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HomeMy WebLinkAboutMP22-022 B R 0, 'S a t C Q �CCK,4 wu� r 19 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 November 28,2023 Scott Bellin&Michelle Bellin 221 Tree Top Crescent Rye Brook,New York 10573 Re: 221 Tree Top Crescent,Rye Brook,New York 10573 Parcel ID#: 129.76-1-61 This document certifies that the work done under Mechanical Permit#22-022 issued on 2/15/2022 for the installation of a new condenser and a new air handler has been satisfactorily completed. Sincerely, Steven E.Fews Building&Fire Inspector /to QyE BRC��, l7 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: V LATE: 1 \ `�V -(:)21 PERMIT# ��Y� -1 _ L ISSUED: E T: BLOCK: LOT: LOCATION: ' -,-�v {.. cC* %U ,'VCCUPANCY• ❑ Violation Noted THE WORK IS... PASSED ❑ FAILED REINSPECTION ❑ SITE INSPECTION REQUARED ❑ FOOTING ❑ FOOTING DRAINAGE ❑ FOUNDATION ❑ UNDERGROUND PLUMBING NOTES ON INSPECTION: ❑ ROUGH PLUMBING ❑ ROUGH FRAMING ❑ INSULATION❑ Natural Gas c : r-� , E ����A:L, 1�s ❑ L.P. Gas ❑ FUEL TANK ❑ FIRE SPRINKLER ❑ FINAL PLUMBING ❑ CROSS CONNECTION INAL ❑ OTHER �yE BRcbl '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 :— 1 j DATE: l PERMIT# ISSUED:�`Tr­ SECT: BLOCK: LOT: LOCATION: � �fC r' ❑ 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 ACC'�5 � [IFUEL TANK / ❑ FIRE SPRINKLER C -P CA ❑ FINAL PLUMBING ` \29 []-_CROSS CONNECTION C y CA,(" © VINAL ❑ OTHER ��' _ a N - � p2 W � •a v M • O CA d �' s L ea p C', a eA H a ^ � o w z 10 4,4 UCA 0 O 00 r+ j o o �1 Q A cr O QJ r' A � 4 :,,-d a N � DWI z cd iE .bJll p, a� •., 14. O1� FF"•••1 O W U Q � b cUc044 CN t� �+ cc 1,4 V un V _ � o i� � � E'i O t'-' O •y U I--I o - M4 � O O p4 � W oF' •" �.�' ' i BUILD '�ll MENT D 1E C E 0 E VILi , E OF RYL'ffitOOK FEB 14 2022 938 KING xi,RYE BROoK,NY 10573 -( -066U VILLAGE OF RYE BROOK BUILDING DEPARTMENT .�� yu APPLICATION FOR PERMIT TO INSTALL AND/OR REMOVE HEATING, VENTILATION AND/OR AIR CONDITIONINGf�EQUIPMENT FOR OFFICE USE ONLY: PERMIT FEB 1 2 Approval Date: Permit Fee: S Approval Signature: Other: Disapproved: urc.are nun-retundabtej REQUIRENIENTS FOR RELEASE OF PERMIT fit: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 Brtx)k must be listed as certificate holder)&Workers Compensation Insurance on a NYS Board form(Dorm�t C 105.2 or Form#U26.3;or NY State Workers Compensation Wai-,er) 4. Payment of Fees/Unit: RESIDENT IAL=S I00.00/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, ALA204PRLherchy made to the Building Inspector of the Village of Rye Brook for a permit for the installation and or removal of the I I VAC 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: 7-11 Tre,6+op SBL: ��9. �/���.�f Zone: PIZs 2. Property Owner: 5&04 B e I I i n Address: 1-7-1 !(t e,{W C(&seet1 f Phone#: 9 17-5 3 8- 7754 Cell#: S 9rl to email: 3. Contractor: l r(Ai(, Melhn814 Address: 91 0 N Nin Wett,Paff cAcs�et Phone#:QIq-g3� -9301 Wo 6o5 Cell#: 54mc- email: �fgVDJ rig QI'Gf;L-tje6AAntWI,COM 4. Applicant: kr64i6 Address: 466 N MQ;n wpa, �oTf (,,esS r Phone#: 11q-j3H -83oj Cell!#: S4m6 emaih bfQvo)rgArc�h.-Mech94,f.41,CnM 5. Scope of Work:New Installation( )•Replacement ft•Removal( )•Other( ): 6. List Equipment: I nbe, HT1R3o3oH1000W ton4enseT. I7rgneTEM3AaB3oS31SR q'ir homier, 7. Location of L•'quipment: � 8. Method of InstallationlRemoval(tint all equipment needed to perform job): t STATE OF NEW YORK,COUNTY OF WESTCHESTER ) as: J�ors ny B f qva ,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 Gun f rq(,+ r _ 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 ilniform Fire Prevention 8t Building Code,the Code of the Village of Rye nrook and all other applicable laws,ordinances and regulations. Sworn to before me