HomeMy WebLinkAboutBP21-238PERMIT DATE: 9 oZ 1 c� a -
SECTION �r BLOCK LOT
TYPE OF WORK �S Q� 2
JOB LOCATION ` r Q�e
OWNER f�St /7d/rQ 1,)e crescelzo &Z5 _/ D- l0/1� 0
CONTRACTOR i m al /-i7 /k lC e s Zc (v oo,3a
EST. COST o> �� J C /FEE / VP
vCO # -C� FEE 1s�.�iOlVe C7 DATE 203-a
TCO # FEE DATE
INSPECTION REC R
DATE
FOOTI N G
INSP
FOUNDATION
FRAMING
RGH FRAMING
INSULATION
PLUMBING O
RGH PLUMBING
GAS
SPRINKLER rc:;r �e ��--
ELECTRIC
LOW4OLT 0
ALARM
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FINAL
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OTHER APPROVALS
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VILLAGE OF RYE BROOK
WESTCHESTER COUNTY, NEW YORK
No: 22-059
Certtficate of Orcupaucp
This is to certify that Jwx/'a & Crll-esc-enz-�D
of, A! , having duly filed an application on
-'DY ] ' /, 20 requesting a Certificate of Occupancy for the premises known as,
I 1 Brook— L.al-?e , Rye Brook,NY, located in a Zoning
District and shown on the most current Tax Map as Section: C. Block: / Lot:
and having fully complied with the requirements of the Building Code and the Zoning Ordinance under Building
Permit No. I aC 3,F-3 em
, issued `� /-7 20 o2 J , 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: K` O t� / Construction:
for the following purposes: PP-Pn.i rS C q ue ID �-< YMy )
Subject to all the privileges, requirements, limitations, and conditions prescribed by law, and subject also to the
following:
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
LN
r which the building or premises is designed or intended. Furthermore, it does not relieve such owners or persons from
omplying with any lawful order issued with the object of maintaining the premises or building in a safe and lawful condition.
o changes or rearrangement in the structural parts of the building or in the exit facilities shall be made,and no enlargement,
hether by extending on any side or by increasing in height shall be made nor shall the building be moved from one location
another until a permit to accomplish such change has be obt 'n o the But 'ng Inspector.
uilding Inspector,Village of Rye Brook:
Date: APR 2 6 1022
D E v E � `� BUILD1Nd TMENT For office use onl
PERMIT# /-
VILLAGE OF RYE BROOK ISSUED: - -3
APR — 7 2022 B 938 KING STREET,RYE BROOK,NEw YORK 10573 DATE: - -]c-
VILLAGE OF RYE BROOK (914)939-0668 FEE: W�jV&:L PA0ID
BUILDING DEPARTMENT www.rvebrook.org
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
t►t►►►►►►►►►►►►►ttt►►►►►t■ttR►/►'►►►►►t��►►ttt►►►tt►t►►►tt■►►■t►►►►►tt►►it►►t■ttt►tt►►tt►►t►►►►►t►►t►t►►t►►►►ttt►►t►►t►►t►►t►►tt►
Address:
Occupancy/Use: / r4-444 Parcel ID#: 13S, / 3 —/— 8 Zone:
Owner: ,/V�f2�} ,LP���'/�C p Address: 1a,6 k- L-44L2,
,�,/
P.E./R.A. or Contractor: �° Cf Address: 70 &Z,00ad 71"/U-
Person in responsible charge: '&f2� �) eWLAA- Address: 5,4'"
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:
��y I.�
STATE OF NEW YORK,COUNTY OF WESTCHESTER as:
�V7/�&& -0 �6J e Za being duly swom,deposes and says that he/she resides atK—
in C"t Nf Applicant) (No.and Street)
e o0b ,in the County of (/U� �S��,1� in the State of ,that
(City/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:$ CDD- ,
for the construction or alteration of IUDIpf/Y j duk
� -2
Deponent further states that he/she has examined the approved plans of the structure/work 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
day of ( ,20, day of , 20
Signatur f Property Owner Signature of Applicant
5 e A) 1-0
' t Nroperty Own Print Name of Applicant
Notary Public SHARI MELILLO Notary Public
Notary Public, State of New York
N 10. 01t.,E6160063 8/12/2021
Qualified in WestclieE ter County
Commission Expires January 29.201-13-1
�E BRC�v�
1982 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 r . brook.org
- - - - - - - - - - - - - - - - - - - - INSPECTION REPORT - - - - - - - - - - - - - - - - - - - -
ADDRESS :_, � DATE:
PERMIT Y 2 I ' ISSUED: » SECT: j� l�--BLOCK: LOT:
LOCATION: fl1_1 OCCUPANCY: G-
❑ VIOLATION NOTED THE WORK IS... ,eACCEPTED ❑ 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
❑ ROSS CONNECTION
FINAL
OTHER
QyE BRCuk.
