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Home My WebLink AboutMP16-113 1 VILLAGE OF RYE BROOK MAYOR 938 King Street, Rye Brook,N.Y. 10573 ADMINISTRATOR Paul S. Rosenberg (914) 939-0668 Christopher J. Bradbury www.ryebrook.org TRUSTEES BUILDING& FIRE Susan R Epstein INSPECTOR Stephanie J.Fischer Michael J. Izzo David M. Heiser Jason A. Klein CERTIFICATE OF COMPLIANCE December 13, 2021 Danielle Riverso &Jodi Riverso 210 Ivy Hill Lane Rye Brook, New York 10573 Re: 210 Ivy Hill Lane, Rye Brook,New York 10573 Parcel ID#: 129.76-1-3 This document certifies that the work done under Mechanical Permit #16-113 issued on 9/12/2016 for the installation of a new oil fired boiler/burner and a new hot water heater has been satisfactorily completed. Sincerely, Michael J. Izzo Building& Fire Inspector /tg Qy BRC�j�. O� 2m w � 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 - - - - - - - -y - - - - - _ - -- - - - ADDRESS : Y 0 , V1s0-0 DATE: 1 W Z l PERMIT# 1 ISSUED: G SECT: BLOCK: , LOT:—' LOCATION. �\ CCUPANCY: ❑ VIOLATION NOTED THE WORK IS.,;---,3--'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 / "I~INAL t'❑ A OTHER DIMENSIONS .,.a 3)j STANDARD EQUIPMENT: -� 5.Od9(C) t arn.n l c-i--1 c�- suCDlh Factory Tested and Assembled Cast Iron Section Assembly ` p' (jacket and collector hood are n I �--� I not assembled on 7,8 and 9 a ` section blocks) a r,� all Insulated Steel Jacket k —� ■ Aluminized Steel Flue Collector P•WGO Front side A-WGO Front a.t,, Hood with Flue Cap on Top Outlet (convertible to rear q outlet) 0 V ■ Swing-Away Burner Mounting Door 8, N� Alternate return-"A"units only ■ Refractory Blanket and Target E, 1/2 Pressure/temperature gauge Wall in Combustion Area H 3/4 Drain Valve ■ Circulator(Taco 007)-When L 3/4 High limit/circulator control Ordered N 1/2 Piping to expansion tank or automatic air vent ■ High Limit Control with Circulator R, 3/4 Relief valve Relay and LWCO Function ■ Electrical Junction Box with Supply"Ca(inches) Dimension(inches) Wiring Harnesses C p ■ Junction Box Cover Plate with Service Switch d a� is Two Vent Pipe Brackets WGO-2 11/4(circulator flange) 11/2 11/2 10 V2 13 3/4 ■ Pressure/Temperature Gauge WGo-3 11/4(circulator flange) 11/2 11/2 13 V2 16 7/8 ■ 30 PSIG ASME Relief Valve WGo-4 11/4(circulator flange) 11/2 11/2 13 5/8 16 7/8 (boiler sections tested for 50 PSIG working pressure) WGo-S 11/4(circulator flange) 11/2 11/2 16 7/8 20 ■ Drain Valve WG0-6 1 1/4(circulator flange) 11/2 11/2 20 23 1/8 ■ Barometric Damper W60-7 not applicable 11/2 11/2 23 V8 26 V4 ■ Built-in Air Separator WG0-8 not applicable 11/2 11/2 26 V4 29 3/8 WG0-9 not applicable 11/2 11/2 293/8 32V2 OPTIONAL EQUIPMENT: ■ High-Efficiency Fiame-Retention RATINGS Burner AHRI Mialmum Oil Burner(Beckett AFG,Carlin input eerunad / chimney EZ or Riello).Specify 2-Stage Fuel / r Rating Ratings moo, sizo � Unit(optional) if Required. a� `' ` �rA�`" r�4 ■ Vent Damper Kit 4� $ y'+ +ate` .?