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Home My WebLink AboutMP21-189 DRY t lC 4.0 oJV L VILLAGE OF RYE BROOK MAYOR 938 King Street, Rye Brook,N.Y. 10573 ADMINISTRATOR Jason A. Klein (914)939-0668 Christopher J.Bradbury www.ryebrookny.gov TRUSTEES BUILDING & FIRE INSPECTOR Susan R. Epstein Steven E. Fews Stephanie J.Fischer David M. Heiser Salvatore W.Morlino CERTIFICATE OF COMPLIANCE July 12,2024 Phyllis Milton,Trustee of the Phillis Milton Revocable Trust 10 Doral Greens Drive East Rye Brook,New York 10573 Re: 10 Doral Greens Drive East, Rye Brook,New York 10573 Parcel ID#: 129.35-1-5 This document certifies that the work done under Mechanical Permit #21-189 issued on 12/7/2021 for the installation of a new gas furnace,condenser and humidifier has been satisfactorily completed. Sincerely, Steven E. Fews Building&Fire Inspector /to �yE BRC�uk cu � 1982 BUILDING DEPARTMENT ❑BUILDING INSPECTOR D 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 : )= \ - / ._ `• F DATE: 'f L , `/ PERMIT# ISSUED: '` SECT: / j BLOCK: % LOT: LOCATION: „ r_. S ° r OCCUPANCY: ❑ VIOLATION NOTED THE WORK IS... ❑ ACCEPTED ❑ REJECTED/ REINSPECTION ❑ SITE INSPECTION REQUIRED ❑ FOOTING ❑ FOOTING DRAINAGE ❑ FOUNDATION ❑ UNDERGROUND PLUMBING NOTES ON INSPECTION: ❑ ROUGH PLUMBING ❑ ROUGH FRAMING ❑ INSULATION ❑ NATURAL GAS ❑ L.P. GAS ❑ FUEL TANK ❑ FIRE SPRINKLER ❑ FINAL PLUMBING ❑ CROSS CONNECTION FINAL OTHER /--� ✓A - _ a � a C a let a F� lqt W lz °y0. � 8 Ey F oo � a� ifs, •o a+ a tn W � ✓' O � W E'i O p Q' O � � O � A > > g Im co x .ter � c,, 0 Un � � � O -aw Cll� UO U Z °� x � � � • � w x �i O � '-a G4 a � o �•�� a Z O d A F w Q �° 0,a r• A Q Qr '� FLy ��j p� [7 > > IO CY, rV•r W p �" v c`- I BUILD MENT � VIL E OF RY OOK DEC _ 7 2021 938 KING ET RYE BR ,NY 10573 ;0 _ 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#:DE Approval Date: C Q Permit Fee: $)ao�� Approval Signature: l� Other: Disapproved: (Fees are non-refundable) REQUIREMENTS FOR RELEASE OF PERMIT&CERTIFICATE OF COMPLIANCE: I. 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 fisted as certificate holder) &Workers Compensation Insurance on a NYS Board form(Form#C105.2 or Form#U26.3/or NY State Workers Compensation Waiver) 4. Payment of Fees/Unit: RESIDENTIAL- $100.00/unit- COMMERCIAL=$350.00/unit. 5. Inspection by the Building Department for removal and/or installation. (48 hour notice required) 6. Electrical work requires a separate Electrical Permit& Electrical Inspection. 7. Plumbing/Gas work requires a separate Plumbing Permit& Plumbing Inspection. Application dated, is hereby made to the Building Inspector of the Village of Rye Brook for a permit for the installation and or removal of the HVAC equipment as listed below.The applicant and property owner,by signing this document agrees that said equipment will be installed and/or removed in conformance with all applicable Local,County,State&Federal laws, codes,rules and regulations. 1. Address: Ia 3 prDCGI 52. 3eu= LJytBL: Zone: 14b 2. Property Owner: Nsi 111c, �. X*Q1\ Address: 1u1)txcLt 6reer►r IN11e St c$ 14ytim. Phone#: 91 q- 934- p55'-4 Cell#: email:�,n�opk{wuw,.wed 3. Contractor: %,%u,n lsJM.r•nQv% Address: 2(e yreela l AVekut 3 E v4Vb&L u4 "Z3 Phone#: Qtt4- la416- I oc O Cell#: email: �Rvoel%4". to" 4. Applic Address: (a Vireelck 3 ElydRvct In'Z! Phone#: CiN-G90- 1000 Cell#: email: .nCa�v,oehlclny•cOwt 5. Scope of Work: New Installation( )• Replacement( )•Removal( )•Other( ): 6. List Equipment:We,.J SO(nak C- oP3,4)-± IS%--r b!!!(An}5-ran co.-Acr�>?r 7. Location of Equipment: I S+ 'F1L-,a,r layNrtvr� g-oy~, 8. Method of Installation/Removal(list all equipment needed to perform job): 1 8/12/2021 STATE OF NEW YORK,COUNTY OF WESTCHESTER ) as: SQWN0L+ 4Lt-n kAs3y"Av% ,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 `50VN0.