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HomeMy WebLinkAboutBP21-329PERMIT # 4 SECTION L TYPE OF WORK JOB LOCATLON CONTRALTO EST. vO # TCO # FOOTING FOUNDATION FRAMING RGH FRAMING INSULATION PLUMBING ED RGH PLUMBING GAS SPRINKLER ELECTRIC LOW -VOLT C� ALARM 0 AS BUILT FI NA L 9. DaTE: � BLOCK % 1/ -N4 v.,, A I/ c-�In Q� FEEA b'21a`F� FEE DATE INSPECTION RECORD DATE lNSP .t Z Z, � , • I.J;iT�lL PAlt j!)�)a3 I OTHER APPROVALS[ - `BOT e C' 0 :-,ado cyl/ �395- &oz/o ZBA ! OTHER ME Open Permit Letter Sent - f ��-/ 0 c /14es/o .�-r jy aj� «���� 10/6/2022 Qy� DR(� L �J tC w JJV >� 198 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 Steven E. Fews Stephanie J. Fischer David M. Heiser Salvatore W. Morlino CERTIFICATE OF COMPLIANCE April 23,2024 Peter Elkins&Lee Elkins 26 Beechwood Boulevard Rye Brook,New York 10573 Re: 26 Beechwood Boulevard, Rye Brook,New York 10573 Parcel ID#: 135.36-1-32 Building Permit#21-329 issued on 12/21/2021 for a Rooftop Solar Array This certifies that the rooftop solar array,installed under the above captioned permit has been satisfactorily completed. Sincerely, Steven E. Fews Building&Fire Inspector /to E�R� For office use onl ID BUILDINGEtTMENT PERMrr VILLAGE OF RYE BROOK ISSUED: SEP 2 1 2022 938 KING STRE)I T>RYE BROOK,NEW YORK 10573 DATE: �9 9 �06 CU FEE: h ,"��S— PAIDSK VILLAGE OF RYE BROOK 1 , BUILDING DEPARTMENT , 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 •rssssrssrswtr►•ss+sswssrrr+s++w+wrrsesss+swwswsrwrsssssswwsawrsssss+ss••wswswssssss+•w►•wwrwstsss■srss+sw+rswssts•srss►•r+s+ Address: 26 Beechwood Blvd �PY61% r- ,NY 10573 Occupancy/Use: residential Parcel ID#: 135.36-1-32 Zone: R-25 Owner: Peter Elkins Address: 26 Beechwood Blvd Port Chester,NY 10573 P.E./R.A. or Contractor: Tesla Energy Operations Address: 15 Tarkett Dr Unit 4 New Windsor,NY 12553 Person in responsible charge: Frank Saladino of Tesla Address: 15 Tarkett Dr Unit 4 New Windsor,NY 12553 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: Peter Elkins being duly sworn,deposes and says that he/she resides at 26 Beechwood Blvd (Print Name of Applicant) (No.and Street) in Port Chester ,in the County of Westchester in the State of NY ,that (Cih%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:S 122.925.00 for the construction or alteration of. installation of a solar roof 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 r Sworn to before me this o2 day of J U ti , 20 day of Ul" Signature of Property Owner Signature of Applicant Peter Elkins �tG r v(L e 1 n ame of Property Owner Print Name of Applicant .' - )Z��u Ly,' " -M Notary Public Notary Public SHARI MELILLO Notary Public,State of New York =01CO6327155 No.O1ME6160063 NOTARY POF NEW YOW 8/12/2021 Regis6327155 Qualified In Westchester County Qu CountyCommission Expires January 29,2023 Commiss 29,20 �yE BRcb • 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.ore - - - - - - - - - - - - - - - - - - - - INSPECTION REPORT - - - - - - - - - - - - - - - - - - - - ADDRESS : 1 y — � � �' ` �.1 DATE: PERMIT# ISSUED:, ( , SECT: " BLOCK: LOT: LOCATION: \ OCCUPANCY: ❑ Violation Noted THE WORK IS... ❑ PASSED ❑ FAILED 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 • 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 ryebrook.org - - - - - - - - - - - - - - - - - - - - INSPECTION REPORT - - - - - - - - - - - - - - - - - - - - ADDRESS : lJ (' T 'w O ! Y DATE: )C '1� 1�3Z­11 PERMIT# b' /e` 1 ISSUED: I�r`� SECT:��� BLOCK: LOT: LOCATION: �a�� \� Sc� GC r� UPANCY: \ ❑ VIOLATION NOTED THE WORK IS... ❑ ACCEPTED "EJECTED/REINSPECTION ❑ SITE INSPECTION k�j\ onc% Ovkc%'�- REQUIRED ❑ FOOTING ❑ FOOTING DRAINAGE ❑ FOUNDATION ❑ UNDERGROUND PLUMBING NOTES ON INSPECTION: / ❑ ROUGH PLUMBING ( �� ❑ ROUGH FRAMING \\\ ❑ INSULATION ❑ NATURAL GAS 'C\ ❑ L.P. GAS t QICc C(--en FUEL TANK \ ❑ FIRE SPRINKLER ` P i t V Q ❑ FINAL PLUMBING ❑ CROSS CONNECTION l� t ❑ FINAL ❑ OTHER C1 N ' ' Q O ^ aj O i = w 14 �. 