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HomeMy WebLinkAboutMP22-114 V �9 406 annivm aW 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.or� TRUSTEES BUILDING & FIRE INSPECTOR Susan R Epstein Michael J. Izzo Stephanie J. Fischer David M. Heiser Salvatore W. Morlino CERTIFICATE OF COMPLIANCE August 16,2022 Debra Nanus 130 Brush Hollow Crescent Rye Brook,New York 10573 Re: 130 Brush Hollow Crescent,Rye Brook,New York 10573 Parcel I D#: 129.76-1-130 This document certifies that the work done under Mechanical Permit #22-114 issued on 7/18/2022 for the installation of a new oil fired boiler has been satisfactorily completed. Sincerely, 2 k / 4 Steven E. Fews Assistant Building&Fire Inspector /to Qye BRMOv,t. Zm w 1982•��O BUILDING DEPARTMENT ❑BUILDING INSPECTOR �SSISTANT BUILDING INSPECTOR VILLAGE OF RYE BROOK / [J LODE ENFORCEMENT OFFICER 938 KING STREET • RYE BROOK,NY 10573 (914) 939-0668 FAX (914) 939-5801 www.ryebrook.org - - - - - - - - - - - - - - - - - - - - INSPECTION REPORT - - - - - - - - - - - - - - - - - - - - r"IADDRESS : �/ v V�\� C` ATE: �� \ t U� PERMIT# ' \ 1 ISSUED: SECT: , �� $LOCK: ' LOT: 1� �M114 LOCATION: r1` (` C l `c � C� O`UPANCY: �\ ❑ 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 fy FINAL /❑ OTHER v tN x Cl.� r� a o C° U ■ F W a � �� o r � � a W O O o. sa � cd O W P4 a � w ■ F—+ i.r O 04 .o 72 41, v a AQ �, g ° , Er �+ ski 4 ° 4 3log v V� T .Ln CA a1 U fd o,, � t U �I Nbc O y o 0 D Q z a 8 1L� 00 av V C\ CN W4 � � v � � � O zZ ti vw ' u V w r © A z a vX o b C v ow °aa (41 ( � MQ QJ w H o z � 00, yd v' O w °A „ • cu 6 BUILD C. )CRTMENT D �, V �,,/] �" VILG E OF RYE BROOK 938 KIN ET RYE BROOK,NY 10573 JUL 18 2022 ID -0668, o k:o�r 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#: JUL1 8, Approval Date: 2022 Permit Fee: $ Approval Signature: Other: Disapproved: V77�� (fees are non-refundable) REQUIREMENTS FOR RELEASE OF PERMIT& CERTTFICATE OF COMPLIANCE: I. 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, Q$21DUis hereby made to the Building Inspector of the Village of Rye Brook for a permit for the installation and or remov 1 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. r I. Address: 1'3b 7R�,p A-) "CA\I-3,D Urea ea� SBL: 17.1.76 - 1 -13 0 Zone: 2. Property Owner: t Ow-t._, Address:���?,A-1 QaaC4 Phone#: 914-Jn - 7?,32 Cell#: email: e1ne U5 to valan_Mt 3. Contractor: Address: Phone#:�tkg CSA •_61tQQ Cell#: email: ��"ec 4. Applicant: WS.S p1�r�hcx►1 K�CMrn4 dress: �y�� h*- r-,`�r, 'S'CE'PnWxAC, C{�.�,+� Phone#:Q\4• •��C� Cell#: email:ggr,r,c fAPN, ,�,� ,•, , 5. Scope of Work:New Installation( • RgnlacPrnent( )• Removal( )•Other 6. List Equipment: I ^ 5 �` 5im&"1"oex_ 7. Location of Equipment: +c bosn;C M- 8. Method of Installation/Removal(list all equipment needed to perform job): �Ao r-,A—t �t` :f� 1 H/12/2021 r oNfltdli&t (-4(.ft't%t ST OF COUNTY OF WE0W'Ii£S'F6& ) as: being duly swom,deposes and states that he/she is the applicant above named, (print name of i ual signing as the applicant) and further states Aat(s)he is the Icgal owner of the property to which this application pertains,or that(s)he is the J2� for the legal owner and is duly authorized to make and file this application. (indicate archil-L scam,agent,amm.ey,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 �3 Sworn toJ2CJ[ore me this ` 3�\ day of ,20_15�_ day of 20�_ Signature of Pro er Signature of Applicant �✓us h "� Print Na Property Print Na plicant Noiary Public Notary u SEA YTLC AN LYTLE NOTARYPUBLI NOT'lRYPUBLZ MY COMMISSIbo Expires Aug;v,2^,S WY COMMISslon Expires Aug,31.2025 ; This application must 5e properly completed in its entirety and must include the notarized signature(s)of the legal owner(s)of the subject pf6perty,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 retumed to the applicant. sn 2no21 - 1 1 I - • • f � beat � r: i ti There are models and sizes available for every installation and environment. Fits under stairs and inside small closets! Our patented spiral boiler precisely controls the flow c of water and flue gases k N for the best heat transfer. Plus! No pins. baffles or micro passages to foul and f reduce efficiency over time. EK2 Swing down door for easy service and cleaning! • Exceptionally clean burning • Virtually unlimited hot showers! • ASME certified construction • Stackable model available • 5 zone control • Easily piped to multiple zones • Plus! Outside combustion air connection to Cuts up to 40% off home heating bills! • Light weight construction 0 Accepted For Use City of New York IISTIU Department of Buildings MEA 140-03-E ••. • i � � • • I • A 1 • I I11 • EM System 2000 is an integrated system - R' makes both heat and hot water! Oilheat home heating systems Homeowners enjoy economical heat, plus virtual endless hot showers with lower energy System 2mit Qilheat performance' Y 9Y Lifetime limited warranty/option to transfer. costs. Plus, System 2000 delivers significant Energy recovery standard on all systems, savings over electric or traditional hot water making methods, with whisper quiet operation! - BENEFITSES 10 feet forced counter flow passages Maximum heat recovery POWER VENTING Homeowners who Wat net stack temperature to 67 efficiency Water content:EK1-2'h gal.,EK2=4 gal. Rapid Rapid heat ffi up,cool down plan to save money by converting from Wet base design Minimizes heat losses expensive electric heat to oilheat often High temperature combustion chamber Incinerates fuel-clean,safe heat _ Bioheat compatible Works with renewable fuel standard find themselves up against a brick wall: Jacket/insulation:EKl=901bs.,EK2=110lbs. Minimizes heat losses the high cost of chimney construction. Buried combustion Quiet operation But with System 2000's unique combustion 3116'pressure vessel steel throughout 50%thicker than boiler tubes No chimney ASME code construction and Carefully Inspected,pressure tested, is needed! chamber, combined with a 10 foot long flue Nat'l Board of Pressure Vessels registered and certified Ground level ases leave System 2000 clean, venting passage, g y All welded and threaded connections No gaskets to leak or service stays relatively and relatively cool. So they can be vented Built-In dynamic air elimination Eliminates air from system,no"gurgles" cool! directly through-the-wall. No chimney is Front cover swings down Easy access to all components Large open passages Easy to clean and inspect needed.!An excellent benefit for home- Standard burner and accessories Serviceable with normal stock parts owners converting from electric heat, Small size Compact and stackable installations heat pumps or for new home construction. Chimney venting Ideal for retrofit