°��^ ` o°jy� q' ■ W-M 5&10 Year Homeowner V o °91, Protection plan 210 aQ�¢l o�m aJ Fes° mc'�c o m Q�3m �+ ? `- _ a Q L Q ■ W-M Indirect-Fired Water Heaters i • wco-2RD 0.70 98 86 75 870 .Oio axe 6 15 540 I WGO-2 0.70 98 86 75 86.4 .010 8X8 6 15 540 • WGO-3RD 0.80 112 98 85 87.0 .010 8X8 6 15 595 NOTES: { W60-3 0.95 133 115 100 85.3 .020 8X8 6 1s 595 Add"P"for packaged boiler(WGO-2 i • 1 WGo-.IRD 1.00 140 123 107 87,0 010 8X8 6 15 645 through WGO-6 only).Add"A"for W60-4 1.20 168 145 126 85.0 .010 8X8 6 1s 645 boiler only(WGO-2 through WGO-9). • WG0-5RD 1.20 168 148 129 87.0 .015 8X8 7 1s 760 (1) No.2 fuel oil-Commercial Standard Specification CS75-S6.Heating Value W60-5 1.45 203 175 152 85.0 .015 1 8x8 7 15 760 l WGO-6RD 1.40 196 173 ISO 87.0 .015 axe 7 15 860 of oil-140,fl00 6 WGO-e 1.75 245 212 184 85.0 .015 8X8 7 15 86O (2}Based on standarrdd test procedures . est prescribed by the United States • WGO-7RD 1.60 224 197 171 87.0 .015 8X8 a 15 930 Department of Energy at combustion WGO-7 2.00 280 242 210 85.0 .015 8X8 a 15 930 l condition of 13 1/2%CO2 and-0.02" WGO-9 2-55 357 295 257 ( - .030 SX12 8 20 O35 l (3)MBH refers to thousands of BTU "ENERGY STAR`compliant with Version 3,0 Boiler Specification of 87%J`F.J=enfy when installed at per hour the reduced burner rate(R)and with the optional vent damper kit(0).Burners shipped with standard (4)Net AHRI ratings are based on net rate nozzle,reduced rates achieved through nozzle change-refer to burner instructions or boilers installed radiation adequate for the rating label for correct selection, requirements of the building, I the interest p continual improvements in product and performance,weirMcLain rose ves including a piping and pickup the right to chznae specifications without notice. allowance of 1.15-sufficient for normal r�rE,r rrc * Sconditions.Provide additional WM1410 8R0_018_WGO SA DOE '.. allowance only for unusual piping c us �r and pick up loads. Ultra SuperSLOr Dimensions Specificatior,-. .'.,', 'r":ate,'. yr r.�;::� :,:r. ;.•- ?"s.'.,."q, ".. gaF;l VIA a. 4.1 \� o IA, s S1 S2 E RI , " - A 8 C D E F G Floor to Heat Dimensions Domestic Bailer Floor to Boiler Domestic Exchanger Shipping Model Ht Diameter Connections Connections Floor to Boiler Supply,; Return Out Capacity Surface Weight SSLRO "^'` 27 19.1/4 . 3j4 1"NPT 51-9 3/4 .a*'% _,�. tR1=5 1/4" SSU-30 39 1/2" 19 1/4" 3/4" 1"NPT S1-9 3/4" R1-5 1/4" 34" 30 15 SQ FT 62 LBS SSU_ 28 1/2' 23 1/4' 3/4 1"NPT 51.9 3/4" R1-51/4" 22" 30 ` 15 SQ FT 71 LBS SSU-45 52 112" 19 1/4" 3/4" 1"NPT S1-9 3/4" R1-5 1/4" 461" 45 20 so f 1 12 LBS SSU 50 521/2 23:IJ4' 1"• :::;;. : 1"NPT Si.9 3/4" R1=5 1/4" 46'� ' "` 60 20 SQ FT 109 LBS SSU-80 72" 23 1/4" 1 1/2" 1"NPT 51-29" R1-6" 64 3/4" 80 34 SQ Fi 143 LBS SSU-119 73 1/4" 27 , . 1 1/2" .' 1 NPT' S1 30 1/4 "', R1 71/4 66 119 34 SQJ 212 LES 551J-45C 42 23 1/4" 3/4" 1"Nr'T S1-9 3/4" S2-18 3/4" RI-5 1/4" R2-14" 32" 45 40 SQ FT 106 LBS SSU-60C 52 1/2" •234/4" 1" 1"NPT 51'9 3/4": 52- 3/4" R1-51/4 112-14": 43 1/4".; ,. .60.,-, . " 40.5Q FT- 126 LII5 SSU-80C T"' 23 1/4" 1 112" 1"NPT 51-29" 52-29" 11-6" 112-6" 61 3/8" SD 68 SCl FT 175 LBS SSU-119C :74". 27" 1-1/2" 1"NPT 51-301J4" 52-30°1/4" R1-71/4"; R2-71J4"' 613/$".: 118, .. 68SQ FT.' 24Z E9•� FEATURES OPTIONAL EQUIPMENT cut�4 .h 31fiL Stainless Steel Aquastat Control * ,,Ss .y� Finned 90/10 Cupronickel Heat Exchanger -Thermostatic Mixing Valve gy§ &' � qua.# Stainless Steel Aquastat Well -Bronze Pump www.htproducts.com120BraleyRoad, East Freetown, P �. V r - .� JOO T -r? 171 � i f s JJ E ,"7 �i w a00 n. `! CIZ 414 _ � e a �a Now _Q` M cn ;16 MID A � Q C4 co) z CN 4f e 7 r 1:6 •• � p„ Gel Gil G. f � e: T��i�+ '�'r�+ �y��M�+��.�•�•'�.