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HomeMy WebLinkAboutMP22-042 o Am ann7 ic Jk'1L3 LYW VILLAGE OF RYE BROOK MAYOR 938 King Street, Rve Brook,N.Y. 10573 ADMINISTRATOR Jason A.Klein (914) 939-0668 Christopher J. Bradbury www.eyebrook.org TRUSTEES BUILDING& FIRE INSPECTOR Susan R. Epstein :Michael J. Izzo Stephanie J. Fischer David M. Heiser Salvatore W. Morlino CERTIFICATE OF COMPLIANCE June 28,2022 Frank Brookfield&Eleanor Brookfield 3 Acker Drive Rye Brook,New York 10573 Re: 3 Acker Drive, Rye Brook,New York 10573 Parcel ID#: 135.44-1-57 This document certifies that the work done under Mechanical Permit #22-042 issued on 3/25/2022 for the installation of a new oil fired boiler has been satisfactorily completed. Sincerely, 1 Michael J. Izzo Building&Fire Inspector /to QyE BkC 1982 BUILDING DEPARTMENT ❑ UILDING INSPECTOR ASSISTANT BUILDING INSPECTOR VILLAGE OF RYE BROOK ❑CODE ENFORCEMENT OFFICER 938 KING STREET • RYE BROOK,NY 10573 (914) 939-0668 FAx (914) 939-5801 www ryebrook.org \ - - - - - - - - - - - - - - - - - - - INSPECTION REPORT - - - - - - - - - - - - - - - - - - - - ADDRESS: 1 DATE: PERMIT# ISSUED: SECT: , BLOCK: LOT: LOCATION: OCCUPANCY: 72\y ❑ VIOLATION NOTED THE WORK IS... [ ACCEPTED ❑ REJECTED/REINSPECTION ❑ SITE INSPECTION REQoiBED ❑ 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 : : o � N RT ^d w ■ = QI N (N uCA C W W a M M o y F. A" �r N to � N W a - - O o _ OE. o W o v C a a Q = 0 a o "0 ,�/ O ~ A I cn v y >,cr y v en o 14 co _ z a a o U U ^a w v o M� = W O O O w a WH C) � W Z ,., 'O 00 w v Lo z Z b w V t V ww 240 cn � Q © w O ICI w g v v v V w ZO _ V a O � 9 � x : V z A � C o 0 = M od :" 0 Q 5 0 � a �I =1 a P-4 �-4 W � � -d BUILD G DEP�K MENT D 0 VED VIL E OF RITE OOK MAR 2 4 2022 938 KING `_TRF FT Rvf, BR01) NY 10573 (91.4)933-0668.: 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#: _zffla-) -©'y - Approval Date: MAR 2 5 25L, Permit Fee: $ Approval Signature: Other: Disapproved: (fees are non-refundable) REQUIREMENTS FOR RELEASE OF PERMIT&CERTIFICATE OF COMPLIANCE:_ 1. Properly completed& Signed Application. 2. Site/Staging Plan if Required by the Building Inspector. 3. Copy of Licensed Contractor's Liability Insurance. (Village of Rye Brook must be listed as certificate holder) & Workers Compensation Insurance on a NYS Board form(Form#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, OI Y 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. I. Address:, SBL: 1�rj — Zone: —�C7 2. Property Owner: r-Cyry< � -d�e Address: r Phone#: �y . ',)�Sy(_Cell#: email:3. Contractor: UJ�S rT_ �,Q Address:R10 [�`• U) �. ,Cis); Phone#: Y � � Cell#: email:=�rv;c.t c�eLx�-# r n� @UX54tM-ePA4. 9 4. Applicant: Address:Ei(� {\�,�„� �' si. ,C- ,lr Phone#:q m.CPA .290D Cell#: email:,,rele 5. Scope of Work: New Installation( )•Re laa ewment •Removal( )•Other( ): 6. List Equipment: ! l .1 S 7. Location of Equipment: r 8. Method of Installation/Removal(list,all equipment needed to perform job): 1 8/1 212 02 1 r&TATE OF NC*r--"RK,COUNTY OF as ` en being duly sworn,deposes and states that he/she is the applicant above named, (print name of individual signing as the al licant) and Vher state thathe,is he Tegal 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. Indic a arclutec,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 174' Sworn to before me this ! ?r ' day of 20 L7r-l- day of ! M-�L 20 71 J Signature of Property Own q g gnature of�licut i� ,e Print of Property Ow Print Name plicant Noiary Public Notary Public— >-t SEAN LYTLE NOTARYPUBLIC SEAN LYTLE y Cornmfsslon Expires Aug,31,2025 NOTAR''PVBLIC My Commission Explret Auo. 31, 'Mar This application must be properly completed in its entirety and must include the notarized signatures) of the legal n1vr..er(s) of the subject property, and the applicant of record in the spaces provided. Any application not properly completed in its entirety and/or not properly signed shall be deemed null and void and will be returned to the applicant. z 9/1 212 02 1 . e! bill Your fucuts up to VC0 40or more .' ► h M. "...I.....M... ..