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HomeMy WebLinkAboutMP22-167 11 y 4016 anni coax* VILLAGE OF RYE BROOK MAYOR 938 King Street, Rve Brook,N.Y. 10573 ADMINISTRATOR Jason A. Klein (914) 939-0668 Christopher J.Bradbury www.tyebrook.or TRUSTEES BUILDING& FIRE INSPECTOR Susan R. Epstein Michael J. Izzo Stephanie J. Fischer David M. Heiser Salvatore W.Morlino CERTIFICATE OF COMPLIANCE December 8,2022 Paul Tiso&Faye Tiso 4 Brookridge Court Rye Brook,New York 10573 Re: 4 Brookridge Court, Rye Brook,New York 10573 Parcel ID#: 141.43-1-85 This document certifies that the work done under Mechanical Permit #22-167 issued on 11/8/2022 for the installation of a new condenser and a new gas fired furnace has been satisfactorily completed. Sincerely, Michael J. Izzo Building&Fire Inspector /to �E 4RO '9b2 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 - - - - - - - - - - - - - - - - - - - - \ Z ADDRESS :— �_ V `�/ DATE: �� PERMIT# l l \� 2 ISSUED: `� SECT: 1�\ = BLOCK: ' LOT: vu c c LOCATION: �C� �c� C�C��,L OCCUPANCY: � '� ❑ VIOLATION NOTED THE WORK IS... A ACCEPTED ❑ REJECTED/REINSPECTION ❑ SITE INSPECTION REQUIRED EQUID ❑ FOOTING � �� ���� S��`y ❑ FOOTING DRAINAGE ❑ FOUNDATIONS �` v ❑ UNDERGROUND PLUMBING NOTES ON INSPECTION: D ❑ ROUGH PLUMBING ❑ ROUGH FRAMING ❑ INSULATION ❑ NATURAL GAS ❑ L.P. GAS . . ❑ FUEL TANK ❑ FIRE SPRINKLER ❑ FINAL PLUMBING ❑ CROSS CONNECTION FINAL ❑ OTHER ti. a a a N N N A a QI \ ` y Cd C G (f) 0,! ate.. O.� k z a oa En Ln p x a° u y v t>p "a u O .ti a O W It °" o d 3 u ~ M+I v r} W 2 72 I+M oo H R. a p marIs- � b a ONOv oc � � g a Vz � W H CN �"?Q w � ' Q ¢ z . H U en w F Go � G° � U W � � W �Zz r °Ocn R+ z H y 0-4 v C7 ° Z a U $ b � ►—� ► w x a H u. O R. UCA W CA z y O o V O O V � � � 0 z Z p off ." •. A d R+ W QI Rr y u �I a a a w x BUILD MENT D F C F E V E VII. OF RY + OOK NOV ' 8 2022 938 KING ET RYE BR ,NY 10573 d 4 , 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#: gi�QD— ! 6 7 Approval Date: NOV 8 P ZZ Permit Fee: f A.J Approval Signature: Other: Disapproved: (fees are non-refundable) REOUIREMENTS FOR RELEASE OF PERMIT&CERTIFICATE OF COMPLIANCE: l. 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=$I00.00/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, //` - c�c4 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. �} 1. Address:-L4 SBL: E . (4 f ~ 7� Zone: 2. Property Owner: ?R, `;5 p Address: Phone#: 1(`t �6 - r>T ( 01-_ ^Cell#: email: 3. Contractor:QP4— (z �WA-C- Address: 1,1 b �.2e5i= )tau Phone#: ° 1 �� j '3 4/0 Cell#: email: p 4. Applicant: 4et_cp__ Address: 1 kt rlesw- r1�; ` 1�li✓►S Phone#: �y—3 (n �_ Cell#: email: S. Scope of Work:New Installation*Q . Replacement( )•Removal( )•Other( ): 6. List Equipment: r aCA 7. Location of Equipment: C,4:, L,r\4, (`pJ 1\Ss� i -s- �p Cj�r (I M ., ,t t1uC�_ 8. Method of Installation/Removal(list all equipment needed to perform job): t� 1 8/12/2021 STAT *VW K,7 l► OF WESTCHESTER ) as: //''/��/f����V// // ,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 th legal owner of the property to which this application pertains,or that(s)he is the Co A!bCAt �4 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 conforma ce with the details as set forth and contained in this application and in any accompanying approved plans and specifications,as ell as in accordance with the New York State Uniform Fire Prevention&Building Code,the t e t age o k