��+�■ ��3��S� ��Cis��3 G �E BRnv BUIL MENT VIL OKDD 938 KIN . : , . ,NY 10573 AUG Z 3 2016 (914)9 939-5801 or VILLAGE OF RYE BROOK ELECTRICAL PERMIT APPLICATIO BUILDING DEPARTMENT Westchester County Master Electricians License Required FOR OFFICE USE ONLY AW:J? 11 EP N: Approval Date: Application Fee: S Approval Signature: Vl� Permit Fee: S Disapproved: Other: (fees are non-refundable) ********************w************w********#****w****w*www********w*w*wwwww****************wwww**** Application dated, is hereby made to the Building Inspector of the Village of Rye Brook NY, for the issuance of a Permit to install and/or remove electrical equipment, wiring, fixtures ,or to perform other high or low voltage electrical work as per the detailed statement described below. The applicant & property owner, by signing this document agree that all electrical work performed will be int conformance with all applicable Federal,State,County and Local Codes. 1.Address: SBL: Zone: 2.Property Owner: �� Address: Phone#: �� jl/� �, l�, — -lie Cell#: email: 3.Master Electrician: Address: Lie, #: �S_Phone#: r{/ yCell#: 40 — (;,b email a-0 �«Y�r c ��,LIA L t� Company Name: a jA r C Address: 4.Proposed Electrical Work/Fixture Count: ul I STATE OF_ W YORK,COUNTY OF WESTCHESTER ) as: f Q ,' duly swom,deposes and states that he/she is the applicant ova named,and does further pr t n e of individ ii ing as applicant) state that(s)he is the legal owner of the property to which this application pertains,or that(s)he is the 19 A/r I�A C-rp for the legal owner and is duly authorized to make and file this application. (indi architect,contractor,agent attorney,etc.) The undersigned further states 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 York State Uniform Fire Prevention&Building Code,the Code of the Village of Rye Brook and all other applicable laws,ordin d regulations. Sworn t re me this Sworn t e met day of 0 day o t 20_ � Si ure If rope vveheir gna a Ap ' 19Lb Pri me o Prop fty Owner intNdmeof Applicant r. ON N44�N1J$ -S A F NEW PORK Not7mE T0 6100238 YORK Cual g 6100 8a—County G1Weatc star County My mmisalon Ex rea t3ctobar 14, 20 My Cxptrea ctober 14, 20 ---F. 1/5/16 .. ..:v_. .. :-r-'1�MM�Ys.a r.—.fr�.rL6�.ian�,.��.a.._r_+i _,_ •_'--_�_a J.�:J-+i./f� .. .. Westchester Rockland Electrical Inspection Services, Inc. Phone: 914-347-3595 DO NOT WRITE HERE--FOR OFFICE USE ONLY 43 North Lawn Avenue Fax: 914-347-3596 Elmsford, NY 10523 ILDING PER IT NO. TEMP# DATE I ] V � � . CITY OR VILLAGE ZIP CODE TOWNSHIP COUNTY STREET AND NO.OR ROAD _ POLE NUMBER ° BETWEEN WHAT TWO CROSS STREETS IS PREMISES LOCATED? SECTION BLOCK LOT OCCUPANT'S NAME 9 BUILDING OCCUPANCY OWNER'S NAME AND ADDRESS HOME TELEPHONE NUMBER CURRENT SUPPLIED BY FROM THEIR OFFICE WORK TELEPHONE NUMBER LIST BELOW ALL EQUIPMENT WHICH YOU INSTALLED NUMBER OF OUTLETS NO,OF FIXTURES& MOTORS HEATERS OFFICE USE LOCATION LAMP RECEPTACLES ONLY SIQEWALL SWITCH INCADE FLUORE NO, H.P.EACH NO. WATTS EACH INSPECTION OUTSIDE E BASEMENT I �-/� -7 1 a FL. AUG 2 2016 -4 t) 2-FL. 3R6FL BUILDING DE A@TME T ' REMARKS:LIST OTHER ELECTRICAL DEVICES NOT SET FORTH ABOVE: THIS APPLICATION IS INTENDED TO COVER THE ABOVE LISTED ITEMS TO BE INSPECTED.IF AT ANY TIME OF INSPECTION ADDITIONAL ITEMS HAVE BEEN INSTALLED,YOU ARE AUTHORIZED TO MAKE THE INSPECTION AND ADJUST THE FEE FOR THE ADDITIONAL ITEMS INSPECTED AS PROVIDED BY THE APPLICANT.THE APPLICANT DECLARES THAT THERE IS NO OPEN APPLICATIONS FOR