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BP21-183
PERMIT# O�I' �� DATE: � �� ai/ p(p; c�lo of41 SECTION �- "� BLOCK LOT / _ TYPE OFWORK�1�1/�jL��d _ .SE��f'� �� �ip L�Qr' JOB e •�1 CONTRACTOR /Gf � � -8 � _C.-� B�EST. COST � C�� Opp "� 1/CO # r-�o� � �g� � — �� DA /� e�l4C�e�1 �07� � .. � _- _.� � - q�y�a�o-�a9os TCO # FEE � DATE _ _ _ INSPECTION RECORD DATE FOOTING FOUNDATION FRAMING RGH FRAMING INSULATION PLUMBING RGH PLUMBING GAS SPRINKLER ELECTRIC LOW -VOLT 0/ ALARM 0 AS BUILT FINAL fNSP �_....a..l�� OTHER APPROVALS ARB �0►' / � 07� c�a (�011- BOT � __ ZBA OTHER n�r�s� ��p��i� e o� /(•� �s��s� �l 3a� �" �� FINISHED BASEMENT NOT APPROVED FOR USE AS A SEPARATE APARTMENT OR DWELLIN4 UNIT THIS- gU1LpING MUST BE POSTED WITH A PERMANEM CONSTRUCTION TYPE IDENTIFICATION SIGN; O PRIORTOTHEIS UANCEOFA C/0, W�� �Q' r �� � �/ ✓ /ion �/ ��/�� ` AS REQUIRED BY NY STATE U1W_ f�I 2�/Zo2 c� l�� VILLAGR* W RYE BROOK WESTCHES COUN NEW PORK �4oY/ NO: 22-198 Certificate of ®ccupaucp This is to certify that of, XiVe, &06k, IV Y having duly filed an application on N�Vemb, &"20 c,[ requesting a Certificate of Occupancy for the premises known as, Rye Brook,NY, located in a Q- /'—g Zoning District and shown on the most current Tax Map as Section: Block: __) Lot: and having fully complied with the requirements of the Building Code and the Zoning Ordinance under Building Permit No. t2/-1 ,issued -? v2 & 20 c;2 / , such authority and permission is hereby granted to the property owner to lawfully occupy or use said premises or building or part thereof listed under the following New York State Classifications, Use: /� �d�I - � �11V Construction: for the following purposes: 2JrnJ ' J C1 )b0S`e17? P?-1 V f7�r 201-h D Jooy' ;(Pp I acerrPj,?4 Subject to all the privileges, requirements, limitations, and conditions prescribed by law, and subject also to the following: FINISHED BASEMENT NOT APPROVED FOR USE AS A SEPARATE APARTMENT OR DWELLING UNIT This certificate does not in any way relieve the owners or any person or persons in possession or control of the premises, building,or any part thereof from obtaining such other permits or licenses as may be prescribed by law for the uses or purposes for which the building or premises is designed or intended. Furthermore, it does not relieve such owners or persons from complying with any lawful order issued with the object of maintaining the premises or building in a safe and lawful condition. No changes or rearrangement in the structural parts of the building or in the exit facilities shall be made,and no enlargement, whether by extending on any side or by increasing in heig t s all be m shall the building be moved from one location to another until a permit to accomplish such change has b o ned B ilding Inspector. Building Inspector,Village of Rye Brook: Date: DEC 2 1 2022 t 6t +4 Jvy, �yJ V4�4 rJ 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 December 21,2022 Benjamin Stahl&Jadyn Stahl 6 Deer Run Rye Brook,New York 10573 Re: 6 Deer Run, Rye Brook,New York 10573 Parcel ID#: 135.57-1-1 This document certifies that the work done under Mechanical Permit#21-201 issued on 12/27/2021 for the installation of a new condenser and ductless system has been satisfactorily completed. Sincerely, Michael J. Izzo Building&Fire Inspector /to D EQEN ID BUILDING DEPARTMENT For office use only: p PERMIT NOV 16 2022 VILLAGE OF RYE BROOK ISSUED: -7,W,o--al 938 KING STREET,RYE BROOK,NEW YORK 10573 DATE: —^ &— VILLAGE OF RYE BROOK (914)939-0668 FEE: — PAmJR BUILDING DEPARTMENT - wwwxyeb rook.orc, APPLICATION FOR CERTIFICATE OF OCCUPANCY,CERTIFICATE OF COMPLIANCE, AND CERTIFICATION OF FINAL COSTS TO BE SUBMITTED ONLY UPON COMPLETION OF ALL WORK, AND PRIOR TO THE FINAL INSPECTION rwsss*ssss*sssss*twtssstssssws**swss+ssrsssrswswsst*s+s*rtwssrtswww*trwssstwwsssts+rsst*rssss*twsws*astr++++stssss*srsssrssws Address: (0 yeeIL- Z'-) Occupancy/Use: FatyWy Parcel ID#: 13 5' Zone: Owner: !&GF9"S4,WlkA 41CARt-- Address: '& V>.Ve9- to P.E./R.A. or Contractor: Xb&C 6r0 ,C Address: d 0IeST�I/� 1 4)90� OOAZt-,I�A)V `� Person in responsible charge: / Address: yQ&)e fV7/0 Application is hereby made and submitted to the Building Inspector of the Village of Rye Brook for the issuance of a Certificate of Occupancy/Certificate of Compliance for the structure/construction/alteration herein mentioned in accordance with law: STATE OF NEW YORK,COUNTY OF WESTCHESTER as: �3C14-JAVA I la e7'[j"L— being duly sworn,deposes and says that he/she resides at to (Print Name of Applicant) J (No.and Street) in R=j Sag-0 V-�. t in the County of V1eF-"rr-VA65r4L in the State of that ity;Town Village) he/she has supervised the work at the location indicated above,and that the actual total cost of the work,including all site improvements, labor,materials,scaffolding,fixed equipment,professional fees,and including the monetary value of any materials and labor which may have been donated gratis was:$ 5 6, 00 0 for the construction or alteration of F I&�1s ?A*t�&gCAJ _.rA,604-- s `f►Tta PCO I`"'('10 cee` e'v Deponent further states that he/she has examined the approved plans of the structureiwork herein referred to for which a Certificate of Occupancy/Compliance is sought,and that to the best of his/her knowledge and belief,the structure/work has been erected/completed in accordance with the approved plans and any amendments thereto except in so far as variations therefore have been legally authorized,and as erected/completed complies with the laws governing building construction.Deponent further understands that it shall be unlawful for an owner to use or permit the use of any building or premises or part thereof hereafter created,erected,changed,converted or enlarged,wholly or partly,in its use or structure until a Certificate of Occupancy or Certificate of Compliance shall have been duly issued by the Building Inspector as per§250-10.A.of the Code of the Village of Rye Brook. Sworn to before me this Sworn to before me this ,!i day of ce_ k , 20 ;Lt>— day of , 20 �natureof Pce erty Owner Signature of Applicant 'FEE^-ySAw►1(J CSC W K t_ _ Print Name of Proper Owner Print Name of Applicant Notary Public Notary Public MICHELLE M.POMBO NOTARY PUBLIC,STATE OF NEW YORK Registration No.02PO6070477 Qualified in Westchester County Commission Expires March 4,2026 QyE BRC�k. 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.Uebrook.org - -- - - - - - - - - - - - - - - - - - INSPECTION REPORT - - - - - - -- - - - - - - - - - - - - ADDRESS : � v� DATE: PERMIT# 2 - 1 �� ISSUED: l ACT: 3' -ALOCK: LOT: ! LOCATION: T-7 k N y V OCCUPANCY: -2 1 V ❑ 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 QyE BRC�k. BUILDING DEPARTMENT ❑ UILDING 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 - - - - - - - - - - - - - - - - - - - - C ADDRESS:— � � V DATE: PERMIT# 2 1 ' ISSUED: ( SECT: I �. J�LOCK: LOT: LOCATION: \ S '`/ spm OCCUPANCY: , } ❑ VIOLATION NOTED THE WORK IS... ❑ ACCEPTED UV REJECTED/REINSPECTION ❑ SITE INSPECTION REQUIRED ❑ FOOTING ❑ FOOTING DRAINAGE ❑ FOUNDATION ❑ UNDERGROUND PLUMBING NOTES ON INSPECTION: ❑ ROUGH PLUMBING ❑ ROUGH FRAMING ❑ INSULATION c ❑ NATURAL GAS L \ ' `J� Ov� ��rb c ❑ FUEGAS I r CO �71 ❑ FIRE SPRINKLER ❑ FINAL PLUMBING ❑ CROSS CONNECTION a/FINAL ❑ OTHER QyE BRC��. 