this Sworn to before me this fl day of 20 day of ,20 St6n tuir roperty Owner Signature of Xpplicant &7-0 Qe /I( " j�onn\l Brgyo Pri ame of Property O ner Prin ame of Applicant ntary Public Notary Put1,lteWhalen Ulna{Nhalen Notary Public,State of New York Notary Public,State of NOWYOrk No.01WH6394580 No.01 WH6394580 Qualified in Westchester County Qualified in Westchester County Commission Expires July 8,2023 Comrnission Expires Juty 8.2023 This application must be properly completed in its entirety and must include 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. 2 i;i 12/2021 � � c � C .r o� � C „ s ,� Q Q � C cr o cam.. L rRANE' rrold. up..A.: 'ata Convertible Air Handlers 1-1/2 — 5 Ton TEM3AOB18S21 SA TEM3AOB24S21 SA TEM3AOB30S31 SA �` e TEM3AOB36S31 SA TEM3AOC42S41 SA o 0 TEM3AOC48S41 SA • TEM3AOC6OS51 SA o I \ U The TEM3 series air handler is designed for installation in a closet, utility room,alcove,basement,crawlspace or attic.These versatile units are applicable to air conditioning and heat pump applications.Several models are available to meet the specific requirements of the outdoor equipment.Field installed electric resistance heaters are available. March 2015 22-1879-1C-EN �I7/IngersollRand 0 TRWE` Product Specifications MODEL TEM3A0B18S21SA TEM3AOB24S21SA TEM3AOB3OS31SA TEM3AOB36S315A RATED VOLTS/PH/HZ 208-230/1/60 208-230/1/60 208-230/1/60 208-230/1/60 RATINGS,-) See O.D.Specifications See O.D.Specifications See O.D.Specifications See O.D.Specifications INDOOR COIL—Type Plate Fin Plate Fin Plate Fin Plate Fin Rows—F.P.1. 3-14 3-14 3-14 3-14 Face Area(sq.ft.) 4.37 4.37 4.37 4.37 Tube Size(In.) 3/8 3/8 3/8 3/8 Refrigerant Control TXV TXV TXV TXV Drain Conn.Size(in.)ib- 3/4 NPT 3/4 NPT 3/4 NPT 3/4 NPT DUCT CONNECTIONS See Outline Drawing See Outline Drawing See Outline Drawing See Outline Drawing INDOOR FAN—Type Centrifugal Centrifugal Centrifugal Centrifugal Diameter-Width(In.) 9 X 7 9 X 7 10 x 8 10 x 8 No.Used 1 1 1 1 Drive-No.Speeds Direct-3 Direct-3 Direct-3 Direct-3 CFM vs.in.w.g. See Fan Performance See Fan Performance See Fan Performance See Fan PPrformancPTahle Table Table Table No.Motors—H.P. 1-1/4 1-1/4 1-1/2 1-1/2 Motor Speed R.P.M. 1075 1075 1075 1075 Volts/Ph/Hz 208-230/1/60 208-230/1/60 208-230/1/60 208-230/1/60 F.L.Amps 1.3 1.3 2.5 2.5 FILTER Filter Furnished? No No No No REFRIGERANT R-410A R-410A R-410A R-410A Ref.Line Connections Brazed Brazed Brazed Brazed Coupling or Conn.Size—in. 3/4 3/4 3/4 3/4 Gas Coupling or Conn.Size—in. 3/8 3/8 3/8 3/8 Liq. DIMENSIONS HxWxD HxWxD HxWxD HxWxD Crated(In.) 46x21x24 46x21x24 46x21x24 46x21x24 Uncrated 45-1/8 x 18-1/2 x 21-1/8 45-1/8 x 18-1/2 x 21-1/8 45-1/8 x I8-1/2 x 21-1/8 45-31/8 x 18-1/2 x 21-1/8 WEIGHT Shipping(Lbs.)/Net(Lbs.) 116/110 116/110 116/110 116/110 (a) These Air Handlers are A.H.R.I certified with various Split System Air Conditioners and Heat Pumps(AHRI STANDARD 210/240).Refer to the Split System Outdoor Unit Product Data Guides for performance data. M 3/4"Male Plastic Pipe(Ref:ASTM 1785-76) 0 Remote filter required. 4 22-1879-1 C-EN 0 TRWE` Minimum Airflow CFM TEM3AOB18S21SA,TEM3A0B24S21SA Heater Minimum Heat Speed Tap With Heat Pump Without Heat Pump BAYHTR1504BRK,BAYHTR1504PDC,BAYHTR1504LUG, Low Low BAYHTR15058RK,BAYHTR1505PDC,BAYHTR1505LUG BAYHTR1508BRK,BAYHTR1508PDC,BAYHTR150BLUG, BAYHTR1510BRK,BAYHTR1510PDC,BAYHTR1510LUG, Low Low BAYHTR3510LUG TEM3AOB30S31SA,TEM3AOB36S31SA Heater Minimum Heat Speed Tap With Heat Pump Without Heat Pump BAYHTR1504BRK,BAYHTR1504PDC,BAYHTR1504LUG, Low Low BAYHTR1505BRK,BAYHTR1505PDC,BAYHTR1505LUG BAYHTR1508BRK,BAYHTR1508PDC,BAYHTR150BLUG, BAYHTR1510BRK,BAYHTR1510PDC,BAYHTR1510LUG, Low Low BAYHTR3510LUG BAYHTR1515BRK,BAYHTR3515LUG,BAYHTR1519BRK