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HomeMy WebLinkAboutMP22-092 � 1 � DR ' 19 AM QnaftwwaW VILLAGE OF RYE BROOK MAYOR 938 King Street, Rye Brook,N.Y. 10573 ADMINISTRATOR Jason A. Klein (914) 939-0668 Christopher J.Bradbury wrww.ry-ebrook.org TRUSTEES BUILDING& FIRE INSPECTOR Susan R. Epstein Michael J. Izzo Stephanie J. Fischer David M. Heiser Salvatore W. Morlino CERTIFICATE OF COMPLIANCE June 13,2022 Theodore Marrow&Toby Marrow 223 Tree Top Crescent Rye Brook,New York 10573 Re: 223 Tree Top Crescent, Rye Brook,New York 10573 Parcel ID#: 129.76-1-59 This document certifies that the work done under Mechanical Permit #22-092 issued on 6/1/2022 for the installation of a new condenser has been satisfactorily completed. Sincerely, Michael J. Izzo Building&Fire Inspector /to '9�2jBUILDING DEPARTMENT ❑BUILDING INSPECTOR SSISTANT BUILDING INSPECTOR VILLAGE OF RYE BROOK LODE ENFORCEMENT OFFICER 938 KING STREET • RYE BROOK,NY 10573 (914) 939-0668 FAx (914) 939-5801 www ryebrook.org - - - - - - - - - - - - - - - - - - - - INSPECTION REPORT - - - - - - - - - - - - - - -- - - - - ADDRESS: ` DATE: PERMIT# ISSUED: SECT: c-�. ALOCK: I LOT LOCATION: 1�, S Q� OCCUPANCY: ❑ VIOLATION NOTED THE WORK IS... ACCEPTED ❑ REJECTED/REINSPECTION ❑ SITE INSPECTION \ REQUIRED ❑ FOOTING �011 ❑ 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 ❑ F L THER a N O M a w O u F pia, o C� ?C ca i o Ga On (--� � �;) v n,o o y N w W C� -o H M N -4 w V a �J a� M a o 04 o 010 F Oas 00 go W �_ z o ° U Mai G1 I--� M Q cn o Q C U F� A � H U tz °a te z ; A OGOP � v V U cn A p x � A � � c W ~ W P. � U F Cn ►� ° z 0 q c, 0 C •�] r a+ W w U0 W � a � w z o o U V wi o I�i a cnt> 7a."'1.0 I.y N A a Z J 0 P: u W NF .��a �I a MENT BUILDY VIL ' OF RY OOK MAY 3 1 2022 938 KING ET RYA.BR ,NY 10573 ��� 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#: Mr —0g/;- Approval Date: JUN 1 Permit Fee:S zoo 7P- � Approval Signature: Other: Disapproved: Ifees are non-refundable) ,�,��,r��*x*,�x**Yx*,r*�*���:x***��***�*:r:�:�tr*�,�,t�*�*:t�*+xx�**:�*:��x:t,�*��*x**:�**�:*x*,r************,►************ RE UIREMENTS FOR RELEASE OF PERMrr&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 Wai"er) 4. Payment of Fees/Unit: RESIDENTIAL=$I00.00/unit-COMMERCIAL=$350.00/unit. 5. Inspection by the Building Department for removal and/or installation.(48 hour notice requires!) 6. Electrical work requires a separate Electrical Permit& Electrical Inspection. 7. Plumbing/Gas work requires a separate Plumbing Permit&Plumbing Inspection. �`***'#***#***********dr********i�****k*t-k*k**k**A*9t*�c9:iP********k'****************n*x S Application dated,%, � )'cD is hereby made to the Building Inspector of the Village of Rye Brook for a permit for the installation and or removal of the H 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. Q Q 1. Address:,22 3 Tree. TOP Gres(61►4 SBL:�e�, 716 Zone: A0 2. Property Owner.TO 6 y Mq rro Ig/ Address: 223 Tree, TO C f e5 e en Phone#: q I -937 - 2.35 Cell#: 914-137-1235 email:t ro1N ,Lom 3. Contractor: Arc4I & Me-G6ni Address: WO-Norf1► Mel!, wee�-.PQri Cite ar Phone#: 714 -134 — 83n1 Cell#: 41g134-9301 email: �rgUo�f�Gl`GI` iG-/►12G�gnPcQ�.