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HomeMy WebLinkAboutMP18-1253I1o(Zc� PERMIT # SECTION _ TYPE OF JOB LOCK INSr FOOTING FOUNDATION FRAMING RGH FRAMING INSULATION PLUMBING 0 RGH PLUMBING GAS SPRINKLER ELECTRIC LOW -VOLT O ALARM AS BUILT C] FINAL Lp R►7611FRI _ 35o zo cc t 1 I��0 C7� J G �a I �°' OTHER APPROVALS ARB �— BOT PS IZBA OTHER Open Permit Letter Sent 7%I (mo/19 too 49a+.i v a. VILLAGE OF RYE BROOK MAYOR 938 King Street, Rye Brook,N.Y. 10573 ADMINISTRATOR Jason A. Klein (914)939-0668 Christopher J. Bradbury www.iyebrook.org TRUSTEES ACTING BUILDING&FIRE INSPECTOR Susan R. Epstein Steven E. Fews Stephanie J. Fischer David M. Heiser Salvatore W. Morlino CLARIFICATION OF RECORD January 18,2023 Jeffrey Fischer&Shelley Fischer 2 Horseshoe Lane Rye Brook,New York 10573 Re: 2 Horseshoe Lane, Rye Brook,New York 10573 Parcel ID#: 135.51-1-3 Mechanical Permit#18-125 issued on 9/10/2018 to Install a 22KW Natural Gas Fired Generator An inspection of the of the above referenced property on January 17,2023,reveals that although Mechanical Permit#1&125 dated 9/10/2018 was issued,the installation of a 22kw natural gas fired generator was never done, and this permit is rendered null and void. Sincerely, Steven E. Fews Acting Building&Fire Inspector /to �E BRO 04 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 �o o� �� �, DATE: PERMIT# ISSUED: 4Q 1�SECT: ­� . LOCK: LOT: LOCATION: 1 S ,( OCCUPANCY: ❑ VIOLATION NOTED THE WORK IS... ACCEPTED 0 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 � ��C l S �(A ❑ FINAL PLUMBING ❑ CROSS CONNECTION ❑ FINAL ,P-OTHER Laura Petersen From: Steven Fews Sent: Friday, January 13, 2023 3:19 PM To: office@zaccagnino.net Cc: Laura Petersen; Tara Orlando Subject: RE: 2 Horseshoe Lane Expires: Saturday, May 13, 2023 12:00 AM Good Afternoon Brian, If the work was never performed and there is no generator on site, I will need to do a site inspection before the permit can be voided. I will look to get there some time next week. Afterwards we will be in touch about the new permit. Thank You. Steven E. Fews Acting Building Inspector& Fire Inspector Office (914) 939-0668 From: office@zaccagnino.net<office@zaccagnino.net> Sent: Friday,January 13, 2023 12:44 PM To: Steven Fews <SteveFews@ryebrook.org> Subject: 2 Horseshoe Lane Good Afternoon Steve, I was instructed to inform you that work on a generator permit at the above location was never performed. When we got to the ConEd stage of planning, they wanted quite a lot of money and the customer decided to shut the whole process down. I would like for the generator permit at 2 Horseshoe In to be canceled/voided if you can. We have a permit for some different work at the house and this is barring our progress. Thanks, Brian Zaccagnino Electric 81 Maple Avenue Rye, NY 10580 914-921-3244 Fax: 914-921-1722 i Ln CV = Y i ?` Owl m c1c � Rl F• OwC M S �° 'a o . �= ¢ � oEa .-. m = Qc a a0 14 tg Q 8 ... C en � 3 Y � � > > � W Im 0 .0 _ �J arE3 06 ON Q LL V v V+ h U r , w ""' � ! :�: Y � � •- g 4' c % ° Grp � Sl -5 EBAP C Q o < Q 3 W Q Z U >. E E CZ i < R ' BUILDING-Eii2 'ARTMENT AUG 2 7 2018 VILLAOF RYE 4400K 938 Kllvc STR) �T RYE BRCU NY 10573 VILLAGE OF RYE BROOK (914)939-0'i 18_y (9� '39-5801 BUILDING DEPARTMIENT www� k.br v. *********************************************************************************************************** FOR OFFICE USE ONLY: Approval Date: SEP ` 2 �P mit# Application# Approval Signature: ' ARCHITECTURAL REVIEW BOARD: Disapproved: ; Date: BOT Approval Date: Case# Chairman: PB Approval Date: Case# Secretary: ZBA Approval Date: Case# Other: Application Fee Permit Fees CL APPLICATION TO INSTALL A PERMANENT STANDBY BACKUP GENERATOR Application dated: l c� is hereby made to the Building Inspector of the Village of Rye Brook for the issuance of a Permit to install a permanent standby ba kup generator in accordance with§250-4.1.of the Code of the V illage of Rye Brook,as per detailed statement described below.Please note that electrical and plumbing permit applications must be filed separately by those licensed professionals,and that separate permits are required for the installation of any related fuel tanks.Further note that all applications for commercial use will require a site plan approval from the Village Planning Boardprior to the issuance of any permit. 