Low Low TEM3A0C42S41SA,TEM3AOC48S41SA Heater Minimum Heat Speed Tap With Heat Pump Without Heat Pump BAYHTR1504BRK,BAYHTR1504PDC,BAYHTR1504LUG, BAYHTR1505BRK,BAYHTR1505PDC,BAYHTR1505LUG Low Low 13AYHIR15086RK,13AYHIR15U8PDC,BAYHIK1508LUG, BAYHTR1510BRK,BAYHTR1510PDC,BAYHTR1510LUG, Low Low BAYHTR3510LUG BAYHTR1515BRK,BAYHTR3515LUG,BAYHTR1520BRK Low Low TEM3A0C6OS51SA Heater Minimum Heat Speed Tap With Heat Pump Without Heat Pump BAYHTR1504BRK,BAYHTR1504PDC,BAYHTR1504LUG, BAYHTR15056RK,BAYHTR1505PDC,BAYHTR1505LUG Low Low BAYHTR1508BRK,BAYHTR1508PDC,BAYHTR1508LUG, BAYHTR1510BRK,BAYHTR1510PDC,BAYHTR1510LUG, Low Low BAYHTR3510LUG SAYHTR1515BRK,BAYHTR3515LUG,BAYHTR1520BRK Low Low Low=Taps 1-3 22-1879-1C-EN 7 0 Performance and Electrical Data Table 3. Air Flow Performance TEM3AOB3OS31SA(a),TEM3A0836S31SA(a)(b) EXTERNAL STATIC AIRFLOW (In w•g) Speed Taps-230 VOLTS Speed Taps-208 VOLTS High Med Low t High Med Low t 0.1 1461 1336 979 1406 1173 834 0.2 1404 1291 971 1352 1152 819 0.3 1344 1242 962 1295 1121 810 0.4 1281 1188 944 1234 1081 804 0.5 1214 1130 916 1169 1035 791 0.6 1142 1066 876 1100 981 768 0.7 1 1066 997 1 1026 920 732 1. Values are with wet coil,no filter,and no heaters 2. CFM Correction for dry coil=Add 3% 3. t=Factory setting a) ForTEM3AOB3OS31SA and TEM3AOB36S31SA in downlfow applications,airflow must not exceed 1200 cfm due to condensate blow off. b) For TEM3AO836S31SA,the recommended speed tap is medium at 0.4"external static pressure. Table 4. Electrical Data TEM3A0830S31SA,TEM3AO636S31SA No.of 240 Volt 208 Volt Heater Model No. Circuits/ Capacity Heater Minimum Maximum Capacity Heater Minimum Maximum Phases kW BTUH Amps per Circuit Overload Amps per Circuit Overload kW BTUH Circuit Ampacity Protection Circuit Ampacity Protection No Heater 2.5• 3 15 2.5* 3 15 BAYHTR1504BRK BAYHTR1504PDC 1/1 3.84 13100 16.0 23 25 2.88 9800 13.8 20 20 BAYHTR1504LUG BAYHTR1505BRK BAYHTR1505PDC 1/1 4.8 16400 20.0 28 30 3.6 12300 17.3 25 25 BAYHTR1505LUG BAYHTR1508BRK BAYHTR1508PDC 1/1 7.68 26200 32.0 43 45 5.76 19700 27.7 38 40 BAYHTR1508LUG BAYHTR1510BRK BAYHTR151OP(X 1/1 9.6 32800 40.0 53 60 7.2 24600 .34.6 46 50 BAYHTR151OLUG BA 156RK- (,Ircuit 9.6 32800 40.0 53 60 7.2 24600 34.6 46 50 CUIt 1 1(0 a) 2/1 BAYHTR1515BRK- 4.8 16400 20.0 25 25 3.6 12300 17.3 22 25 Circuit 2 BAcuit 10) 2/1 19BRK- rcuit Ci 1(a 9.6 32800 40.0 53 60 7.2 24600 34.6 46 50 BAcuit2 198RK- Circuit 2 9.6 32800 40.0 50 50 7.2 24600 34.6 43 45 BAYHTR351OLUG 1/3 9.6 32800 23.1 32 35 7.2 24600 20.0 28 30 BAYHTR3515LUG 1/3 14.4 49200 34.6 46 50 10.8 36900 30.0 40 40 BAYHTR1515BRK with single circuit 1/1 14.4 49200 60.0 83 90 10.8 36900 51.9 73 80 power source kit BAYSPEKT201A BAYHTR1519BRK with single circuit 1/1 19.2 65500 80.0 108 110 14.4 492UO 69.2 94 100 power source kit BAYSPEKT201A =Motor Amps a) MCA and MOP for circuit 1 contains the motor amps 22-1879-1C-E N 9 TRANS` TEM3 Air Handler and Heater Matrix Allowable Combinations TEM3 MINIMUM HEATER AIRFLOW CFM—HEATER MATRIX BAYHTR1504BRK* BAYHTR15088RK* BAYHTR1504PDC* BAYHTR1508PDC* BAYHTR1504LUG* BAYHTR1508LUG' BAYHTR1515BRK* Model No, gAYHTR1504LU * BAYHTR1510BRK* gAYHTR3515LUG* BAYHTR1519BRK* BAYHTR1520BRK* BAYHTR1505PDC* BAYHTR1510PDC BAYHTR1505LUG* BAYHTR51OLUG* LUG* BAYHTR3510LUG TEM3AOB18S21S* L/L L/L —— —— —— TEM3AO824S21S* L/L L/L —— —— —— TEM3AOB30S31S* L/L L/L L/L L/L -- TEM3AO836S31S* L/L L/L L/L L/L —— TEM3AOC42S41S* L/L L/L L/L —— L/L TEM3AOC48S41S* L/L L/L L/L —— L/L TEM3AOC60S51S*(-) L/L L/L L/L -- L/L 1. Cooling/HP Airflow 2. *=Followed by two digits �-) Taps 1-3=Low,Tap 4=Med,Tap 5=High 12 22-1879-1 C-EN � TRNVE Electrical Data Figure 1. TEM3AOB18— C48 © WARNING__ c.. _ HAZARDOUS mIA6[' IH%qq(RcI al[1[CLKk rop[I H%—%IE1D,( I II Kpt[CL■rpl%ITICHi•. ,\.N s.w.H.wH P•M•r MNHN,.H•.I.w I40, m CAUTION ' i• I USE COPPIR CC.IDIC lots ONLI• NHI I[W HN4l AA pl aS�GN110 k(Iri OL11 LEGEND Y�N • s s 1 _ N\r �Ip11� -.F ,KL•r CAWLr+Hf[ r role Hl[I nIc,r1WtT mf::H IFS I �I-H • s l 1 r �I' I �F N rau,ne rt•o HWsI asHw, .yt.r CdfL[I q 1r(MIS10P a I ® LISrtO WI.E ❑ ca.fcnoW H19aun r[Wtl r(wqu �, HHrAcrHc cat ❑I11[IKI1(/WE rIWHWI I ,I I .