�m
F 0
1982 BUILDING DEPARTMENT
❑BUILDING INSPECTOR
ASSISTANT BUILDING INSPECTOR VILLAGE OF RYE BROOK
❑CODE ENFORCEMENT OFFICER 938 KING STREET • RYE BROOK,NY 10573
(914) 939-0668 FAX (914) 939-5801
www ryebrook.org
- - - - - - - - - - - - - - - - - - - - INSPECTION REPORT - - - -- - - - - - - - - - - - - - - -
ADDRESS : VO� c' \ \ \ DATE:
PERMIT# ISSUED:c q L(SECT: BLOCK: LOT:
LOCATION: ' S C OCCUPANCY:
❑ VIOLATION NOTED ,THE
W ORK IS... ❑ ACCEPTED ❑ REJECTED/REINSPECTION
❑ SITE INSPECTION ` U 1 REQUIRED
❑ FOOTING \
❑ FOOTING DRAINAGE
❑ FOUNDATION
❑ UNDERGROUND PLUMBING NOTES ON INSPECTION:
❑ ROUGH PLUMBING
❑ .ROUGH FRAMING
INSULATION /\ c�
❑ NATURAL GAS , U \ C U� t •
❑ L.P. GAS S C
❑ FUEL TANK
❑ FIRE SPRINKLER
❑ FINAL PLUMBING SVMe l U
❑ CROSS CONNECTION S1
❑ FINAL
❑ OTHER \ \s \ N CA LA c
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BUILDING DEPARTMENT OCT 2 5 2021 DD
VIL ,GE OF RYE BROOK
938 KIN(� NY 10573 VILLAGE OF RYE BROOK
BUILDING DEPARTMENT
.or
ELECTRICAL PERMIT APPLICATION
Westchester County Master Electricians License Required
OFFICE
FOR USE ONLY BP#: 'a/ ` a 3 '
U EP#: ,z::) /— c-),- /�-7
U
Approval Date: OCT 2 7 R Permit Fee: $
Approval Signature: Other: 4( o/y'o a -- =27Q�C;
Disapproved:
(fees are non-refundable)
Application dated,/0 c 4/ 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. D
1.Address: / DR�a,� C,4rJ n SBL:13J� 73 /-9 Zone:4 —/0
2.Property Owner: S"VV E YK� %)O Address: SA AiF—
Phone#: 9/y y�O 6Q&Cell#: email: A AQ&'7vcal MT4 �0gN'f-ItLo '1
3.Master Electrician: Icb N* e o L' Address: 103 1 k AlIV kA/) /S /V
Lic.#: � Phone
#: qh 5DI�6 'Z Cell#: 9�y���/637 email: — RIB . 1f ec
Company Name: ^S7 Address:
4.Proposed Electrical Work/Fixture Count: f/I�,2q &-J/AW ` ArM 46-0/1'&S roR Lt)A -N 1
/
4AM e Q n�,%ze �OA(,e /4-5 /VfXR)
*********************************************************************************************************
STATE OF NEW YORK,COUNTY OF WESTCHESTER ) as:
D►11 11� Ip 1 q/61 r ,being duly swom,deposes and states that he/she is the applicant above named,and does finther
(print name of individdal sig 6 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 81!dQ/c$I
for the legal owner and is duly authorized to make and file this application. (indicate architect,contractor,agent,attorney,etc.)