1. Job Address:. 2. Parcel ID#: Zone: -t Z 3. N.Y.State Construction Classification: N.Y.State Use Classification: 4. Proposed C jenerator&Fuel Type(Describe in detail): A! / rn 4 5. Property Owner: Address: L� Phone# �`� / �!�LCell# email: f'I GG'7 Applicant: C Address:q f 2CL t4 cy Phone# 1 / ` - Cell# [ ��✓� email;�^!� i No' Architect or Engineer(if applicable): Address: Phone# Cell# email: i General Contractor: 1- C _ Address:q� Q G'X - 7 Phone#/ ! 2�� y Cell# Co — email: C N 0 QC .4 R* _M ril 12.8.16 6. Give exact dimensions from proposed generator to lot lines: front yard: 6 L/ rear yard: 16 0'f—t- right side yard: 3, 7A left side yard: 0 LY 7. If building is located on a corner lot,which street does it front on: /L C,- 8. Will the proposed project disturb 400 sq.ft.or more of land,requiring a Stormwater Management C ntrol Permit from the Village Engineer as per Chapter 217 of the Code of the Village of Rye Brook? Yes: No: 9. Will the proposed project require a Site Plan iew by the Village Planning Board as per Chapter 209 of the Code of the Village of Rye Brook? Yes: No: (provide detailed drawings as per Chapter 209) 10. Will the proposed project require a Steep Slopes Permit as per Chapter 213 of the Code of the Village of Rye Brook? Yes: No: (provide a detailed topographical survey) 11. Is the lot or any portion thereof located in a Wetland as per chapter 245 of the Code of the Village of Rye Brook? Yes: No: ✓ (provide a detailed survey indicating the Wetland&Buffer Zone) 12. Is the lot or any portion thereof locate to a Flood Zone as per the FEMA Flood Insurance Rate Map#36119CO279 dated 9/28/07? Yes: No: 13. Will the proposed p oject require a Tree Removal Permit as per Chapter 235 of the Code of the Village of Rye Brook? Yes: No:7a tree replanting schedule may be required) 14. Does the proposed ploject involve a Home-Occupation as per Chapter 250-38 of the Code of the Village of Rye Brook? Yes: No: - If so,indicate: TIER I: TIER I11: TIER III: 15. What is the total estimated cost of construction: $ I dF v)—0 (The estimated cost shall include all site improvements,labor,material,scaffolding,fixed equipment,professional fees,and material and labor which may be donated gratis) 16. Estimated date of completion: STATE QFNJ.W Y(}j' COUXTY OF WESTCHESTER ) as: l' 6 54le-Ky ,being duly sworn,deposes and states that he/she is the applicant above named, (print naar a 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 '�" t' t (--for the legal owner and is duly authorized to make and file this application. (indicate archit 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 be me this 2 y , 20 day of , 20 ySignatuf p tTy Owner / Si re o pplicant tint Name of Pro Owner Prin NamgQlfc ST IN ON Mp1A bb►TTWtIC+ OF 'VMK No: 11NIC OF W YORK No ubli A l Q l dp N N (A of cowmy in k county Gwranl..wn E 14 30 " }111iiSrlt bineprRp�I+ mpleted in its entirety and must include he nottanze gn (s)of t e I gal owner(s)of the subject property, d the applicant of record in the spaces provided.Any plication not prop rly completed in its entirety and/or of properly signed shall be deemed null and void,and will be returned to the applicant. Please note that application fees are non-refundable. 2.10.15 Ln Clq ON Flo Olt • 1.0 IL tn Z 40 ale O con < < � a p w Q e �, N � w - .