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HomeMy WebLinkAboutMP22-104 t[G ti;Jjy G ��4ry`CVVyi . 19 ` t".` annivm[1W VILLAGE OF RYE BROOK MAYOR 938 King Street, Rye Brook,N.Y. 10573 ADMINISTRATOR Jason A. Mein (914) 939-0665 Christopher J.Bradbury www.ryebrook.org TRUSTEES BUILDING & FIRE INSPECTOR Susan R. Epstein Michael J. Izzo Stephanie J. Fischer David M. Heiser Salvatore W. Morlino CERTIFICATE OF COMPLIANCE August 2,2022 Vito Federici&Elizabeth Federici 36 Garibaldi.Place Rye Brook,New York 10573 Re: 36 Garibaldi Place, Rye Brook,New York 10573 Parcel ID#: 141.43-1-37 This document certifies that the work done under Mechanical Permit #22-104 issued on 6/29/2022 for the installation of a new hot water heater has been satisfactorily completed. Sincerely, Michael J. Izzo Building& Fire Inspector /to �E BRC��. '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 : v -`Y ��AA 6 l DATE: 1 `� PERMIT# 1 I 22 ISSUED: v CT: BLOCK:�y LOT'/ -7 '1 LOCATION: OCCUPANCY. ❑ VIOLATION NOTED THE WORK IS... ACCEPTED ❑ REJECTED/REINSPECTION ❑ SITE INSPECTION // REQUIRED ❑ FOOTING ❑ FOOTING DRAINAGE ❑ FOUNDATION ❑ UNDERGROUND PLUMBING NOTES ON INSPECTION: ❑ ROUGH PLUMBING ❑ ROUGH FRAMING ❑ INSULATION ❑ NATURAL GAS ❑ L.P. GAS ❑ FUEL TANK ❑ FIRE SPRINKLER ❑ FINAL PLUMBING ❑ CROSS CONNECTION FINAL OTHER _ _ O � � a _ !I � N N �c N \ W LL 7 4 A. V Vl rn a� a J ycdo ■ CA 06. v H ■ q d .AT � en 0 '00 IN .. 'o °n � o-7 W CIO s W � a d Q+ O W U o N 0 Avbv � U 0-4 ■ 1'7-i W U Uo Z n � O �j a �Vdw 0Qt _ 0 bA ON M�1 W U C p FW 00 MM c� d O 5 -v v� 421 w w FaTyi w o F Q v V w z � U z PLO O w v ii N14 BUILDING DEPARTMENT D VILLAGE OF RYE BROOK J U N 2 8 2022 938 Knvc STREET RYE BROOK,NY 10573 (914)939-0668 VILLAGE OF RYE BROOK www.ryebWk:org BUILDING DERARTMENT APPLICATION FOR PERMIT TO INSTALL AND/OR REMOVE HEATING, VENTILATION AND/OR AIR CONDITION,IN/G EQUIP,MIE/NNT FOR OFFICE USE ONLY: PERMIT#: Approval Date: JUN 2 9 21 Permit Fee: $ Approval Signature: Other: Disapproved: tr_: (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 date vY 's hereby made to the Building Inspector of the Village of Rye Brook for a permit for the installation and oWr re oval of the HVAC equipment as listed below.The applicant and property owner,by signing this document agrees that said equipment will be installed and/or removed in conformance with all applicable Local,County, State&Federal laws, codes,rules and regulations. } ` 1. Address: 3� b i q i SBL: Y3 -1 _ Zone: !a'r 2. Property OwnerE , Address: 49A* q3 Phone#: 7b r 3) - L L L Cell#: email: �y 3. Contractor. tL-V Mw Address: LLA Ti51 0,,2 rZo �J(�/ . Phone#: 1. - p Cell#: t y - U b email: y(,�/L_ l 0 fG V 1990A-Zll• 4. Applicant: rrao � Co ��,�- Address: -3 3�P� Phone#-P� - -26 S Cell#, r LZ 6 r email:PM C /O Y G,-� 5. Scope of Work:New Installa 'on •Replacement( )•Removal O•Other 6. List Equipment: 6 -Lop Il (iT W °L 1 e�'_"1" 7. Location of Equipment: GL�e-1 yl C t)j 8. Method of Installation/Removal(list all equipment needed to perform job): 1 8/12/2021 RK,COUNTY OF ) as: E—G A �—" ru J ('tX, ,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 '�"kr4 C±-e(— 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 �� Sworn to before me this day of ,�n� ,20_aa,— day of u r•A- , 20 Signature o roperty Owner Signature of Applicant Print Na f Property Owner Print Name of Applicant Notary Public Notary Public eEAN LYTLE SEAN UT'T-F r— ` NOTAkYPUBLIC NOTARrnwic lily Pommission Expi,e::Aug.31,2025 MY C<lmmis810n Expires Aug.31,2CU3 Thys-ap�lica*,ion,must be properly completed in its entirety and must include the notarized signatures) of the 'ke al owner(s) of the subject property, and the applicant of record in the spaces provided. Applications 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- 8/12/2421 1 Heat-flo Heat-flo's high efficiency indirect water heaters are made with quality stainless steel materials that provide excellent heat transfer and a longer tank life,as well as abundant hot water and low operating costs.Indirect water heaters work in conjunction with a boiler to heat the water that's circulated through the heat exchanger in the tank. When paired with an high efficiency boiler,Heat-flo's indirect water heaters can generate over 50%more hot water than many water heaters of similar size. FEATURES AND BENEFITS INCLUDE: QUALITY DESIGN & CONSTRUCTION Tanks and coils are all stainless steel construction. • Large,smooth-wall coils deliver full output for years-no finned tubing to collect lime and sediment. • Over 2"of insulation,providing less than 1°/hr.heat loss. • Flexible thermoplastic jacket that will not corrode and resists denting. EASY INSTALLATION • All connections are on top on the standard units for a neat,quick,and clean installation. • Brass drain and relief valves are factory installed. • Thermal control is supplied. RESIDENTIAL & COMMERCIAL • • Models are available in 30,40,50,60,80,and 115 gallon sizes. • : • • Bank together 80 and 115 gallon units for applications with high water heating demands. : • • • Limited warranty residential installation,5 year commercial. • • • SYSTEM CONNECTION CONFIGURATIONS FOR EACH MODEL BOILER 3/4"NPT 3/4"NPT HOT RECIRC. T&P VALVE RECIRC. T&P VALVE OUTLET RETURN PORT PORT 1-1/2"NPT t.0" T&P VALVE 8'0" HOT OUTLET 0 HOT O NPT NOT OUTLET DOMESTIC BOILER 1-1/4"NPT 1-1/4"NPT COLD ---SUPPLY BOILER BOILER INLET SUPPLY RETURN 8.0" r 8.0" FRONT FRONT FRONT 1.1/2"NPT BOILER SUPPLY - 1-1/2„NPT 0 • BOILER O 0 RETURN _AQUAS AT L�AQUASfATWELL. O AQVASTAT > 1 1/2"NPT 1-1/1"NPT COLDINLET COLDINLET 0 WITH 0 - WITH 0 ' DRMN VAW�E. INTERNAL DRUNVALVE. INTERNAL : D"N VAINt BAFFLE •'s BAFFLE STANDARD&NO UNITS C UNITS XNO UNITS 0. Wtenek DIMENSIONS & CAPACITIES Conforms tout S70 174ond NSF/ANS1372 ALL HEAT-FLO PRODUCTSARE Certified to CAN/CSA PROUDLY ENGINEERED&BUILT SrVC2Z2No.110-94 IN THE USA MODEL HF-30 30 7.3 35.8 23.5 3/4 1 150 90 85 HF-40 40 7.7 45.2 23.5 3/4 1 150 90 100 HF-40L 42 7.4 35.8 28.0 3/4 1 150 90 100 HF-40R 40 7.7 45.2 23.5 3/4 1 150 90 100 HF-50 50 8.2 55.2 23.5 3/4 1 150 90 110 HF-60 60 &6 62.3 23.5 3/4 1 150 90 125 1ISI HF-60L 60 7.7 45.2 28.0 3/4 1 150 90 120 RNG HF40 80 8.2 55.2 28.0 1 1 150 90 140 THEHF-115 115 9.1 74.5 28.0 