THE ABOVE WITH ANY OTHER INSPECTION COMPANY.WREIS, INC. IS NOT LISTING,LABELING.UNDERWRITING OR CERTIFYING ANY EQUIPMENT, MATERIALS OR DEVICES WHICH ARE PERFORMED BY OTHER CERTIFIED TESTING AGENCIES OR INSPECTION COMPANIES,THE APPLICANT,OWNER,OR AUTHORIZED AGENT AGREES TO ALL THE ABOVE TERMS AND CONDITIONS AS SET FORTH FOR THE APPLICATION. SIZE OF SERVICE FEEDERS CHARACTER OF WORK NEW r-] ADDITIONAL I EXPOSED U CONCEALED p MUST ENTER APPLICANTS IDENTIFICATION NUMBER SERVICE ENTERS BUILDING OVERHEAD IF- UNDERGROUND 0 AVOID DELAYS BY GIVING FULL AND ACCURATE INFORMATION.ALL SPACE MUST BE FILLED IN OR APPLICATION MAY B ETURNED. NAME OF COMPANY DAB OgAPPI.ICATION SIGNATURE,-OF APP 7 C. - L _ X STREET ADiDREW TELEPHONE NO. CITY OR POET OFFICE I} 2 P C LICENSE NO.WHEN APPLICABLE -)IS Milli ti RWESTCNESTER ROCKLANO ELECTRICAL INSPECTION SERVICES,INC. RE10 BY THIS CERTIFICATE OF COMPLIANCE THE Westchester Rockland Electrical Inspection Services 43 North Lawn Ave, Elmsford, NY 10523 914-347-3595 (Office) 1 914-347-3596 (Fax) CERTIFIES THAT Upon the application of: Upon premises owned by: Zaccagnino Electric Jodi& Danielle Riverso 81 Maple Avenue Rye NY 10580 Located at: 210 Ivy Hill Lane, Rye Brook, NY 10573 Certificate Number: 417162 Section: Block: Lot: BDC: Permit Number: EP:17-002 BP:MP16-113 A visual inspection of the electrical system at this premise described as a Residential occupancy,wherein the premises electrical system consisting of electrical devices and wiring,described below, located in/on the premises at: 210 Ivy Hill Lane, Rye Brook, NY 10573 ❑Basement ❑1st Floor ❑2nd Floor ❑3rd Floor ❑Garage ❑Attic ®Outside Inspection was conducted in accordance with the NYS and NFPA 70-08 and detail of the installation,as set forth below,was found to be in compliance therewith on 1/26/2017 Name Quantity Elating Circuit Type Boiler 1 120 volt Hot Water Heater 1 This Certificate has been approved by Westchester Rockland Electrical Inspection Services. This certificate may not be altered in any way. This certificate is valid for work performed before date of inspection only. YYYY AiIl�a CERTIFICATE OF LIABILITY INSURANCE DATE 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 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 Stephanie Payne NAME' Pan a Yn Brown & Brown of New York Inc. dba Spain Agency PHONE (845)628-4500 FAX No:(845)62e-1804 625 Route 6E-MAIL DDRESS:sP a e@ ainins.com A INSURERS AFFORDING COVERAGE NAIC II Mahopac NY 10541 INSURER AAmerica. Fire and Casualty Co. 24066 INSURED INSURER B Ohio Security Insurance Co 24082 Thuesen Mechanical Corp. INSURERCOhio Casualty Insurance Co 24074 345 Lexington Ave. INSURERDROchdale Insurance Company 12491 INSURER E: Mt. Kisco NY 10549 1 INSURERF: COVERAGES CERTIFICATE NUMBER:16-17 Master w 16-17 WC 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 TYPE OF INSURANCE A DL SUBR POLICY EFF POLICY EXP LTR POLICY NUMBER (MMIDDIYYYY1 fMMfDDIYYYY1LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE S 1,000,000 A CLAIMS-MADE �OCCUR DAMAGE TO RENTED 300 000 PREMISE Ea occurrence _ S X BXA55558075 7/31/2016 7/31/2017 MED EXP(Any one person) $ 15,000 PERSONAL B ADV INJURY S 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE S 2,000,000 % POLICY JECT LOC PRODUCTS-COMPIOPAGG S 2,000,000 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,ODO Me accident B