� lot co ;.To 11C 7 z Vf Z L OEM w t 3 is m 0 ''. > c L) 00 ONE" rn r^ uj ;D �zNt Z Z r-O 0-4 cr rA � 3 w < #WIN Nftp� z 96 z . . . . . . . . . . . c BuIL9 , E DEpR�. MENr AUG 2 7 2018 VILL' 6E OF RYE � OK 938 KINIL ���E:r RYE B NY 105 3 VILLAGE OF RYE BROOK (914) 93� ��, r?�( .� y3�-5801 BUILDING DEPARTMENT w -ti: ELEcrRICAL PERMIT APPLICA,r[ON Westchester County ':Master Electricians License Required( FOR OFFICE USE ONLY -•A 47 1 5 r 1 t3- EP#: J G Approval Date: SEP — 5 2018 Application Fee: S Approval Signature: Permit Fee: S Disapproved: Other: (fees are non-refundable) Application dated, Wjqlly is hereby made to the Building Inspector of the Village of Rye Brook NY, for the issuance of a Permit to install an 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 in conformance u�with all applicable Federal, State,County and Local Codes. 1.Address: i I . 4b`ri 4certLp, SBL: ' 3 Zone: 2.Property Own�"7 Address: _ �o Phone#: C Cell#: email: e(ah h . C am 3.Master Electrician: A j.q W n Z 4 fr cr Gk i A 4'D Address: o f � � �5 Lic.#: 7 s-5- Phone# 3�y Cell#: oI(f Cl Ca I I fp C1 email: y, Company Name: ct C A. Cft 16 Address: �� /f/ju/ Zp, k-el h 103 G 4.Proposed Electrical Work/Fix/tune Count: ********************************************************************************************************* STATE OF NEW YORK,COUNTY OF WESTCHESTE-R ) as: being duly sworn,deposes and states that he/she is the applicant above named,and does further (print name of individual signing as the applicant) state 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 1 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 New York State Uniform Fire Prev� ton Building Code,the Code of the Village of Rye Brook and all other applicable laws,ordinances and regulations. worn to fore me this Sworn togire this day o - 0-- - — day of Si e gnat of A /ican U Pri ame of Property weer in Name.of Appli- FE40 tt t AA�N4t� p 1, STEV N 4. fVOtV Notary Public "1TA�l I�IJEI 1TE F NEW YORK NOTAR, PUL JEW YORK Ol Abt�il' 9 No. 0 Ab g Qunl•� 'd i eat star County Qualified i W cheste Count My Comm on E ra October 11, 20(_ My Commiss n Ezplres October 11, 20- � Phone: 914-347- 5 'Westchester Rockland Electrical Inspection Services, Inc. DO NOT WRITE HERE-FOR OFFICE USE ONLY 43 North Lawn Avenue L 1 Fax: 914-347-3596 Elmsford, NY 10523 ,jb BUILDING PERMIT NO. TEMP# DATE �j ++ CITY OR VILLAG V V r�a $IP ODE -7 TOWNSHIP --�-- CO,way I % 1 �- AND NO.DWROAD / - POLE BE BETWEEN WHAT TWO CROSS STREETS IS PREMISES LOCATED? SECTION BLOCK LOT NT'S BUILDING OCCUPANCY f_ S NAME AND HOME TELIEr NUMB R 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 SIDEWALL SWITCH INCADE FLUORE NO. H.P.EACH NO. wATrs. `IN5,PECTION OUTSIDE � BASEMENT 1-FL. 11 AUG 2 7 2018 2-FIL �^+ 3' FL DING E)EPA S t1E r 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/IGENCI ES 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❑ ADDTIONAL D EXPOSED❑ CONCEALED❑ MUST ENTER APPLICANTS IDENTIFICATION NUMBER SERVICE ENTERS BUILDING OVERHEAD❑ UNDERGROUND AVOID DELAYS BY GIVING FULL AND ACCURATE INFORMATION.ALL SPACE MUST BE FILLED IN OR APPLICATI MAY BE RETURNED. NAME OF COMPANY _ DATE OF APPJ-ICATIO SIGN A 0FdP ICANT zace u �r,)311K X O. 6 A -e G--e %/TELEPHONE Clya r CRY OR POST OFFICE LP CODE UCENBE NO.WHEN APPLICABLE Y G a •Mike Izzo From: Mike Izzo Sent: Thursday, August 29, 2019 9:15 AM To: 'Chabi' Cc: Steven Fews;Tara Gerardi; Liz Caruso Subject: RE: Your letter dated July 16, 2019 - Permit expiration at 2 Horseshoe Lane. MP18-125 Attachments: Fuel Tank 3.21.19.pdf, 610.pdf Dear Mr. &Mrs. Fischer, Your request for an extension to your open permit #MP18-125 has been approved. Please note the new expiration date is March 10, 2020. Regarding the switch from natural gas to LPG; in addition to your electrician and plumber,you must also retain the services of an LPG supplier such as Suburban Propane, Paraco Gas, or any other acceptable LP supplier of your choosing to file for a