2 U L. C ■ � W it x �% � N Q 4��•U 96 W MCI M � Gn C/1 T..4 oo v000 W o O N �^ �' `o eD Ca rA ww A w O . co v� h� ., oo w z v, w �,u •� NowW 0 Q M Gwri o z c Gri ► 'ter00 r MCI Cl\ ,� w O 0 = 3oE � � c�, kf) O � d' � � ✓� Q cw=1 �+ � � Z L3 a00 Ln Vtn U5r o 0 5 z c c c b Q a F+ V o c90 "� a a V W z r3 O U z C7 H A z COR � y o > > d� a a w > = RII, �b BUILDING DEPARTMENT © VILLAGE OF RN'E ROOK --- 938 KING EET RVE BROOK,NY 10573 DES _ 8 2021 (914, 9 +„ ¢8 r�J!91$),939-5801 VILLAGE OF RYE BROOK • BUILDING_DEPARTMENT FOR OFFICE L!SE ONIA: Approval Date: DEC ZV2� ermi€# -349 Application# Approval Signature: ARCHITECTURAL REVIEW BOARD: Disapproved: Date: BOT Approval Date: Case# Chairman: M L PB Approval Date: Case# Secretary: ZBA Approval Date: Case# Other: // Application Fee: ..�,!"� Permit Fees: APPLICATION TO INSTALL PHOTOVOLTAIC SOLAR ARRAY Application dated: 1 0?/ `7 13 1 is hereby made to the Building Inspector of the Village of Rye Brook NY,t'or the issuance oft Permit for the installation of a Photovoltaic Solar Array as per dctailcd statement described below. 1. Job Address: 26 Beechwood Blvd SBL: 135.36-1-32 Zone: R-25 2 Type,kW& Location of Array,to.,caddiuonal-sheets ifnecessam): Tesla Solar Roof, 21.29kW, system will cover entire roof. 3.Property Owner: Peter Elkins Address: 26 Beechwood Blvd, Port Chester, NY 10573 Phone#917-747-0420 Cell# e-mail elkins25@hotmail.eom 4.Applicant: Justine Cognato of Tesla Energy Operations, Inc. Address: 1073 Rt 94, Unit 4, New Windsor, NY 12553 Phone#845-275-6011 Cell#845-395-6040 e-mail Jcognato@tesla.com 5. Design Engineer: Yunanto Yurianto, P.E. Address:5760 Legacy Drive, Plano, TX 75024 Phone#972-896-5373 Cell# e-mail yuriagntoy@barun-corp.com 6.Solar contractor: Tesla Energy Operations, Inc. Address: 1073 Rt 94, Unit 4, New Windsor, NY 1255: Phone#845-275-6011 Cell# XUS - 3q S- (o 0q o e-mail Jcognato@tesla.com 7. Occupancy;(I-Fam.,2-Fam.,Commercial.ctc )Pre-construction: 1-F8m Post-construction:1-Fam 8. If building is located on a corner lot,which street does it front on:Traffic Cir 9. N.Y.State Construction Classification: N.Y.Slate Use Classification: 10. Construction Type&Location.)( )Typical Western Lumber Frame;( )Timber Frame[TC],( )Wood Truss[TT]; ( )Pre-engineered wood[PW];Located;O Floor Framing[F];l )Roof1'raming[R];O Floor&Roof Framing[FR]:Other: 11. Number of stories: 2 Roof Style:,(h..ip,shed_mansard.etc 1` 12. Will a New Roof Be Installed: No ❑ Yes wila,ale.00i9ng pcorm r,rojuv d to ev-rux)l an esistmt;bufldins) 13. Roofing Material&Number of Layers: Existing_comp shingle / 1 layer. New: Tesla Solar Roof/ 1 layer r all12. 14. Will the proposed project disturb 400 sq.ft.or more of land,or create 400 sq.ft.or more of impervious coverage requiring a Stormwater Management Control Permit as per§217 of Village Code? No:V Yes: ❑ Area: 15. Will the proposed project require a Site Plan Review by the Village Planning Board as per§209 of Village Code? No: V Yes: ❑ (if yes,applicant must submit a Site Plan Application.&provide detailed drawings) 16. Will the proposed project require a Tree Removal Permit as per§235 of Village Code?No:tyJ Yes: ❑ (Yves,applicant must submit a Tree Removal Permit Application) 17. Does the proposed project involve a Home-Occupation as per§250-38 of Village Code? No: V Yes: ❑ Indicate:TIER 1:—TIER II:—TIER III:_ (it-yes,a Honic0ccupation Permit Application is required) 18. What is the total estimated cost of construction: $ 122,925 (Note:The estimated cost shall include all site improvements,labor,material.scaffolding,Fixed equipment.professional Pecs,including any material and labor which may tx;donated gratis-If the final cost exceeds the estimated cost,an additional fee will he required prior to issuance or the C/O). Approx. 2-4 Weeks after permit issuance Approx. 2-4 Weeks after start 19. Start Date: _Completion Date: _ This application must bear the notarized signature(s)of the legal owner(s)of the subject property,and the applicant of record in the spaces provided.Any application not properly completed in its entirety and/or not properly signed shall be deemed null and void and will be returned to the applicant.Please note that application fees are non-refundable. STATE OF NEW YORK,COUNTY OF WESTCHESTER ) as: 1 Justine Cognato ,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, Contractor for the legal owner and is duly authorized to make and file this application. (indicate architect,contractor,agent,attorneN.