y L.R Gas �A ,S FUEL TANK ��7ratiJ I ❑ FIRE SPRINKLER ❑ FINAL PLUMBING ❑ CROSS CONNECTION erfINAL ❑ OTHER Thermo Proldu Thermo "7�1 Oil Furnaces MEMO i� JN,TflO S/� _ 93 � iYwee PrIN � t, h .4 3. 1-01 6 The Thermo Pride Story 'Peace of Mind"Lifetime Limited Located in the United States,Thermo Pride has a 70-year Warranty-Industries Best heritage of superior workmanship, We are so confident of our furnace quality that we stand product innovation and small town behind our products with our"Peace of Mind"Lifetime work ethic. We are committed to Limited Warranty. The in- handcrafted products and home- dustries only non-prorated, • 1 town values like comfort,reliability, automatically transferred heat durability,quiet operation and ' exchanger warranty. Should you sell your home,the heat high efficiency. You will appreci- exchanger warranty will automatically transfer to the ate the peace-of-mind that comes new owners. Thermo Pride furnaces also come standard from knowing your Thermo Pride with a"Peace of Mind"10-year parts warranty. See furnace is anything but a mass- warranty certificate for details. produced,low-cost compromise between quality and price. Made in the USA �N1T"sr� The Octatherm Advantage We're proud that Thermo Pride fur- naces are engineered and Our furnaces are unique in that we use an Octatherm heat manufactured in the United States. exchanger. The time-tested eight-sided design is at the " Thermo Ride heart of Thermo Pride's reputation for r Comfort- Warmer than our high efficiency,reliability and durability. r Competition This design forces flue gases into a high rate of agitation as they pass through "Temperature rise"makes the difference between feeling the heat exchanger. This increases heat warm air or the feeling of cool air blowing across you transfer and efficiency,resulting in r A when the furnace is on. It is the difference in tempera- more uniform surface heating. Our heat ture from the point where it exchangers are fabricated of 13-gauge enters the furnace to the point 80' copper-coated steel. The copper coating helps prevent where it exits. The higher the 70' -- -- corrosion and promotes the best heat transfer. temperature rise the warmer 60' _ the air when it enters the so Handcrafted High Quality rooms. We achieve a 60°to 40 70°F temperature rise across Each Thermo Pride furnace is powder-coat painted inside our full line of oil furnaces. m' r7 and out after it is formed for a durable, POWDER This air temperature is up to 10' tough finish that will ensure long life 30°F warmer than the compe- °' and a quality appearance. The inter COATED tition providing far Temperature Rise locking insulated furniture grade steel TOUGH" superior comfort. cabinet helps retain heat within the furnace and prevents annoying vibrations during operation. The rounded corners add structural strength and a pleasing appearance to the cabinet. Chrome Plated Handles Standard High i Rounded Corners and Efficiency Flame Retention Interlocking Cabinet Panels Beckett AFG Burner - give added Stability and Optional Beckett NX on Quiet Operation OH6 Series Optional Riello Burner or Carlin Burner available on some models '+.. 