tank installation permit. I have attached the appropriate application hereto for your convenience. Please note the tank installation application must be accompanied by a site plan based on your property survey showing the proposed location of the tank to be reviewed and approved by the Building Department. Such installation must conform to all applicable Local and NY State Codes. I have also attached a copy of the most recent survey we have on file for your property. Following completion of the installation we will require an updated survey which includes the new the tank and generator. Regarding the permit extension, please arrange for all work to be completed and successfully inspected, and for all paperwork&fees to be remitted to the Village such to facilitate the issuance of the Certificate of Completion for the generator and LPG tank on or before March 10, 2020. Thank you. lfficlwd(T Izzo Building &Fire Inspector Village of Rye Brook, NY Phone—(914) 959-0668 Fax—(914) 959-5801 mizzoArvebrook.org From:Chabi [mailto:chabi@aol.com] Sent:Thursday,August 29, 2019 7:44 AM To: Mike Izzo<Mlzzo@ryebrook.org> Cc:Steven Fews<Steve Fews @ryebrook.org>;Tara Gerardi <tgerardi@ryebrook.org>; Liz Caruso <ECaruso@ryebrook.org> Subject: Re: Your letter dated July 16, 2019- Permit expiration at 2 Horseshoe Lane Dear Mr. Izzo, After considering the options you were kind enough to offer, we have decided would like to extend our open generator permit; MP18-125. Currently it appears that the in-ground LPG option should fulfill our needs. We will amend our application as soon as we confirm this is the way we would like to proceed. Until then, please extend our existing application. 1 . Thank you, Jeff and Shelley Fischer -----Original Message----- From: Chabi <chabi0_)aol.com> To: Mlzzo <Mlzzo0_)rye brook.org> Cc: SteveFews <SteveFewsa-rvebrook.orq>; tgerardi <tgerardi(a_Eye brook.org>; ECaruso <ECarusoCa_ryebrook.org> Sent: Sun, Jul 28, 2019 3:47 pm Subject: Re: Your letter dated July 16, 2019- Permit expiration at 2 Horseshoe Lane Dear Mr. Izzo, Thank you for taking the time to reply with exactly what we asked for: very professional, experienced and detailed alternatives. It's taken us a week just to digest your suggestions. We are going to further look into our options as you suggested and will get back to you by Sept. 5th. Thanks again, Jeff and Shelley Fischer -----Original Message----- From: Mike Izzo <MlzzoCaD_ryebrook.org> To: chabi(d)aol.com <chabi(d-)aol.com> Cc: Steven Fews <SteveFews(Q[yebrook.org>; Tara Gerardi <tgerardia,rye brook.orq>; Liz Caruso <ECarusoa-rve brook.ong> Sent: Mon, Jul 22, 2019 9:02 am Subject: FW: Your letter dated July 16, 2019- Permit expiration at 2 Horseshoe Lane Dear Mr. & Mrs. Fischer, Thank you for contacting me regarding your open generator permit; MPl 8-125. We understand that you are cancelling the project and we will void out the permit as per your request. Unfortunately the Village does not provide refunds for application or permit fees. As to your desire to install emergency stand-by power to protect your home,there are viable options to natural gas generators. Many homes in Rye Brook have stand-by generators powered by liquid propane gas(LPG). Given the size of your property it should be a relatively simple exercise to find a suitable location for an underground or above ground LPG tank. You could simply amend the application with a permit to install either an above-ground or in-ground LPG tank and move forward with the current generator permit. In the alternative there are passive residential emergency stand-by power systems which utilize large batteries charged by your house power, or by a combination of house power and solar power. Such systems store energy in the batteries for use in a power outage. The capacity of the system is flexible and designed around your needs. If you