1 1 150 90 175 ' , ` , HIGH OUTPUT UNITS HF-60-HO 60 15.1 62.3 23.5 1 1 150 90 140 HF-80-HO 80 14.8 55.2 28.0 1 1 150 90 155 HF-80-HO-C BO 14.8 55.2 28.0 11/2 1 1/4 150 90 155 HF-115-HO 115 15.6 74.5 28.0 1 1 150 90 190 HF-115-HO-C 115 15.6 74.5 28.0 11/2 11/4 150 90 190 HF-85-XHO 87 28.7 63.5 28.0 11/2 11/2 150 90 215 HF-115-XHO 115 28.7 74.5 28.0 1 11/2 1 11/2 150 90 240 180' F BOILER SUPPLY RATINGS r HF-30 176 233 149 206 111.560 14.0 5.3 HF-40 193 254 157 218 117,870 14.0 5.7 HF-40L 186 251 150 215 116,000 14.0 5.3 HF-40R 193 254 157 218 117,870 14.0 5.7 HF-50 196 254 165 231 125,000 14.0 6.0 HF-60 231 298 177 244 132,340 14.0 6.2 HF-60L 211 272 157 218 117,785 14.0 5.7 HF-80 241 306 169 234 126,980 14.0 6.0 HF-115 291 363 188 260 140,890 14.0 6.0 HIGH OUTPUT UNITS HF-60-HO 353 468 299 414 221,000 14.0 10.1 HF-80-HO 366 479 294 407 220,440 14.0 9.9 HF-80-HO-C 386 507 314 435 235,510 21.0 15.8 HF-115-HO 413 532 310 429 232,135 14.0 10.8 HF-115-HO-C 423 545 320 442 239,530 21.0 16.7 HF-854HO 649 868 571 790 428,000 28.0 13.0 HF.115-XHO 674 893 571 790 428,000 28.0 13.0 Note:All ratings are based on 180°F boiler water supply and SOT cold water inlet. In the interest of continuous improvement,specifications are subject to change without notice. s G�J A P.O. i. • i ' 8 A 01569, O � �� t7 PHONE: i i 4 i i 4 •• ssue:: Heayt-flo �� Heat-floE-MAIL: SALES@HEAT-FLO.COM 0 '• . . a a Ln N N ■ 0 a 00 a p 11 � � v ■ FBI eq Ln M x Q eq w ? A W W p Ln ] r O W V o 1 uc] �. W U c.7 H x z z w I z �h A 0 --0 00 Z C7 q o W � Z °� z °z A a ov 0-4 0 c cr w tri o � cn o a $ x U 0. h z � w w 14449444942 gttg tot 4- Cato 44 to �I a w X � V rc� D BUIL DEP MENT VIL E OF RYE OK ��N 2 E 2022 938 KIN ET RYE Bl ,NY 10573 i _0 VILLAGE OF RYE BROOK .or ! BUILDING DEPARTMENT PLUMBING PERMIT APPLICATION FOR OFFICE USE ONLY A?< I O � PP #: CD=-)—o Approval Date: 2 9 2m Permit Fee: $ Approval Signature: Other: Disapproved: (fees are non-refundable) ****************************************** ****************************************************** Application dated, L 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 Plumbing as per detailed statement described below.The applicant&property owner,by signing this document agree that said plumbing work will be in conformance with all applicable Federal,State,County and Local Codes.4 �^ 1.Address: �,(� C-1(or., Q0L4_ K_ SBL: ��1 43 — �� Zone:F d�/� 2.Proposed Work: zyks1cQ 3.Property Owner:j K.. y, Ve A-cr;Li Address: C)Li 1 L4-'1 - . CQ5'(VPPnla)l -' C Phone#: Cell#: email: p� �� �( 1� 4.Master Plumber: ` C o S t ✓k Adrdr'ess:�j 3 + a h I wt M44 K�4 Lic.#: IT IL�- Phone#: 7 �i Cell#: '!t/ d email: �� / �//may Company Name?— �� .� ��wl Address/ /✓rN)��--/ ��u/ 17 e�C� INDICATE FIXTURES&LINES TO BE INSTALLED AS PER THE FOLLOWING SCHEDULE: Location Water Urinals Drinking Sinks Showers Bath Laundry Domestic Fire Sanitary Natural/ Other* Total Closets Fountains Tubs Tubs Service Service Sewer LP Gas Basement I 1 st Floor 2nd Floor 3`d Floor 4'Floor 5`h Floor Exterior 5.* List Other Equipment/Provide Details: AeCA90 ��— „ 1 jnPC�;- T�M A i.