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.ore - - - - - - - - - - - - - - - - - - - - INSPECTION REPORT - - - - - - - - - - - - - - - - - - - - ADDRESS : `�-� \��� DATE: PERMIT# ISSUED: 4 SECT: BLOCK: LOT: LOCATION: � C �1 OCCUPANCY: ❑ VIOLATION NOTED THE WORK IS... ,ACCEPTED ❑ REJECTED/REINSPECTION ❑ SITE INSPECTION REQUIRED ❑ FOOTING 1 ( + ❑ FOOTING DRAINAGE ❑ FOUNDATION ❑ UNDERGROUND PLUMBING NOTES ON INSPECTION: ❑ ROUGH PLUMBING ❑ ROUGH FRAMING ❑ INSULATION a ❑ NATURAL GAS ❑ L.P. GAS ❑ FUEL TANK 1 ❑ FIRE SPRINKLER (may\E� SJS V l ❑ FINAL PLUMBING 'M �Ct �` 1 VuMp ��J C` t o c tJ ❑ CROSS CONNECTION Ji r ❑ FINAL �2C ❑ OTHER QyE BRC�k cu � >9a2 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: f 'Z 2— 6 PERMIT#� L I �3 ISSUED: Z 2 SECT:` -BLOCK: LOT: 2, LOCATION: N��iT�T�� - OCCUPANCY: ❑ VIOLATION NOTED THE WORK IS... ❑ ACCEPTED / S rEINSPECTION ❑ SITE INSPECTION v REQUIRED ❑ FOOTING ❑ FOOTING DRAINAGE ❑ FOUNDATION ❑ UNDERGROUND PLUMBING NOTES ON INSPECTION: ❑ ROUGH PLUMBING ❑ ROUGH FRAMING ' INSULATION NATURAL GAS LD 1--.�— -7cD►� ❑ L.P. GAS ❑ FUEL TANK V ❑ FIRE SPRINKLER StE� -% �-zj�pC-�t_ ❑ FINAL PLUMBING ❑ CROSS CONNECTION ❑ FINAL ❑ OTHER �E BRC��. O� tim '9a2 BUILDING DEPARTMENT ❑BUILDING INSPECTOR i,; A SISTANT 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 - - - - - - - - - - - - - - - - --- - - s a ADDRESS: DATE'L PERMIT# 1 ' \ J ISSUED: -SECT: BLOCK: LOT: LOCATION: c. �� � OCCUPANCY: 2. 1 !_ ❑ VIOLATION NOTED THE WORK IS... ACCEPTED ❑ REJECTED/REINSPECTION ❑ SITE INSPECTION REQUIRED ❑ FOOTING ❑ FOOTING DRAINAGE ❑ FOUNDATION ❑ UNDERGROUND PLUMBING NOTES ON INSPECTION: ❑ ROUGH PLUMBING (} ROUGH FRAMING F❑ INSULATION , ❑ NATURAL GAS ❑ L.P. GAS ❑ FUEL TANK ❑ FIRE SPRINKLER ❑ FINAL PLUMBING ❑ CROSS CONNECTION ❑ FINAL ❑ OTHER �QyC,BRC��. �m 1982 BUILDING DEPARTMENT ❑B ILDING 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 Uebrook.org - - - - - - - - - - - - - - - - - - - - INSPECTION REPORT - - - - - - - - - - - - -- - - - - - - ADDRESS: V V " DATE: 1 �� k� PERMIT# V ` 1 , y ISSUED: CI ECT: BLOCK: LOT: LOCATION: 1J` V �' / OCCUPANCY: L l l J ❑ VIOLATION NOTED THE WORK IS... ACCEPTED ❑ REJECTED/REINSPECTION ❑ SITE INSPECTION REQUIRED 'FOOTING c-1 \ f ❑ 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 a N N w all i e Q � MM � C7 ICI Fes- ti00 !- N S Liz � OC p oe = :. G C N V: H W pGo � H a � ow A00 W Z Z z o f z r•� F. oN MCI r� z ki O ►� ~ � � � ZO A °� � z w w - W t" N E L Gsl W U w z o, z A F A 6 cx �p a o w a A w 4494i 44419eig4i444444444414A44&404441444 44944444 44 44414 [3R_C��,- o �� � ov BUILDING DEPARTMENT DEC 3 ZO21 VILLAGE OF RYE BROOK 938 KING STREET RYE BROOK,NY 10573 VILLAGE OF RYE BROOK (914)939-0668 BUILDING DEPARTMENT wwwaftook.org ELECTRICAL PERMIT APPLICATION Westchester County Master Electricians License Required FOR OFFICE USE ONLY BP#: �r� f� EP#: c:; e 3 3 Approval Date. DEC '� Permit Fee: $ Approval Signature: Other: Disapproved: (fees are non-refundable) Application dated, j 3 1 is hereby made to the Building Inspector of the Village of Rye Brook NY, for the issuance of a Permit to install an or renlove 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: 17 I/ eC/1 fl,,^) SBL: / 3 f 7 - Zone: k 2.Property Owner: &0/ems J&A/ Address:: Phone#: Cell#:S1lp—lo JS_—,es �/!S 7 email: 1°51y J 3.Master Electrician: /RbwK Address: (0ltyJ.4c l /lv 5 tJ• 30JA 5s t e— i^'I Lic.#: q 9 Phone#: Cell#: �('�-�6 y—�0 7.Z�mai1: ��f�9�/� e PCti� e�C�/�C•��'� —r�— Company Name: P(j A I Ile-C�'C Address: � bi-Ad Rol • fo P J)lt..,.., 4.Proposed Electrical Work/Fixture Count: ?� Arc et fe-64 CS L,i J /3 f„ %c dke /C f 3 ********************************************************************************************************* STATE OF NEW YORK,COUNTY OF WESTCHESTER ) as: 111#.1A 44 Afi!y ,being duly swom,deposes and states that he/she is the applicant above named,and does fitrther (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 C19-✓��t6r�'� 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 me this ` 21 day of ,20 day of - - 20__� Signature of Property Owner igna �of Applicant Print Name of Property Owner Name of Applicant '� Q_A� 2 Notary Public Nc&�XRtNL�JLLO Notary Public, State of!dew York No. 011;: E615:)''G3 Q,!ali;ied in Westch_<:ter County Commission Expires Januan+29,20 8/12/2021 STATEWIDE • Service With Ititegrity 0•0 SWIS JOBAPPLICATION0. Office Use Elect.Permit# -- Date Bldg Permit# Utility ID# Final Certificate# City/Village 7G %}/�0/C Zip / ; f 3 Township County (.;-��t Address DPr� ��,� C�Street Section/3�f-7 Block � Lot ' Owner Name/Address(If different than above) Contact Number Basement ❑1st Fl. ❑2nd Fl. ❑3rd Fl. ❑More Than 3 Fl. ❑Garage ❑Attic ❑Outside ❑Residential ❑Commercial Receptacles Special Recept GFCI AFCI Switches Dimmers Smoke Alarms Carbon Monox Hood Trash Compact 1 Amt Amps Range(s) Cooktop(s) Oven(s) Dishwashers Refrigerator Disposal Microwave Warm Draw Inca scent Fluorescent SERVICE Amperage Voltage 1 P 3P #Meters #Disconnect ❑Underground ❑New ❑Reconnect ❑Overhead ❑Change ❑Visual Re-Inspection ❑ Safety Re-Inspection ❑ Re-Inspection Additional Information DEC 13 2021 VILLAGE OF RYE BROOK BUILDING DEPARTMENT This application is valid for one(1)year from the date received by SMS.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.The applicant declares that there is no open applications for the above address with any other inspection company.The applicant,owner or authorized agent agrees to all the above terms and conditions as set forth for the application. Inspector Date Finalized Inspector# Company Name Date o_ . - 7 - � Signature Address ! i %,, , City/State /� 5 a,'� Zip Code License# ` Phone# �— State Wide Inspection Services CAC1080 Main Street Fishkill, NY 12524 X U Tb 845 2 Phone 914-219-119-1062 Fax STATE WIDE INSPECTION SERVICES Email: ofce(aswisny.com Website: www.swisny.com Service With Integrity BY THIS CERTIFICATE OF COMPLIANCE STATE WIDE INSPECTION SERVICES CERTIFIES THAT: Upon the application of: Upon Premises Owned by: Pearl Electric Stahl Residence Frank Franco 6 Deer Run 6 Laurel Rd. Rye Brook, NY 10573 South Salem, NY 10590 Located at: 6 Deer Run, Rye Brook, NY 10573 Section: Block: Lot: Electrical Permit Number: EP21-327 135.57 Certificate Number: 2021-6664 Building Permit Number: BP21-183 A visual inspection of the electrical system was conducted at the Residential occupancy described below.The electrical system consisting of electrical devices and wiring is located in/on the premises at: 6 Deer Run, Rye Brook, NY 10573 The Basement was inspected in accordance with the NYS and NFPA 70-2017 and the detail of the installation,as set forth below,was found to be in compliance on the 21st day of April 2022. Name Quantity Rating Circuit Type Receptacles 26 Switches 13 Smoke Detectors 05 Visual Inspection Only; Not Tested BY SWIS Luminaires 33 .r i Officer: Frank J. Farina This certificate may not be altered in anyway and is validated only by the presence of a seal at the location indicated.This certificate is valid for work performed on the date of inspection only. ti i- ' 00 N w w a 0.4 z i C4 a y W z o ti en moo Ln x p `n z Q C� w "s A V F � Uz � 00 a0-0 10-4 a � } M w< c Q � o ' � N . Z w ►� W z a 8 LO i W w W W F o f W 03 f� N P. g 0-0 �Y . i W v � a a � � ° ►yi ' . � • F, Q 0 A w F BUILDING DEPARTMENT SEP 15 2022 DI VILLAGE OF RYE BROOK 938 KING STREET RYE BROOK,NY 10573 VILLAGE OF RYE BROOK (914)939-0668 L BUILDING DEPARTMENT \VWW.ryebrook.or.g jPLUMBING PERJMIIT APPLICATION FOR OFFICE USE ONLY BP#: tD /—/ O 13 PP#: �— SEP Approval Date: 1 4 .2021 Permit Fee: S Approval Signature: Other: Disapproved: (fees are non-refundable) Application dated,S• 0 ' 21/ 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 Plumbing as per detailed statement described below.The applicant&property owner,by signing this document agree that said plumbing work will be in conformance with all applicable Federal,State,County and Local Codes. 