}ICriN I'�0\as rH1k �1- cwA<cH� BK/BL r a.(r a aP _ p rEaHlwt a wa« n � CONTROL BOX — I _v+n.HfsrolHHcx rc .Hr� a..�`uEtwrat• ( BLOWER ti r�sE SEC,IOk U nf.f1 L.WIH.., �+�cr+G tA•la lDl Iq I10( IOIF S: R I 0(A my rop(sAf Hoh[WOf I % R *I D IO y fur Cyl(1 Y .wow rWC t.3rf10 fAr S!ApIA AI(rDA Rr((R1 W,IAI H. `(� cir110 xr fi iW1145 GHIbW1 Yrrti(ONR�/ WOTOR �HH[y C. IRS AWE RHO.Di YA.1 bIY AIL p,W:%C,Irlos 1J C0g1(i+-PE TJ 1.(IMI'm 111G 14 111 HEW.(011•a 901. Figure 2. TEM3AOC60 WARNING 1�Y.ayAt A„'fi,> HAZARDOUS VGLT AGE' Y �, DiSC01p[C!AU[EECTRI(AL POI[D INc[UD,IK ITEVOTE DnCONNICu BUM%RrIUNO. ,D I <\r H.If\r.r•.I....rr 1 A\Ir,1.1..rf ........ .Ircfs..I •.1.rr• CAUTION I E USE COPPER CONDUCTORS OktY- BAF 00 TERWINALS ARE NOT DCIIDNID 10 ACCEPT 011fl 11PEL Or C011WTORSI _ f.•Hrre I.b..�.1 rwt<0\�y<I.f•c cIvL4.H. -_ LEGEND I I I g -W IELAr LIN1IAu ra PF POLARIZED PCW (f(IULE NOUSIpGI R I 7E it DELAY COIITACT NO PN POLARIZED PLUG (MALE HDUSI4r) I ® TWISTED MIRE F THE-1510R COInfCr10W \/ p WIRE Kur OR COIErfCr(n HAOYETIC COIL 0 rERIIIw T"JISEEnIfR • EARTM GRMM 77791T JUWI IOW '--\_ fl6E / . I -RI— CAPICI FOR TERW IHAL&Cn'.c:ouAIL7 1. caaR of.,w O IpSUAT[D T[YAIL IERIII NAL BK/BL COLOR M..,ERUI[-ton v ❑ 14SUTATED WE( rERWINAI g( DLALx RD rEo DR GRAHCE HIGH YOITAGE H & BLUE N<I IE M CRELIH CONTROL BOX_ — (n [noel IL YELLOW M Pump I —L00 YOIIACA x :INK CR_MEW'EL1OW BLOOER SECTION 7 grESI H.fa MIV DA[RAno4i Wovf la ILAIF 11AXIS10ARR ICAO IO of twv C(NIt.II ANSI DAWN.I10,41" L ,1 I 1.SPIED IAP'S SO JBI FOR ttr[R[y([OWL 1. Sf( NSTALLCRS 6UH0(rq MULE [ULED T f Tll _ i ,RED;[n:yD;:N,0c1 Ire:�:Aa ONE NO OR IrN HEAn.c w xu. P�ulro H.w'..I........Ap( D CONNECT IT ID LE YIiHK PlU4 N L(WAIT.CCNIM 90., L — — — I IHI[CHO•ES WA,N0I 9(IS(/a A,L WOOER t, *LEw1IL+P.01(CIED H111I4ILIr P.HN+ID rKY p90/1HSPo1 IEv 00 22-1879-1 C-E N 13 TRRME' Field Wiring Figure 3. Field Wiring Diagrams HEAT PUMP SYSTEMS AC SYSTEMS Thermostat Air Handier Outdoor Thermostat Air Handier Outdoor Unit Unit 24 VAC HOTI K t -----R ----ffR 4 VAC HOT R -- -- -� FAN � -----[-G FAN 124VAC � I Comm24 DB/ -- --- B I' -- -- - Jj Common glue Common Blue SOV I� _ -- III L�� J COOL/HEAT ] -- - -III, _ COOLING �� 1st STAGE I iL_JI IL T—�I ry 2ndSTIG --- W1 IHEAT - ---- Wi 2nd STAGE IF W White v White FMEREATGENCY --_ - XZ - WZ Dirk Black Pink In AC systems for multiple stages of electric heat, jumper W1 and W2 together if comfort control has only one stage of heat. 14 22-1879-1 C-F N � TRM/E TEM Convertibility Figure 4. Multi-Position Air Handier *=No Internal Modifications Required. 0 D n f U 0 F—-� o 0 0 0 Refrigerant / Connections Downflow • Condensate Drains U o Upflow Q Condensate 0 La Drains Vertical Upflow* Vertical Downflow cf 00 O <A,rflow QC ❑FLJ'= I I r ��❑ Q� Airflow eEl o E:�:11(=� 1 Horizontal Left Refrigerant Horizontal Right Condensate Connections Condensate Drains Drains Horizontal Left* Horizontal Right 22-1879-1 C-F N 15 0 TRWE' TEM3 Air Handler Dimensional Data i i ® I - � o , d 0 a , 0 0 , Model No. H W D TEM3AOB1RS21SA 45.02 iR.50 21.13 TEM3AOB18S21SA 45.02 18.50 21.13 TEM3AOB3OS31SA 45.02 18.50 21.13 TEM3AOB36S31SA 45.02 18.50 21.13 TEM3AOC42S41SA 51.27 23.50 21.13 TEM3AOC48S41SA 51.27 23.50 21.13 TE M 3AOC60S51 SA 51.27 23.50 21.13 16 22-1879-1 C-EN TRAME` rrodur-f