(al►1 4. Applicant: Aoft,fty BrLIVO _Address:Vo Na arf 61,6te-r Phone#: 91q-934-83s1 Cell#: J14-134 -9301 email: r�VoJt"�gCGf+`c-It1Brltani�l c5o+�1 5. Scope of Work:New Installation( )•Replacement o-Removal( )-Other( }: 6. ListEquipment: (1) Tr%ne 4TTR3034H1 o4 Condenjer, 7. Location of Equipment: To +h e 12 F� of f h e, Ire P lu e from 14 co S de. 8. Method of Installation/Removal(list all equipment needed to perform job): I 8/l2/2021 STATE OF NEW YOM COUNTY OF WESTCItESTER ) as: Th o AI%Y Brgy e ,being duly sworn,deposes and states that he/she is the applicant above named, (print namc 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 G on4 rQ c4 of for the legal owner and is duly authorized to make and file this application. (indicate architect,contractor,agent,attorney,etc.) That all statements contained herein are true to the best of his/her knowledge and belief,and that any work performed,or use conducted at the above captioned property will be in conformance with the details as set forth and contained in this application and in any accompanying approved plans and specifications,as well as in accordance with the New York State Uniform Fire Prevention&Building Code,the Code of the Village of Rye Brook and all other applicable laws,ordinances and regulations. Sworn to before me this O Sworn to before me this day of 20 day of M 10.1 20 949' Signature/of Property Owner Signature of" Applicant �Ae0iN fC in kcrow) .)II otntqy Ogg VG — - Priyqqame of Property Owner Print ame of Applicant i a (A I I A("I- h 1 o. ublic otary tla Notary Public,State of New York HMmy Public,State of New York No.OIWH6394580 No.01 WH6394580 Ouallfied in Westchester County Oualified in Westchester County Commission Expires July 8,202,3 Catrtr vssion Expires July 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 8/12/2021 � va c � CN D � s 0 11 �� c� 0 0 f'p 173'/z Ivy Hill Crescent Rye r y Brook, NY 10573 914-939-2440 dm� D ECIENE May 25, 2022 MAY 3 1 2022 ID VILLAGE OF RYE BROOK Toby Marrow BUILDING DEPARTMENT 223 Treetop Crescent Rye Brook, NY 10573 Re: Emergency AC Replacement Dear Toby Marrow, The Architecture and Grounds Committee (A&G) has reviewed your application for the above named work. This project requires a permit from The Village of Rye Brook. You are directed to submit this letter to the Village along with your permit application. Once the permit is obtained, a copy must be provided to A&G for final review and consideration. Work on the project may not begin until you receive written notice of acceptance from A&G. If any changes are made to the original plans submitted to A&G, due to input from the Village or arising during construction, the Committee must be notified in writing. Work cannot proceed until you receive written approval for those changes. Failure to comply with these procedures will result in fines and/or work stoppage. If you have any questions, please contact me at: Property Manager. Ashlee Pasquale Property Manager TRAl F Product Data Split System Cooling 4TTR3018H1000N 4TTR3024H1000N 4TTR303OH1000N - 4TTR3036H1000N 4TTR3042E 1000N =_ _ 4TTR3043A1000N 4TTR3048E1000P 4TTR3048E1000N 4TTR3049A1000N 4TTR306OE1000N November 2019 22-1842-8P-EN ORPingersoJlRand 0 TRANE" Outline Drawing --Blo --- -1 p"" SFRVICF