1.Address: (a 17e r IZ Pli A SBL:_1�5_ 5 Zone: �3 2.Proposed Work p-etow4 L AAp Ig` i ljlaL,tf tH k 4 3.Property Owner: Ik n�b.wls.N _ Address: /���a- tS l , Vone#: q PA" a0`1 •ZLASk GOR emaiL•►,�evl' ;tt •e. 4.Master Plumber: U6 M,L- Address: q7 A ff Q Q Thor„4MM 1 10S77 Y Lic.#: Qk"e_—Phlo_ne-#-:1 Cell #: �(-qD - zz email:��,,1pj14&y12 6,'.. Company Name: Cs�xsllQlw: ddress: / ILJ INDICATE FIXTURES& LINES TO BE INSTALLED AS PER THE FOLLOWING SCHEDULE: Location Water Urinals Drinking Sinks Showers Bath Laundry Domestic Fire Sanitary Natural/ Other* Total Closets Fountains Tubs Tubs Service Service Sewer LP Gas Basement 1� Ist Floor 2nd Floor 3"�Floor Floor 5i6 Floor Exterior 1 5.*List Other Equipment/Provide Details: 15 t.)Cx6�n e-v- (Notarized Signatures Required Next 2 Pages) 8/12/2021 STATE OF NEW YORK,COUNTY OF WESTCHESTER ) as: 6,r—� SAm t rJ 4-jjA l-{L— _,being duly sworn,deposes and states that he/she is the applicant above named, (print name of individual signing as the applicant) and further states 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.) 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 is day of Au 20 oZ 2 day of 4iggnKati of Property Owner Signature o Ap r Print Name of Property Owner Print Name of Applicant ?ice Vr\-0 4Notarylic "NOTUAR% CHELLE R POMBO Notary Pt$}lj I MEULLO C,UM OFNLIVYORK Notary Public,State of New York n No.02PO6070477 No.OIME6160063 QualiSed in WedthaftCo®ty Qualified In Westchester County. Commission Expires Mwd 4,2026 Commission Expires January 29,20 This application must be properly completed in its entirety and Hurst include the notarized signature(s)of the legal owner(s)of the subject property, and the applicant of record in the spaces provided. Applications 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- { 8/12/2021 y IE BUILD NG DEPARTMENT VILLAGE OF RYE BROOK SEP 15 2022 938 KING STREET RYE BRO(j1C,NY 10573 (914)939-0668 VILLAGE OF RYE BROOK ��Nv��.ryebruol:.t)► BUILDING DEPARTMENT AFFIDAVIT OF COMPLIANCE VILLAGE CODE §216 • STORM SEWERS AND SANITARY SEWERS THIS AFFIDAVIT MUST BEAR THE NOTARIZED SIGNATURE OF THE LEGAL PROPERTY OWNER AND BE SUBMITTED ALONG WITH ANY BUILDING OR PLUMBING PERMIT APPLICATION. ANY BUILDING OR PLUMBING PERMIT APPLICATION SUBMITTED WITHOUT THIS COMPLETED AND NOTARIZED FORM WILL BE RETURNED TO THE APPLICANT . STATE OF NEW YORK, COUNTY OF WESTCHESTER ) as: U� C—t (A ,residing at, (Print name) (Address%,hcrc you h%e) being duly sworn,deposes and states that(s)he is the applicant above named, and further states that(s)he is the legal owner of the property to which this Affidavit of Compliance pertains at; �p PC-w- t'U t.) ,Rye Brook,NY. (7oh Address) Further that all statements contained herein are true,and that to the best of his/her knowledge and belief, that there are no known illegal cross-connections concerning either the storm sewer or sanitary sewer, and further that there are no roof drains, sump pumps, or other prohibited stormwater or groundwater connections or sources of inflow or infiltration of any kind into the sanitary sewer from the subject property in accordance with all State, County and Village Codes. - Sworn to before me this day of A U , 20 —L — c v (Ni�tary Puhli�l MICHELLE M.POMBO NOTARY PUBLIC,STATE OF NEW YORK RcgisStadon No.02PO6070477 _3_ QW&ed in Watchcster C'Wty C a:mission Expires March 4,2026 8/12/2021 0 n C y c o w Ad o DA m ° w 0 F. o Ism - � � o O� F v O � WOC) V v � U A w ►� >' oE � � m 0-0 W � � I� " � Q � FQ' � o� v� � •� o` Vj as 00 , � W c= a W H o z aC26 o .=$� a Z Q a O z8 098 1 sm 3 W " Q z V A � o F A � c } •= � � � BUILD 1 MENT I IEFFED VIL OOK 938 KING wy �� W 10573 DEC 11 2021 VILLAGE OF RYE BROOK BUILDING DEPARTMENT APPLICATION FOR PERMIT TO INSTALL AND/OR REMOVE HEATING, VENTILATION AND/OR AIR CONDITIONING EQUIPMENT FOR OFFICE USE ONLY: PERMIT#: Approval Date: O E C 2 1 1 PP Permit Fee: $ Approval Signature: Other: Disapproved: (fees are non-refundable) *+r*,►t*w,r,r,r*w*x*x*,twt,t*,ttr,t*,t,t*rt*,r,r,t******,r*a**sw.�w *,►,►,r*w,r,r,t**,tx,e**,r,r*,r*+c*,tt*�**w*r►w*,r*w*,r*t*****w*,r**,► REOUIREMENTS 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(Form#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. ********,r****!*** ,e***+t,►**,t,r!*****,►,t,t*,t,t*rt,t,t,t,r**,r,t*,r,t****,r,►*******tr,t**,t*,r*,rrt*,t,t****tt*,t*,trt,t**,t***,t Application dated, C / is hereby made to the Building Inspector of the Village of Rye Brook for a permit for the installation and or rem val of the HVAC 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. I. Address: IV SBL:135,57 ls3 57—l—/ Zone: —/c)L C GN 2. Property Owner: J�c� �Fl 1'-71 N %7)�d G , Address: b 24. i-L.S'iFa/yC Phone#: CeI[ : 9/ 2ttS/ � ll__ email: �✓�/S'�M/,1J 3. Contractor.�A V 4e S /V��i/niG C ! C Address: l/ o 11-161/ei —F Phone#: 9 -7 7 Cell#:9/4' `j 3 756 email:-61VeAC--11 wnoM 4. Applicant: AZ16- H1 0/ Address: 1192,r.,�vt4E—jgk,�-, /07/1 Phone#: 9 U,y'7 J^ 6 6 93 Cell kc�/ 7 CG email C)�Mc+M. 5. Scope of Work:New Installation QQ•Replacement( )•Removal( )•Other( ): 6. List Equipment: /— 6- r L,1-S 1 S' S—,, 7. Location of Equipment: BASE 8. Method of Installation/Removal(list all equipment needed to perform job): WAL` a A k!E - 1 8/12/2021 STATE OF NEW YORK,COUNTY OF WESTCHESTER ) as: V& N1 being duly sworn,deposes and states that he/she is the applicant above named, (print name of individual signing as the applicant) And fimther states that(s"--is the legal owner of the property to which this application pertains,or that(s)he is the �cy v; '<<'� • for the legal owner and is duly authorized to make and file this application. (indicate architec contractoF agent.attorney,etc.) That all statements contamed 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 /(O V-- day of D P,� C M�f(' .20 1 I day of 20 c�-J � Signature of Property Owner Signature of Applicant Print gada perty Owner Print Name of A cant Notary blic MICHELLE M. MB0 Notary Public,State of New York MICHELLE M. POMBO No.02PO6070477 Notary Public,State of Ney ','ork Qualified in Westchester County No.02P06070477 Commission Expires March 4,2022 Qualified in Westchester County Con mission Expires March 4,20^ This application must be properly completed in its entirety and mus 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. z 9/12/2021 -- -- oz p w J J Q 1 C71 X w o U C7 W W Z r --'� D= /°1 jC °nagjL i38: o�6i6t r= i yy ee : r 9� i E3� 9 E• fi'! i i J � SID HARVEY INDUSTRIES, INC. 551 S. COLUMBUS AVE. MOUNT VERNON, NY 10550 PAGE 1 PHONE: (914) 668-3631 liar FAX #: (914) 668-2344 STORE003@SIDHARVEY.COM 0076716 Z, DAVE'S HEATING & A/C INC ��, DAVE'S HEATING & A/C INC 119 LONGVUE TERRACE b 119 LONGVUE TERRACE (Z YONKERS NY 10710 YONKERS NY 10710 PHONE: (914) 771-6653 PHONE: (914) 771-6653 FAX #: (914) 771-6651 FAX #: (914) 771-6651 DATE P.O. # SVIA JOB NAME 15 j 21 FUJI'I'SU F 1:C:' 5072 CASH CA4 DESCRIPTION THE PRICES BELOW ARE VALID FOR 10 DAYS AND WILL BE SUBJECT TO CHANGE IF THE SUPPLIER CHANGES OUR COST. ********MUST HAVE A VALID P O # IN P O FIELD************** ** ONLY DAVE THE OWNER ALLOWED TO USE THIS ACCT ***** ASU9RLF1 EVAP UNIT,INDOOR 9K WALL MULT ASU9RLFi ASU7RLF1 EVAP UNIT, INDOOR 7K WALL MULTI ASU7RLF1 ASUI5RLF1 EVAP UNIT, INDOOR 15K WALL MULT ' ASUI5RLF1 AGU12RLF EVAP UNIT, INDOOR 12K FLOOR ' AGU12RLF AOU45RLXFZ COND UNIT,OUT 45K 17.7-19.7S AOU45RLXFZ MULTI ZONE W1-353 LINE SET, 1/4X3/8X1/2, 50FT 4062050OB3B6 FLARE,MINISPLIT FUJITSU a �.