L s: j Split System Cooling 4TTR3018H1000N 4TTR3024H1000N 4TTR3030H1000N — 4TTR3036H1000N 4TTR3042E1000N = _ 4TTR3043A1000N 4TTR3048E1000P - 4TTR3048E1000N 4TTR3049A1000N 4TTR3060C1000N .r- November 2019 22-1842-8P-EN AR)IngersollRand TRINE' Outline Drawing SERVICE PANEL C ELECTRICAL AND REFRIGERANT y COMPONEN I CLEARANCES 1 PER PREVAIUNG CUDES \ \ TOP DISCHARGE AREA SHOULD BE UNRESTRICTED FOR AT LEAST 152415 FEET) AROVE UNIT.UNIT SHOULD BE PLALT O SO ROOF RUN-OFF WATER DOES NOT POUR DIRECTLY ON UNIT AND SHOULD BE AT LEAST 305112-)FROM WALL AND ALL SURROUNDING SHRUBBERY ONTWO SIDES. OTHERTWO SIDES UNRESTRICTED ._ -_ .-_ 1 I ELECTRICAL SERVICE K PANEL 25111 222 QMT 01A.HOLE _ I A LOW VOLTAGE 28.611-1/8)DW.K.O.WITH i 22-2 ON)DNA.HOLE IN CONTROL BOX BOTTOM FOR ELECTRICAL POWER SUP[V LIQUID LINE SERVICE VALVE,- .F. N E I.D.FEMALE BRAZE LX CONNECTION WITH 1'4'SAE L -- FLME PRESSURETAP FITTINGS G ` FIG I K.O.FOR ALTERNATE ELECTRICAL ROUTING Fpm Dvwl.Dt52tL9R -- GAS LINE 14TURN BALL SERVICE VALVE, -D" ID.FFMAt F BRA2FD CONNFCTION WFTH 1/4'SAF FLARE PRESSURE IAP HI IING.A Model Base A B C D E F G H J K 41fR3018H 2 28-3/4 (28-1/2 25-5/8) 3/4 3/B (5 (2-1/4 715/8 (1-1/2) 18 4TTR3024H 2 28 3/4 28-1/2 25 5/8 3/4 3/8 5-3/837 — Z-5/8 8-1/4` 2-1/4 IS 47fR3030H 2 28-3/4 28-730 1/2 25-5/8 3/4 3/8 513/8 2-5/8 8-1/4 2-1/4 18 4TTR3036H 3 28-3/4 32-5/8 29-3/4) 3/-1 3/8 (5756 13/8 3-1/8 (7-3/4 (2-3/8) 20 0 829 7 152 98 219 8 08 4TTR3042E 3 (28-3/4) (32-5/8 (29-3/4 7/8 3/8 6) (3-7/8) (8-5/8) (3-3/8) (20) 741 47TR3043A 4.2 29 1/8) (3741/4) 34�1/4) 7/8 3/8 (6) (3-7/8 (8-5/8) 3-3/8) (20) 4TTR304RE 3 (36-3/4) (32-5/8) (29-3/4) 7/8 3/8 6) 3-7/8) (8-5/8) (3-3/8) (20) 4TTR3049A 4.2 (29 1/8) (3741/4) (3471/4) 7/8 3/8 (6) (3-7/8) (8-5/8) (3-3/8) (20) 4TfR3060E 4.4 (37�/8) (3741/4 (34�1/4) 7/8 3/8 (6) 3-7/8) (8-5/8) (3-3/8 20 2 22-1842-8P-EN 0 TRWE` Product Specifications Model No.W 4TTR3018111000N 4TTR3024111DOON 4TTR3030111000N P0WERCONNS.—V/PH/HZ1b) 208/230/1/60 208/230/1/60 208/230/1/60 MIN.BRCH.CIR.AMPACITY 12 18 16 BR.CIR.PROT.RTG.—MAX.(AMPS) 20 30 25 COMPRESSOR CLIMATUFFO-SCROLL CLIMATUFF04-SCROLL CLIMATUFF®-SCROLL RL AMPS—LR AMPS 9—48 12.8—58.3 12.3—63 Outdoor Fan FL AMPS 0.64 0.64 0.9 Fan HP 1/8 1/8 1/8 Fan Dia(inches) 23.0 23.0 18.9 Coil SPINE FINTM SPINE FINTM SPINE FIN— Refrigerant R-4IDA 5 LBS.,11 OZ 5 LBS.,9 OZ 4 LBS.,2 OZ LINE SIZE—IN.O.D.GAS(0 3/4 3/4 3/4 LINE SIZE—IN.O.D.LIQ.1 % 3/8 3/8 3/8 Charge Spec.Subcooling 10°F 10°F 101F Dimensions H x W X D Crated(IN.) 34 x 30.1 x 33 34 x 30.1 x 33 30 x 27 x 30 Weight—Shipping(lbs.) 167 169 157 Weight—Net(lbs.) 140 142 137 Optional Accessories: Anti-short Cycle Timer TAYASCT501A TAYASCT501A TAYASCT501A Evaporator Defrost Control AY28X079 AY28XO79 AY28X079 Rubber Isolator Kit BAYISLT101 BAYISLT101 BAYISLT101 Extreme Condition Mount Kit BAYECMT023 SAYECMT023 BAYECMT023 Start Kit BAYKSKT263 BAYKSKT263 BAYKSKT263 Crankcase Heater Kit BAYCCHT302 BAYCCHT302 BAYCCHT302 Seacoast Kit BAYSEAC001 BAYSEAC001 BAYSEAC001 Low Ambient Kit BAYLOAM103 BAYLOAM103 BAYLOAM103 Refrigerant Lines et(d) TAYREFLN950 TAYREFLN950 TAYREFLN7* Service Valve Panel Cover - - 0; Certified in acwrddrK;c with the Unitary Air-Londibuncr cyuiprricnt Lcrtification Pru9ram which is based on AHRI standard 210/240. (b) Calculated in accordance with N.E.C.Only use HACR circuit breakers or fuses. (0 Standard line lengths—60',Standard lift—60'Suction and Liquid line.For Greater lengths and lifts referto refrigerant piping software Pub*32-3312-0*(*denotes latest revision). 1a> *=15,20,25,30,40 and 50 foot lineset available. 22-1842-8P-E N 3 0 TAMLW. Product Specifications Model No.(a) 4TTR3048E1000N/P 4T7R3049A1000N 4TTR306OE1000N POWER CONNS.