-. F. A.......r..e./ h more than boilers with muc omparabla AFUE energy ratings c Brookhaven National artment of Energy of Integrated In a US pep The Performance Z000, with called stem JL Lab study S I heatHyd _ Lab study Heating Systems,' y has the hi hest annual Recovery, among ALL cast • Energy rating boilers! et odulating condensing and and 95 AFUE me - iron ^! Ad UP TU n4► 88 /o ARE ate'; W • 1I& OF .. y, w - I • c. 1 1 • 'See actual •.r ' warranty for details, • System 2000 Frontier out A design that's so smart it's The unique Brain, controlling simple! �H the world's smartest boiler! HOT WATER 11tII ROOM LI V IND KITCHEN Energy Kinetics' boiler technology OEN FAMILY ROOM BEOR ,,,,,,•., outperforms and outlasts the •••�•• �, p competition. It's the boiler with EN ERGY ICS �.,•. KINIFT The Brain, our Energy Manager. On board The Energy Manager's energy diagnostics and"play recovery maximizes home heating by play"information efficiency, cuts fuel bills and is make understanding and y servicing boiler operation perfectly integrated with our low easy for everyone. mass boiler. It heats quickly, gets The Brain/Energy Manager is covered by a five year the job done, then searches for warranty and lifetime left over energy In the system protection piar,! and sends the remaining heat aft = into your home or hot water. FIVE YEARWARRANTY �esu�t� AND LIFETIME PROTECTION PLAN The r e n e rg y ENERGY N is wasted! Patented System The Pate Y • boilers . . . . by Design! ExceptionalEnergy Kinetics' engineers deconstructed every component of all cast iron boilers and developed a proven 30 year spiral design for the highest efficiency. With dozens of improvements over traditional boilers, it is easy to see why it outlasts and outperforms the competition. Here are some highlights: Specially formulated steel with no gaskets, sections or pins to foul, clean or leak. { • High Performance ceramic chamber for near perfect combustion and ultra clean operation. • Swing down door for easy access. • Over 90 pounds of jacketing and insulation for quiet, efficient operation. • Built-in superior air elimination The heart of System 2000 is our proven for quiet, efficient operation. 30-year low mass spiral steel energy converter that no cast iron or combi boiler can match. lasts and outperforms other boilers! Hard water?NEW!Our unique SEALIX`coated plate heat exchanger is shielded from mineral build up and corrosion! virtually ll unlimited hot water! y! plus! More hot water using less energ Energy Kinetics' boiler design combines Our both heat and hot water into one unit. thermos like Energy Kinetics' hot water tanks use a high - d performance plate heat exchanger that allows the tanks to completely heat from the top down with the energy in the boiler. Our tanks finish hot and fully charged, and the boiler finishes cool with no wasted heat. or 40 1 ICM ' ' ! n Scan this code to access WITH ENERGY RECOVERY additional System 2000 data online. Silent burner cover for whisper Swing down Built in stand keeps —r W00 quiet operation.Inside is the ceramic door for easy System 2000 off the cold floor. d 2"of thick more effic iency en insulation cy and quiet operat operation. servicing. ®— ' !'—'"Is� 01118 .. ---- The Quiet Sound! 