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 —`i� Sworn to before me this 7 day of i YIe r,20 1 day of 1. eember ,20 Z l Notary Pu lie Notary Public - p Signature of Koperty Owner Si ture41"ApplicghT- F e 1�►'Al Print Name of Property Owner Print Name of Applicar t DEBRA M. COHEN NOTARYPUBMIc s AT©OF NEW yORK NOTARY PUBLIC-STATE OF NEW YORK Registration No.01C06327155 NO. 01 C06129832 Qualified in Orange County Qualified in Westchester County - Commission Ex Tres June 29,20 ■ ■ �r•. My Commission Expires 07-05-2025 Eta -iA7 BUIL T �'ARTMENT VI ,OF RYE BROOK DEC — 8 2021 938 KING ET RYE BROOK NY 10573 fi I VILLAGE OF RYE BROOK }f ` .-06b8J i BUILDING DEPARTMENT FOR OFFICE USE ONLY: Approval Date: Permit e /" Application# Approval Signature; ARCHITECTIJ L-�REVIEW BOARD: Disapproved.- Date: BOT Approval Date: Case# : Chairman: PB Approval Date: Case# Secretary: ZBA Approval Date: Case# 1 Other: Application Fee: P1> Permit Fees: ROOF PERMIT APPLICATION Application dated: 1-ap, oZ t is hereby made to the Building Inspector ofthe Village of Rye Brook,NY, for the issuance ofa 1'ermit to Re-Roof an Existing Building,as per detailed statement described below. 1. Job Address: 26 Beechwood Blvd sBL: 135.36-1-32 Zone: R-25 Property owner: Peter Elkins Address: 26 Beechwood Blvd, Port Chester, NY 10573 Phone#: 917-747-0420 cell#: email: elkins25@hotmail.eom t. Applicarrt: Justine Cognato of Tesla Energy OperationSAddress: 1073 Rt 94, Unit 4, New Windsor, NY 12553 Phone#: 845-275-6011 Cell #: email: lcognato@tesla.com 3. hoofing contractor: Tesla Energy Operations, Inc. Address: 1073 Rt 94, Unit 4, New Windsor, NY 12553 Phone#: 845-275-6011 Cell#: email: 4. Job Description,list all Methods&Materials: Installation of a Tesla Solar Roof, removal of existing roof. Tesla # SR-SAUL-1 Underlayment, Tesla Model # SR60T1 roofing tile 5. Estimated Cost of Job:a _ (No 11':Tim estimated cost shall include all site improvements,labor.material.•call'olding.fixed equipwumi,professional fens,and inaleriai and labor which maN be donated gratis.) 6. If corner property,indicate street frontage. Traffic Cir 7. Construction Type: 7> NYS Construction Class: _rs 8. Number of stories: 2 Height: _ 9. Is garage being re-roofed:No:( )•Yes:Oo Attached No:{ )•Yes:O(j Number of Cars: 1 __ 10. Is roof peaked,hip,mansard,flat,etc: Peaked/flat 11. Estimated date of completion:_ T130-Pending Review Board approvals -I- fix a Please note that this application must include the notarized signature(s) of the legal owner(s) of the above-mentioned property, in the space provided below. Any application not bearing the legal property owner's notarized signature(s) shall be deemed null and void, and will be returned to the applicant. STATE OF NEW YORK,COUNTY OF WESTCHESTER ) as: Justine Cognato of Tesla Energy Operations , 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 Contractor i Agent for the legal owner and is duly authorized to make and f le this application. (indicate architect,contractor,agent,attorney,etc.) That all statements contained herein are true to the best of his/her knowledge and belief,and that any work performed,or use conducted at the above captioned property will be in conformance with the details as set forth and contained in this application and in any accompanying approved plans and specifications,as well as in accordance with the New York State Uniform Fire Prevention&Building Code,the Code of the Village of Rye Brook and all other applicable laws,ordinances and regulations. Sworn to before me this Sworn to before me this 1 day of DCeM �. , 20 c_k� day of-Dec e#"ket ,20_Z_L_ tgnature of Property Owner Si atur of App t P �L. Justine Cognato Print Name of Property Ow r Print Name of Applicant Q&�k_ Notary Public Notary Public DEBRA M. COHEN ANIY M.CONN NOTARY PUBLIC-STATE OF NEW YORK NOTARY PUBLIC,STATE OF NEW YORK NO. 01 C06129832 Registration No.01 CO6327155 Qualified in Orange County Qualified in Westchester County Commission Expires June 29,20 My Commission Expires 07-05-2025 81t N N N N N W 1 N � � w ■ ` I W s7 t- a 0^0 U O r v It M z 7 " � W ■ ■ M z C v ^�� H E ■ � G ` O o o w Ln ~ ~ A W ^ rT00 `n C o 00 w Ao a O V Z wzP � � � it � } o (7 Q � � C a w o - C V ■ z d- w z W M F R z 8 xitu � w w W a z o o ° Q+ n zz o z � W 3 n F8 v O w z N A w z a ad O U a • BUILDING 6EPARTMENTRVILLAGE OF RYE $ROOK J U N 2 8 2022 938 K]vq ET RYE B � ,NY 10573 (914)9 939-5801 VILLAGE OF RYE BROOK n orgBUILDING DEPARTMENT ELECTRICAL PERMIT APPLICATION Westchester County