*1-t vX jl;e'sy"Ay► 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 30fIL Sworn to before me this 30+fL day of ,20_L_ day of t .►►'i ,t 20� Sign re of Property Owner Signa c of Applicant Print Name of Pro erty Owner Pe-e€A t Notary Public Notary Public JENNIFER RIVERA JENNIFER RIVERA Notary Public-State of New York N0.ojR1638go56 Notary Public-State of New York Qualified in Bronx County 2023 NO.OIR16388056 fission Expires Feb 25, Qualified in Bronx County tie y m roper y completed in its entirety and 4tyi&9Vf�°t't€�'P'[bta§"dW n ure(s) of egal owner(s) of the subject property, and the applicant of recor in the spaces providedl Any application not properly completed in its entirety and/or not properly signed shall be deemed null and void and will be returned to the applicant. 2 8/12/2021 800SA/801 SA Input Capacities: 45,000 thru 155,000 BTUh I Legacy 80, Single-Stage Multi-Speed ECM, Non-Condensing Gas Furnaces Product Data PERFORMANCE ® ® • Single Stage gas valve • Fixed-Speeds,Constant Torque(FCT)ECM blower motor OI � QuieTechT"'noise reduction system O � • Microprocessor based"smart"control center • Adjustable heating air temperature rise PER®®® • Enhanced diagnostics with LED and reflective sight glass, non-volatile fault code memory,and self test feature • Perfect LightTm Igniter 1 • Patented blocked vent safeguard designed to ensure proper furnace venting • Inner door for tighter sealing INSTALLATION FLEXIBILITY • 4-way Multipoise furnace, 13 vent applications • HYBRID HEAT®Dual Fuel System compatible l • All models are chimney friendly when used with accessory vent kit Select sizes approved for twinning,refer to accessory kit listing THE 800SA/801SA GAS FURNACE AI90165 APPLICATIONS • Compact design-only 33-1/3 in.(847 mm)tall The 800SA/801 SA LegacyTm Line 4-way Multipoise Gas Furnaces . Propane convertible with gas conversion accessory feature Bryant's QuieTechTM noise reduction system for incredibly quiet induced draft operation. Applications are easy with 4-way multipoise Convenient Air Purifier and Humidifier connections design, through-the-furnace downflow venting, 13 different venting CERTIFICATION options,and designed for easy service access.An inner blower door is provided for tighter sealing in sensitive applications.The 800SA/801 SA • Cabinet air leakage less than 2.0% at 1.0 in. W.C. and cabinet air furnaces are approved for use with natural or propane gas, and the leakage less than 1.4%at 0.5 in.W.C.when tested in accordance with 801 SA-Low NOx units are designed for California installations and can ASHRAE standard 193 be installed in air quality management districts with a 40 ng/J NOx . Residential installations eligible for consumer financing through the emissions limit. Retail Credit Program IPA J o ISO 9001 Quality XMI CERTIFIED,, ' LEGACY Use of the AHRt Certified TM Mark indicates a manufacturer's participation in the program. For verification of certification for individual products, go to www.ahridireeto y.or& A200122 800SA/801SA:Product Data SPECIFICATIONS Unit Size 36045E14 36045E17 3607OE14 3607OE17 48070E17 4807OE21 42090E17 RATINGS AND PERFORMANCE All Standard 44,000 44,000 66,000 66,000 66,000 66,000 88,000 Input Btuh All Low NOx Upflow Nonweatherized ICS All Low Nox 42,000 42,000 63,000 63,000 63,000 63,000 84,000 Downflow/Horizontal Output Capacity All Standard 36,000 35,000 54,000 54,000 54,000 53,000 71,000 (Btuh)t All Low NOx Upflow Nonweatherized ICS All Low Nox 34,000 34,000 51,000 51,000 51,000 51,000 68,000 Downflow/Horizontal AFUEt 80% Certified Temperature Rise Range-°F(°C) 30-60 30-60 30-60 35-65 25-55 25-55 