00000 r.. 0 System 2000 is virtually silent. Y At 62 decibels, other boilers NOISE LEVELS OF OTHER BOILERS: �, .. .,. make It hard t0 hear a TV in the next room. At just 47 ' decibels — the sound of a private conversation - - �� , System 2000 is virtually System silent!To understand _ how significant this decibel difference is, realize that a boiler that is just one decibel higher is 30 percent louder! FOOD BLENDER A VACUUM CLEANER ROOM AIR CONDITIONER MICROWAVE OVEN A boiler that's just one decibel higher is 30 percent louder! EM and EK2 System 2000 Frontier and Stackable Installation Dimensions EK1:41" EK1/EK2 Frontier Dim"A" W/O box With box "B" EK2:49" _ EK1:2112" - Installed dimensions with* a low profile boiler base Beckett AFG 8" 9 1/2" 9" - 2419 - EK2:291 or a standard boiler base.** Carlin EZ-1 9" 9 1/2" 9" 1 - Shown without the required Carlin EZ Gas 11 5/8" 12 3/4" 14 3/4" 9„ -- water storage tank. At right:Dimensions"A"and"B" — EK1:41" depending on different burners. EK2:49" EK1:21 z" 24" - EK2: 292" 7 -"A" - 30" 7 9" sJ / 1 - ' ❑ __—__1 �.. • _ 73" 1swing down door 1 .. i 1 "* 40 gallon 56""xr 30 7y 7 �i Lo-Boy 4s water storage EK1/EK2 StaCkable 1 1l 34" tank installs Installed dimensions V1 91 a 1 Swing down door Expansion beneath with StaCkable base. 4 tank stackable 1 f 1 1 Low profile base 9f1 boiler.* 291 StaCkable 17"* base 2"it installed with a low profile base and a Beckett AFG burner. ' • Service clearances:20"from front door •• • face,0"left side and right side.Clearance Oilheat home heating system up to Domestic to combustibles:4"from the rear cover, Input Gross output BTUlhr AFUE Hot Water' 16"above to cover;4"from flue pipe. s;t. x a�owrea '° p p p .68 GPH 83,000 87.9% 169 Gal/Hr. Included(factory piped and assembled): 1 .74 GPH 90,000 87.7% 180 Gal/Hr. Boiler base, blocked vent switch,dynamic -- .85 GPH 104,000 87.5% 202 Gal/Hr. air elimination manifold. ON/OFF switch, 1.00 GPH 121,000 86.2% 228 Gal/Hr. surge protection and junction box, 3/4"drain l 'Domestic hot water rating based on first hour draw with 77°F rise and 40 gallon tank valve, plate heat exchanger on hot water ' Energy Convener weight 270 lbs. _ models,circulator and door safety switch. Draft regulator not required or recommended — Oilheat home heating system due to advanced combustion chamber. 9 Y Up to Domestic Input Gross output BTU/hr AFUE Hot Water' ' 1.20 GPH 147,000 87.6% 269 Gal/Hr. 1.40 GPH 175,000 87.0% 313 Gal/Hr. Weight 270 lbs 350 lbs Resolute RT 1.60 GPH 190.000 135.5°/ 336 Gal/Hr. 2t/Z 4 No chimney?No power vent? 1.75 GPH 2O6,000 84.0% 360 Gal/Hr. Water Content gallons gallons NO PROBLEM!Look at Resolute RTI 'Domestic hot water rating based on first hour draw with 77'F rise and 40 gallon tank. Air Inlet Pipe 2" 3" r r Energy Converter weight 350 Ibs. Or scan the code+� Boiler Flue Outlet 4" 6" at right to see 4 1. r• , •• • the complete ,=V Chimney Liner bolers. Minimum Flexible line of all �_j� +ti, Natural Gas and Propane home heating system 5" Dia. 6"Dia. Energy Kinetics 1E Input Up to Domestic rl BTU/hr Gross output BTU/hr AFUE Hot Water' Hydronic Supply 1" 11/4" 80,000 70,000 88% 149 Gal/Hr. Hydronic Return 1" 1'/4" 100,000 88,000 88% 177 Gal/Hr. 120,000 105,000 87% 203 Gal/Hr. Hydronic Circulator Taco 007e Taco 0010 1,0' 1 ENERGY ,so,000 129,000 Ss% 241 Gal/Hr. KINET/CS� 'Domestic hot water rating based on first hour draw with 77°F rise and 40 gallon tank. Better hearing,biggermvmgs from t� Energy Converter weight 270 lbs. Energy Kmehcs f-dr,of produrt, s.. Lifetime limited x .• • �yus"MIm warranty on the Energy Kinetics/System 2000 • i 1 + !