installations Power venting is the safest method of side Power vent chimneyless option available Save thousands on chimney construction wall venting and is a low cost alternative to chimney construction. EX1 TRONTIER SPECIFICATIONS Oilheat home heating system Domestic Input Gross output AFUE Hot Water' 68 GPH 83,000 BTU/HR 87.9% 170 Gal/Hr. .74 GPH 90,000 BTU/HR 87.7% 180 Gal/Hr. .85 GPH 104,000 BTU/HR 87.5% 202 Gal/Hr. 1.00 GPH 121,000 BTU/HR 86.2% 228 Gal/Hr. Domestic hot water rating based on first hour draw with 77°F rise and 40 gallon tank. Energy Converter Weight 270 lbs. fir... FRONTIER SPECIFICATIONS Oilheat home heating system Domestic Input Gross output AFUE Hot Water* 1.20 GPH 147,000 BTU/HR 87.6% 293 Gal/Hr. 1.40 GPH 175,500 BTU/HR 87.0% 334 Gal/Hr. 1.60 GPH 190,500 BTU/HR 85.5% 368 Gal/Hr. 1.75 GPH 2O6,000 BTU/HR 84.0% 395 Gal/Hr. 'Domestic hot water rating based on first hour draw with 77°F rise and 40 gallon tank. _- Energy Converter Weight 350 lbs. w C} J 0 0 0 Lifetime limited A warrantyon w tJFEnME LIMITED WARRANTY Digital Energy r+ � us SM Manager and E w �i*ENERGY ASME pressure V�KINET!cs vessels LISTED H �^* t As an ENERGY STAR®Partner,Energy Kinetics has yx. determined that model EK1 meets the ENERGY STAR* guidelines for energy efficiency for oil heat input from 0.68 L to 0.85 gph.®The color yellow for heating boilers is a registered trademark of Energy Kinetics. Accepted For Use City of New York ❑� Department of Buildings MEA 140-03-E web site ENERGY KINETICS® Easy service compact oilheat EK1 Frontier, with 40 gallon low boy tank and stand 51 Molasses Hill Road, Lebanon, New Jersey 08833 T: 800 323 2066 • F: 800 735 2068 visit: www.energykinetics.com EK1 and EK2 System 2000 Frontier and Stackable Installation Dimensions EK1:41" EK1/EK2 Frontier Dim"A" W/O box With box "B" EK2:49" _ EK1:212" Installed dimensions with ++ a low profile boiler base* Beckett AFG 8" 9 1/2' 9 _ 24" _ EK2:292 Shown nwithtstorage tank. Riello40F5 13' 9 N/A/A 9 A++ or a standard boiler base.** Carlin EZ-1 9 water i t required 15" r i i At right:Dimensions'A*and"B" _ EK1:41" - - depending on different burners. EK2:49" - EK1:212" 24" - EK2:292" "A" -' 30" Ul9. 1 _ 73" I sang aow"n��� , 30 � 48" ' 40 gallon 56" Lo-Boy water storage EK1/EK2 Stackable 34++ / tank installs Installed dimensions 91++ I Swing down door Expansion beneath with stackable base. 4 t-k stackable _r 1 t t boiler. Low profile base 911* ^Bf1 29gr+ Stackar— ninv ba:.. , �17 i- _ •• t t t 2"A 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 i Oilheat home heating system Up to Domestic to combustibles:4"from the rear cover; t + Input Gross output BTU/hr AFUE Hot Water* 16"above top cover;4"from flue pipe. .68 GPH 83,000 87.9% 169 Gal/Hr. Included(factory piped and assembled): i .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, I 1.00 GPH 121,000 86.2% 228 Gal/Hr. surge protection and junction box,3/4"drain '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 Converter weight 2701bs. models,circulator and door safety switch. • •• • Draft regulator not required or recommended Oilheat home heating system Up to Domestic due to advanced combustion chamber. Input Gross output BTU/hr AFUE Hot Water' 1.20 GPH 1 ,000 87. % Gal/Hr. Weight 270 Ibs 350 Ibs Resolute"RT 1.40 GPH 17575,000 87.0 313% 313 Gal/Hr. 1.60 GPH 190,000 05.5% 336 Gal/Hr. Water Content 21/2 4 No chimney?No power vent? 1.75 GPH 2O6,000 84.0% 360 Gal/Hr. gallons gallons NO PROBLEM!Look at Resolute RT! 