- SUBMITTAL ASUI 5RLF1 Y Inverter 1 Pump ill BTU Wall Mount Job Name Location Date Engineer Approval Submitted To Construction Submitted By Unit No Reference Drawing No PRODUCT FEATURES -Wireless remote controller •Auto)CoollDry)FanjHeat modes •24 Hr.timer -Powerful mode -Cold prevention *Auto Restart MODEL NUMBERS nformation Indoor Unit ASUI5RLF1 Nominal Capacity 14,000 REQUIREMENTSLINESET ear Connection Method Flare 7 Year Compressor,5 Year Parts out-of-the-box Warranty Liquid Gags in(mm) O1/4(06.35) wARaArrr 01/2(012.70) Material PP+LLDPE Drain hose in 0 9/16(I.D.),0 5/8 to 011/16(O.D.) mm 013.8(I.D.),015.8 to 016.7(O.D.) it 10 Year Compressor,10 Year Parts Warranty when registered within !INDOOR DIMENSIONS 30 days of Installation in a residence Net(H x W x D) In 10-9/16 x 33-1/16 x 8 mm 268 x 840 x 203 Gross(H x W x D) in 10-5/8 x 34-13/16 x 14-3/4 mm 270 x 884 x 336 12 Year Compressor,12 Year Parts Warranty when registered within Net Weight Ib(kg) 19(8.5) 30 days of Installation in a residence,and Installed by a Fujitsu Elite Gross Weight 23(10.5) contractor SPECIFICATIONSELECTRICAL Voltage/Frequency/Phase 208/230 V-60 Hz Voltage Range 187-264 V ENCLOSURE Running Current A 0.25 Enclosure Material Polystyrene Input Power W 28 Color White SOUND PRESSURE 0 :ACCESSORIES High 42 UTY-TfRX 3rd Party Thermostat Converter Cooling Medium 38 UTY-XCBXZ2 Interface Kit Low 33 UTY-RNNUM Wired Remote Indoor Unit Quiet dB(A) 25 UTY-RVNUM Wired Remote w/backlight High 42 UTY-RSNUM Simple Remote Heating Medium 38 UTY-XWZXZ5 Dry Contact Wire Kit Low 35 Fj-RC-WIFI-1 NA Intesis Wired WIN module Quiet 27 FJ-IR-WIFI-1 NA Intesis IR WIN module r' UTY-TFNXZ2 WIFI Interface Module High 430(730) Cooling Medium 353(600) Low 312(530) Airflow Rate Quiet CFM(m3/h) 212(360) High 430(730) Heating Medium 362(615) Low 330(560) Quiet 221 (375) co- ETLN: 3170288 Due to continuous product Improvements,specifications are subject to change without Intertek notice. Please log in to the Fujitsu Portal for the most up-to-date documentation Effective Date: 1 0/112 0 1 9 Version ASUI5RLF1 -2019B https://portal.fujitsugeneral.com www.fujiLsugeneral.com co FUJITSU SUBMITTAL ASUI 5RLF1 a i Inverter DrNew 0':iven Heat Pump 15,000 BTU Wall Mount Type DIMENSIONS Units:In.(mm) 33-1/16(840) 8(203) s� rn 0 N m 33-1/16 840 1.3/4 45 14.5116 364 13-7/8 f353E3-1116 78 N I 1 � N e I_ +i. ,o -7116 for i e inlet or i c rnfet 4- /16 (88) 12-5/8(321) 12-3;8(315) (116) r, The Fujitsu logo Is a worldwide trademark of Fujitsu General Limited.The Halcyon logo and name Is a worldwide Note:Specifications are based on the Following conditions: trademark of Fujitsu General Limited and is a registered trademark in japan,the USA and other countries or areas. Coaling:Indoor temperature of on t follow DD/6TF(19.4'Q WB,and outdoor temperature of 95'F(35'Q D8775'F Copyright 2018 Fujitsu General America,Inc.Fujitsu s products are subject to continuous Improvements.Fujitsu reserves Cooling)IndVVEI Heating:Indoor temperature of 70'F(21.1'.'C)WB,F and out oor and outdoor temperature of 475 the right to modify product design,specifications and Information In this brochure without notice and without Incurring any obligations. (8.3-C)D121/437(6.1•Q W0.Pipe length:25ft.(7.5m),Height difference:Oft.(0m)(Outdoor unit-Indoor unit). FU ITSU SUBMITTAL ASU7RLF1 a Inverter Driven Heat Pump 7,000 BTU Wall Mount1 Job Name Location Date Engineer _ _ Approval Submitted To Construction Submitted By Unit No Reference _ Drawing No PRODUCT FEATURES *Wireless remote controller -Auto JCoolIDrylFanlHeat modes •24 Hr.timer -Powerful mode *Cold prevention -Auto Restart MODEL , Indoor Unit ASU7RLF1 Nominal Capacity 7,000 REQUIREMENTSLINESET ear Connection Method Flare 7 Year Compressor,5 Year Parts out-of-the-box Warranty Liquid in(mm) 01/4(06,35) WARRANTY Gas 03/8(09.52) Material PP+LLDPE Drain hose In 0 9/16(I.D.),0 5/8 to 0 11/16(0.D.) mm 013.8(I.D.),015.8 to 016.7(O.D.) A; 10 Year Compressor,10 Year Parts Warranty when registered within 1 1 1 DIMENSIONS 30 days of installation in a residence Net(H x W x D) In 10-9/16•33-1/16•8 HIM 268 x 840 x 203 Gross(H x W x D) in 10-5/8 x 34-13/16 x 14-3/4 mm 270 x 884 x 336 12 Year Compressor,12 Year Parts Warranty when registered within Net Weight lb(kg) 19(8.5) 30 days of Installation In a residence,and Installed by a Fujitsu Elite Gross Weight 23(10.5) contractor E(IFICATIONS Voltage/Frequency/Phase 208/230 V-60 Hz Voltage Range 187-264 V ENCLOSURE Running Current A 0.13 Enclosure Material Polystyrene Input Power W 15 Color White SOUNDAC(ESSORIES High 36 UTY-TTRX 3rd Party Thermostat Converter Cooling Medium 32 UTY-XCBXZ2 Interface Kit Low 29 UTY-RNNUM Wired Remote Indoor Unit Quiet dB(A) 21 UTY-RVNUM Wired Remote w/backlight High 36 UTY-RSNUM Simple Remote HeatingMedium 32 UTY-XWZXZ5 Dry Contact Wire Kit Low 29 FJ-RC-WIFI-1 NA Intesis Wired WIFI module Quiet 22 FJ-IR-WIFI-1 NA Intesis IR WIFI module 1' UTY-TFNXZ2 WIFI Interface Module High 330(560) Cooling Medium 294(500) Low 253(430) Airflow Rate Quiet CFM(m3/h) 182(310) High 330(560) Heating Medium 294(500) Low 253(430) Quiet 194(330) ETLN:3170288 Due to continuous product Improvements,specifications are subject to change without Intertek notice. Please log in to the Fujitsu Portal for the most up-to-date documentation Effective Date: 10/1/2019 Version ASU7RLF1 -2019B https://portal.fujitsugeneral.com 't r 1 11 t t• 11F.1 I t3 FUJITSU SUBMITTAL ASU7RLF1 a�n Inverter Driven Heat Pumt 0, /. iii : t DIMENSIONS f Units:In.(mm) 33-1/16(840) 8(203) N_ ai O 1 1 1 L a (33-1/16(840)) m 16-1/8(410) 16-15116(430) 12-3/16(310) 11-5/8(295) 04 Kill, e J, �. E T-- zt O �L pp 02-9116 065 6-1/2(165) 5.11/16(144) 02-9/16 065 for pipe inlet 7(178) 9-3/16(233) for pipe inlet 12-5/8(321) 12-3/8(315) The Fujitsu logo is a worldwide trademark of Fujitsu General Limited.The Halcyon logo and name Is a worldwide Note:Specifications are based on the following conditions: trademark of Fujitsu General Limped and Is a registered trademark In Japan,the USA and other countries or areas. Copyright 2018 Fujitsu General America,Inc.Fujitsu's products are subject to continuous Improvements.Fujitsu reserves Cooling:Indoor temperature of 80'F(26.7'C)DB/67'F(19.4'C)WB,and outdoor temperature of 957(35'C)DB17S'F the right to any obligations.dlfy product design,speclBratlons and Information In this brochure without notice and without Incurring (8 3 C)DB/43-F(6Ing:Indoor 1 C)WB.Pipe length:re of 70'F 25h.(75m),Heights difference60k.WOmind outdmr(Outdoor unit temperature nit)of , 't r 1 11 t t- FUJITSU SUBMITTAL 45RLXFZ a Inverter Driven Heat Pump 0'JVVzKz W_ ^_ 00 'idmome" Ili BTU Multi Zone job Name Location Date Engineer Approval Submitted To _ Construction Submitted By Unit No Reference _ _ Drawing No PRODUCT FEATURES •Operate as few as one Indoor unit or all indoor units •Mix&match from 4 indoor unit styles Inn::n pi FUfITSU •Blue-fin condenser coil coatings IIlllilllll i �j', -- Mr MODEL NUMBERS Warranty Information System 45RLXFZ Outdoor Unit AOU45RLXFZ Indoor Unit Non-Ducted Ducted Mix @8� EFFICIENCIES SEER 19.7 17.7 18 7 7 Year Compressor,5 Year Parts out-of-the-box Warranty WARRANTY EER 10.5 9.8 10.2 HSPF 10.3 9.3 9.8 COP kW/kW 3.6 3.46 3.53 i! Btu/hW 12.3 11.8 12.0 OUTDOOR TEMPERATURE OPERATION RANGE 10 Year Compressor,10 Year Parts Warranty when registered within 30 Cooling .F(•C) 14 to 115(-10 to 46) days of Installation in a residence Heating 5 to 75(-15 to 24) CAPACITIES Total Capacity Range 34,000 to 54,000 Btu/h Cooling Rated 45000 12 Year Compressor,12 Year Parts Warranty when registered within 30 Min.