X ANY AUTO BODILY INJURY(Per person) S ALL OWNED SCHEDULED BAA55558075 7/31/2016 7/31/2017 BODILY INJURY(Peraccderit) $ AUTOS AUTOS NON-OWNED PROPERTY DAMAGE HIRED AUTOS AUTOS Peracadent $ $ - X UMBRELLA UAB OCCUR EACH OCCURRENCE S 4,000,000 C EXCESS LIAR CLAIMS-MADE AGGREGATE $ 4,000,000 DED I % I RETENTIONS 10,000 �US055558075 7/31/2016 7/31/2017 $ WORKERS COMPENSATION S I PEfF ERH AND EMPLOYERS'LIABILITY YIN ANY PROPRIETOWPARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 1,000,000 OFFICER/MEMBER EXCLUDED? N 1 A D (Mandatory In NH) RWC3412505 5/1/2016 5/1/2017 E.L.DISEASE-EA EMPLOYE $ 11000,000 If yyes,describe under DESCRIPTIONOF OPERATIONS below E.L.DISEASE-POLICY LIMIT 1$ 1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space Is required) Certificate holder is named as Additional Insured as their interests may appear subject to policy terms and conditions. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Village Of Rye Brook THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 938 King Street ACCORDANCE WITH THE POLICY PROVISIONS. Rye Brook, NY 10580 AUTHORIZED REPRESENTATIVE Michael Spain/SP1 Q 1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD INSn25 r9ntentl Certificate of NYS Workers' Compensation Insurance Coverage Page 50 of 125 STATE OF NEW YORK WORKER'S COMPENSATION BOARD CERTIFICATE OF NYS WORKERS' COMPENSATION INSURANCE COVERAGE Ia.Legal Name and address of Insured(Use street address only) Ih.Business Telephone Number of Insured Thuesen Mechanical Corp$.Thuesen Management Corp 914-241-7499 345 Lexington Ave Mt Kisco,NY 10549 lc.NYS Unemployment Insurance Employer Registration Number of Insured 1 d.Federal Employer Indentification Number of Insured Work Location of Insured(Only required if coverage is specifically limited or Social Security Number 061405021 to certain location in New York State,i.e.a Wrap-Up Policy) 2.Name and Address of the Entity Requesting Proof of Coverage 3a.Name of Insurance Carrier (Entity Being Listed as the Certificate Holder) Rochdale Insurance Company Village of Rye Brook 938 King Street 3b.Policy Number of entity listed in box"Ia": Rye Brook,NY 10580 RWC3412505 3c.Policy effective period: 5/1/2016 to 5/1/2017 3d.The Proprietor,Partners or Executive Officers are: included(Only check box if all partners/officers included) all excluded or certain partners/officers excluded This certifies that the insurance carrier indicated above in box"3"insures the business referenced above in box"la"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 Certification of Insurance to the entity listed above as the certificate holder in box"2". The Insurance Carrier will also notify the above certificate holder 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. Please Note:Upon the 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: Henry C.Sibley (Print name of authorized representative or licensed agent of insurance carrier) ;/ 2 ff _ Approved By: /1 4/28/2016 (Signature) (Date) Title: Underwriting Manager Telephone Number of authorized representative or licensed agent of insurance carrier:CarrierPhone Please Note:Only insurance carriers and their licensed agents are authorized in issue the C-105.2 form.Insurance brokers are NOT aurhori:ed io issae it. C-105.2(9-07) mhtml:file://C:\Users\Thuesen Main\Downloads\Thuesen- C105.2 Renewal Certs.mht 4/28/2016