need more power or want an extended run time, more batteries are designed into the system. This type of system is generally not considered if you wish to run the entire home for a week or more. However it could be suitable to operate your pumps, and perhaps the HVAC and some interior appliances for a limited time if designed properly. The utilization of a solar charging component in addition to the house power can extend run time as well. Since your permit doesn't expire until September 5, 2019, I will hold off with the cancellation to give you time to consider your options. Should we fail to hear from you by September 5, 2019, we will cancel the permit at that time. Thank you. 2 Michael J . Izzo Building & Fire Inspector Village of Rye Brook,NY Phone—(914)939-0668 Fax—(914) 939-5801 mizzo@rvebrook.org From: Chabi fmailto:chabi(a-aol.com� Sent: Sunday, July 21, 2019 11:58 AM To: Mike Izzo <Mlzzo(a)-ryebrook.org> Cc: Steven Fews <SteveFews(a-)-rye brook.org> Subject: Your letter dated July 16, 2019 - Permit expiration Subject: Re: Your letter dated July 16, 2019 - Permit expiration Jeffrey & Shelley Fischer Re: 2 Horseshoe Lane, Rye Brook, NY 10573 Notice of$500.00 Fee for Expired Permits Open Mechanical Permit#18-125 Issued: 9/10/2018 - Expiration Date: 9/10/18 Notice of Close Out: Dear Mr. Izzo, Firstly, thank you for the courtesy you extended back last year when my wife and I met with you at your office. Please be advised we were all set to proceed with the installation of the new generator we discussed with you, when Con Ed threw a monkey wrench into the project. On top of all the other considerable costs, Con Ed notified us through our contractor that we need an upgraded gas line from the street to our home at a punitive cost of over$16,000 beyond everything else we had already budgeted (copy attached). I made numerous attempts to speak with anyone at Con Ed to investigate alternative solutions, but my attempts were fruitless. Countless calls and messages never answered and never returned. I subsequently was informed that Con Ed would not communicate with me on the subject, only with the contractor who submitted the project. The dramatically increased cost killed the project dead in its tracks. Attached please find the notice of Gas Service Layout Revision and Notice of Cancellation (coincidentally just received a few days ago). We were unaware that we were supposed to inform your office that we would not be going forward with the project. We are doing so now. We are still very concerned about our home, particularly the situation with our sump pumps, in the event of future power outages. We cannot express how appreciative we would be for any advice you might be able to provide based on your experience with other such situations. Thank you for your attention, Jeffrey H. Fischer cc Steven E. Fews <stevefews(d_)rye brook.org>; 3 ) ± � � . � , . . .. { © � � {E777 \ | ^^ !ƒ� � Z! „. . M _!k! ! ; 7 yƒ� * ]� � § \\ Ir • > . °) cc 7c -1 \ t 0 LLJ o e: _; _§ rL., r ml-rm nnnn nrnr mmn. J O L�mot.W.L VILLAGE OF RYE BROOK MAYOR 938 King Street, Rye Brook, N.Y. 10573 ADMINISTRATOR Paul S. Rosenberg (914)939-0668 Fax (914)939-5801 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 July 16, 2019 Via I'Class Certified Mail Jeffrey Fischer& Shelley Fischer 2 Horseshoe Lane Rye Brook,New York 10573 Re: 2 Horseshoe Lane, Rye Brook,New York 10573 Notice of$500.00 Fee for Expired Permits Open Mechanical Permit#18-125 Issued: 9/10/2018 -Expiration Date: 9/10/2019 Dear Property Owner, Please allow this letter to serve as a reminder that your open permit(s)noted above, as is the case with all Building Permits issued by the Building Department must be closed out with a Certificate of Occupancy or Certificate of Compliance in accordance with §250-10.A. of the Code of the Village of Rye Brook. Building Permits have a life of