13-Gauge Octatherm Peace of Mind 10 Year Parts Heat Exchanger Delivers Warranty Higher Efficiency Lifetime Heat Exchanger Warranty Automatically Transfers to Subse- quent Homeowners for Increased Resale Value of your Home Combustion Observation Port for Easy Burner Calibration Dual Service/Clean-out Ports Placed for Easy Access Exclusive Copper Coated on OH6,OL6,OH8 Heat Exchanger Provides Corrosion Resistance and Burner&Controls Enclosed ( ! Superior Heat Transfer in Vestibule for Safety and Quiet Operation Standard Direct Drive Blower Motor Advanced High Efficiency Controls Mounted at the Front of Cabinet for Optional ECM Motor Available for Increased Easy Setup and Access Electrical Efficiency,Comfort and Operation anRun&BMW It%=OwNuIIId-wNaw—aw Premier Oil Furnace with ECM Blower Motor Add Air Conditioning Condensers and Cased Coils When you want to experience exceptional comfort,increased electrical efficiency and quieter operation,choose a furnace Add Thermo Pride air conditioning condenser and cased coils model with an ECM blower W-d-d Fum—N.h.LANM to your Thermo Pride oil furnaces for added indoor comfort. motor. The ECM motor is an -_V.d..l.Sp..d NM..L..W Offered in two efficiency levels,the TC7 Series offers up to 16 ultra-high efficiency DC motor SEER efficiencies while the TC4 Series offers 14 SEER efficien- that operates more efficiently cies. The TC7 Series is approved for all U.S.Regions while the than standard direct drive TC4 Series are approved for North motors. LX and Southeast Regions. Both series meet the Department of Energy's • Save energy with theOtQ4 efficiency rating requirements. increased electrical _ efficiencyof the ECM motor utilizing DC power,especially '-���==` g P P Y Go to wwwthermopride.com under �..���==Z when you run the blower for long periods of time. Air Conditioning to download the Evaporator Coil Applicaton Guide. • Slow start ups and shut down equals quiet operation, ---w This guide also contains the AHRI greater efficiency and more comfortable temperatures. reference numbers. • Automatically adjusts for various duct systems and —=—= conditions by varying its RPM. p �� • Operates at lower speeds in constant circulation mode for optimum air filtration,even temperatures and lower operating costs. OPROJA&W DIMENSIONS WARM AIR OUTLET RETURN AIR INLET FLUE APPROX. BTU)H (INCHES) (INCHES) (INCHES) DIA, MAXIMUM A/C CAPACITY SHIP ',ucr:E a uE :,F-E OUTPUT(2) W x L x H W x L W x L (IN) STD. UPGRADE WEIGHT le) LOW PROPILE HIGHSOY-OH SERIES PREMIERE HIGHBOY WITH ECM BLOWER MOTOR OH6FA072DV4 Front 85-86.1(31 60,000/72,000/90,000 20 x 30 x 45 18 x 19 23 x 14 5 4 — 280 OH6FA072DV4N Front 85.6 71,000(Beckett NX) 20 x 30 x 45 18 x 19 23 x 14 5 4 — 280 OH8FA119DV5 Front 85.8-86(3) 101.000M20,000/132,000 24-1/2 x 36-1/2 x 50-1/8 20 x 20 23 x 14 7 5 — 390 HIGHBOY WITH PSC DIRECT DRIVE BLOWER MOTOR OH6FA072D48 Front 85-86 1(3) 60,000/72,000/90,000 20 x 30 x 45 18 x 19 23 x 14 5 4 — 280 OH6FA072D48N Front 85.6 71,000(Beckett NX) 20 x 30 x 45 18 x 19 23 x 14 5 4 — 280 OH8FA119D60 Front 85.8-86 131 101,000/120,000/132,000 24-12 x 36-1/2 x 50-1/8 20 x 20 