40-70 (17-33) (17-33) (17-33) (19-36) (14-30) (14-30) (22-39) Certified External HeaVCool 0.10/0.50 0.10/0.50 0.12/0.50 0.12/0.50 0.12/0.50 0.12/0.50 0.15/0.50 Static Pressure Heating 710 760 982 985 1175 1305 1203 Airflow CFM$ Cooling 1 1080 1215 1005 1005 1515 1545 1210 ELECTRICAL Unit Volts-Hertz-Phase 115-60-1 Operating Voltage Min-Max 104-127 Range Maximum Unit Amps 5.6 7.6 5.6 5.6 10.8 10.0 8.3 Unit Ampacity 7.8 10.3 7.8 7.8 14.3 13.3 11.0 Maximum Wire Length 47(14.3) 36(11) 47(14.3) 47(14.3) 25(7.6) 27(8.2) 33(10.1) (Measure 1 Way in Ft(M) Minimum Wire Size 14 Maximum Fuse or Ckt Bkr Size(Amps)** 15 Transformer(24v) 40va External Control Heating 12va Power Available Cooling 1 35va Air Conditioning Blower Relay Standard Controls Heating Blower Control Solid State Time Operation Burners(Monoport) 2 2 3 3 3 3 4 Gas Connection Size 1/2in.NPT GAS CONTROLS Mfr WhiteRodgers Gas Valve Min.inlet pressure 4.5(Natural Gas) (Redundant) (In.W.C.) Max.inlet pressure 13.6(Natural Gas) (In.W.C.) Ignition Device Hot Surface Factory installed orifice Size 43 BLOWER DATA Direct Drive Motor HP 113 1/2 1/3 1/3 3/4 3/4 1/2 Motor Full Load Amps 4.4 6.4 4.4 4.4 9.60 8.8 6.8 RPM(Nominal)Speeds 1050-5 1050-5 1050-5 1050-5 1050-5 1050-5 1050-5 Blower Wheel Diameter x Width -In.(mm) 10 x 6 10 x 8 10 x 6 11 x 8 11 x 8 lox 10 11 x 8 (254 x 152) (254 x 203) (254 x 152) (279 x 203) (279 x 203) (254 x 254) (279 x 203) '. Gas input ratings are certified for elevations to 2000 ft.(610 M). In USA,For elevations above 2000 ft(610 M),reduce ratings 4 percent for each 1000 ft(305 M)above sea level.Refer to National Fuel Gas Code NFPA 54/ANSI Z223.1 Table FA or furnace installation instructions. t. Capacity in accordance with U.S.Government DOE test procedures. $. Airflow shown is for bottom only retum-air supply for the as-shipped speed tap.For air delivery above 1800 CFM,see Air Delivery table for other options.A filter is required for each return-air supply.An airflow,reduction of up to 7 percent may occur when using the factory-specified 4-5/1 6-in.(110 mm)wide,high efficiency media filter.. •". Time-delay type is recommended. ICS=Isolated Combustion System Manufacturer reserves the right to change,at any time,specifications and designs without notice and withotrt obligations. 2 800SA/801SA:Product Data SPECIFICATIONS (continued) Unit Size 4809OE21 6009OE21 6009OE24 6011OE21 6011OE24 60135E24 60155E24 RATINGS AND PERFORMANCE All Standard 88,000 88,000 88,000 110,000 110,000 132,000 154,000 Input Btuh All Low NOx Upflow Nonweatherized ICS All Low NOx 84,000 84,000 84,000 105,000 105,000 126,000 147,000 Downflow/Horizontal Output Capacity All Standard 72,000 71,000 72,000 90,000 90,000 107,000 125,000 (Btuh)t All Low NOx Upflow Nonweatherized ICS All Low NOx 68,000 68,000 69,000 85,000 86,000 102,000 119,000 Downflow/Horizontal AFUEt 80% Certified Temperature Rise Range°F(°C) 35-65 25-55 30-60 30-60 30-60 40-70 45-75 (19-36) (14-30) (17-33) (17-33) (17-33) (22-39) (2541) Certified External Heat/Cool 0.15/0.50 0.15/0.50 0.15/0.50 0.20/0.50 0.20/0.80 0.20/0.50 0.20/0.50 Static Pressure Heating 1418 1650 1565 1890 1930 1760 195 Airflow CFM$ Cooling 1445 1980 1960 2040 2005 1810 1965 Electrical Unit Volts-Hertz-Phase 115-60-1 Operating Voltage Min-Max 104-127 Range Maximum Unit Amps 8.3 13 10.3 13.4 10.7 10.7 10.7 Unit Ampacity 11 16.90 13.50 17.40 14 14 14 Maximum Wire Length (Measure 1 Way in Ft 33(10.1) 34(10.4) 27(8.2) 33(10.1) 26(7.9) 26(7.9) 26(7.9) (M)) Minimum Wire Size 14 12 14 12 14 14 14 Maximum Fuse or Ckt Bkr Size(Amps)** 15 20 15 20 15 15 15 Transformer(24v) 40va External Control Heating 12va Power Available Cooling 35va Air Conditioning Blower Relay Standard CONTROLS Heating Blower Control Solid State Time Operation Burners(Monoport) 4 4 4 5 5 6 7 Gas Connection Size 1/2in.NPT GAS CONTROLS Mfr. WhiteRodgers Min.inlet pressure Gas Valve (In.W.C.) 4.5(Natural Gas) (Redundant) Max.inlet pressure 13.6(Natural Gas) (In.W.C.) Ignition Device I Hot Surface Factory installed orifice Size 43 BLOWER DATA Direct Drive Motor HP 1/2 1 3/4 1 3/4 3/4 3/4 Motor Full Load Amps 6.80 11.50 8.80 11.50 8.80 8.80 8.80 RPM(Nominal)Speeds 1050-5 1050-5 1050-5 1050-5 1050-5 1050-5 1050-5 Blower Wheel Diameter x Width-In.