&. Y�fC.0 1l-k�U (Notarized Signatures Required Next 2 Pages) 8/12/2021 a�z�STATE OF piFWT01M,-COUNTY OF as: being duly sworn,deposes and states that he/she is the applicant above named, (prinT t 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 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. Z � Sworn to before me this f,� Sworn to before me this Z day of X- ,20 day of � ,20_2, _ Signature o operty Owner a e of Applicant V 1-tc f�.1 2F�+ aAA,. Cam' s b1 Print Name of Property Owner Print Name of Applicant —-t> - DAE GON KIM Notary Public f New York Notary Public I ICense Number:01 K16392677 Expiration Date:08/19/2023 SEAN LYTLE Qualified in Westchester County NOTARYPU'&ZJC Ny Commission EXP1f$$A:y,41, 2025 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. Applications 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 BUILD MENT p Q V VIL 'UF OOK 938 KING E� ��BytQ� NY 10573 JUN 2 8 2022 61�or VILLAGE OF RYE BROOK BUILDING DEPARTMENT AFFIDAVIT OF COMPLIANCE VILLAGE CODE §216 • STORM SEWERS AND SANITARY SEWERS THIS AFFIDAVIT MUST BEAR THE NOTARIZED SIGNATURE OF THE LEGAL PROPERTY OWNER AND BE SUBMITTED ALONG WITH ANY BUILDING OR PLUMBING PERMIT APPLICATION. ANY BUILDING OR PLUMBING PERMIT APPLICATION SUBMITTED WITHOUT THIS COMPLETED AND NOTARIZED FORM WILL BE RETURNED TO THE APPLICANT . Css N-t cGit- tea+r �'"QtA STATE OF NEW-Y C, COUNTY OF v+'sTef1ES -E-R ) as: 31, V, Co a-���z� d�T t �d�21\e , residing at, - CieKrY,-4 cr-. d6d 3j (Print name) (Address where you live) being duly sworn, deposes and states that(s)he is the applicant above named, and further states that(s)he is the legal owner of the property to which this Affidavit of Compliance pertains at; _,Rye Brook,NY. (JobAddress) Further that all statements contained herein are true, and that to the best of his/her knowledge and belief, that there are no known illegal cross-connections concerning either the storm sewer or sanitary sewer,and further that there are no roof drains, sump pumps, or other prohibited stormwater or groundwater connections or sources of inflow or infiltration of any kind into the sanitary sewer from the subject property in accordance with all State, County and Village Codes. r (Signature roperty Owner(s)) 17 r1-0 P_t_eJ (Print Name of Property Owner(s)) Sworn to before me this G'( day of ��� , 20D1., (Notary Public) SEAN-LYTLE. . NOT"YPUBLYC My Commission Explro4 Aug.31,2C?S an�nmi 7DATE(MM/DDIYYYY) �� CERTIFICATE OF LIABILITY INSURANCE s/zz/zozz THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT Ellen Greig NAME: BNC Insurance Agency POHCNo Ext: (914)937-1230 FAX No): (914)937-1124 90 S Ridge St Ste UL-2 E-MAIL s: egreig@bncagency.com ADDRE INSURER(S)AFFORDING COVERAGE NAIC p Rye Brook NY 10573-2836 INSURERA: Merchants Mutual Insurance Company 23329 INSURED INSURER B: Nicosia Mechanical Contracting INSURER C: Inc INSURER D: 1333a North Avenue INSURER E New Rochelle NY 10804-2149 INSURER F COVERAGES CERTIFICATE NUMBER: CL225306124 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADDLSUBR POLICY EFF POLICY EXP LIMITS LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER MMIDD/YYYY MM/DD/YYYY X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000.000 A 500,000 CLAIMS-MADE X OCCUR PREMISES Ea occurrence $ MED EXP(Any one person) $ 15,000 A Y BOP1085304 05/16/2022 05/16/2023 PERSONAL 8 ADV INJURY $ Included GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY ECT PRO ❑ LOC PRODUCTS-COMP/OP AGG $ 2,000,000 J OTHER: Cyber Liability $ 100,000 AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000 Ea accident X ANY AUTO BODILY INJURY(Per person) $ A OWNED SCHEDULED CAP1064875 05/16/2022 05/16/2023 BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS HIRED HNON-OWNED PROPERTY DAMAGE $ X AUTOS ONLY AUTOS ONLY Per accident X UMBRELLA Lit X OCCUR EACH OCCURRENCE $ 4,000,000 A EXCESS LAB CLAIMS-MADE CUPIO01099 05/16/2022 05/16/2023 AGGREGATE $ 4,000,000 DIED I X1 RETENTION $ 10,000 $ WORKERS COMPENSATION PER 0 H- AND EMPLOYERS'LIABILITY YIN STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE ❑ N/A E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ T I . . DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Village of Rye Brook is included as Additional Insured when required under written Contract or Agreement. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN Village of Rye Brook ACCORDANCE WITH THE POLICY PROVISIONS. Building Department AUTHORIZED REPRESENTATIVE 938 King Street Rye Brook NY 10573 c ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD NEW Workers' s°are Compensation CERTIFICATE OF Board NYS WORKERS' COMPENSATION INSURANCE COVERAGE 1 a. Legal Name and address of Insured (use street address only) 1 b. Business Telephone Number of Insured NICOSIA MECHANICAL CONTRACTING INC 1c. NYS Unemployment Insurance Employer 1333A NORTH AVE#295 Registration Number of Insured NEW ROCHELLE NY 10804 1d. Federal Employer Identification Number of Insured or Work Location of Insured (Only required if coverage is specifically Social Security Number limited to certain locations in New York State, i.e. a Wrap-Up Policy) 80-0927730 2. Name and Address of the Entity Requesting Proof of 3a. Name of Insurance Carrier Coverage (Entity Being Listed as the Certificate Holder) Hartford Underwriters Insurance Company Village of Rye Brook 30104 Building Department 3b. Policy Number of Entity Listed in Box 1a": 938 KING ST 76 WEG AC9354 RYE BROOK NY 10573-1226 3c. Policy effective period: 05/02/2022 to 05/02/2023 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 "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 it confer any rights or responsibilities beyond those contained in the referenced policy. This certificate may be used as evidence of a Worker's 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: Danielle Clausen (print name of authorized representative or licensed agent of insurance carrier) Approved by: ;c fPc (Jon, 06/22/2022 (Signature) (Date) Title: Operations Manager Telephone Number of authorized representative or licensed agent of insurance carrier: (877) 287-1316 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) Form WC 88 31 21 F Printed in U.S.A. www.wcb.ny.gov Page 1 of 2