23 x 14 7 5 — 390 HIGHBOY WITH 2-STAGE RIELLO BURNER 3 ECM BLOWER MOTOR 74.000-89,000 High OH6FX072DV4 Front 87 61,500-72,000 Low 20 x 30 x 45 18 x 19 23 x 14 5 4 — 280 LOWBOY-OL SERIES PREMIERE LOW PROFILE LOWBOY WITH ECM BLOWER MOTOR 18x20 18x18 OL6FA072DV5 Front 86.5.87.0(3) 60,000772,000/90,000 20 x 50 x 34-3/4 20 x 20(4) 20 x 18(4) 5 5 — 315 Optional Flange Optional Flange 18x20 18x18 OL6RA072DV5 Rear 86.5-87.0 13) 60,000772,000/90,000 20 x 50 x 34-3/4 20 x 20(4) 20 x 18(4) 5 5 — 315 Optional Flange Optional Flange PREMIERE LOWBOY WITH ECM BLOWER MOTOR OL11-105FDBE Front 85-8313) 105,000 25 x 54-12 x 46-1/2 20 x 20 20 x 16 6 3.5 — 500 OL11-105RDBE Rear 85-83(3) 105,000 25 x 54-12 x 46-1/2 20 x 20 20 x 16 6 3.5 — 500 OL16-125FDBE Front 85 125,000 27 x 58-12 x 46-1/2 22 x 22 22 x 18 7 5 — 560 OL16-125RDBE Rear 85 125,000 27 x 58-12 x 46-1/2 22 x 22 22 x 18 7 5 — 560 OL20-151 FDE Front 85 153,000 27 x 58-12 x 50-1/2 22 x 22 22 x 18 7 5 — 600 OL20-151 RDE Rear 85 153,000 27 x 58-12 x 50-1/2 22 x 22 22 x 18 7 5 — 600 LOWBOY WITH PSC DIRECT DRIVE BLOWER MOTOR OLS-85FDBP Front 85/861') 88 OOOBS G,00(3) 25 x 50-1/4 x 43-1/4 20 x 20 20 x 14 6 3.5 4 410 OL5-86RDBP Rear 85/86(1) 88 000/85 000(3) 25 x 50-1/4 x 43-1/4 20 x 20 20 x 14 6 3.5 4 410 18x20 18x18 OL6FA072D48 Front 86.5-87.0(3) 60,000(72,000190,000 20 x 50 x 34-314 20 x 20(4) 20 x 18 1 ) 5 4 — 315 Optional Flange Optional Flange 18x20 18x18 OL6RA072D48 Rear 86.5-87.0(3) 60,000/72,000/90,000 20 x 50 x 34-3/4 20 x 20(4) 20 x 18(4) 5 4 — 315 Optional Flange Optional Flange OL11-106FDBP Front 85/83,0(3) 104 000/101 000(3) 25 x 54-12 x 46-1/2 20 x 20 20 x 16 6 3.5 4 500 OL11-106RDBP Rear 85/83.0(3) 104,000/101,000(3) 25 x 54-12 x 46-1/2 20 x 20 20 x 16 6 3.5 4 500 OL16-125FDBP Front 85 129.000 142,000 27 x 58-12 x 46-1/2 22 x 22 22 x 18 7 5 — 560 OL16-125RDBP Rear 85 129.000 142,000 27 x 58-12 x 46-1/2 22 x 22 22 x 18 7 5 — 560 OL20-161FD Front 85 153,000 27 x 58-12 x 50-1/2 22 x 22 22 x 18 7 5 1 — 600 OL20-161 RD Rear 85 153,000 27 x 58-12 x 50-1/2 22 x 22 22 x 18 7 5 — 600 LOWBOY BELT DRIVE BLOWER MOTOR OL33-20OF'S Front 81 5 lei 200,000 34 x 72 x 60-W4 28 x 28 28 x 24 9 5 10 1025 OL33-20OR'S' Rear 81 5(6) 200,000 34 x 72 x 60-3/4 28 x 28 28 x 24 9 5 10 1025 HORIZONTAL-OT SERIES HORIZONTAL WITH PSC DIRECT DRIVE BLOWER MOTOR OT11-105FBP �ront 83 101,000 24-12 x 74 x 24 20 x 20 20 x 20 6 3.5 4 445 OT11-10SRSP(7) Rea• 83 101.000 24-12 x 74 x 24 20 x 20 20 x 20 6 3.5 4 445 OT16-126FBP(7) Front 83 123.000 26 x 74 x 26 22 x 20 22 x 20 7 5 — 500 OT16-125RBP(7) Rear 83 123,000 26 x 74 x 26 22 x 20 22 x 20 7 5 — 500 COUNTERPLOW/NORIZONTAL-OD SERIES COUNTERFLOW f HORIZONTAL WITH PSC DIRECT DRIVE BLOWER MOTOR OD6RA072D48 Rear 85.7 60,000/72,000/90,000 20 x 30 x 45 18 x 20 18 x 19 5 4 — 250 OD6FA072D48 Front 85.7 60,000/72,000/90,000 20 x 30 x 45 18 x 20 18 x 19 5 4 — 250 COUNTERFLOW/HORIZONTAL WITH ECM BLOWER MOTOR OD6RA072DV5 Rear 85.7 60,000f72.000/90,000 20 x 30 x 45 18 x 20 18 x 19 5 5 — 250 OD6FA072DV5 Front 85.7 60,000/72,000/90,000 20 x 30 x 45 18 x 20 18 x 19 5 5 — 250 L Seasonal efficiency(Annual Fuel Utilization Efficiency) 5.Shipped knocked down. 2. BTU outputbased on Annual Fuel Efficiency Rated by manufacturer. 