The undersigned finther 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 SworVtobe e thisday of 20 d y o ,20,4
Signature of Property Owner Agnif6re of Applicant T
1%AlA( tj - rIA�1��L
Print Name of Property Owner er It Name of Appli nt
Notary Public NoWyAjqULLO
Notary Public, State of New York
No.01 ME6160063
Qualified in Westchester County
Commission Exnires J-vni iarf P4 waa
sil2/2021
STATEWIDE •
Service With hitegrity
1:1 Main Street, Fishkill, NY 12524 1 email:office@swisny.com
SWIS • C APPLICATION tel845.202.7224914.219.1062 1 SWISNY.corn • •
Office Use Elect.Permit# Date
Bldg Permit# Utility ID#
Final Certificate#
City/Village Zip Township County
Address Cross Street Section Block Lot
Owner Name/Address(if different than above) Contact Number
❑Basement ❑ 1 st FI. ❑2nd A. ❑3rd FI. ❑More Than 3 Fl. ❑Garage ❑Attic ❑Outside ❑Residential ❑Commercial
Receptacles Special Recept GFCI AFCI Switches Dimmers Smoke Alarms Carbon Monox Hood Trash Compact
Amt Amps
Range(s) Cooktop(s) Oven(s) Dishwashers Refrigerator Disposal Microwave Warm Draw
Incandescent Fluorescent
SERVICE
Amperage Voltage 1 P 3P #Meters #Disconnect ❑Underground ❑New ❑Reconnect
❑Overhead ❑Change
❑Visual Re-Inspection ❑ Safety Re-Inspection ❑ Re-Inspection
Additional Information
RIEU ID]
;
OCT 2 5 0021
VILLAGE OF RYE BROOK
BUILDING DEPARTMENT
This application is valid for one(1)year from the date received by SWIS.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 Signature
Address City/State Zip Code
License# Phone#
AFFIDAVIT IN SUPPORT OF FEE WAIVER RELATED TO HURRICANE IDA
STATE OF V t w COUNTY OF�,()
a/31IV� —mp.,p/0 (insert name), being duly sworn, deposes and says
OI am the applicant for a Build' rmit/Certificate of Occupancy /Demolition Permit
electrical Permi /Plumbing Permit/Fence & Wall Permit
1VMec anica ermit/ Pod Permit(circle all that apply)
2. I am the legal owner of property located at
Rye Brook,New York (insert street address) OR I am the
(Architect/Contractor/Engineer/Attorney) (circle one) for the legal owner of property
located at 1 69WN- 4ANlc-f , Rye Brook,New York
and I am duly authorized by property owner SAN ��f� be-cke<'6c�
to make and file the accompanying application.
3. The following is a description of(1) the work to be performed under the permit for which
I am applying; and (2) how the work arose as a direct result of Hurricane Ida:
4 Pe I[p S J )A-k 1L 4A MA W Q
4. The work described herein arose as a direct result of Hurricane Ida and d s not include
Work which was not caused by Hurricane Ida.
Sworn to before me this 2-
Day of(�)C P-�c', 20 Z
N to Public w---- --�--�--
Jill M. Astrologo .r A�, FF i
Notary Public State of New York
No. 01 AS6207674
Qualified in Dutchess ppunty OCT 25 2021
My Commission Exp. _
VILLAGE OF RYE BROOK
BUILDING DEPARTMENT
State Wide Inspection Services
CA-1) 1080 Main Street
Fishkill, NY 12524
To0 S 845 202-7224 Phone
914-219-1062 Fax
STATE WIDE INSPECTION SERVICES Email: office@swisny.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:
RST Electric Sandra Decrescenzo
Donald Imperioli 11 Brook Lane
103 Shonnard Place Rye Brook, NY 10573
Yonkers, NY 10703
Located at: 11 Brook Lane, Rye Brook, NY 10573
Section: Block: Lot: Electrical Permit Number: EP21-270
135.73
Certificate Number: 2021-5713 Building Permit Number: BP21-238
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: 11 Brook Lane, Rye Brook, NY 10573
The First Floor and Garage were 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 27`h day of January
2022.
Name Quantity Rating Circuit Type
Receptacles 33
GFCI 07
AFCI Breakers 06
Switches 10
Officer: Frank J. Farina
This certificate may not be altered in any way 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.
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DATE(MWDDIYYYY)
AcoRO® CERTIFICATE OF LIABILITY INSURANCE
`►� 08/10/2021
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 CONTANAME: ALEXIS ANN SALUBRO
Albert Palancia Agency, Inc. HOI%N Ell: (914)698-1373 FAx -0125
ac No):(914)698
PO BOX 26 E-MAIL lexis
ADDRESS: alexis@palanciainsurance.com
Mamaroneck, NY 10543 INSURERS AFFORDING COVERAGE NAICS
_ INSURER A: Evanston Insurance company 5 78
INSURED PRIME BUILDING SERVICES, INC. INSURERB: Worldwide Facilities LLC
DBA PRIME HOME IMPROVEMENTS INSURERC: ShelterPoint Life Insurance Company
370 ELWOOD AVE, SUITE 202 INSURERD:
HAWTHORNE, NY 10532 INSURER E:
INSURER F:
COVERAGES CERTIFICATE NUMBER: 10009084-618461 REVISION NUMBER: 36
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.