and all other applicable laws,ordinances and regulatio Sworn to before me this Sworn to before me this '7`4) day of ,20 day of ,20 'Z Signa t reof Property Owner Signat eofA /� Applicant 5 s" c o-- 11KL / o Print Name of Property Owner Print Name of Applicant ENNIFER HANSOM Not ublic NOTARY PUBLIC-STATE OF NEW YORK No.01 RA62887 3 '�N M 81J02Z0 Q NDtAilli PUBLIC,VM QF NeI y0W Duah ied in Westchester CoV Reyistra"M No.01stw7wis y Commission Expires 09- -202- MYQuWW In Westchest'r IM This application must be properly completed in its entirety and must include the notarized signature(s)of the legal owners) 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. 2 811 212 02 1 ifeating ana AM9001AC900 HEATING INPUT.• 40,000-120,000 BTU/H TWO STAGE, 9-SPEED ECM GAS FURNACE 80%AFUE Contents Nomenclature........................................2 Product Specifications...........................3 Dimensions............................................5 Airflow Data...........................................7 Wiring Diagram ...................................23 Accessories..........................................24 Standard Features Cabinet Features • Two-stage gas valve provides quiet, • Fully insulated, heavy-gauge steel cabinet economical heating with durable baked-enamel finish • Efficient and quiet multi-speed ECM circulator motor • Multi-position installation: • SureStart®Silicon Nitride igniter AM9C80:upflow,horizontal left or right designed for long igniter life AC9C80:downflow,horizontal left or right • Self-diagnostic control board • Removable bottom for side-or • Low constant fan speed circulates air bottom-return applications throughout the home • Convenient left or right connection • Quiet,two-speed induced draft blower for gas/electric service • California Low NOx emissions-compliant • Cabinet air leakage<_2% models available • Coil and furnace fit flush • Can no longer be installed in California's for most installations South Coast Air Quality Management District (SCAQMD)on or after October 1,2019. • AHRI Certified; ETL Listed .�.:.- � cowR�Nv wrtN coerogNr wml E WA sys EN ENNRONWNTAL/YSTM C `�� to ® CEr1TIElEO 8Y IXN GL CERTIFlED BY p1Y OL Intertek 'Complete warranty details available from your local dealer or at www.amana-hac.com.To receive the Lifetime Unit Replacement Limited Warranty(good for as long as you own your home)and 10-Year Parts Limited Warranty,online registration must be completed within 60 days of installation.Online registration is not required in California or Quebec. SS-AM9C80/AC9C80 www.amana-hac.com 8/21 Amana•is a trademark of Maytag Corporation or its related companies and used under license to Goodman Company,L.P.,Houston,Texas. NOMENC,.ATURE A M 9 C 80 040 4 C * ** 1 2 3 4 5,6 7,8,9 10 11 12 13,14 BRAND ENGINEERING A-Amana*Brand Major/Minor Revisions A-Initial Release B-Ist Revision CONFIGURATION NOx M-Upflow/Horizontal N=>40 NG/J NOx C-Downflow/Horizontal X=<40 NG/J NOx MOTOR CABINET WIDTH 9- Nine Speed ECM A-14" C-21" B-17%:" D-24%" Gas VAWE MAximum CFM C-2 Stage 3-1200 CFM 4-1600 CFM 5-2000 CFM AFUE MBTU/H 80-80%AFUE 92-92%AFUE 030-30,000 BTU/h 080-80,000 BTU/h 96-96%AFUE 97-97%AFUE 040-40,000 BTU/h 100-100,000 BTU/h 060-60,000 BTU/h 120-120,000 BTU/h 2 www.amana-hac.com SS-AM9C80/AC9C80 . SPECIFICATIONS HEATING CAPACITY High Fire Input(BTU/h)' 40,000 60,0E?C1 80,000 80,000 80,000 80,000 80,000 100,000 High Fire