Master Electricians License Required FOR OFFICE USE ONLY BP#: 0/-3 a 9 LP #: Approval Date: JUN 2 9 OZ Permit Fee: S Approval Signature: Other: Disapproved: (fees are non-refundable) Application date( �v-e�8�� is hereby made to the Building Inspector of the Village of Rye Brook NY, for the issuance of a Permit to install and/or remove electrical equipment,wiring, fixtures,or to perform other high or low voltage electrical work as per the detailed statement described below. The applicant & property owner, by signing this document agree that all electrical work performed will be in conformance with all applicable Federal, State,County and Local Codes. 1.Address: 26 Beechwood Blvd SBL: 135.36-1-32 Zone: R-25 2,proper Owner: Peter Elkins Address: 26 Beechwood Blvd Phone#: 917-747-0420 Cell#: email: elkins25@hotmail.eom 3.Master Electrician: Frank Saladino of Tesla Energy Operations Address: 1073 Rt 94,Unit 4,New Windsor,NY 12553 Lic.#: 1814 Phone#: 408-763-7754 Cell#: email: Saladino@tesla.com Company Name: Tesla Energy Operations, Inc. Address: 1073 Route 94, Unit 4, New Windsor, NY 12553 4.Proposed Electrical Work/Fixture count: Wiring and equipment for the 21.29kW Tesla Solar Roof and three 13.5kWh Energy Storage System. STATE OF NEW YORK,COUNTY OF WESTCHESTER ) as: Frank Saladino being duly sworn,deposes and states that he/she is the applicant above named,and does fw4her (print name of individual signing as the applicant) Contractor state that(s)he is the legal owner of the property to which this application pertains,or that(s)he is the for the legal owner and is duly authorized to make and file this application. (indicate architect,contractor,agent,attorney,etc.) The undersigned further states that all statements contained herein are true to the best of his/her knowledge a-+d 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 0' 7 Sworn to before We this off-] day of to 20 0� day of ,20 _� Sil#iatdre of Prop6171MWer Signature o Zicant 7� +�� ��, Frank Sno t Name ofpropeAy Owner Print Name of Applicant Notary PuSWRI MELILLO Notary Public Notary Public,State of New York AMY M.CONN No.O1ME6160063 NOTARY PUBLIC,STATE OF NEW YORK Qualified In Westchester County Registration No.01C06327155 Commission Expires January 29,20�a Qualified in Orange County Commission Expires June 29.20 3/21/19 INSPECTIONSTATEWIDE Service With bitegrity 1:1 office@swisny.com *SWIS JOBAPPLICATION :4 1 • • 1•21 SWISNY.com I SWISTraining.com Office Use Elect.Permit 11 Date /`Z714 Bldg Per r Z 2,1 Utility ID# Final Certificate# City/VillagePly (p A, Zip ICS' Township ,� County Address �O P_I 000 V LIA Cross Street +'Section/3s-f 36 Block f Lot 32 Owner Name/Address(If different than above) _ AA f I k i n� Contact Number C� 1/Z�_ 6 2e ❑Basement ❑1st Fl. ❑2nd Fl. ❑3rd Fl. ❑More Than 3 Fl. arage ❑Attic Q Outside EfResideYntial ❑YCommercial 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 N IJZ i Z v i SL d h nP "� JUN 2 8 2022 JD1 A 6;I'o 4 VILLAGE OF RYE BROOK ' ZZ BUILDING DEPARTMENT � In,,����5 ����s���P�•�-� l Goy d���►�Z �� 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 instalk t 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 ��S'L yet r Date {j -2 7 Z� Signature , Address O t City/State t,,I>,i�� � t(, Zip Code c� License# ' , Phone# 'V I_� State Wide Inspection Services 1080 Main Street Fishkill, NY 12524 VK U I 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: Solar City DBA Tesla Energy Peter Elkins 15 Tarkett Drive- Unit 4 26 Beechwood Boulevard New Windsor, NY 12553 Rye Brook, NY 10573 Located at: 26 Beechwood Boulevard, Rye Brook, NY 10573 Section: Block: Lot: Electrical Permit Number: EP22-122 135.36 32 Certificate Number: 2022-3421 Building Permit Number: BP21-329 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: 26 Beechwood Boulevard, Rye Brook, NY 10573 The Photovoltaic System 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 20th day of June 2022. Name Quantity Rating Circuit Type PV Modules 297 Inverters 02 AC Disconnect 01 Load Center 01 Energy Storage Systems 02 J 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. Version#94.4 PIL Project/Job# 1054902 SEP 21 2022 RE: Installation Approval Letter VILLAGE OF RYE BROOK Project: Peter Elkins Residence BUILDING DEPARTMENT 26 Beechwood Blvd y Port Chester,NY 10573 