6.Certified thermal efficiency. 3.The second figure represents ratings with Rialto burner option. 7.These models have exposed bumen.T-units not approved for attic installation. 4.Optional Range size Included with furnace. B. Shipping weights Include the burner.Weights are approximate. r1 Many of our oil furnaces are Energy Star qualified.Go to wwWenergystargov for qualifying unit details. ©sot Visit us at www.thetmopride.com win your sm.n i nam.wour PLO21005 Rev110817 gym,tom C 2017 Thermo Products,LLC ''-.� n�it;�.� --�j t4 n Win �n,i t�• !''� rn !f'ti �': r t r _ � 1 �n•YG, t.r.. n �""�,... �4, n �•�., �lli sn r O� d "� L d .dll�v a•�• � p i<t 4•• �► ljy i•• !! +� •�• 6/�`'� •••• ' v •• �'►��} }` ••• it , �o:T- �• 111',11'►11 �����p�� 11111111111 ��•� i`i lllll�ll l+ 6�� 11�1/1�11�'4R�� �' ,1�I/ID,1 '� � 1,D��, !`�E 18� 11�1�, ����'^ .•�.^'_�CY9n�:.�.. k,i "b,::,•.wela JrfFa. w�im.Illelll::'£=: t�r-Illelll + i' ,aY'-IIIIe 111:F�:`ea 'oF•`tY`,Illelll..!£. 4:i,.llllleil ll'.••��d�.f �'i�`.Ill dell ll'.:`?II:v nnPN`"' •4 tiY 1. Sze. / -` z oj .4 CIS r•% r� 6o CO 4-1 INS LU Iry •.,:. ' ♦i I • , . ;41•` : I Qy •�I W O U W C7 a 0 �;Proais)t� "ice' a I r-• �,y Co Z F- o 'o '� ,section ' '=7^ r/ i y�:✓.� r 1 O V = Z 3 ;, ( "gyp 1�e �., .a> . /,"•—�... � W O 4.. 0 <(arDD�yz 00 ' Allr— U)Ar- I ♦ , A a CIS OR CIS u CO U a� : • if 1>/'�1W•J •"mil` l:&6, $•�i. 1 �tu+• , 1f,= ,lel� i 1 1 1 l/l V OF- OR Wjr 1i¢ ���.� r �zJtO� St�•;" O � O`. O <rl ` r:,h - `tF�lli *� v `�IIWvP�;?✓r 'n,.v. K",�' /��L ''+,iry tl'�,��.'- .:'��' v I�t>" +l ���NIHN,��1r.�s s. �.�ti' tiN aJ vtiv • _\ram �•: '4 CERTIFICATE OF LIABILITY INSURANCE F_`�"='_ 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 polity, certain policies may require an endorsement, A statement on this certificate does not confer rights to the certificate holder In Ileu of such endorsements• PRODUCER CONTACT NA E: CLIENT CONTACT CENTER FEDERATED MUTUAL INSURANCE COMPANY PHONE FAX HOME OFFICE: P.O.BOX 328 A/C No Eat:8BB-333-4949 A/C No:507-446-4664 OWATONNA, MN 55050 EDDRIESS:CLIENTCONTACTCENTEReFEDlrqS.COM INSURERIS AFFORDING COVERAGE NAIC p INSURER A:FEDERATED MUTUAL INSURANCE COMPANY 13935 INSURED 330-130.6 INSURER 8: WESTMORE FUEL COMPANY INCORPORATED INSURER C: 86 N WATER ST GREENWICH,CT 06830.5886 INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:36 REVISION NUMBER:0 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 DL SUBR POLICY NUMBER POLICY EFF POLICY EXP LIMITS L INS WVD MIDDI Y Y M/DD/ V X COMMERCIAL OENERAL LIABIUTY EACH OCCURRENCE $1,000,000 �HCLAIMS-MADE a OCCUR DAE,SE TO RIC.EcTED c $100,000 MED EXP(Any one poraon) $5,000 A N N 9062815 06/01/2020 06/01/2021 PERSONAL&ADV INJURY $1,000,000 CE 'L ACOR OA E LIMIT APPLIES PER: OENERAL AOOREOATE $2,000,OOD X POLICY �jE�T ❑LOC PRODUCTS•COMPIOP A00 $2,000,000 OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $1,000,000 X ANY AUTO BODILY INJURY(Par pereon) OWNED AVTOS ONLY SCHEDULED A AUTOS N N 9062815 06/01/2020 06/01/2021 BODILY INJURY(Per accldcnI) HIRED AUTOS ONLY AUNON-OWNEDOSLPROPERTY DAMAGE AUTOS ONLY r