-Max. BTU/hW 12,OO",000 days of installation In a residence,and installed by a Fujitsu Elite Rated 48000 '' contractor Heating Min.-Max. 12,000-54,000 REQUIREMENTSLINESET i. Connection Method Flare Outdoor Unit Cooling CFM(m3/h) 2,472(4,200) Liquid 01/4(06.35)x 5 Airflow Rate Heating 2,472(4,200) Gas in(mm) 03/8(09.52)x 3+01/2(012.70)x 2 CONNECTABLE INDOOR UNIT Pre-Charge Length ft(m) 164(50) Slim Duct(ARU) Maximum Length 262(80) TYPE Wall Mount(ASU) Maximum Length Each 82(25) Compact Cassette(AUU) Minimum Length 49(15) Floor Mount(AGU) Minimum Length Each 16(5) NUMBER 2 to 5 Max.Height Diff. 49(15) CIOUTDOOR DIMENSIONS Net(H x W x D) in 39-5/16 x 38-3/16 x 14-9/16 mm 998 x 970 x 370 Gross(H x W x D) in 45-3/4 x 45-1/4 x 18-13/16 mm 1,162 x 1,150 x 478 Net Weight lb(kg) 205(93) Gross Weight 229(104) SOUND PRESSURE Outdoor Unit Heating Cooling dB(A) 53 55 0- Outdoor Unit ETLN: 91987 Due to continuous product Improvements,specifications are subject to change without Intertek notice. Please log in to the Fujitsu Portal For the most up-to-date documentation Effective Date: 10/16/2019 Version 45RLXFZ-2019A https://portal.fujitsugeneral.com 13 FUJITSU SUBMITTAL 45RLXFZ a�n Inverter Driven Heat Pump tit BTU Multi Zone Type R410A Charge lb oz 8 lb 13 oz g 4000 Oil Type RB68 Voltage/Frequency/Phase 10 208/230 V 60 Hz Voltage Range 187-264V Rated Current(A) Cooling 18.8 20.1 19.4 Heating 17 17 17.1 Maximum Operating Current 23.8 Starting Current A 20.1 MCA 28.9 Maximum Circuit Breaker 30 Rated Input Power Cooling 4.28 4.59 4.43 (kW) Heating 3.88 3.89 3.9 Max.Input Power Cooling 4.77 4.86 4.82 (kW) Heating 4.32 4.41 4.37 DIMENSIONS Units:In.(mm) 25-1932 inch 650 mm L1� — 1 1.e..n. a� a r.... 95 mm 39.5 16 1,+<„ O996 mn+ 71 3"6— The Fujitsu logo is a worldwide trademark of Fujitsu General Limited.The Halcyon logo and name is a worldwide trademark Note:Specifications are based on the following conditions: of Fujitsu General Umited and Is a registered trademark in Japan,the USA and other countries or areas.Copyright 2018 Cooling:Indoor temperature of 80•F(26.M DB167'F 11 9.4 Q WS,and outdoor temperature of 957(35'C)DB175T Fujitsu General America,Inc.Fujitsu's products are subject to continuous Improvements.Fujitsu reserves the right to modify (23.9'C)WB.Heating:Indoor temperature of 70*F(21.11C)1011/607(15.6'C)WB,and outdoor temperature of 47•F(8XQ product design,specifications and Information in this brochure without notice and without incurring any obligations. D117437(6.1'C)WB.Pipe length:25ft.(7.5m),Height difference:OR(0m)(Outdoor unit-indoor unit). 1 + t 1 11 �• 1 co FUJITSU alcyon *HFI T4�e-� Hybrid Flex Inverter ' Submittal1 . 9,000 l t Inverter Driven Ileat Pump Job Name: Date: Location: Approval: Engineer: Construction: Submitted to: Unit#: Submitted by: Drawing#: Reference: General Features -Refrigerant Type R410A. *Removable air filter -Wired and wireless remote controllers *Program timer *Auto changeover •5 years standard parts warranty -Weekly timer 'Eligible for 10 year or 12 year parts 1 -Removable open panel warranty.See warranty statement *Super quiet operation for details. Model Information Temperature Settine Range Evaporator.........................................................................ASU9RLF1 Cooling....................................... (18°C-32°C) Condenser compatibility •........•••.••....6 F-90 F mp ty.........AOU9RLFW1,AOUI8RLXFZ,AOUI8RLXFZH eating......................................................... 60°F-88°F(16°C-30°C) AOU24RLXFZ,AOU24RLXFZH Enclosure AOU36RLXFZ,AOU36RLXFZI,AOU36RLXFZH atetial...............................................................Galvanized Steel Sheet AOU45RLXFZ,AOU48RL.XFZ1 Sound Pressure Level Electrical.........................................................208/230V AC 1ph-60Hz Cooling Available Voltage Range...................................................208/230+/-10% •gh/Medium/L.ow/Quiet...............37 dB(A)/33 dB(A)/29 dB(A)/21 dB(A) Minimum Circuit Ampacity..............................................................0.20 A Heating Full Load Amps........................................................................0.16 A •gh/Medium/Low/Quiet.............37 dB(A)/33 dB(A)/29 dB(A)/22 dB(A) InputPower...............................................................................17 W Dimensions RunningCurrent.......................................................................0.15 A x W x D capacity ,(mm)..........................................................10-9/16 x 33-1/16 x 8(268x840x203) Nominal Cooling..................................................................9,000 Btu/h Connection Pine Fan Motor Liquid..... 1/4"in.(6.35 mm) ................................................................... Type:DC............. .........................................................Cross flow xl Gas 3/8"in.(9.52 mm) MotorOutput................................................ ............................30 W ethod(Liquid/Gas)........................................................ ................Flare Fan Motor Protection.......................................off:221 f 18°F(105 f 10°C)Drain hose Airflow Rate on:194 f 18°F(90 f 10°C)Material..........................................................................PP+LLDPE Cooling(High/Medium/Low/Quiet) Size..............09/16(I.D.),05/8 to 011/16[013.8(I.D.),015.8 to 016.7 O.D.)] 353 CFM(600 m3/h)/306 CFM(520 m3/h)/253 CFM(430 m3/h)/182 CFM(310 m3/h)Weight Heating(High/Medium/Low/Quiet) et..............................................................................19 lbs.(8.5 kg) 353 CFM(600 m3/h)/306 CFM(520 m3/h)/253 CFM(430 m3/h)/194 CFM(330 m3/h) Gross...........................................................................23 lbs.(10.5 kg) Heat Eachaneer Dimensions Accessories fired Remote Controller...................................................UTY-RNNUM (H x W x D)in.(mm).........................12-5/8 x 24-13/16 x 13/16(320x630x20) acklit Display..................................................................UTY-RVNUM Fin Pitch...........................................................Main 23 FPI/Sub 18 FPI Simple Remote Controller......................................................UTY-RSNUM Rows x Stages.......................................................Main 2 x20/Sub 1 x4Dry Contact Wire Kit.......................................................UTY-XWZXZS Pipe Type(Material)....................................................................Copper Interface Kit..................................................................UTY-XCBXZ2 Type(Material)............................................................................Aluminum tertekoETL Number U9RLF1..............................................................................91986 Fujitsu General Amnia,Inc. 353 Routs 46 won psc aa.&vem...t..dma.eo..oDommu... din..q�. ttgtau FavRdd,NJ-U24 Cm9 tedva ia�.Y,a of 10'P(06.7•C7 DfY69T(19.M'C�are,and mY.a aq..mn R934 Ra'n DB/!fT Ra.9'C7 are, Tdl Fns:I-odd.NJ 0347A D.reF(aa,s sq.�..r•ro r Rt.t tc7 Darsa•r Ra.c7 aa'&ma m,tea m�..a.,,r�7•t*R71'�7 DtW)T(s.t t'C)are. I of 2 Fu[:(973)936-0W7 Pip.