Date of Review 7/7/2022 Permit# 21-329 Date of Install 6/16/2022 AHJ Village of Rye Brook SC Office New Windsor,NY Design Criteria: Applicable Codes=2020 RCNYS/BCNYS/EBCNYS with 2020 NYSUCS,ASCE 7-16,and 2018 NDS Risk Category=II Wind Speed=120 mph(3-s Gust-Vult),Exposure Category C,Partially/Fully Enclosed Method Ground Snow Load=30 psf To Whom It May Concern, i have reviewed the Solar Roof M installation that was specified for this project to verify that the installation was completed in conformance with the permitted plans and specifications.The review is limited to the loading on the structure directly supporting the installed array(s). The system that is currently installed sufficiently complies with the code and permitted plans,and any minor structural or layout changes are also compliant with the referenced code(s). Should you have any further questions or requirements pertaining to this project,please do not hesitate to contact me. �e0F NEW)-, NY 5�P �-�0 YUR� Digitally signed by 1 1 ianto DN DN: nto Yuri V r cn=Yuriantonlo Vurianlo ([! c=US o=Unaffiliated i a n t o ou=A01410D00000176BO 7CBF250000A7A2 s�O 8� �� Reason:I am the author�019 Loc this document OFESS Date:2022-07-08 By Yuri at 10:33:40 AM, 7/8/2022 1033-0500 Tesla,Inc. T = 5 L n (a 4" QKKIUQJl.0 aW VILLAGE OF RYE BROOK MAYOR 938 King Street,Rye Brook,N.Y. 10573 ADMINISTRATOR Jason A. Klein (914) 939-0668 Christopher J. Bradbun w,vk-w.aebrook.or TRUSTEES INSPECTOR Susan R. Epstein Michael J. Izzo Stephanie J. Fischer David M. Heiser Salvatore W. Morlino - --—•-- �l __�,—✓-�v_o�.� gas Dear Rye Brook Building Permitte Please allow this letter to serve as a srting - - - - ] from the date of issuance,and that e i Gjdse ge code allows the Building Inspector to cot -�- � ' owner. To request a permit extension plea al /,;� C tj��/ _ - Please note that should you fail to ✓ J r fail to receive a permit extension from th, : Fee in accordance with Village Code. The Ig time to complete the work and inspectic Thank you for your attention in th. .ire any further information. Michael J. Izzo Building&Fire Inspector mizzo g'jjryebrook.or /to cc: Steven E. Fews,Assistant Building Inspector Tara A. Orlando,Planning& Zoning Secretar. Laura Petersen,Office Assistant 0 ti O O w 0 aI tn cn d ��ro N.4,NN M 72Cd O v oz p 3 -� &W 0. N pG M n Y o_ 00 Z �aE,W Yp u� i U � Q N J o0 J C jY co M Q� Building Permit Check List&Zoning Analxsis 'Address: Co _c lk� c)D ���-- SBL Zone: :�a-2.0 Use: 7il 1J Const.Type: s Other. Submittal Date: 1 Z Z Revisions Submittal Dates: Applicant: V-J �. Nature of Work: Z 25 S !-A f)- 2 O cJ F l S Reviews:ZBA: DEC - 9 2021 pB: BOT: Other. OK 1 I>v e- ( ( ) FEES:Filing: 'f S'� BP: J y C/O: Legalization: ( ) („YAPP: Dated Notarized ✓SBL: �rvss I.D. Cross Connection: H.O.A.: ( ) ( ) Scenic Roads: Steep Slopes: Wetlands: Storm Water Review: Street Opening ( ) ( ) ENVIRO: Long. Short Fees: N/A: ( ) ( ) SITE PLAN:Topo: Site Protection S/W Mgmt.: Tree Plan: Other. ( ) ( ) SURVEY:Dated Current: Archival• Sealed Unacceptable: ( ) ( PLANS:Date Stamped Sealed ✓ Copies: Z Electronic ✓ Other. ( ) (.License: ✓ Workers Comp: ✓ Liability: ✓ Comp.Waiver. Other. ( ) ( ) CODE 753#: 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.:_Batter)r_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. O O 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. 21 (J�ARB mtg.date 2I I r 1 z+ approval notes: ( )ZBA mtg.date: approval: notes: ( )PB mtg.date: approval:- notes: REOLMU Exis TNG PROPOSED NOTES E A Date: Circle: Fr n Front: Front: Sides: Rear: Main Cov Accs.Cow. Ft.HS : Sd.HS • GFA: Tot.imp: F Im : PazP Height/Stories: notes: , BUILDING DEPARTMENTDD VILLAGE OF RYE BROOK DEC - 8 2021 938 KING STREET RYE BROOK,NY 10573 (914)939-0668Trook.or (914)939-5801 VILLAGE OF RYE BROOK B wwyv. BUILDING DEPARTMENT 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:26 Beechwood Blvd Date of Submission: _► a 711 a t,a 1 Parcel ID 4: 135.36-1-32 Zone: R-25 Proposed Improvement(Describe in detail): APPLICANT CHECK LIST: Installation Of a Tesla Solar Roof (21.29kW- MLS'I' BE COMPLETED BY THE APPLICANTThe following items must be submitted to the Building 3082 sq. ft. ) and three 13.5kWh Energy Department by the applicant-no exceptions. Storage Systems. 1. ( .Completed Application 2.