PANEL c ELECTRICAL AND REFRIGERANT COMPONENT CLEARANCES PER PREVAILING CODES TOP DISCHARGE AREA SHOULD BE UNRESTRICTED FOR AT LEAST 1524(5 FEET) ABOVE UNIT.UNIT SHOULD BE PLACED 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 UNRESTRKTED ELECTRICAL SERVICE K PANEL 1 25 11) I Il 222(7M)OLA.HOLE A LOW VOLTAGE - ` 1 28.6(1-1/8)DIA.K.O.WITH 22.247M)DIA.HOLE IN CONTROL BOX BOTTOM FOR ELECTRICAL POWER SUPLY LIQUID LINE SERVICE VALVE. F' ID.FEMALE BRAZE CONNECTION WITH 1/4•SAE � FLME I'R[SSURETAP FITTINGS G �1 �- KO.FOR ALTERNATE ELECTRICAL ROUTING From Dwg.D152M GAS LINE 114TURN HALL SERVICE VALVE, 'D" LET.FEMALE BRAZED CONNFCTION WITH 1/4-SAF FLARE PRESSURE 1AP HT IING.A Model Base A B C D E F G H 3 K 4TTR3018H 2 0 24 51 3/4 3/8 1 5 194 38 457 28-3/4 (28-1/2 25-5/8) 5 2-1/4 7-5/8 1-1/2 18) 4TTR3024H 2 30 4 1 3/4 3/8 1 6 10 7 457 28-3/4 28-1/2 (25-5/8 5-3/8 2-S/8 8-1/4 2-1/4 18) 4TTR3030H 2 730 24 651 3/4 3/8 1 210 57 4 7 28-3/4 28-1/2 25-5/8 5-3/8 2-5/8) 8-1/4 (2-1/4) (18 4TTR3036Hr4. 30 829 56 3/4 3/8 13 79 19 60 08 28-3/4 32-5/8 29-3/4 5-3/8 3-1/8 7-3/4 2-3/8 20 4TTR3042E 30 829 756 7/8 3/8 1 8 19 8 08 (28-3/4) (32-5/8) (29-3/4) (6) (3-7/8) (8-5/8) 3-3/8) (20) 741 4TTR3043A (29-1/8 (3741/4) 34-71/4) 7/8 3/8 6) (3-7/8 (8-5/8) (348) (20 4TTR3048E (36-3/4) (32-5/8) (2 3/4) 7/8 3/8 6) (3-7/8) (8-5/8) (3-3/8) (20) 4TTR3049A (2941/8) (3741/4) 34�1/4) 7/8 3/8 (6) (3-7/8) 8-5/8 3-3/8)152 8 219 86 E 20 4TTR3060E (37 1/8) (37-41/4) (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.0) 4-TTR301SHI000N 4TTR3024H1000N 4TTR303OH1000N POWER CONNS.—V/PH/HZ(b) 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 CLIMATUFFrr:-SCROLL CLIMATUFFG-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 FIN— SPINE FIN— Refrigerant R-410A 5 LBS.,I i 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 10OF 10°F 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(ibs.) 167 169 157 Weight—Net(lbs.) 140 142 137 Optional Accessories: Anti-short Cycle Timer TAYASCT501A TAYASCT501A TAYASCT501A Evaporator Defrost Control AY28X079 AY28XO79 AY28XO79 Rubber Isolator Kit BAYISLT101 BAYISLT101 BAYISLT101 Extreme Condition Mount Kit BAYECMT023 BAYECMT023 BAYECMT023 Start Kit BAYKSKT263 BAYKSKT263 BAYKSKT263 Crankcase Heater Kit BAYCCHT302 BAYCCHT302 BAYCCHT302 Seacoast Kit BAYSEAC001 BAYSEAC001 BAYSEAC001 Low Ambient Kit BAYLOAM103 BAYLOAM103 BAYLOAM103 Refrigerant Lineset(d) TAYREFLN950 TAYREFLN950 TAYREFLN7* Service Valve Panel Cover - - - :J (d) Certified in accordance with the Unitary Air-conditioner equipment certification program which is based on AHRI standard 210/240. (n) Calculated in accordance with N.E.C.Only use HACR circuit breakers or fuses. (c) Standard line lengths—60',Standard lift—60'Suction and Liquid line.For Greater lengths and lifts refer to refrigerant piping software Pubs'32-3312-0*(*denotes latest revision). (d) *=15,20,25,30,40 and 50 foot lineset available. 