`1,245.7u(73.4�di5—OL(Om)(owd—mi-a mil awvw.fuiiwamcal am CO FUJITSU Ae!al:cy7o�*-HF1 brld Flex Inverter 9 . [Unit:in.(mm)] 33-1/16 (840) 8 (203) (n N_ (D O (33-1/16 (840)) v M 16-1/8 (410) 16-15/16 (430) ;? 12-3/16 (310) 11-5/8 (295) 00 o o ww�e�. o e o o (V (o •�.....� rn N aunsoot T III I IV NO O ILA .". - e �W 00 e 02-9/16 065 6-1/2 (165) 5-11/16(144) 02-9/16 065 for pipe inlet 7 (178) 9-3/16 (233) J for pipe inlet 12-5/8 (321) 12-3/8 (315) FUrITSU The Fujitsu logo is a registered trademark of Fujitsu Limited. Fujitsu General America,Inc. 6 West 353 Route 4 The Halcyon logo and name is a trademark of Fujitsu General America,Inc.Copyright 2016 Fairfield 4 West Fujitsu General America,Inc. 7004 Toll Free:1-888-888-3424 Fujitsu's products are subject to continuous improvements. Fujitsu reserves the right to Fax:(973)836-0447 modify product design,specifications and information in this brochure without notice and 2of2 www.fujitsueeneral.com without incurring any obligations. co FUJITSU UBMITTAL AGUI2RLF a Inverter Driven Heat ' 12,000 BTU Floorr I Job Name Location Date Engineer Approval Submitted To Construction Submitted By Unit No Reference Drawing No PRODUCT FEATURES 'Wireless remote controller •AutolCoollDrylFanlHeat modes •24 Hr.timer -Powerful mode -Cold prevention *Auto Restart MODEL Indoor Unit AGU12RLF Nominal Capacity 12,000 LINESET REOUIREMENTS ear Connection Method Flare 7 Year Compressor,5 Year Parts out-of-the-box Warranty Liquid in(mm) 01/4(06.35) WARRANTY Gas 03/8(0 9.52) Material PVC Drain hose In 0 9/16(I.D.),0 11/16(O.D. mm 013.8(I.D.),016.7(O.D.) A 10 Year Compressor,10 Year Parts Warranty when registered within INDOOR DIMENSIONS 30 days of Installation in a residence Net(H x W x D) in 23-5/8 x 29-1/8 x 7-7/8 JIV Prim 600 x 740 x 200 Gross(H x W x D) in 27-9/16 x 32-5/16 x 12-3/16 mm 700 x 820 x 310 12 Year Compressor,12 Year Parts Warranty when registered within Net Weight lb(kg) 31 (14) 30 days of installation in a residence,and Installed by a Fujitsu Elite Gross Weight 37(17) contractor SPECIFICATIONSELECTRICAL Voltage/Frequency/Phase 208/230 V-60 Hz Voltage Range 187-264 V ENCLOSURE Running Current A 0.18 Enclosure Material Polystyrene Input Power W 20 Color White SOUND I High 42 UTY-TTRX 3rd Party Thermostat Converter Cooling Medium 36 UTY-RNNUM Wired Remote Low 30 UTY-RVNUM Wired Remote w/backlight Indoor Unit Quiet dB(A) 22 UTY-RSNUM Simple Remote High 42 UTY-XWZXZ5 Dry Contact Wire Kit Heating Medium 38 Fj-RC-WIFI-1NA Intesis Wired WIFI module Low 32 FJ-IR-WIFI-1 NA Intesis IR WIFI module Quiet 22 High 353(600) Cooling Medium 288(490) Low 224(380) Airflow Rate Quiet CFM(m3/h) 159(270) High 353(600) Heating Medium 300(510) Low 241 (410) Quiet 159(270) 0_ ETLN: 3170288 Due to continuous product improvements,specifications are subject to change without Intertek notice. Please log in to the Fujitsu Portal for the most up-to-date documentation Effective Date: 10/42019 Version AGU12RLF-2019B https:Hportal.fujitsugeneral.com t • t 111 t t• t CP FUJITSU SUBMITTAL AGUI2RLF a�n Inverter Driven Heat Pump 12,000 BTU Floor Mount Type DIMENSIONS Units:In.(mm) 7-7/8(200) 0 c%s N 29-1/8(740) I Side view Front view 111 ■ INSTALLATION PLACE 4(100)a more ' 4(g0i or more G � 2(50)a morn 5(1 g0)or bolow Irom tho noor The Full tsu logo is a worldwide trademark of Fujitsu General Llml ted.The Halcyon logo and name Is a worldwide Note:Specifications are based on the following conditions: trademark of Fujitsu General Limited and Is a registered trademark In Japan,the USA and other countries or areas. Cooling:Indoor temperature of n the (follow DB/6TF(19.4'w WB,and outdoor temperature of 95'F(35'w DB/75'F Copyright 2018 Fujitsu General America,Inc.Fujitsu's products are subject to continuous Improvements.Fuj ltsu reserves Cooling:WB.Heating:Indoor temperature of 70•F(21.1'g:DB/60', (15.o•t outdoor and outdoor temperature D n5 the right to modify product design,specifications and Information in this brochure without notice and without Incurring ( ' p g ( ' g ( '( ' 77 any obligations. (8.3'w DB/43'F 6.1•C WB.Pipe length:25ft. 7.5m,Height difference:Oft. Om Outdoor unit-Indoor unit). 'F t 1 11 F t• Building Permit Check List&Zoning Analysis Address: � ��� Z SBL: -�r Zonei l L` 1 2 se: 2 l Const.Type: Other. Submittal Date: �{ 1 2( Revisions Submittal Dates: Applicant: l A %� l_ Nature of Work: N l ri 0,0 Z— c-- Reviews:ZBA: A P R - 9 2021 PB: BOT: Other. OK�( ) FEES:Filing. S• BP: �Z.S p • C/O: Legalization: ( ) (.)/APP: Dated: ✓ Notarized: SBL: s I.D. Cross Connection: ✓ H.O.A.: ( ) ( ) Scenic Roads: Steep Slopes: Wetlands: Storm Water Review: Street Opening ( ) ( ) ENVIRO:Long. Shore Fees: N/A: ( ) ( ) SITE PLAN:Topo: Site Protection S/W Mgmt.: Tree Plan: Other. ( ) ( ) SURVEY:Dated: Current: Archival• Sealed. Unacceptable: ( ) (v�IPLANS:Dat Stamped Sealed: -/ Copies: Z Electronic. Other ( ( ) License: ✓ Workers Comp: Liability: �mp.Waiver. Other. ( ) ( ) CODE 7S3#: Dated: N/A: HIGH-VOLTAGE ELECTRICAL:Plans: Permit: N/A Other. ( ) ( ) LOW-VOLTAGE ELECTRICAL.Plans: Permit: N/A: Other. FIRE ALARM/SMOKE DETECTORS:Plans: Permit: H.W.I.C.:_Battery:_Other. PLUMBING Plans: Permit: Nat. Gas: LP Gas: N/A/: Other. ( ) ( ) FIRE SUPPRESSION:Plans: Permit: N/A: Other. ( ) ( ) H.V.A.C.: Plans: Permit: N/A Other. ( ) ( ) FUEL TANK:Plans: Permit: Fuel Type: Other. ( ) ( ) 2020 NY State ECCC: N/A: Other. ( ) ( ) Final Survey: Final Topo: RA/PE Sign-off Letter. As-Built Plans: Other. ( ) ( ) BP DENIAL LETTER: C/O DENIAL LETTER: Other. ( ) ( ) Other. GARB mtg.date: Z l Z approval• notes: ✓ ►"'1 v:�: ( )ZBA mtg. date: approval:- notes: ( )PB mtg.date: approval• notes: APPROVED REQUIRED EXISTING PROPOSED NOTES APR 2 6 2021 Area: Date: Circle: Froze Front: Front: Sides: Main Cov: Accs.Cov Ft.H Sb: S .HS : GFA: Tot. FL.Img: Paz ' Height/Stories: notes: D C� �� I11'j' L� (�~ i BUILDING DEPARTMENT VILLAGE OF RYE BROOK APR - 7 2021 1 938 KING STREET RYE BROOK,NY 10573 (914)939-0668 FAx(914)939-5801 VILLAGE OF RYE BROOK BUILDING DEPARTMENT w-ww.rSebrook.oil-2 ._ _ ARCHITECTURAL REVIEW BOARD CHECK LIST FOR APPLICANTS This form must be completed and signed by the applicant of record and a copy shall be submitted to the Building Department prior to attending the ARB meeting. Applicants failing to submit a copy of this check list will be removed from the ARB agenda. Job Address:6 Deer Run Rye Brook, NY Date of Submission: April 7, 2021 Parcel ID#:135.57-1-1 zone:R-12 Proposed Improvement(Describe in detail): APPLICANT CHECK LIST: Basement Renovation, Install Egress window, MUST BE COMPLETED BY THE APPLICANT The following items must be submitted to the Building Replace 2 panel glass door w/4 panel glass door. Department by the applicant-no exceptions. Replace existing patio doors w/ same size window 1. (x)Completed Application 2. (x)Two(2)sets of sealed plans. (one full size(maximum Property owner:Benjamin & Jaclyn Stahl allox�able lAin .i/� 36"x 42-) and one 1 I"x1T") Address: 6 Deer Run Rye Brook. NY 10573 3. (X)Two(2)copies of the property survey. 4. (x)Two(2)copies of the proposed site plan. Phone# 516-695-5954 5. (X)One electronic/disc copy of the complete application materials. Applicant appearing before the Board: 6. (X)Filing Fee. Benjamin & Jaclyn Stahl 7. (rva)Any supporting documentation. Address: 6 Deer Run Rye Brook. NY 10573 8. 0/a)HOA approval letter.(if applicable) 9. (x)Photographs. Phone# 516-695-5954 10.(n/4 Samples of finishes/color chart.