-V/PH/HZ(b) 208/230/1/60 208/230/1/60 208/230/1/60 MIN.BRCH.CIR.AMPACITY 28 28 27 BR.CIR.PROT.RTG.-MAX.(AMPS) 45 45 45 COMPRESSOR CLIMATUFFO-SCROLL CLIMATUFF0-SCROLL CLIMATUFF5-SCROLL RL AMPS-LR AMPS 21.8-117 21.8-117 20.8-127.1 Outdoor Fan FL AMPS 0.93 1.05 1.05 Fan HP 1/5 1/5 1/5 Fan Dia(inches) 23 23 27.5 Coil SPINE FIN" SPINE FIN'" SPINE FIN- Refrigerant R-410A 6 LBS.,7 OZ 6 LBS.,7 OZ 7 LBS.,10 OZ LINE SIZE-IN.O.D.GAS(1) 7/8 7/8 7'8 LINE SIZE-1N.U.D.LIQ.(L) 3/8 3/8 3/8 Charge Spec.Subcooling 101F 101E 101F Dimensions H x W X D Crated(IN.) 42 x 30.1 x 33 42 x 30.1 x 33 42.4 x 35.1 x 38.7 Weight-Shipping(lbs.) 233 212 246 Weight-Net(lbs.) 197 189 211 Optional Accessories: Anti-short Cycle Timer TAYASCT501A TAYASCT501A TAYASCT501A Evaporator Defrost Control AY28XO79 AY28XO79 AY28X079 Rubber Isolator Kit BAYISLT101 BAYISLT101 BAYISLT101 Extreme Condition Mount Kit BAYECMT004 BAYECMT004 BAYECMT004 Start Kit BAYKSKT263 BAYKSKT263 BAYKSKT263 Crankcase Heater Kit BAYCCHT301 BAYCCHT301 BAYCCHT301 Seacoast Kit BAY`LACUUI BAYSEACUUI BAYSEAC001 Low Ambient Kit BAYLOAM 103 BAYLOAM 103 BAYLOAM 103 Refrigerant Lineset N) TAYREFLN3* TAYREFLN3* TAYREFLN3* Service Valve Panel Cover TAYSVPANL0044AA TAYSVPANL0044AA TAYSVPANL0044AA (a) Certified in accordance with the Unitary Air-conditioner equipment certification program which is based on AHRI standard 210/240. ib) Calculated in accordance with N.E.C.Only use HACR circuit breakers or fuses. W Standard line lengths-60',Standard lift-60'Suction and Liquid line.For Greater lengths and lifts refer to refrigerant piping software Pub*32-3312-0'(•denotes latest revision). 1) +=15,20,2S,30,40 and 50 foot lineset available. Sound Power Level A-Weighted MODEL Sound Power Full Octave Sound Power(dB) Level[dB(A)] 63 125 250 500 1000 2000 4000 8000 Hz' Hz Hz Hz Hz Hz Hz Hz 4TTR3018H 1 72 73.7 71.4 65.4 68 67.3 62.9 56 50.3 4TTR3024H1 74 47.9 60.5 64.1 71.2 71.2 69.0 58.2 51.5 4TTR3030H1 72 69.9 69.6 69.1 68.6 68.7 60.9 56.2 48.9 4TTR3036111 68 74.7 65.0 65.2 66.4 163.6 58.7 1 56.3 52.8 4TTR3042E1 72 77.6 68.3 67.4 65.6 67.4 58.2 54.1 47.6 4TTR3043A1 72 77.6 68.3 67.4 65.6 67.4 58.2 54.1 47.6 4TTR3048E1 74 72.5 72.3 69.2 67.5 72.3 60.2 55.2 54.2 4TTR3049A1 74 72.5 72.3 69.2 67.5 72.3 60.2 55.2 54.2 4TTR3060E1 71 81 72 69 69 66 60 57 54 Note:Rated in accordance with AHRI Standard 270-2008`For Reference Only 22-1842-8P-E N 5 � TR�11VE Accessory Description and Usage Anti-Short Cycle Timer— Solid state timing device that prevents compressor recycling until five(5)minutes have elapsed after satisfying call or power interruptions.Use in area with questionable power delivery, commercial applications, long lineset,etc. Evaporation Defrost Control — SPST Temperature actuated switch that cycles the condenser off as indoor coil reaches freeze-tip conditions.Used for low ambient cooling to 30°F with TXV. Rubber Isolators — Five(5)large rubber donuts to isolate condensing unit from transmitting energy into mounting frarne or pad.Use on any application where sound transmission needs to be minimized. Hard Start Kit— Start capacitor and relay to assist compressor motor startup.Use in areas with marginal power supply,on long linesets,low ambient conditions,etc. Extreme Condition Mount Kit— Bracket kits to securely mount condensing unit to a frame or pad without removing any panels.Use in areas with high winds,or on commercial roof tops,etc. AHRI Standard Capacity Rating Conditions AHRI Standard 210/240 Rating Conditions 1. Cooling 80°F DB,67°F WB air entering indoor coil,95°F DB air entering outdoor coil. 2. High Temperature Heating 47°F DB,43°F WB air entering outdoor coil,70°F DB air entering indoor coil. 3. Low Temperature Heating 17°F DB air entering indoor