•�)Two(2)sets of sealed plans. inns toil size ;maximum Property owner: Peter Elkins allo vable plan size=0-,42"', and one I 1-xl7") 26 Beechwood Blvd, Port Chester, NY 10573 3. (' )Two(2)copies of the property survey. Address: 4. (�)Two(2)copies of the proposed site plan. Phone#917-747-0420 5. 4/)One electronic/disc copy of the complete Applicant appearing before the Board: application materials. 6. ( /)Filing Fee. Justine Cognato of Tesla Energy Operations, Inc. 7. Any supporting documentation. 1073 Rt 94, Unit 4, New Windsor, NY 12553 8. ( ) HOA approval letter. gfapplicoble) Address: 9. ( Photographs. Phone#845-395-6040 10.( )Samples of finishes/color chart. (a sample boa,•d or nrodei may be presented the night ofthe meeting) Architect/Engineer: Yurianto Yurianto, P.E. Phone#845-275-6011 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 7 _ day of �oC l Y�Q l^ , 20 day of December 20 X 1 ,,?i�gnatSre of Property Owner Sign t re of ApplicJZV .� �,N Justine Cognato Print Name of Property Owner Print Name of Applicant �— M .1a4 ---- Jotary Public Notary Public DEBRA M. COHEN AMY M. ONN NOTARY PUBLIC-STATE OF NEW YORK NOTARY PUBLIC,STATE OF NEW YORK NO. 01C06129832 Registration No.01CO6327155 Qualified in Westchester County Qualified in Orange County ; Commission Expires June 29,20 My Commission Expires 07.05-2025 VILLAGE OF RYE BROOK BUILDING DEPARTMENT 938 KING STREET, RYE BROOK,NY 10573 (T) 939-0668 (F) 939-5801 ARCHITECTURAL REVIEW BOARD Wednesday, December 15, 2021 ANNOUNCEMENT: PER THE GOVERNOR'S EXECUTIVE ORDER THIS MEETING WILL BE HELD VIRTUALLY THROUGH THE ZOOM PLATFORM. THE PUBLIC CAN ACCESS THE MEETING THROUGH THE FOLLOWING LINK: hops://us02web.zoom.us/*/81417970741 OR BY OPENING ZOOM AND ENTERING THE MEETING ID: 81417970741 NAME & LOCATION TYPE OF APPLICATION MOTION SECOND APPROVED REJECTED APPL.# 26 Beechwood Blvd New Solar Roofing System Consent '�LC 5656 Agenda 4 Loch Lane 4'0" High Black Aluminum Consent 5657 Picket Fence Agenda 2 Hills Point Lane 6'0" White Vinyl Privacy Consent 5658 (Baumrind) Fence Agenda 545 Westchester Refurbish Exterior Steps, 5659 Ave (Castiglia) Railing,New Aluminum Awning, & Retaining Wall 23 Elm Hill Drive Window Reconfiguration 5660 (Lin) To Facilitate Interior Alterations 48 Rock Ridge New 1 Family Dwelling 5661 Drive (Kouloukis) w/Attached 2 Car Garage 12 Berkley Drive Rear 1 Story Addition& 5662 New Blue Stone Walk ML NM MR SE JM ✓ SF AC MI KC ' f TIR [EcE �vFc-i ID DEC - 8 2021 Version#93.8-1 VILLAGE OF RYE BROOK PIL BUILDING DEPARTMENT November 12,2021 RE: CERTIFICATION LETTER ProjecVJob#1054902 Project Address: Elkins Residence 26 Beechwood Blvd Port Chester,NY 10573 AHJ Rye Brook Village SC Office New Windsor Design Criteria: Applicable Codes=2020 RCNYS/BCNYS/EBCNYS with 2020 NYSLICS,ASCE 7-16,and 2018 NDS Risk Category=II Wind Speed=120 mph(3-s Gust-Vutt),Exposure Category C,Partially/Fully Enclosed Method Ground Snow Load=30 psf TYP MP:Roof DL=8 psf,Roof LL/SL=20.8 psf(Pre-SR),Roof LL/SL=17 psf(Post-SR) Note: Per IBC 1613.1; Seismic check is not required because Ss=0.281 <0.4g and Seismic Design Category(SDC)=B<D To Whom It May Concern, Solar Roof TM is a roofing system comprised of both PV and non-PV roofing elements.Please refer to the product data sheets,third-parry certifications,and installation documentation for further information. Installation of Solar RoofT11 over a single layer of composite shingles is acceptable per the manufacturer's installation instructions.If the existing roof has more than one layer of shingles,or any non-comp shingle roofing,a full tear-off is required.The net installed weight of the Solar RoofT11 system is 3.1 psf,is evenly distributed,and no roofing overlays are permitted.Consequently,the net additional loading impact to existing gravity bad resisting elements is less than 5%and no further analysis was performed. Where required by the installation manual or conditions above,installer shall perform a full tear-off of all existing layers of roofing material above existing sheathing/decking.Installer shall verify existing roofing,and sheathing/decking satisfy installation instructions.Installer shall verify roof framing is in suitable condition that does not exhibit any signs of structural damage which may diminish the capacity of its members or connections