22-1842-8P-E N 3 0 7RAW Product Specifications Model No.W 4TTR3048E1000N/P 4TTR3049A1000N 4TTR3060EI000N 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 CLIMATUFF®-SCROLL CLIMATUFF(&-SCROLL CLIMATUFFO-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 FINTM 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(0 7/8 7/8 7/8 LINE SIZE-IN.O.D.LIQ.i 3/8 3/8 3/8 Charge Spec.Subcooling 10°F 10°F 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 AY28XO79 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 BAYSEAC001 BAYSEAC001 BAYSEAC001 Low Ambient Kit BAYLOAM 103 BAYLOAM 103 BAYLOAM 103 Refrigerant Lineset(d) 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. (b) 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 Puba32-3312-0*('denotes latest revision). a '=15,20,25,30,40 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 4TTR3018HI 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 4TTR3030H 1 72 69.9 69.6 69.1 68.6 68.7 60.9 56.2 48.9 4TTR3036H 1 68 74.7 65.0 65.2 66.4 63.6 58.7 56.3 52.8 4TTR3042E1 72 77.6 68.3 67.4 65.6 fl72.3 58.2 54.1 47.6 4TTR3043A1 72 77.6 68.3 67.4 65.6 58.2 54.1 47.6 4TTR3048E1 74 72.5 72.3 69.2 67.5 60.2 55.2 54.2 4TTR3049A1 74 72.5 72.3 69.267.560.2 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-EN 5 7RANE' Schematic Diagrams Figure 1. 1.5—3.5 Ton Models TO POWER SUPPLY PER UNIT NAMEPLATE AND LOCAL CODES CF FAN CAPACITOR - SEE►EOWCT DATA CIS ■IRE CONNECTOR ' rat orrioNAL START CPR COMPRESSOR EIT!cCESaoRI ---------------- m CA RUN CAPACITOR y m / CAS x CS STARTING CAPAC I TOR FOr-------RDA---��--•----jam�F♦B I�_ ---BKfBI������ MS to 2 CSR CAPACITOR SWITCHING RELAY L�R I_________ r ___, DDT OUTDOOR THERMOSTAT 4 - BK/BL - xpco M18M PRESSURE CUTOUT SWITCH CAPACITOR LPco LOW PRESSURE CUTOUT SWITCH OD B ORJ Ms COMPRESSOR MOTOR CONTACTOR FAN P I Ilia TNS TRANSFORMER MT R BK nFC H R CPR I IOL INTERNAL OVERLOAD PROTECTOR rxERNAur R '--- � m MOTFCTED I INTEMALLY --------'1 -—-—- TYPICAL I I TYPICAL xpto LPco I AIR HANDLER t I mWARN I NG mCAUT I ON THERMOSTAT HAZARDOUS VOLTAGEI USE COPPER CONDUCTORS ONLY ac m Ir I O DISCONNECT ALL ELECTRICALMIT TEIRIIRALS ARE NOT DESIGNER POWERIRCLIDING REMOTE TO ACCEPT OTER TYPES OF CORDUCT%$. DISCONNECTS BEFORE SERVICING. IIL�JI I Fdlvo fe H 20 ory auie Iorp "RiPw �+�c►' —I � I � —� Fallvo b llunAoa4"ter leforo se""iy cu(else BL ---�-- Yo I I ' severe perelsel i1jery or I I deekl. NOTES I HE— AT I CONTROLS ,-c'a or IIRf X2 BK/BL I1 �U-BK - OF C NNER - --BK--- KAN m RD a ORANK i RLEE W WIFE OR ONEER OOT-A wl tO►T10RAL1 i Q ' — 1 r rL rzuw M PNSLE ,-O O-BK--------' �� I— ' I , I------BK----------' I L------- I ' DIFFER: W W A rA AT AIR RAWLER. I UEOOT-11 F E[M ' ----i ' --� MST w MOUNTED REMOTE Or CONTROL 50 11 B ---I— — , I I AN APPROVED I"TINR PROOF ENCLOSwE. B ( i 2. IF OOT-A ii ROT ISEI.All J NPER DETNEER 2N ' I , NI e W AT AIR NLwLEN. BL I R ,,(/p\� S. LW VOLTAGE 124 VI I IELI■IRIRG MUSE lE 11 ADD rIMIMUII. _ ---J—�--RD� I e, SSE COMER CtlWCTONS wLYI TO POWER SUPPLY POUR I STALLFOR CANADI ATIONS CLANADIENNES PER LOCAL CODES ���--T I----_--J --------' CAUTION: NOT SUITABLE FOR USE ON SYSTEMS EXCEEDING 150V-TO-GRMND ATTENTION:NE CONVIENT PAS AUX INSTALLATIONS DE PLUS DE 150 V A LA TERRE PRINTED FROM D15T0/7P03 REVA 22-1842-8P-E N 7 A1* R CERTIFICATE OF LIABILITY INSURANCE DATE 12/20/D/YV1 Y7 12202021 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 statem-rift on this certificate does rat confer rights to the certificate holder in lieu of such erxlorsement s. PRODUCER CONTACT FEDERATED MUTUAL INSURANCE