twelve (12) months and the expiration date is noted on the front of the permit. Please be advised that should you fail to properly close out your permit(s) in accordance with the law, effective November 1, 2009 the Village will be imposing a $500.00 Administrative Fee in connection with all open expired Building Permits issued after January 1, 2003. Please note that this Administrative Fee applies to each individual permit and must be remitted in addition to any other required fees associated with closing the permit(s), as well as any court imposed fines should a summons(es)be issued. Thank you for your attention in this matter, and please feel free to contact this office should you require any further information. Michael J. Izzo Building& Fire Inspector mizzo_,ryebrook.org /ec cc: Steven E. Fews, Assistant Building Inspector o a O o r� 2 � � r- 0 �a a(,+o vv N O O 1 L .L u-) Cl� n, m g El a w o CD PG o ►� a m co �.�■ ,-3 CC f.' Y o ® >: 00 Z W cc -�� co L6 OAN �. 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GENERAC 16/20/22 kW features and benefits Engine • Generac G-Force design Maximizes engine"breathing"for increased fuel efficiency.Plateau honed cylinder walls and plasma moly rings helps the engine run cooler,reducing oil consumption resulting in longer engine life. • "Spiny-lok"cast iron cylinder walls Rigid construction and added durability provide long engine life. • Electronic ignition/spark advance These features combine to assure smooth,quick starting every time. • Full pressure lubrication system Pressurized lubrication to all vital bearings means better performance,less maintenance and longer engine life.Now featuring up to a 2 year/200 hour oil change interval. • Low oil pressure shutdown system Shutdown protection prevents catastrophic engine damage due to low oil. • High temperature shutdown Prevents damage due to overheating. Generator • Revolving field Allows for a smaller, light weight unit that operates 25% more efficiently than a revolving armature generator. • Skewed stator Produces a smooth output waveform for compatibility with electronic equipment. • Displaced phase excitation Maximizes motor starting capability. • Automatic voltage regulation Regulates the output voltage to±1%prevents damaging voltage spikes. • UL 2200 listed For your safety. Transfer Switch(if applicable) • Fully automatic Transfers your vital electrical loads to the energized source of power. • NEMA 3R Can be installed inside or outside for maximum flexibility. • Remote mounting Mounts near your existing distribution panel for simple,low-cost installation. Evolution— Controls • Auto/Manual/Off illuminated buttons Selects the operating mode and provides easy,at-a-glance status indication in any condition. • Two-line LCD multilingual display Provides homeowners easily visible logs of history,maintenance and events up to 50 occurrences. • Sealed,raised buttons Smooth,weather-resistant user interface for programming and operations. • Utility voltage sensing Constantly monitors utility voltage,setpoints 65%dropout,80%pick-up,of standard voltage. • Generator voltage sensing Constantly monitors generator voltage to ensure the cleanest power delivered to the home. • Utility interrupt delay Prevents nuisance start-ups of the engine,adjustable 2-1500 seconds from the factory default setting of five(5)seconds by a qualified dealer. • Engine warm-up Ensures engine is ready to assume the load,setpoint approximately 5 seconds. • Engine cool-down Allows engine to cool prior to shutdown,setpoint approximately 1 minute. • Programmable exercise Operates engine to prevent oil seal drying and damage between power outages by running the generator for 5 minutes every other week.Also offers a selectable setting for weekly or monthly operation providing flexibility and potentially lower fuel costs to the owner. • Smart battery