prior to commencement of roofing installation. I certify that installation of the Solar Roof TM system on this job,given no presence of existing structural damage at time of installation;meets the criteria outlined in Section 503 of the IEBC/CEBC(aRerations to existing structures)and is therefore permitted by code without alterations or strengthening of the existing framing. OF NEWyo NY 5�P�AAtJ�D y1j, 5' Diggally signed by Yunanto * YL� to Yurlento DN =Vuriento Yunanto c=US-Unaffifated ou=A01110D00000116801 Yu r' to ReasonI am the author of A Locatioment this n Date 21 0 21-11-12 - 101980 (G� ARO00 FESSION'� By Yuri at 9:16:21 PM, 1111212021 Tesla,Inc. T = 5 L n t- 1 R �[E Version#93.8-1 DEC - 8 2021 PIL VILLAGE OF RYE BROOK BUILDING DEPARTMENT November 12,2021 RE: CERTIFICATION LETTER Project/Job#1054902 Project Address: Elkins Residence 26 Beechwood Blvd Port Chester,NY 10573 AHJ Rye Brook Village SC Office New Windsor Design Criteria: Applicable Codes=2020 RCNYS/BCNYS/EBCNYS with 2020 NYSLICS,ASCE 7-16,and 2018 NDS Risk Category=II Wind Speed=120 mph(3-s Gust-Vult),Exposure Category C,Partially/Fully Enclosed Method Ground Snow Load=30 psf TYP MP:Roof DL=8 psf,Roof LUSL=20.8 psf(Pre-SR),Roof LL/SL=17 psf(Post-SR) Note: Per IBC 1613.1; Seismic check is not required because Ss=0.281 <0.4g and Seismic Design Category(SDC)=B<D To Whom It May Concern, Solar Roof TM is a roofing system comprised of both PV and non-PV roofing elements.Please refer to the product data sheets,third-party certifications,and installation documentation for further information. Installation of Solar Roof TM over a single layer of composite shingles is acceptable per the manufacturer's installation instructions.If the existing roof has more than one layer of shingles,or any non-comp shingle roofing,a full tear-off is required.The net installed weight of the Solar RoofTm system is 3.1 psf,is evenly distributed,and no roofing overlays are permitted.Consequently,the net additional loading impact to existing gravity bad resisting elements is less than 5%and no further analysis was performed. Where required by the installation manual or conditions above,installer shall perform a full tear-off of all existing layers of roofing material above existing sheathing/decking.Installer shall verify existing roofing,and sheathing/decking satisfy installation instructions.Installer shall verify roof framing is in suitable condition that does not exhibit any signs of structural damage which may diminish the capacity of its members or connections prior to commencement of roofing installation. I certify that installation of the Solar Roof TM system on this job,given no presence of existing structural damage at time of installation;meets the criteria outlined in Section 503 of the IEBC/CEBC(aterations to existing structures)and is therefore permitted by code without alterations or strengthening of the existing framing. 4 foF NEW y0 NY O YURI Dgaally signed oy Yunanto YLff to Yun ent° 7k Yur =Yunanto Yunanto o=US-Unaffiliated 1 ou=A11111D10000178B0T Y u r to CBF250000MA2 r Reason I am the author of C) this L document Q 980 � 21 2116 06 00 1-1 z A 101 ROFESSIONP By Yuri at 9:16:21 PM, 11/12/2021 Tesla,Inc. T = 5 L n J .r' IT M At 40 • a� 0 /t� ADZ � 3 N U L CO . • vs ' N� 4 'x _ HplandaleRd� � � � • � W 4 t , 3 1 '+�� °ate\, .,.,• :�� , . 1�°° # y' � •Jam+ w ter, r- . m} O R � i.wi 40 e r 00 �O t w w `m odla�d Ot p4P/ M ♦ ��,;:t' '���� {4 �• Yam~' ;T•i���,, `�'� �•, a 1 ••. `'� s�/ ��`y •" #I i � t v. �� .,. �,, .17�.���� 'may ,�� : .�_ ` , �•� � ` 1-^ S 4f r]c �f t �l.` /pJ� ,z, .11{'� i . / � A',�?� •.'mac i�i �.6�'+4 � r �•• .11 ���. ^:f'{�• ,z-: Alf 1 �+ lit yyR• � �1 ,� \ Il • AW "1 or { ! VA 4 l 'r�rr T � y L I ♦ _ i ILA _� QJ 14- i m if 11 i fAj•;�� ♦♦♦♦ I � it �� •� '�� � . 4 e r N _ Gam: ,� • i_ y �• r. C ! 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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 Kayla Ferrell MARSH RISK& INSURANCE SERVICES NAME: y FOUR EMBARCADERO CENTER,SUITE 1100 (A/CC o,Ext). 