COMPANY NAME: CLIENT CONTACT CENTERPHONE - HOME OFFICE: P.O.BOX 328 A C. Ext:888-333-4949 ac No):507-446-4664 CANATONNA, MN 55060 ADDRESS:CLIENTCONTACTCENTER FEDINS.COM INSURER IS)AFFORDNIG 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: 460N 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 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 POUCY NUMBER POLICY EFF POLICY EXP LIMITS LTR INSR WVD MMIDDIYYYV MWDDIYYV X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $1,000,000 DAMAGE CLAIMS-MADE u OCCUR PREMISE T Ea ocarrerxe $100,000 AD MED EXP(My one person) EXCLUDED A N N 9907993 01/18/2022 01/18/2023 PERSONAL&ADV INJURY $1,000,000 N'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $2,00 X 0Q00 POLICY ❑JE T ��LOC PRODUCTS-COMPIOP AGO $2,000,000 (OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $1,000,000 M.acd X ANY AUTO BODILY INJURY(Per person) OWNED AUTOS ONLY SCHEDULED A AUTOS N N 9907993 01/18/2022 01/18/2023 BODILY INJURY(Per accident) HIRED AUTOS ONLY NON-OWNED P AUTOS ONLY P r ERROPERTY DAMAGE X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $5,000,000 A EXCESS LIAB CLAIMS-MADE N N 9907994 01/18/2022 01/18/2023 AGGREGATE $5,000,000 DED I X I RETENTION$10.000 WORKERS COMPENSATION OTH- AND EMPLOYERS'LIABILITY Y I N X PER STATUTE ER ANY PROPRIETORIPARTNERIEXECUTIVE 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 If yes,describe under DESCRIPTION OF OPERATIONS below E. DISEASE-POLICY LIMIT $1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Addiboml Remarks Schedule,may be atached it more space is required) CERTIFICATE HOLDER CANCELLATION 286468-4 90 0 VILLAGE OF RYE BROOK 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 © 1988-2015 ACORD CORPORATION.All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD PORK Workers' CERTIFICATE OF STATE Compensation NYS WORKERS' COMPENSATION INSURANCE COVERAGE Board 1 a.Legal Name&Address of Insured(use street address only) 1 b.Business Telephone Number of Insured ARCTIC MECHANICAL INCORPORATED 914-934-8301 460 N MAIN ST PORT CHESTER,NY 10573-3310 1 c.NYS Unemployment Insurance Employer Registration Number of Insured Work Location of Insured(Only required if coverage is specifically limited to 1d.Federal Employer certain locations in New York State,i.e.,a Wrap-Up Policy) Identification Number of Insured or Social Security Number 06-1596446 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 of Rye Brook Cert 90 938 King St 3b.Policy Number of Entity Listed in Box"1 a" Rye Brook NY 10573-1996 9298530 3c.Policy effective period 01/182022 to 01/182023 3d.The Proprietor,Partners or Executive Officers are �x 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"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 wil send this Certificate of Insurance to the entity listed above as the certificate holder in box'7. 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: Theresa A Riecke ((Print name of authorized representative or licensed agent of insurance carrier) Approved by: lit 12202021 lSignature) (Date) Title: AUTHORIZED REPRESENTATIVE Telephone Number of authorized representative or licensed agent of insurance cattier: 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.ny.gov