ILTR TYPE OF INSURANCE ADDL SUER POLICY NUMBER POLICY EFF W=D EXP YYM LIMITS
A COMMERCIAL GENERAL LIABILITY Y 2DD3679 03/14/2021 03/14/2022 EACH OCCURRENCE $ 2,000000
IMAGE TO ED
CLAIMS-MADE F—x1 OCCUR PREMISES Ea occu ence $ 100,000
MED EXP(Any one person) $ 5 000
PERSONAL 6 ADV INJURY $ 2,000,000
GENT AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 4,000,000
X POLICY JE 0 LOC PRODUCTS-COMP/OP AGG $ 4.000.000
OTHER: $
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $
Ea accdent
ANY AUTO BODILY INJURY(Per person) $
OWNED SCHEDULED
AUTOS ONLY AUTOS BODILY INJURY(Per accident) $
HIRED NON-OWNED PROPERTY DAMAGE $
AUTOS ONLY AUTOS ONLY Per accident
$
UMBRELLA LIAB OCCUR EACH OCCURRENCE $
EXCESS LIAB HCLAIMS-MADE AGGREGATE $
DIED RETENTION$ $
B WORKERS COMPENSATION V9WC204687 02/28/2021 02/28/2022 X PER OTH-
AND EMPLOYERS'LIABILITY STATUTE ER
ANY PROPRIETOR/PARTNER/EXECUTIVE Y� N/A E.L.EACH ACCIDENT $ 600,000
OFFICER/MEMBER EXCLUDED?
(Mandatory In NH) I E.L.DISEASE-EA EMPLOYEE $ 500,000
If yes,describe under
DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000
C D350659 02/28/2021 02/28/2022
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required)
VILLAGE OF RYE BROOK IS INCLUDED AS ADDITIONAL INSURED WITH RESPECT TO GENERAL LIABILITY
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
ENGINEERING 8r PUBLIC WORKS DEPARTMENT THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN
VILLAGE OF RYE BROOK ACCORDANCE WITH THE POLICY PROVISIONS.
938 KING STREET RYE BROOK
RYE BROOK, NY 10573 AUTHORIZED REPRESENTATIVE
r
P (AAS)
1988-2015 ACORD CORPORATION. All rights reserved.
ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD
Printed by AAS on August 10,2021 at 11:44AM
INEWK Workers' CERTIFICATE OF
ATE Compensation NYS WORKERS' COMPENSATION INSURANCE COVERAGE
Board
1a. Legal Name&Address of Insured(use street address only) 1 b. Business Telephone Number of Insured
(914)683-8081
PRIME BUILDING SERVICES, INC.
DBA PRIME HOME IMPROVEMENTS 1 c. NYS Unemployment Insurance Employer Registration Number of
370 ELWOOD AVE, SUITE 202
HAWTHORNE,NY 10532 Insured
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
13-4047830
2.Name and Address of Entity Requesting Proof of Coverage 3a. Name of Insurance Carrier
(Entity Being Listed as the Certificate Holder) National Liability&Fire Insurance Company
ENGINEERING&PUBLIC WORKS DEPARTMENT 3b. Policy Number of Entity Listed in Box"1 a"
V9WC204687
VILLAGE OF RYE BROOK
938 KING STREET
RYE BROOK, NY 10573 3c. Policy effective period
02/28/2021 to 02/28/2022
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"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 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".
The insurance carrier must notify the above certificate holder and the Workers' Compensation Board within 10 days IF a policy is canceled
due to nonpayment of premiums or within 30 days IF there are reasons other than nonpayment of premiums that cancel the policy or
eliminate the insured from the coverage indicated on this Certificate. (These notices may be sent by regular mail.) Otherwise,this
Certificate is valid for one year after this form is approved by the insurance carrier or its licensed agent, or until the policy
expiration date listed in box"3c",whichever is earlier.
This certificate is issued as a matter of information only and confers no rights upon the certificate holder. This certificate does not amend,
extend or alter 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: Joseph T.Palancia
(Print name of authorized representative or licensed agent of insurance carrier)
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Approved by: ,A ( � ��C'`-- I--- Qg /Q 2-07 f
(Signature) (Date)
Title: Agent
Telephone Number of authorized representative or licensed agent of insurance carrier: (914)698-1373
Please Note: Only insurance carriers and their licensed agents are authorized to issue Form C-105.2. Insurance brokers are NOT
authorized to issue it.
C-105.2 (9-17) www.wcb.ny.gov