415-743-8025 / �g CALIFORNIA LICENSE NO.0437153 E-MAIL SAN FRANCISCO,CA 94111 ADDRESS: Attn:SanFrancisco.Certs@marsh.com/FAX 212-948-0398 INSURE S AFFORDING COVERAGE NAIC A CN104275261-STND-GAWUE-21- INSURER A:Zurich American Insurance Company 16535 INSURED esla Energy Operations,Inc. INSURER B:Steadfast Insurance Company 26387 901 Page Avenue INSURER C:American Zurich Insurance Company 40142 Fremont,CA 94538 INSURER D:N/A N/A INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: SEA-003420547-22 REVISION NUMBER: 4 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 PWDDY LTR MMIDD/YYYY LIMITS /{ X COMMERCIAL GENERAL LIABILITY GLO1074588-04 10/31/2021 10/31/2022 EACH OCCURRENCE $ 2.500,000 CLAIMS-MADE �OCCUR Includes Host Liquor Liability DAMAGE TO—PREMISES EaEoccu en ce $ 2,500,000 FX SIR:$750,000 MED EXP(Any one person) $ 5,000 B X Tort Con.8C Liab,No XCU Exd SXS-7426362-02(Excess GL- 10/31/2021 10/31/2022 PERSONAL&ADV INJURY $ 2,500,000 GEN'L AGGREGATE LIMIT APPLIES PER: Limit:$6,750,000 excess of primary GENERAL AGGREGATE $ 20,000,000 I'1 X POLICY❑PRO- LOC GL limits on right;applies to PRODUCTS-COMProP AGG $ 6,000,000 JECT OTHER: Solar Products Only) $ A AUTOMOBILELIABILITY BAP 1074586-04 10/31/2021 10/31/2022 COMBINED SINGLE LIMIT $ 10,000,000 Ea accident X ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS HIRED NON-OMED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY Per accident q, I — $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ REXCESS LIAB CLAIMS-MADE AGGREGATE $ DECO RETENTION$ $ C WORKERS COMPENSATION WC 1074583-04(ADS) 10/31/2022 X PER X OTH- AND EMPLOYERS'LIABILITY STATUTE ER /{ Y/N WC 1074584-04(MA,WI) 10/3112021 10I31/2022 1,000 000 ANYPROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ A OFFICER/MEMBER EXCLUDED? N/A CA XSWC EWS 1074585-04 $50M is XS 10/31/2021 10/31/2022 (Mandatory In NH) ( E.L.DISEASE-EA EMPLOYEE $ 1,000,000 It yes,describe under $10M SIR;$1 M EE/EA is XS$10M SIR) E.L.DISEASE-POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES (ACORD 101.Additional Remarks Schedule,may be attached if more space is required) Evidence of insurance CERTIFICATE HOLDER CANCELLATION Village of Rye Brook SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 938 King Street THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Rye Brook,NY 10573 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE Xis RW &l rr4ua wc S ©1988-2016 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD YORlc Workers' CERTIFICATE OF STATE Compensation NYS WORKERS' COMPENSATION INSURANCE COVERAGE Board la.Legal Name&Address of Insured(use street address only) 1 b.Business Telephone Number of Insured 6SO-963-5100 Tesla Energy Operations,Inc. 901 Page Avenue 1c.NYS Unemployment Insurance Employer Registration Numberof Fremont,CA 94538 Insured 49-892777 Work Location of Insured(Only required if coverage is specifically limitedto 1 d.Federal Employer Identification Number of Insured or Social Security certain locations in New York State,i.e.,a Wrap-Up Policy) Number 02-0781046 2.Name and Address of Entity Requesting Proof of Coverage 3a.Name of Insurance Carrier (Entity Being Listed as the Certificate Holder) American Zurich Insurance Company Village of Rye Brook 3b.Policy Number of Entity Listed in Box"1a" 38 King Street WC 1074583-04 Rye Brook, NY 10573 3c.Policy effective period 10/31/2021 to 10/31/2022 3d.The Proprietor,Partners or Executive Officers are ®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"3"insures the business referenced above in box 1a"forworkers' 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 isearlier. 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: Susan B. Kendziora (Print name of authorized representative or licensed agent of insurance carrier) Approved by: _-C t Ce 10/31/2021 (Signature) (Date) Title:Vice President-Enterprise Support Operations Telephone Number of authorized representative or licensed agent of insurance carrier:800-382-2150 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.4ov INTERNAL USE ONLY -0(ncoC-)n m-vM�2oa =moo f-M C D � D<-�cn-0-0ZaO ZKOrnT1mm wD -� 0��< ZU m m F= D r X G7 C r � m � n Q C D O >< m� r= D NacnZ(- _ n pZ-D < �m mm(�0--jm zmD o co�o� r''D=� rn�-I F7S Z< r CD ;:a r O r O 0 n C G7 m m D p o��zZ� '^ m Z a i XN nor n 0 0� I C-) 7D C n< m -0 CD � � � � m � y n D can' mrnC Ornz� � 0� Mm cn o �. Q n< Cn Cn z r _ z D C� D m �� _ 4 rrimN Z, 0 � C D Z p �DZzn O� m� r�C rn nD O a (C D � O � T ^ O Q �� -Om mrn�mg c �C) oao= I�l a tt =a .. 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