coil. 4. Rated indoor airflow for heating is the same as for cooling. AHRI Standard 270 Rating Conditions — (Noise rating numbers are determiend with the unit in cooling operations.)Standard Noise Rating number is at 95°F outdoor air. Model Nomenclature 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 Outdoor Units 4 T W V 0 0 3 6 A 1 0 0 0 A A Refrigerant Type 2=R-22 4=R.410A TRANE Product Type i W=Split Heat Pump T=Split Cooling Product Family V=Variable Speed M or B=Basic Z=Leadership—Two Stage A=Light Commercial X=Leadership L=Side Discharge R=Replacament!Retad Family SEER 3=13 6=16 0=20 4=14 8=18 5=15 9=19 Split Svstem Connections 1-45 Tons i 0=Brazed Nominal Capacity in 000s of BTUs Major Design Modifications Power Supply 1=200-230r V60 or 208-230I1i60 3=200-23013/60 4=460/3160 Secondary Function Minor Design Modifications Unit Parts Identifier G 22-1842-8P-E N 0 7RWE Schematic Diagrams Figure 1. 1.5—3.5 Ton Models TO POWER SUPPLY PER UNIT NAMEPLATE AND LOCAL CODES CF FAN CAPACITOR DEC PRODUCT DATA CN \IRE CONVECTOR —' 8 rrON START -- CPR COMPRESSOR (rL KIT IT OPTIONAL OD/ -- ¢ 1 — , m CID RUN CAPACITOR i m CS Y CS STARTING CAPACITOR Y -I C -ICSR , ao -Or-------RD-------------i BR ---BKIBL---« MS 2 CSR CAPACITOR SWITCHING RELAY R ,__________C_ _ DDT OUTD0011 THERMOSTAT - 8K/BL NPCO NIGH PRESSURE CUTOUT SWITCH CAPACITOR LPCO LOW PRESSURE CUTOUT SWITCH OD B j MS COMPRESSOR MOTOR CONTACTOR MTR8K F C to�_O e CP TMS TRANSFORINTERNAL ER OVERLOAD IOL INTERNAL OVERLOAD PROTECTOR TNERNALLT ---- m PROTECTED I INTEMALLY L---------T -—-—- HPCO LPCO I TYPICAL I i TYPICAL I MARN I NG mCAUT I ON AIR HANDLER ' THERMOSTAT HAZARDOUS VOLTAGEI USE COPPER CONDUCTORS ONLYI ► I O I ( DISCONNECT ALL ELECTRICAL 1 Iw it TEMIINALS ARE NOr Ksion I I POWER IICL1D116 REMOTE TO ACCEPT OTE1 TYPES OF CONDOCTOIS. -- 1 DISCOIWMCTSBEFORE SERVICING. I, oe III .wee dawp 4e IM eplpeNi. o do Ie myFeller H Ilecmet.1 Dever � Wiert serrlriy cu umt RL --- , ' Ieeert Dermal iejery or �-- Yo I des". NOTES �--(BO—PIKRE-OII- -DALn- --H E—AT CONTROL ,I rc LOR OF WINE XZ BK/BL N2 '--tvtalOFWANNER —F— I'-------BK------'1 I --O I s BLACK ON RED of ONANR[ —_J , I I ■ RLIE WN "In IN "EE1 ODT-A (OPTIONAL) i a--� ■I J— NI PP, Pin � IL FELLOW /R rRN►lE O' O-BK.-------' ; r fi�-- I fi ---� ------BK----------- I L-------I I I NOT : I. IF ooT-B is NOT ases. An isorm ---- I -- I N 0 NE AT AlE E O CONTROL R LUKIEI -11 AN APPROVER EATMER PROOF EI0.0RRR. 2. If'0117 IS NOT aKI.AN AW"KTIEER B To$ ' I 1 All 3.LOD VOLTAK 129 V1)FIELD 11RINR NUST K 1/ANN MINIMUM. RDA �/Cp�,)) = --�1-- ( e.ou COPPER CMKTM ON►YI , FOR CANADIAN INSTALLATIONS TO POWER SUPPLY {( �� I_ _—_—_J POUR INSTALLATIONS CANADIERNES PER LOCAL CODES — -------� CAUTION: NOT SUITABLE FOR USE ON SYSTEMS EXCEEDING 150V-70-GROUND ATTENTION:NE CONVIENT PAS AUX INSTALLATIONS DE PLUS DE 150 V A LA TERRE PRINTED FROM D157047PO3 REVA 22-1842-8P-EN 7 ACORO' CERTIFICATE OF LIABILITY INSURANCE 712M/2(MMA)DNYyy) 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 I 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 endorsements . PRODUCER CONTACT FEDERATED MUTUAL INSURANCE COMPANY E: CLIENT CONTACT CENTERPHOE HOME OFFICE: P.O. BOX 328 A/CNNo EXt:888-333-4949 FAA%c No):507A46-4664 OWATONNA,RAN 55060 ADMDRESS:CLIEN'ICUNIACICENIER(W.FLUINS.COM INSURER(S)AFFORDING COVERAGE NAIC N _ INSURER A:FEDERATED MUTUAL INSURANCE COMPANY 13935 INSURED 286-468-4 INSURER B:FEDERATED RESERVE INSURANCE COMPANY 16024 ARCTIC MECHANICAL INCORPORATED INSURER C: 460 N MAIN ST PORT CHESTER, NY 10573-3310 INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:90 REVISION NUMBER:0 THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN iSSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREIVIENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE DL SUBR POLICY NUMBER POLICY EFF POLICY EXP LIMITS LTR INSR WVD MMIDD/YYYY MMIDDIYYY X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $1,000.000 DAMAGE TO RENTED $100 000 CLAIMS-MADE J OCCUR I PREMISES IEa occurr nce MED EXP(Am one person) EXCLUDED A N N 9907993 01/18/2022 01/18/2023 PERSONAL&ADV INJURY $1,ow 000 GEWL AGGREGATE LIMIT APPLES PER: GENERAL AGGREGATE $2,000,000 77 X u r O POLICY —, `J LOC PRODUCTS-COMPIOP AGG $2,000,000 OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $1 t)w 0w aac' X �ANY AUTO BODILY INJURY(Per person) A OWNED AUTOS ONLY SCHEDULEDAUTOS N N 9907993 01/18./2022 01/18/2023 BODILY INJURY(Per accident) NON-OWNED PROPERTY DAMAGE I HIRED AUTOS ONLY AUTOS ONLY '--+ P caden X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $5,000,000 A jEXCESSLIAB CLAIMS-MADE N N 9907994 01/18/2022 01/18/2023 AGGREGATE $5,OW,000 DIEDX RETENTION$10,000 WORKERS COMPENSATION OTH- AND EMPLOYERS'LIABILITY Y I N X PER STATUTE ER ANY PROPRIETORIPARTNER/EXECUTIVE 1 E.L.EACH ACCIDENT $1,000,000 B OFFICER/MEMBER EXCLUDED? NIA N 9298530 01/18/2022 01/18/2023 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $1,000,000 it yes, IPTION OF OPERATIONS below escri ue under DESCRIPTI I E.L DISEASE-POLICY LIMIT $1,000,000 D I DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached F1 more space is requiredl CERTIFICATE HOLDER CANCELLATION 286-468-4 90 0 VII I AGF OF RYF RROOK SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 938 KING ST THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN RYE BROOK.NY 10573-1226 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE tic 1988-2015 ACORD CORPORATION.All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD NEW YORK Workers' CERTIFICATE OF STATE Compensation Board NYS WORKERS' COMPENSATION INSURANCE COVERAGE � 1 a.Legal Narne S Address of Insured(use street address cxtiy) 1 b.Business Telephone Number of lmut W ARCTIC MECHANICAL INCORPORATED 914-934-8301 460 N MAIN ST PORT CHESTER,NY 10573-3310 Ic.NYS Unemployment Insurance Employer Registration Number of Insured Work Location of Insured(Only required if coverage is specifically limited to 1 d.Federal Employer Identification Number of Insured or Social Security certain locations in New Yoik State,i.e.,a Wrap-Up Policy) Number I06-1596446 2.Name and Address of Entity Requesting Proof of Coverage 3a.Name of Insurance Carrier !Entity Being Listed as the Certificate Holder! Federated Reserve Insurance Company Village Rye Brook Celt90 938 Kingg St 3b.Policy Number of Entity Listed in Box"la" Rye Brook NY 10573-1226 9298530 3c.Policy effective period 01/182022 to 01/1 8202 3 3d.The Proprietor,Partners or Executive Officers are ❑X Included.(Only died<box if all partners/officers included) all excluded or certain partners/officers excluded. This certifies that the insurance carrier indicated above in box"T'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 d confer any rights or responsibilities beyond those contained in the referenced policy. This certificate may be used as evidence of a Workers Cot npensatiott contract of insurance or while the undet lying 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: Theresa A Riecke (Pnnt name of authorized rem esentalive or licensed agent of insurance can ier) Approved by: lei �' � 12202021 Signaturef (Date) Title: AUTHORIZED REPRESENTATIVE Telephone Number of authorized representative or licensed agent of insurance carrier: 888-333-4949 Please Note:Only insurance carriers and their licensed agents are authorized to issue Form C-105.2.Insurance brokers are NOT authorized to issue it. C-105.2 (9-17) www.wcb.rTy.gov