'Domestic hot water rating based on first hour draw with 77°F rise and 40 gallon tank. Air Inlet PI pe 2" 3" r Energy Convener wegM 350lbs. Or scan the code Boiler Flue Outlet 4" 6" at right to see I. , • - • the complete ,: } • Minimum Flexible line of all +JNr +ti+ Natural Gas and Propane home heating system 5"Dia. 6"Dia. Energy Kinetics Chimney Liner balers. ❑� r� r Input Up to Domestic BTU/hr Gross output BTU/hr AFUE Hot Water Hydronic Supply 1" 1'/+" 80,000 70,000 88% 149 Gal/Hr. Hydronic Return 1" 1'/4" 10,000 88,000 8 % Gal/Hr. ENERGY 120,000 105,000 877 203% 203 Gal/Hr. Hydronic Circulator Taco 007e Taco 0010 150,000 129,000 86% 241 Gal/Hr. KINETICS 'Domestic hot water rating based on first hour draw with 77°F rise and 40 gallon tank. ..14".bW,,srvirgs hom de Energy Convener weight 270 Ibs. Energy xnerxs Wily of pmdicls Lifetime limited • • ESineusMED/4n warranty on the Energy Kinetics/System 2000- '' � I, Coco 51 Digital Energy Molasses Hill Road,Lebanon,NJ 08833 L-L Manager and on 1 - (800)323.2066 Fax(800)735.2068 Natural Gas and Propane home heating system �- ,, the residential uFET1MELIMITEDWARR�T� ASMEpressure visit www.eriergykinetics.com Input Up to Domestic vessels.See the ERGYactual warranty As an ENERGY STAR°Partner,Energy Kinetics BTU/hr Gross output BTU/hr AFUE Hot Water* EN L4�0 y KINETIC for derails. has determined that model EK1 meets the 175,000 153,000 87% 278 Gal/Hr. ENERGY STAR"guidelines 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. ®The color yellow for heating boilers is a 250,000 209,000 84% 365 Gal/Hr. A registered trademark of Energy Kinetics. 'Domestic hot water rating based on first hour draw with 77°F rise and 40 gallon tank. rL � SME ° ®The color yellow for heating toilers is a Energy converter weight 350lbs. LISTED registered trademark of Energy Kinetics. 10-209e FE9 2021 H :. ^���'G A � �!~A%•� �F`F A �' _�/� A � >, A t fir- f Af '��. DIY �O.I to i ;� � �iOf t �:� `�� O � � ivl. � A 1 '�.0:'..t .y:. . � 1�• . _ 1 1���111.. t/j�1ih' 111i/1�1 It1li�/i1► {� 111///11+11 t� 11/11111►1 11/�111j1 �'�7�.• 't��l 11►: ti t -111�i1s:� ;_111 11►:Y�3 *:'�:.Ill�iil �i 1'�bl 1/►:': 1111 llll.rr i (P��{{ c O • w _ O N it;. •r. 04 l 11 o C�. N 00 00 a� C ❑ r :a 11�www l o U L �•_ �' ;', A C �o Q � � 0 -0 _ 0 CA .ico)► A •^y " «ter#))� _ r L • O = W o U c .k QI O W M �, cncu Zs) FO p ° DI�gCtiOn . cn . L W p a a� .r N- v./ O U 2 z 3 cn i i 'LI W «. .� ry.y W w ►- LL z O 4" j a Q C L .'� INN i VV � � .S � �• d A `° 1 ' � CL I CO V y co y N �' � fir::= � T •c U 2 L •N C O x d((/1v�)>` if 1► ' ►/ t► �_� _ �JJ;.1► 11 4i . . .p,3s; gill N 1'"�. SF"11 d►/1►1 11►INh 1111�jN1 111 1 `' 0111h4 ;"1►�f11�111h� J 1111/�llltil ' NI= *f ;1/11 IIIN // fj IINI ` IIHI 11/1t _, .. +V � E.J`YyS.9'�. _i'`Ji.�S 'Y� .:<l�Vjb•.. L vJ�t .. �'''+G��,yy= ., Sj��� �".�- '`;� CERTIFICATE OF LIABILITY INSURANCE OAT04/271D/YWY o4arao22 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: It 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 5. PRODUCER CONTACT FEDERATED MUTUAL INSURANCE COMPANY PROH CLIENT CQpTAC7SENTER L HOME OFFICE:P.O.BOX 328 A/C N., %1 688- -4 4 !Fn/i No 5074464664 OWATONNA,MN 55060 E-MAIL ADDRESS:CLIENTCONTACTCENTER.