X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $7,000,000 A EXCESS LIAB CLAIMS-MADE N N 9062816 06/01/2020 05/01/2021 AOOREOATE $7,000,000 DED RETENTION WORKERS COMPENSATION OTH- AND EMPLOYERS'LIABILITY Y/N X PER 6TATUTE ER ANY PROPRIETORIPARTNER/EXECUTIVE E.L.EACH ACCIDENT $500,000 A OFFICERIMEMBER EXCLUDED? NIA N 9917566 06/01/2020 06/01/2021 (Mandatory In NH) E,L.DISEASE•EA EMPLOYEE $500,OOD It yes,doccrlbe under DESCRIPTION OF OPERATIONS below E,L DISEASE•POLICY LIMIT $500,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Addlllonrl Remana Schedule,may be■Racked It more apace Is required) CERTIFICATE HOLDER CANCELLATION 330-130-6 35 0 VILLAGE OF RYE BROOK SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 938 KING ST THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN RYE BROOK, NY 10573-1226 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE 4�/`/ O 1988-2015 ACORD CORPORATION.All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD NW Workers' STATE 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 WESTMOREFUELCOMPANY INCORPORATED (203) 531-5656 330-130-6 86 NORTH WATER STREET 1o.NYS Unemployment Insurance Employer Registration Number of GREENWICH. CT 06830-5886 Insured Work Location of Insured(Only required If coverage is specifically ilmlted to 1d, Federal Employer Identification Number of Insured or Social Security certain locations In New York State, l.a., a Wrap-Up Policy) Number 06-0739367 2.Name and Address of Entity Requesting Proof of Coverage 3a.Name of Insurance Carrier (Entity Being Listed as the Certificate Holder) Federated Mutual Insurance Company Village Of Rye Brook 938 King St 3b.Policy Number of Entity Listed in Box"1a" Rye Brook, NY 10573-1226 9917566 3c.Policy effective period 06/01/2020 to 06/01/2021 3d,The Proprietor, Partners or Executive Officers are Included.(only check box If all partnors/oKcars Includod) ® all excluded or certain partnerstotiicers excluded. This certifies that the insurance carrier indicated above in box"3"insures the business referenced above In box"1 a"for workers' compensation under the New York State Workers'Compensation Law. (To use this form, New York(NY)must be listed under Item lA 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". Will the carrier notify the certificate holder within 10 days of a policy being cancelled for non-payment of premium or within 30 days if cancelled for any other reason or If the insured Is otherwise eliminated from the coverage Indicated on this certificate prior to the end of the policy effective period? ®YES EDNO 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 permlt, license or contract Issued by a certificate holder,the business must provide.that certificate holder with a new Certiflcate 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: Amber Madrid (Print name of authorized representative or Ilcansod agent of Insurance carrier) Approved by: 7A4a, �. 4/20/20 (Signature) (Date) Title: Authorized Representative: Telephone Number of authorized representative or licensed agent of insurance carrier: (888) 333-4949 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 (9-15) www.wcb.ny.gov