_ Digital Energy 51 Molasses Hill Road,Lebanon,NJ 08833 �� '+117�1�(�� Manager and on 18001323-2066 Faz(8001 73 5-2068 Natural Gas and Propane home heating system the residential Input up to Domestic LIFETIMEI,IMIIEDWARRA.r7V ASMEpressure visit www.energykinetics.com vessels.See the ENERGY actual warrantyAs an ENERGY STAR'Partner,Energy Kinetics BTU/hr Gross output BTU/hr AFUE Hot Water' I s K NETICS for details. has determined that model EK1 meets the 175,000 153,000 8710 278 Gal/Hr. ENERGY STAREguidelines for energy efficiency 200,000 172,000 87% 308 Gal/Hr. for oil heat input from 0.68 to 0.85 gph. 225,000 192,000 85% 339 Gal/Hr. O The color yellow for heating boilers is a 250,000 209,000 84% 365 Gal/Hr. - q registered trademark of Energy Kinetics. 'Domestic hot water rating based on first hour draw with 77T rise and 40 gallon lank. SME U� OThe color yellow for heating boilers is a Energy Convener weight 350 lbs. U 1``r`' LISTED registered trademark of Energy Kinetics. 10.2098 JAN 2022 H <e.v.�s• �h N'i�: i If. �� : r - :h►I�V a :.h�N .;,• ��i' :�ti h..�, j.. coo � N -�•• ��. \ •r c o: = y K N 1\ . 00 ee u G C w = •" ids. 00 y U U 0 LLJ a .mm O W o v .° W W M �' o � o C) •� � Q�otiection r� LLJ a U O U 2 ZcA Lu O O o w up aQ , LL Z CD I U w CD of OC) • ` ,fir i c� � c � � I =_ . Ili •� Itl O U) .c N i'• a c(„ W cc cc go CIO • Ob w o C �M\ -z .i 1,:• Tv- nI �� it �_� I•• N hh :-, '���IN� _'_ # •, ,h . . l'C1�IH� :i:a s .' 1 i 3. ..��:4 I. �KWIN� •• ': � ,�,0 � 10� 'uYit ���`�i�� ol A� h O 1E$tj�T����� O �•9�,•{t/.a4•�.�`O � `•i� A �7 ,� R v 4y -: - ACOR" CERTIFICATE OF LIABILITY INSURANCE osros2az 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 endorsements. PRODUCER CONTACT FEDERATED MUTUAL INSURANCE COMPANY NAME: CLIENT CONTACT CENTER HOME OFFICE:P.O.BOX 328 IA cNNo Est:888-333-4949 Fn c No):507-446-4664 OWATONNA,MN 55060 ADDRESS:CLIENTCONTACTCENTER FEDINS.COM INSURER(SI AFFORDING COVERAGE NAIC III INSURER A:FEDERATED MUTUAL INSURANCE COMPANY 13935 INSURED 330-130-6 INSURER B: WESTMORE FUEL COMPANY INCORPORATED INSURER C: 86 N WATER ST GREEMMCH,CT 06830-5886 INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:35 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 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 DL SUBR pOl1CV NUMBER POLICY EFF POLICY EXP LIMITS LTR INSR WVD MMIDDIYYYY M /WYY X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $1,000,000 CLAIMS MAG. ❑X OCCUR PI�MIS ES Ea cE TO ryaE n:nce $100,000 MED EXP(Any one person) $5.000 A N N 9062815 OB/01/2021 06/01/2D22 PERSONALS ADV INJURY $1,000,000 N'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE S2,WO,OW X POLICY ❑JECT LOC PRODUCTS-COMPIOP AGO S2,W0,000 OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $1,000,000 �X ANY AUTO BODILY INJURY(Per person) OWNED AUTOS ONLY SCHEDULED A AUTOS N N 9062815 06/01/2021 06/01/2022 BODILY INJURY lPelaaident) HIRED AUTOS ONLY NON-OWNED PROPERTY DAM AGE ^J AUTOS ONLY Per accitlm X UMBRELLA LIAR X OCCUR EACH OCCURRENCE $7,000,000 A EXCESS LIAB CLAIMS-MADE N N 9W2816 06/01/2021 06/01/2022 AGGREGATE $7,000,OW DED I RETENTION WORKERS COMPENSATION X PER STATUTE OTH- AND EMPLOYERS'LIABILITY ER ANY PROPRIETORIPARTNERIEXECUTIVE E.L.EACH ACCIDENT $500,000 A OFFICERIMEMBER E%CLUDEDT NIA N 9917566 06/01/2021 06/01/2022 (MandatwY in NH) E.L.DISEASE-EA EMPLOYEE $500,000 It Yea.describe under DESCRIPTION OF OPERATIONS bRIoW IEl DISEASE-POLICY LIMIT SSOO,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Addloonal Remarks Sdiedule,may be sf dwd it mare spate is regwrad) CERTIFICATE HOLDER CANCELLATION 330-130-6 35 0 VILLAGE OF RYE BROOK SHOULD ANY OF THE ABOVE DESCRIBED POUCIES BE CANCELLED BEFORE 938 KING ST THE EXPIRATION DATE THEREOF, NOTICE WILL BE DEUVERED IN RYE BROOK,NY 10573-1226 ACCORDANCE WITH THE POUCY