�4FEDINS.COM INSURER(S)AFFORDING COVERAGE NAIL 9 INSURER A:FEDERATED MUTUAL INSURANCE COMPANY 13935 INSURED 330.130 6 INSURER B: WESTMORE FUEL COMPANY INCORPORATED INSURER C: 86 N WATER ST —"- --- GREENWICH,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 LTRDL SUER POUCY NUMBER IPOLICY EFF POLICY f%P LIMITS wVD MMIDDrY YYY MMIDDIYYYV X COMMERCIALOENERALLIABILITY EACH OCCURRENCE $1,000,000 CLAIMS-MADE DX OCCUR DDAMAOETO RENTED S1DO 000 -..BL6ll:E21fie R4Uar14j_— . MED EXP(Any one renon) S5,000 A N N 9062815 06/01/2022 06/01f2023 PERSONAL&ADV INJURY $1,000,000 1G N'L AGGREGATE UMIT APPLIES PER. GENERAL AGGREOATE $2,QQQ,QQQ PRO X POLICY `J JECT LOS PRODUCTS-COMP/OP ACC S2,0W.000 OTHER: MTAIMOBITO LIABILITY COIE,MBED SINGLI:LIMIT $1,000,000 AUBODILY INJURY(Per person) SCHEDULEDAOWNED AUTOS ONLY AUTOS N N 9062815 06/012022 06/01I2023 BODILY INJURY(Per eccl,fenD NONUWNED PROPERTY OgIA AGE MIflEO AUTOS ONLY AUTOS ONLY IPer Fc idenB I X UMBRELLA LIAR X OCCUR EACH OCCURRENCE 57,000,000 A EXCESS L.A. ) CLAIMS-MADE N N 9062816 061011'2022 06/01/2023 AGGREGATE S7,000,000 DED RETENTION WORKERS COMPENSATION X PER STATUTE OTN- AND EMPLOYERS'LIABILITY YIN ER ANY PROPRIETORIPARTNERIEXECUTIVE E.L EACH ACCIDENT S5O0,000 A OFFICERIMEMBER ExcLUDEDI �_TO I A N 9917566 06/01/2022 06/01/2023 (MFndelo y In NHI E.L.DISEASE-EA EMPLOYEE S500,000 If yes,desalbe Under DESCRIPTION OF OPERATIONS belpw E.L DISEASE-POLICY LIMIT S500 QQQ DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 10/,Addil,.-I R-0,Sdiedula,may De.Uii—d it more space'.s reRUind) CERTIFICATE HOLDER CANCELLATION 330.130.6 35 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 REPRESEN-ATIVE CU 1988.2015 ACORD CORPORATION.All fights reserved. ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD NEw YdSRt<YOR Eyr(«rs' CERTIFICATE OF ' i 1 STATE ! Compensation Board Board NYS WORKERS' COMPENSATION INSURANCE COVERAGE 13 Legal Name&Address of Insured(use street address ony) 1b.Business Telephone Number of Insured Westmore Fuel Company Incorpciated 203-531-5656 86 N Water St Greenwich CT 06630-5866 1c.MYS Unemployment Insurance Employer Registration Number of Insured Work Location cf Insured(Only required if coverage is specificaPy 1'm8ed to Id.Federal Employer Idenle icalion Number of Insured or Social Security certain locations on New Yorlt State,i.e.,a Wrap-Up Policy) Number 06-C739367 2.Name and Address of Entily Requesting Proof of Coverage 3a.Name of Insurance Carter (Entity Being Listed as the Certificate Hoider) Federated Mutual Insurance Company village Of Rye Brook 933 King St Rye Brook,NY 10573-'226 3b.Policy Number el Entity Listed in 0ox'1 a' 9917566 3c.Policy effect:ve period 06/0ti2022 tc 0610112323 3d.The Proprietor,Partners or Executive Officers are ❑ Included.tonly ctw:k Sox if all panne:i0liice:s included) x] ail 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 veill send this Certificate of Insurance to the entity listed above as the certdicate holder in box"2". The insurance carrier must notif/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 certi5rate 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 DANIELLE SACKETT (Prcd r-P.of aultived rep:esewslivn of liceme:d agent of insura!K raniei; 04/26/2022 Approved by: Fri' (S,gnab,e) (Dale) 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.ry gov