Output(BTU/h)' Natural Gas 32,000 48,000 64,000 64,000 64,000 64,000 64,000 80,000 LP Gas 32,000 48,000 64,000 64,000 64,000 64,000 64,000 80,000 Low Fire Input(BTU/h)' 28,000 42,000 56,000 56,000 56,000 56,000 56,000 70,000 Low Fire Output(BTU/h)' Natural Gas 22,400 33,600 44,800 44,800 44,800 44,800 44,800 56,000 LP Gas 22,400 33,600 44,800 44,800 44,800 44,800 44,800 56,000 AFUEZ 80 80 80 80 80 80 80 80 Available AC @ 0.5"ESP 1.5-3.0 1.5-4.0 3.0-4.0 2.0-5.0 2.5-5.0 2.5-5.0 2.5-5.0 2.0-5.0 Temperature Rise Range(°F) 15-45/15-45 15-45/15-45 30-60/30-60 30-60/30-60 25-55/25-51, 25-55/25-55 20-50/20-50 25-55/25-55 CIRCULATOR BLOWER Size (DxW) 10"x6" 10"x8 10"x8" 10"x10" 10"x10" 10"x10" 11"x10" 10"x10" Horsepower-RPM 1/2 112 1/2 3/4 3/4 1 1 1 No.of Burners 3 3 4 4 4 4 5 ELECTRICAL DATA Min.Circuit Ampacity3 8.7 8.7 8.7 12.45 12.45 15.32 15.32 15.32 Max.Overcurrent Device(amps)" 15 15 15 15 15 20 20 20 SHIP WEIGHT(LBS) 105 107 118 121 129 129 129 124 Natural Gas BTU/h;for altitudes 0-4500'above sea level,reduce input rating by 4%for each 1000'above 45W altitude. z DOE AFUE based upon Isolated Combustion System(ICS) ' Minimum Circuit Ampacity=(1.25 x Circulator Blower Amps)+ID Blovjer amps.Wire size should be determined in accordance with National Electrical Codes.Extensive wire runs will require larger wire sizes. 4 Maximum Overcurrent Protection Device refers to maximum recommended fuse or circuit breaker size.May use fuses or HACR-type circuit breakers of the same size as noted. NOTES • All furnaces are manufactured for use on 115 VAC,60 Hz,single-phase electrical supply. • Gas Service Connection%"FPT • Important:Size fuses and wires properly and make electrical connections in accordance with the National Electrical Code and/or all existing local codes. SS-AM9C80/AC9C80 www.amana-hac.com 3 Heating 8 Air Conditioning ana ASX13 AMERIUS BRAND FOR COMFORT COOLING CAPACITY.- 17,800-56,500 BTU/H ENERGY-EFFICIENT SPLIT SYSTEM AIR CONDITIONER UP To 14 SEER / 12 EER Contents Nomenclature .......................................2 Product Specifications ..........................3 Expanded Cooling Data ........................4 Dimensions ......................................... 22 - Wiring Diagrams .................................23 _ Accessories .........................................25 Standard Features Cabinet Features • Energy-efficient scroll compressor • Heavy-gauge,galvanized-steel • High-density foam compressor cabinet with sound control top design sound blanket • Attractive Architectural Gray powder-paint • Copeland®ComfortAlert`m diagnostics finish with 500-hour salt-spray approval • Factory-installed filter drier • Wire fan discharge grille • Copper tube/enhanced • Steel louver coil guard aluminum fin coil • Compact footprint • Sweat connection service valves • Top and side maintenance access with easy access to gauge ports • Single-panel access to controls with space • Contactor with lug connection provided for field-installed accessories • Ground lug connection • AHRI Certified; ETL Listed 0us �y— ouutrv•vtar �tvnonrnKsysrat OPARO OMIT °®^samB''°.Kol -°t roaam. .mo t�mt. k tertek •Complete warranty details available from your local dealer or at www.amana-hac.com.To receive the 2-Year Unit Replacement Limited Warranty and 10-Year Parts Limited Warranty,online registration must be completed within 60 days of installation.Online registration is not