(mm) 10 x 10 11 x 11 11 x 11 11 x 11 11 x 11 11 x 11 11 x 11 (254 x 254) (279 x 279) (279 x 279) (279 x 279) (279 x 279) (279 x 279) (279 x 279) •. Gas input ratings are certified for elevations to 2000 ft.(610 M). In USA,for elevations above 2000 ft.(610 M),reduce ratings 4 percent for each 1000 ft.(305 M)above sea level.Refer to National Fuel Gas Code NFPA 54/ANSI Z223.1 Table FA or furnace installation instructions. t. Capacity in accordance with U.S.Government DOE test procedures. $. Airflow shown is for bottom only retum-air supply for the as-shipped speed tap.For air delivery above 1800 CFM.see Air Delivery table for other options.A filter is required for each return-air supply.An airflow reduction of up to 7 percent may occur when using the factory-specified 4-5/16-in.(I 10 mm)wide,high efficiency media filter.. '". Time-delay type is recommended. ICS=Isolated Combustion System Manufacturer reserves the right to change,at any time,specifications and designs without notice and without obligations. 3 800SA/801SA:Product Data MODEL NUMBER NOMENCLATURE 1 2 3 4 5 6 7 8-10 11 12-13 14 15 16 Heat Major Cooling Voltage Minor Exchanger Tier.NOx AFUENO. Heating Stages Series Capacity(CFM) Heal Input Motor Type Width (I-phase) Un-used Son 9 8 7 M B 42 060 C 17 A - A I I I I I I I I I I I I C=Como.variable- Speed A 0=80% Constant Airflow B 0=Base 1=80%Low Nox (VCA)ECM 14-14.2" E.v//65. C1=Legacy Line --- E=Fixed-Speeds 17=17.5" --- 2=92% Constant Torque 21=21.0" 2=UltraPrel roC 24=24.5' 3=Ultra Low Nox 5'�'% 24=800 CFM (FCT)ECM e=Ewlution _ 79- 36-1000 CFM 026=26.000 BTU/h V-V�s�t Tor ue 8 98% M=Modulating A 36=1200 CFM 040=40.000 BTU/h vCT)ECM G S=Single Stage B 42=1400 CFM 060=60,000 BTU/h T=Two-Stage C 48=1600 CFM _- D 60-2000 CFM -- 66=2200 CFM A19004_' FURNACE COMPONENTS INDUCER MOTOR VENT ASSEMBLY ELBOW MAIN LIMIT SWITCH PRESSURE (BEHIND GAS VALVE) SWITCH ®1 BLOCKED VENT SWITCH FLUE COLLECTOR BOX tll 0 0 FLAME SENSOR GAS VALVE 1 �I O o MANUAL RESET GAS MANIFOLD LIMIT SWITCHES o 0 HOT SURFACE IGNITOR 1 ` GAS BURNER BLOWER DOOR SAFETY _ SWITCH _ 0 FURNACE CONTROL BLOWER AND BOARD � m MOTOR I A 190086 NOTE:The furnaces are factory shipped for use with natural gas.These furnaces can be field-converted for propane gas with a factory-authorized and listed accessory conversion kit. Manufacturer reserves the right to change,at any time,specifications and designs without notice and without obligations. 4 H2=/ Air Conditioners/Legacy'"Line 5ingle-Stage Air Conditioner Legacy"' Line Single-Stage Air Conditioner 113A Dependable Cooling from the Most Tnrsted Name in Comfort This Legacy Line air conditioner provides low-cost cooling for your home with legendary Bryant reliability.Some models in the Legacy'"Line may not be eligible for installation in the Southeast or Southwest regions of the country.based on Department of Energy minimum efficiency standards in place as of January 1,2015. �� Ask your Bryant&dealer to ensure your newair conditioner meets government regulations for your area. SEER RATING: 13 COMPRESSOR TYPE: Single-Stage SOUND RATING(DECIBELS): aslowas72 ****{T 706 Reviews 5* 517 4* 127 3* 33 2* 15 411111111111 1* � 14 < won SEE DETAILS FEATURES SPECIFICATIONS • Enjoycool summercomfort with 13 SEER&11 EER efficiency EFFICIENCY MANAGEMENT • Quiet performancewith soundaslowas 72 dB • Enjoyenergy savings,remote access capability and in-depth energy reportingwith the Bryant Housewise"'Wi-Ffr' Energy Efficiency 13 SEER/11 EER thermostat. • DuraGuard'"protection system SOUND • Environmentally-sound Puron`refrigerant • 10-year parts limited warranty upon registrations Quiet levels Dur inR most common cooling operating condition:72 d6 CONVENIENCES 'To the original owner.when product is used in an owner-occupied residence.a 10-year parts limited warranty upon timely registration of your new equipment.Warranty period is 5 years if not registered within 90 days.Jurisdictions where warranty benefits cannot be conditioned on registration will automatically receive a 30-year parts Remote access Manage your system from afar with remote access limited warranty.See warranty certificate for complete details. when paired with the Bryant Housewise'"Wi-Fi`a thermostat Reminders Automatic maintenance reminders and service alerts with the Housewise thermostat `Wi-Fi'is a registered trademark of the Wi-Fi Alliance Corporation. TECHNOLOGY Compressor Single-stage scroll Refrigerant Puron'P refrigerant Protections Filter drier Controls supported Bryant Housewise Wi-Fi thermostat and other Preferred series thermostats AESTHETICS 1/3 C �aF 0' :� -for fig. A R 102.' � •j•II N � 11•/•� � 1•1•11 �v /1�1111 1I 1 1 f 1 1 +1 s !i111i'1..... K h �3 o > �w '= co CN f o °' r4; 40 0.0 Cr L CJ C 4 Ln Q y E Q ram•. W W ji W C/) ti V =1� ce. �Gd �� • a. 1` W (D LlJ v r..+ momO N > �- O cc > Q o G;oIa i Ln •�F Qo y G C CV =• y cA ,. cho A^ ` �/o fit( ' . ._� . . . . �. �. .1 � •�• •� s s �.�. ;.j1.-. . . .� . • . . . .�. . . . .. . .(.�.). ate' {` d/1111V�h� r Sr'. 11 1 h h `rt �1y1 11/111 h - �1'11•�1�i1�T�_��'�"'�,'F��7�.,'1�1II1j111�1�s DDff ,aco CERTIFICATE OF LIABILITY INSURANCE DAiE(MM/03/24/2021 Y) 021 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 LuAnn Silano NAME: BNC Insurance Agency A/CON N.Erd: (914)937-1230 IX No: (914)937-1124 90 S Ridge St UL-2 ADORIEss: Isilano@bncagency.com INSURER(S)AFFORDING COVERAGE NAIC 8 Rye Brook NY 10573-2836 INSURER A: Ohio Security Insurance Co. 24082 INSURED INSURER B: Ohio Casualty Ins Co. 24074 Phoenix Mechanical Corp INSURER C: 26 Vreeland Avenue INSURER D: INSURER E: Elmsford NY 10523 INSURER F: COVERAGES CERTIFICATE NUMBER: CL2131000257 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. �7R TYPE OF INSURANCE INSD WVD POLICY NUMBER MM DIDY/YYYY MM/D fDfYYYY LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE �OCCUR PREMISES Ea oocunence $ 100,000 MED EXP(Any one person) $ 15,000 A Y BKS56442472 03/16/2021 03/16/2022 PERSONAL BADVINJURY $ 1,000,000 GEN'LAGGREGATE UMITAPPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY ®JECT PRO- ElLOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000 Ea accident IX ANY AUTO BODILY INJURY(Per parson) $ A OWNED SCHEDULED BAS56442472 03/16/2021 03/16/2022 BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY Per..dent X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 5,000,000 B EXCESS LIAB CLAIMS-MADE US056442472 03/16/2021 03/16/2022 AGGREGATE $ 5,000,000 DED X RETENTION$ 10,000 $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS•LIABILITY Y/N STATUTE _ ER ANY PROPRIETOR/PARTNER/EXECUTIVE ❑ N/A E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY UMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached it more space is required) Village of Rye Brook is included as an additional insured when required under written Contract or Agreement. 