(a sample board or Architect/Engineer: Y Jaclyn clY T n A. Tyler, A I A model may be presented the night of the meeting) Phone#914-204-6404 By signature below, the owner/applicant acknowledges that he/she has read the complete Building Permit Instructions&Procedures,and that their application is complete in all respects.The Board of Review reserves the right to refuse to hear any application not meeting the requirements contained herein. Sworn to before me this Sworn to before me this day of PV n , 20^L day of AlrA , 2014 Sign o PropertyOwner Sign of Applicant Print NIXe of Property Owner Print me of Applicant t Notary Public Notary Public 111 3/21/19 VILLAGE OF RYE BROOK BUILDING DEPARTMENT 938 KING STREET, RYE BROOK, NY 10573 (T) 939-0668 (F) 939-5801 ARCHITECTURAL REVIEW BOARD Wednesday, April 21, 2021 Due to public health and safety concerns from COVID-19, the Architectural Review Board meeting on March 17, 2021 will be closed to members of the public. The public can still watch the live meeting online through Zoom through the app or through the following https://us02web.zoom.us/i/88906948425 If any interested members of the public would like to provide comments during the meeting, comments can be emailed to stevefews@ryebrook.org or called in during the meeting at +1 (929) 205-6099, meeting ID: 889 0694 8425 NAME & LOCATION TYPE OF APPLICATION MOTION SECOND APPROVED REJECTED APPL.# 2 Lincoln Ave Roof Top Solar Array Consent 5160 (Nunez) Agenda 63 Rock Ridge Drive Roof Top Solar Array Consent 5161 (Mundo) Agenda 17 Loch Lane Expand Rear Patio Add New Consent 5162 (Ashby Taurel) Hot Tub Agenda 29 Winding Wood 4'0" High Black Fence In Consent 5163 Road (Demarco) Rear Yard Agenda 85 Valley Terrace New Retaining Walls & Consent 5164 (Krebs) Modify Driveway Agenda 95 Grant Street 4' High Fence In Front Yard Consent 5165 (Tavarez) 6' High Fence. Whit PVC Agenda Vinyl 15 Legendary Circle Roof Top Solar Array Consent 5166 (Tian) Agenda 34 Meadowlark Rd Rear Windows & Door Consent 5167 (Cullagh) Modification to Facilitate Agenda Kitchen Renovation I ICarlton Road New 6' High PVC Pool Consent 5168 (De'Arudda) Fence Agenda ML NM MR SE JM SF AC MI KC 37 Winding Wood Partial 6'High Vinyl Privacy Consent 5169 Road(Cui/Sun) Fence at Side Yards Agenda 66 Tamarack Road New Front Entry Stairs & Consent 5170 (Sibley) Portico Agenda 6 Edgewood Dr Hot Tub On Existing Patio Consent 5171 (Shalem) Agenda 17 Ridge Blvd New 6 High Gray Vinyl Consent 5172 (Kucera) Fence Rear Yard & 4' High Agenda W/gate at Side 6 Deer Run (Stahl) Partial 4'High Wood Febce Consent 5173 w/Mesh @ Rear Yard Agenda 432 N. Ridge St Amendment To Prior Fence Consent 5174 (Gabriel) Approval Fence Color Agenda Change 42 Lawridge Dr Legalize Rear Deck 5175 (Altman) 6 Deer Run(Stahl) Exterior Door& Window ! / ^ 5176 Changes, Finished Basement 44 Bonwit Road Two Tiered retaining Wall 5177 (Rosenfeld) w/Post& Rail Fence & Landscaping 24 Beechwood Blvd 2nd StoryAdditions, Rear 517 i 8 (Moore) Masonry Terrace, Rear Walk, & Replace Existing Walk 46 Winding Wood 2nd Fl Addition,Wood 5179 Road(Meron) Deck, Rear Patio Expansion 18 Boxwoods Place Front& Rear Second Floor 5178 (Wiener) Additions 82 Tamarack Road Legalize& Rebuild Rear 5180 (Sullivan) Deck& Screened Porch I 59 Hillandale Road New Gazebo & Outdoor 5182 (Espinal) Kitchen i 2 Lee Lane(Kirsch) New Front Entry Over 5183 —� Existing Porch ML � NM MR SE f JM SF AC MI KC _f I Berkley Drive Rear Deck Expansion 5184 (Topkis) ML7 NM MR SE JM SF AC - MI --� KC 41N1��'�Ilk, k � �l f1 I!�, .�` 1 �r r ', �` ���r`�l^►� �f,� Y r r` �f ,�.fir'~���•v� •� �` -'\ { yr.P �r if! i' • j Se " r. •� +'Pd •� Ifs �'4 1 + •S�`y�} �.G"li ): t r fn r�►�. +.c. � t i I .s tv __ _ �•. t, t'V, y74.�'tA`ZIL—'y!�_.a •�s .1(%i� l �.� 1�, � - ,t "� /� ., �� �� mF• �� '� �., .��.`'� .'�M'�{' - tip: �; '' _� •� i,� �. ;t�� cAM j 3 . j 1 l • :r . . f I A rr i r ON mv J�r•=l � Lp1`,� � -�. t i e. .-:i rWE � 7 d V � ej 0 % 1 + � 'sue�� ,�� �.r ► f rAAA/ i- r � � s � � -3 O• w t , t _ I i 1 Y .! � t��wn�� 3�v", 'fir. ;5t%i,1 .� �. .. � a. y• �i,�(` 1%lkw . 1 ,1 mr Ig 00 7i��r^�s��.�� ' �*:tip _ t •� Y _ I I ,� f .4A_4 '��$��'r�4 �,ytf, .!.' j ,�.' !C/•� � ..�•/ir� it t 4/�1 ���1 � I ► qL / w� \ l� LT ''�YI..r o ,•:P�)�.1ti.:4 �+�T + T - A , .�I. .. �f i.; ^• �� lyre j� IMP 1 `�. •. /..a V 16 •�bf IM d 1. ti ✓�'��.� J+J s � N�' ��I •t �� _ v _ VAA � ; ��rar.•:+•.�t +�.`9 `kE�, i� `; �.. , �y�•N.r• � �s mow. �ItV. - ilk ir i R( - ' ter. ��. ��• � �` -_ �. � � � , y � / `� �,.n'♦s r ��� ` -, '�w A` Laura Petersen From: Laura Petersen Sent: Monday,April 26, 2021 9:45 AM To: jaclynestahl@gmail.com Subject: Building Permit Application - 6 Deer Run The building permit application has been approved by the Building Inspector, before I can issue the building permit the following items must be submitted to our office, 1. General contractor's contact name & phone number. 2. Copy of general contractor's valid Westchester County Home Improvement License. 3. General contractor's valid liability insurance (the Village Of Rye Brook must be the certificate holder) 4. General contractor's valid workers compensation on a NY State Board form (C105-2 or U26.3) 5. Building permit fee $750.00 (due once permit is issued and ready for pick-up) This information can be emailed to me. Thank you! Laura Petersen Office Assistant Village of Rye Brook 938 King Street Rye Brook, New York 10573 Phone(914)939-0668 1 Fax(914)939-5801 1 1peterseneryebrook.orq 1 Laura Petersen From: Jaclyn Stahl <jaclynestahl@gmail.com> Sent: Thursday,July 8, 2021 10:03 AM To: Laura Petersen Subject: Re: Building Permit Application - 6 Deer Run Attachments: Liability-Rye Brook-07022021.pdf,WC-Rye Brook-07022021.pdf,ADC-Westchester License-03052022.pdf Hi Laura- Apologies for the delay here but below is the contractor's information and attached are the requested documents. If there's anything else you need please let me know.To confirm, once you've noted these are sufficient you'll issue the building permit and then we pick it up along with a payment for$750?Can that be done by credit card or how can we submit payment.Appreciate your help! Victor Pombo AD&C Group, Inc. Tel:914-361-1021 Mobile:914-260-2905 On Mon, Apr 26, 2021 at 9:45 AM Laura Petersen<LPetersen@ryebrook.orQ>wrote: The building permit application has been approved by the Building Inspector, before I can issue the building permit the following items must be submitted to our office, 2- General contractor's contact name & phone number. 