required in California or Quebec. SS-ASX13 www.amana-hac.com 7/20 Amana•is a trademark of Maytag Corporation or its related companies and used under license to Goodman Company,L.P.,Houston,Texas. Supersedes 2/20 NOMENCLATURE A S X 13 036 1 AA 1 2 3 4,5 6,7,8 9 10,11 Brand Engineering• A Amana®Brand Major/Minor Revisions • Not used for order or mentory control Product Category S Split System Electrical N Nominal Split System 1-208/230 V,1 Phase,60 Hz Unit Type Nominal Capacity X Condenser R-410A 018 1A Tons 042 3%Tons Z Heat Pump R-410A 024 2 Tons 048 4 Tons 030 2'1A Tons 060 5 Tons Efficiency 036 3 Tons 13 13 SEER 16 16 SEER 14 14 SEER 18 18 SEER 2 www.amana-hac.com SS-ASX13 PRODUCT SPECIFICATIONS CAPACITIES Nominal Cooling(BTU/h) 17,800 23,000 28,400 33,600 40,000 46,000 57,000 56,500 SEER/EER 13/11 13/11 13/11 13/11 13/11 13/11 13/11 13/11 Decibels 75 75 73 74 75 76 77 77 COMPRESSOR R I A 9.0 13.5 12 8 1% 1 17.9 19.9 25.0 26.4 BRA 48 58.3 64 77 112 109 134 134 CONDENSER FAN MOTOR Horsepower 1/S 1/8 1/8 1/4 1/4 1/4 1/t 1/4 FLA 0.7 0.7 0.7 1.4 1.3 1.3 1.3 1.3 REFRIGERATION SYSTEM Refrigerant Line Size Liquid Line Size("O.D.) A Y A W. A" Xa' Y, A Suction Line Size("O.D.) <" r<" %' 1%' 1%" Refrigerant Connection Size Liquid Valve Size("O.D.) /" '/" W. W. %" W. Suction Valve Size("O.D.)'° /" ''/." W. %"° %;'5 %'s %" Valve Type Swe t Sweat Sweat Sweat Sweat Sweat S�%ea: Swat Refrigerant Charge 69 60 60 62 80 91 9�1' III Shipped with Orifice Size 0.051 0.057 0.061 0.070 0.076 0.080 0.086 0.086 ELECTRICAL DATA Voltage/Phase(60 Hz) 2081230-1 208/230-1 208/230-1 208/230-1 208/230-1 208/230-1 208/230-1 208/230-1 Minimum Circuit Ampacity' 12 17.6 16.7 19.0 23.7 26.2 32.6 34.3 Max.Overcurrent Protection 2 20 30 25 30 40 45 50 60 Min/Max Volts 197/253 197/253 197/253 197/253 197/253 197/253 197/253 197/253 Electrical Conduit Size %'or/" W'or%" W'or%" W'or'W W'or'W %"or'W W,or W, %z"or%" Equipment Weight(lbs) 102 115 115 118 171 175 184 211 Ship Weight(Ibs) 1 L7 128 132 135 189 193 202 233 f Line sizes denoted for 25'line sets,tested and rat in accordance with AHRI Standard 210/240.For other line-set lengths or sizes,refer to the installation&Operating instructions and/of the long line-set guidelines. ' Wire size should be determined in accordance with National Electrical Codes;extensive wire runs will require larger wire sizes a Must use time-delay fuses or HACR-type circuit breakers of the same size as noted. ` Installer will need to supply'/."to%"adapters for suction line connections. s Installer will need to supply%"to 1Y"adapters for suction line connections. NOTES • Always check the S&R plate for electrical data on the unit being installed. • Unit is charged with refrigerant for 15'of%"liquid line.System charge must be adjusted per Installation Instructions Final Charge Procedure. • This product may not be installed in the Southeast(including Hawaii)or Southwest Regions as of Jan.1,2015. SS-ASX13 www.amana-hac.com 3 1 SS'w'rA,�,�. v_ ��Fs'�i�r/"r.�+ ��M, w•-��?'� � _.'°��i►�' \ t♦9• � �T-�'�i�+4� i lv '�4c 1 114�i+, I��1�1�1,1 g ,1c�+�cl,� " . ;;,�PIcP� v � ��14/Pi'� ~ �i,il� c�,; � `, .. .'%j I�<(0)> ,�io•.��1{I{�=� id- =s ti -.aw xv �<(_O)> ?r� tad a+ 7 V1 00 L "��•'� �: cc N CO 4. O ti a fj ON" Y v qj �1 7 V) iih v yuj 1' «O)►� Z o U �o�ection � T ui -i w w d 3 w _ ti ti_ fin. w O = w N p oo Q O :t4 LT. �eCN M„y o I i.