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 ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD INEWK Workers' CERTIFICATE OF ATE Compensation Board NYS WORKERS' COMPENSATION INSURANCE COVERAGE 1 a.Legal Name&Address of Insured(use street address only) 1 b. Business Telephone Number of Insured 9146901000 ADP TotalSource DE IV,Inc. 10200 Sunset Drive 1 c.NYS Unemployment Insurance Employer Registration Number of Miami,FL 33173 LIC/F Insured Phoenix Mechanical Corp. 4605840 9 26 Vreeland Ave Suite B 1d.Federal Employer Identification Number of Insured or Social Security Elmsford,NY 10523 Number Work Location of Insured(Only required if coverage is specifically limited to 133934943 certain locations in New York State,i.e.,a Wrap-Up Policy) 2.Name and Address of Entity Requesting Proof of Coverage 3a.Name of Insurance Carrier (Entity Being Listed as the Certificate Holder) New Hampshire Ins Co Village of Rye Brook 3b.Policy Number of Entity Listed in Box"1 a" 938 King Street WC 038383082 Rye Brook,NY 10573 3c.Policy effective period 07/01/2021 to 07/01/2022 3d.The Proprietor,Partners or Executive Officers are I] included.(only check box if all partners/officers included) ❑all excluded or certain partners/officers excluded. This certifies that the insurance carrier indicated above in box"Y'insures the business referenced above in box"la"for workers'compensation under the New York State Workers'Compensation Law.(To use this form,New fork(NY)must be listed under Item 3A on the INFORMATION PAGE of the workers'compensation insurance policy).The Insurance Carrier or its licensed agent will send this Certificate of Insurance to the entity listed above as the certificate holder in box"T'. The insurance carrier must notify the above certificate holder and the Workers'Compensation Board within 10 days IF a policy is canceled due to nonpayment of premiums or within 30 days IF there are reasons other than nonpayment of premiums that cancel the policy or eliminate the insured from the coverage indicated on this Certificate.(These notices may be sent by regular mail.)Otherwise,this Certificate is valid for one year after this form is approved by the insurance carrier or its licensed agent,or until the policy expiration date listed in box"30, whichever is earlier. This certificate is issued as a matter of information only and confers no rights upon the certificate holder.This certificate does not amend, extend or alter the coverage afforded by the policy listed,nor does it confer any rights or responsibilities beyond those contained in the referenced policy. This certificate may be used as evidence of a Workers'Compensation contract of insurance only while the underlying policy is in effect. Please Note:Upon cancellation of the workers'compensation policy indicated on this form,if the business continues to be named on a permit,license or contract issued by a certificate holder,the business must provide that certificate holder with a new Certificate of Workers'Compensation Coverage or other authorized proof that the business is complying with the mandatory coverage requirements of the New fork State Workers'Compensation Law. Under penalty of perjury,1 certify that 1 am an authorized representative referenced above and that the named insured has the coverage as depicted on this form. Approved by: Adriana Sanchez (Print name of authorize�eepresentative or lice gent of insurance carrier) Approved by: �10�1 06/09/2021 (Signature) (Date) Title: Account Specialist 11 Telephone Number of authorized representative 800-743-8130 Please Note:Only insurance carriers and their licensed agents are authorized to issue Form C-105.2.Insurance brokers are NOT authorized to issue it. C-105.2 (9-17) www.wcb.ny.gov 1004969