2. Copy of general contractor's valid Westchester County Home Improvement License. �3 General contractor's valid liability insurance (the Village Of Rye Brook must be the certificate holder) General contractor's valid workers compensation on a NY State Board form (C105-2 or U26.3) 5. Building permit fee $750.00 (due once permit is issued and ready for pick-up) This information can be emailed to me. Thank you! i DAVEHEA-01 NICH LE ACORO CERTIFICATE OF LIABILITY INSURANCE FDA1E,(1M/DDNYYY)T2 0/ 2021 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 Nichole Picco First Casualty Insurance Agency Inc. PHONE FAX 94 Norwich Rd. (A/C,No,Ext): (A/C,No): Plainfield,CT 06374 aoRIE :npicco@fcigglobal.com INSURERS AFFORDING COVERAGE NAIC# INSURER A:Nor guard Insurance Company 31470 INSURED INSURER B: Dave's Heating And Air Conditioning Inc INSURERC: 119 Longvue Terrace INSURER D: Yonkers, NY 10710 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. INSR TYPE OF INSURANCE ADDL SUER POLICY NUMBER POLICY EFF POLICY EXP LIMITS LTRDDNYYYI A COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE a OCCUR DABP256782 3/9/2021 3/9/2022 DAMAGE TO RENTED PR MI ",."C.) «ence $ MED EXP(Any oneperson) $ 15,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 X POLICY El Spa F1 LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER $ COMBINED SINGLE LIMIT AUTOMOBILE LIABILITY adntj ANY AUTO BODILY INJURY Perperson) OWNED SCHEDULED AUTEO�S ONLY AUTOS SSWNED BODILY INJURY Per accident $ AUTOS ONLY AUTOS ONLY PROPERTY AMAGE Per. er accident UMBRELLA LIAR OCCUR EACH OCCURRENCE EXCESS LIAR CLAIMS-MADE AGGREGATE DED RETENTION$ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY YIN ANY PROPRIETOR/PARTNER/EXECUTIVE N/A E.L.EACH ACCIDENT $ QFFICER/MEMBER EXCLUDED? (Mandatory in CJFFIII E.L.DISEASE-EA EMPLOYE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ __T DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES (ACORD 101,Addttlonal Remarks Schedule,may be attached if more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Village of Rye Brook Building Department THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 9 Y 9 P ACCORDANCE WITH THE POLICY PROVISIONS. 938 King St Rye Brook,NY 10573 AUTHORIZED REPRESENTATIVE ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD YORK Workers' CERTIFICATE OF STATE Compensation Board NYS WORKERS' COMPENSATION INSURANCE COVERAGE 1a.Legal Name&Address of Insured(use street address only) 1b.Business Telephone Number of Insured Dave's Heating&Air Conditioning 914-771-6653 119 Longview Terrace Yonkers,NY 10710 1c.NYS Unemployment Insurance Employer Registration Number of Insured 13-4021927 Work Location of Insured(Only required if coverage is specifically limited to 1d.Federal Employer Identification Number of Insured or Social Security certain locations in New York State,i.e., a Wrap-Up Policy) Number 13-4021927 2.Name and Address of Entity Requesting Proof of Coverage 3a.Name of Insurance Carrier (Entity Being Listed as the Certificate Holder) Rochdale Insurance Company Village of Rye Brook 3b.Policy Number of Entity Listed in Box"la" 938 King Street Rye Brook,NY.10573 KWC1245753 3c.Policy effective period 05/01/2021 to 05/01/2022 3d.The Proprietor,Partners or Executive Officers are ❑ included.(Only check box if all partners/officers included) �X 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 1a"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". 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 Ox NO 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, 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: Forrest Harris (Print name of authorized representative or licensed agent of insurance carrier) Approved by: 12/21/2021 (Signature) (Date) Title: Producer Telephone Number of authorized representative or licensed agent of insurance carrier: 941-927-9500 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 11 Z'' Irit �a' • �'j� •4 ••i•t • t r k ^ � v �'•� '�' �' tv'1�t t r• '.� +vr'b e 1 1 1 ft4�`� #fl, ,111 ,�1 1 Ij 1 + x ++ u 11 11 ►l!•11J1 1, t�4 �f( �1�1.11, '�l�l�k&+�I ari/'1'1'1'h �64�"�ti��'i1•/•/il rlyv�f'1 +a ,�1 f1�1��11.Nf„6, ash�`:1111111 `r -s .+:: fl ll', eAi. ,11111, 1111/111 11111111 1 ,1 t(o)f�• +.y�-- 1�.�,.=:;.: 04 c3 i N ==�, tom.. ry •� o ) p An E cc Ctrs», C O c'7 .lh rAu O y s r srj f�_ � �•r c � ri:; 1 O o U Qc°tectiop 4� Ism` 1 000 rA W y a <% r 1 V U w Y 3 ^ rs. o r i.• Oe5 Z r O = � O >.;� s::�';c1' CSC � — �•'' S ..�i�-.'gam'.r• �. � CQ Ly ,.'�->'v�,'••,r�44 14 tea . E NCN / d � ,: F= t O � M 'rV=•,:sue y � U c y • •raw _ h •(0) Q�Ii:`1/ 1,"�s �. , 1, _ 1 , ! t••• ,fir,•-+-•�-•��^•....^.,F�E"1 "•'t:-ter .-�c-•r+r�.•r; 1'lll' 1��;`-: 1,1 s 5 wilt!-,1 Ih � : +�1l `yG11�1 /11 / d �l!, 1'1�, w /tr, I t �wi� l;��i•!` }i�1 7 ; I i��w�,� c'+ li1.1./� ' ?FI +/i'i1'' s„ w i., •► f•. •� 21 b r� r n. —1, 7 t Y y 1 r t'1: ♦ \ h� 1 4.21 f.'ti UI ((^T! 4 t err r Sn. pW:•�R' rt( yt �. Yi. � •�p�, ��ti��-'�p� "+.•'+ �iu� �p� +����• .•�p� °'Y �;�p�„ ' 'N•- ;gip ��`• S�O�t1 rr- - ti.r v , Ir ,1?i v vr' v 11 - >:xl v 1 - it v t•P •r��{�" A�® CERTIFICATE OF LIABILITY INSURANCE DATE/29/2O21rrY) 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: Janke Caldarar0 John M.Glover Agency PHONE No;203-274-9471 P.O. Box 700 ac o 914 829-9077 Norwalk CT 06852 E-MAIL ADDREss: jcaldararo@johnmglover.com INSURERS AFFORDING COVERAGE NAIC A INSURERA:Utica First 15326 INSURED AD&CGRO-01 INSURERS: AD&C Group, Inc. 18 Cresthill Road INSURERC: Yonkers NY 10710 INSURERD: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:1682499442 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 ADDL:SUBRi,- POLICY EFF POLICY EXP LTR TYPE OF INSURANCE POLICY NUMBER MM/DD MM/DD LIMITS A X COMMERCIAL GENERAL LIABILITY ART515089400 10/29/2020 10/29/2021 EACH OCCURRENCE $1,000,000 DAMAGE Tol RENTED CLAIMS-MADE Fx_]OCCUR PREMISES Ea occurrence $50,000 MED EXP(Any one n $5,000 PERSONAL&ADV INJURY $1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $2,000,000 X POLICY JET LOC PRODUCTS-CCIIIAGG $2,000,000 OTHER: $ AUTOMOBILE LIABILITY OMBINED IN LE LIMI s Ea accident ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per accident $ AUTOS ONLY AUTOS ) HIRED NON-OWNED PROPERTY DAMAGE f AUTOS ONLY AUTOS ONLY Per accident III uMBRELLALIAB OCCUR EACH OCCURRENCE $ EXCESS UAB CLAIMS MADE AGGREGATE $ DED I I RETENTION s WORKERS COMPENSATION PER TH- AND EMPLOYERS'LIABILITY Y/N STATUTE ANYPROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ OFFICER/MEMBEREXCLUDED7 N/A (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ f yes,describe under DESCRIPTION OF OPERATIONS below E.L.-DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS I 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 Village of Rye Brook ACCORDANCE WITH THE POLICY PROVISIONS. 938 King Street AUTHORIZED REPRESENTATIVE Rye Brook, NY 10573 !Y• ,�1�=Cl�u<S ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD NYSIF New York State Insurance Fund WESTCHESTER ONE,44 SOUTH BROADWAY, 10TH FLOOR,WHITE PLAINS,NY 10601-4411 1 nysif.com CERTIFICATE OF WORKERS' COMPENSATION INSURANCE %,0" ^^^^^^ 134195647 AD&C GROUP INC 18 CRESTHILL ROAD YONKERS NY 10710 SCAN TO VALIDATE AND SUBSCRIBE POLICYHOLDER CERTIFICATE HOLDER AD&C GROUP INC VILLAGE OF RYE BROOK 18 CRESTHILL ROAD 938 KING STREET YONKERS NY 10710 RYE BROOK NY 10573 POLICY NUMBER CERTIFICATE NUMBER POLICY PERIOD DATE W1374 349-7 680238 12/18/2020 TO 12/18/2021 7/2/2021 THIS IS TO CERTIFY THAT THE POLICYHOLDER NAMED ABOVE IS INSURED WITH THE NEW YORK STATE INSURANCE FUND UNDER POLICY NO. 1374 349-7, COVERING THE ENTIRE OBLIGATION OF THIS POLICYHOLDER FOR WORKERS' COMPENSATION UNDER THE NEW YORK WORKERS' COMPENSATION LAW WITH RESPECT TO ALL OPERATIONS IN THE STATE OF NEW YORK, EXCEPT AS INDICATED BELOW, AND, WITH RESPECT TO OPERATIONS OUTSIDE OF NEW YORK, TO THE POLICYHOLDER'S REGULAR NEW YORK STATE EMPLOYEES ONLY. IF YOU WISH TO RECEIVE NOTIFICATIONS REGARDING SAID POLICY,INCLUDING ANY NOTIFICATION OF CANCELLATIONS, OR TO VALIDATE THIS CERTIFICATE,VISIT OUR WEBSITE AT HTTPS:/NVWW.NYSIF.COM/CERT/CERTVAL.ASP.THE NEW YORK STATE INSURANCE FUND IS NOT LIABLE IN THE EVENT OF FAILURE TO GIVE SUCH NOTIFICATIONS. THIS POLICY DOES NOT COVER CLAIMS OR SUITS THAT ARISE FROM BODILY INJURY SUFFERED BY THE OFFICERS OF THE INSURED CORPORATION. VICTOR POMBO-PRESIDENT AD&C GROUP INC 1 OF 1 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS NOR INSURANCE COVERAGE UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICY. NEW YORK STATE INSURANCE FUND DIRECTOR,INSURANCE FUND UNDERWRITING VALIDATION NUMBER: 735385798 U-26.3