+ W Q r ti CZ �• ' ti ._ 1 LU -,. w hr• >,. ;; • z. 1 •ter �U � '� l L O is Is' Crcoop m A77. �Il/lil'� ' ACOR" CERTIFICATE OF LIABILITY INSURANCE DATE os/19/2022 Y) 19/2o2z 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 NAME: Andrea Schena BNC Insurance Agency PHONEo C, (914)937-1230 AAI No X (914)937-1124 AIC N Ezt: 90 S Ridge St Ste UL-2 E-MAIL aschena@bncagency com ADDRESS: INSURERIS)AFFORDING COVERAGE NAIC# Rye Brook NY 10573-2836 INSURERA: Merchants Mutual Insurance Company 23329 INSURED INSURER B: Merchants Preferred Insurance Company 12901 Residential Commercial Specialist Heating 8 Air Conditioning Inc INSURER C: dba Res-Com INSURER D: 28 Emerald Lane INSURER E: Mahopac NY 10541-4409 INSURER F: COVERAGES CERTIFICATE NUMBER: CL2252706916 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 LTR TYPE OF INSURANCE POLICY NUMBER MWDD/YYYY MMIDDlYYYY INSD WVD LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000.000 CLAIMS-MADE OCCUR PREMISES Eaoccunence $ 500,000 MED EXP(Any one person) s 15,000 A Y BOP9095976 07/01/2022 07/01/2023 PERSONAL&ADV INJURY $ 1,000,000 IOTHER LAGGREGATE LIMIT APPLIES PER. GENERAL AGGREGATE $ 2,000,000 POLICY ❑XJECTRO- ❑ LOC PRODUCTS-COMP/OPAGG s 2,000,000 $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT s 1,000,000 Ea accident X ANY AUTO BODILY INJURY(Per person) $ B OWNED SCHEDULED CAP9265044 07/01/2022 07/01/2023 BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY Per accident $ X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 1.000,000 A EXCESSLIIAB CLAIMS-MADE CUP9138731 07/01/2022 07/01/2023 AGGREGATE $ 1,000,000 DED X RETENTION $ 10,000 $ WORKERS COMPENSATION PER OTH- 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 S If yes describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 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 an 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. 938 King Street AUTHORIZED REPRESENTATIVES Rye Brook NY 10573 ©1988--2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD YTE K Workers' STATE Compensation CERTIFICATE OF Board NYS WORKERS' COMPENSATION INSURANCE COVERAGE la.Legal Name&Address of Insured(Use street address only) lb.Business Telephone Number of Insured (914)347-3402 Residential Commercial Specialist Heating& Air Conditioning Inc Ic.NYS Unemployment Insurance Employer Res-Com Registration Number of Insured 28 Emerald Lane Mahopac,NY 10541 Id.Federal Employer Identification Number of Insured or Social Security Number Work Location of Insured(Only required ijcoverage is specifically, 133955024 limited to certain locations in New York,i.e.,a Wrap-li Policjq 2.Name and Address of the Entity Requesting Proof of 3a.Name of Insurance Carrier Coverage(Entity Being Listed as the Certificate Bolder) Merchants Mutual Insurance Company 3b.Policy Number ofentity listed in box"la" Village of Rye Brook WCA9100981 938 King Street 3c.Policy effective period Rye Brook, NY 10573 9/15/2022 to 9/15/2023 3d.The Proprietor,Partner or Executive Officer 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 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: Paul Sohigian (Print name of authorized representative or licensed agent of insurance company) Approved by: 9/19/2022 (Signature) (Date) Title: Vice President Telephone Number of authorized representative or licensed agent of insurance carrier: (914) 937-1230 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.wcbny.gov