PROVISIONS. AUT-IORI7�D R1 PRFSFNTATI`,T O 1988-2015 ACORD CORPORATION.All rights reserved. ACORD 25(2016M) The ACORD name and logo are registered marks of ACORD • NEw ` YORK Workers' CERTIFICATE OF `sraTE! tkftttEllSe$Iott NYS WORKERS' COMPENSATION INSURANCE COVERAGE Board Ia.Legal Name 8 Address of Insured(use street address only) 1 b.Business Telephone Number of Insured WESTMORE FUEL COMPANY INCORPORATED 203-531-%56 86 N WATER ST GREENWICH,CT 06830-6886 1c.NYS Unemployment Insurance Employer Registration Number of Insured Work Location of Insured(Only required if coverage is specifically Umitad to t d.Federal Employer Identification Number of Insured or Social Security certain locations in Now York State,Le.,a Wrap-Up Policy) Number 06-0739367 2.Name and Address of Entity Requesting Proof of Coverage 3a.Name of Insurance Carrier (Entity Being Listed as the Certificate Holder) Federated Mutual Insurance Company Q Village Of Rye Brook #35 3b.Policy Number of Entity Listed in Box-1 a- 938 King St Rye Brook,NY 10573-1226 9917666 3e.Policy effective period 06/01/2021 to 06i01l2022 3d.The Proprietor,Partners or Executive Officers are included.(onry chw*box if ail parinersromars inriude d) ® ail excluded or certain pannerslofficers excluded. This certifies that the insurance carrier indicated above in box`3"insures the business referenced above in box"1 a"for workers' compensation under the New York State Workers'Compensation Law.(To use this form,New York(NY)must be listed under Item 3A on the INFORMATION PAGE of the workers'compensation insurance policy). The Insurance Carrier or its licensed agent will send this Certificate of Insurance to the entity listed above as the certificate holder in box"2". The insurance carrier must notify the above certificate holder and the Workers'Compensation Board within 10 days IF a policy is canceled due to nonpayment of premiums or within 30 days IF there are reasons other than nonpayment of premiums that cancel the policy or eliminate the insured from the coverage indicated on this Certificate.(These notices may be sent by regular mail.)Otherwise,this Certificate is valid for one year after this form is approved by the insurance carrier or its licensed agent,or until the policy expiration date listed in box"3c",whichever is earlier. This certificate is issued as a matter of information only and confers no rights upon the certificate holder,This certificate does not amend, extend or alter the coverage afforded by the policy listed,nor does it confer any rights or responsibilities beyond those contained in the referenced policy. This certificate may be used as evidence of a Workers'Compensation contract of insurance only while the underlying policy is in effect. Please Note:Upon cancellation of the workers'compensation policy indicated on this form,if the business continues to be named on a permit,license or contract Issued by a certificate holder,the business must provide that certificate holder with a new Certificate of Workers'Compensation Coverage or other authorized proof that the business is complying with the mandatory coverage requirements of the New York State Workers'Compensation Law. Under penalty of perjury,I certify that I am an authorized representative or licensed agent of the insurance carrier referenced above and that the named insured has the coverage as depicted on this form. Approved by: April Myer (Pnnl name of authonaed representative or licensed agent of insurance cenier) Approved by: 42!L4dRti os,.,,,. ., gnature) (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 authortzed to Issue Form C-105.2.Insurance brokers are NOT authorized to issue it. C-105.2(9-17) www.wcb.ny.gov