charger Delivers charge to the battery only when needed at varying rates depending on outdoor air temperature. Compatible with lead acid and AGM-style batteries. • Main line circuit breaker Protects generator from overload. • Electronic governor Maintains constant 60 Hz frequency. Unit • SAE weather protective enclosure Sound attenuated enclosures ensure quiet operation and protection against mother nature,withstanding winds up to 150 mph.Hinged key locking roof panel for security.Lift-out front for easy access to all routine maintenance items.Electrostatically applied textured epoxy paint for added durability. • Enclosed critical grade muffler Quiet,critical grade muffler is mounted inside the unit to prevent injuries. • Small,compact,attractive Makes for an easy,eye appealing installation,as close as 18"(457 mm)away from a building. GENERAC' 16/20/22 kW features and benefits Installation System • 1 ft(305 mm)flexible fuel line connector Absorbs any generator vibration when connected to rigid pipe. • Direct-to-dirt composite mounting pad Complex lattice design prevents settling or sinking of the generator system. • Integral sediment trap Prevents particles and moisture from entering the fuel regulator and engine,prolonging engine life. Remote Monitoring • Ability to view generator status Monitor your generator via your smarlphone,tablet,or computer at any time via the Mobile Link application for complete peace of mind • Ability to view generator Exercise/Run and Total Hours Review the generators complete protection profile for exercise hours and total hours • Ability to view generator maintenance information Provides maintenance information for your specific model generator when scheduled maintenance is due • Monthly report with previous month's activity. Detailed monthly reports provide historical generator information • Ability to view generator battery information Built in battery diagnostics displaying current state of the battery • Weather information Provides detailed local ambient weather conditions for generator location GENERAC 16/20/22 kW specifications Generator Model G007035-1,G007036-1. 13007038-1,G007039-1 G007042.2,0007043-2 G007037-1(16 kW) (20 kW) (22 kW) Rated Maximum Continuous Power Capacity(LP) 16.000 Watts' 20,000 Watts' 22,000 Watts' Rated Maximum Continuous Power Capacity(NG) 16.000 Watts' 18,000 Watts` 19,500 Watts Rated Voltage 240 240 240 Rated Maximum Continuous Load Current—240 Volts(LP/NG) 66.7/66.7 83.3/75.0 91.7/81.3 r r Total Harmonic Distortion Less than 5% Less than 5% Less than 5% Main Line Circuit Breaker 70 Amp 90 Amp 100 Amp Phase 1 1 1 Number of Rotor Poles 2 2 2 Rated AC Frequency 60 Hz 60 Hz 6OHz Power Factor 1.0 1.0 1.0 Battery Requirement(not included) 12 Volts,Group 26R 540 CCA Minimum or Group 35AGM 650 CCA Minimum Unit Weight(lb/kg) 409/186 448/203 466/211 Dimensions(L x W x H)in/mm 48 x 25 x 29/1 218 x 638 x 732 Sound output in dB(A)at 23 ft(7 m)with generator operating at normal load" 67 67 67 Sound output in dB(A)at 23 it(7 m)with generator in Quiet-Test'"low-speed exercise mode" 55 55 57 Exercise duration 5 min 5 min 5 min Engine Type of Engine GENERAC G-Force 1000 Series Number of Cylinders 2 2 2 Displacement 999 cc 999 cc 999 cc Cylinder Block Aluminum w/Cast Iron Sleeve Valve Arrangement Overhead Valve Overhead Valve Overhead Valve Ignition System Solid-state w/Magneto Solid-state w/Magneto Solid-state w/Magneto Governor System Electronic Electronic Electronic Compression Ratio 9.5:1 9.5:1 9.5:1 Starter 12 VDC 12 VDC 12 VDC Oil Capacity Including Filter Approx.1.9 qt/1.8 L Approx.1.9 qt/1.8 L Approx.1.9 qt/1.8 L Operating rpm 3,600 3,600 3 600 Fuel Consumption Natural Gas ft3/hr(m3/hr) 1/2 Load 218(6.17) 204(5.78) 228(6.46) Full Load 309(8.75) 301(8.52) 327(9.26) Liquid Propane ft3/hr(gal/hr)[I/hr] 1/2 Load 74(2.03)[7.70] 87(2,37)[8.99] 92(2.53)[9.57] Full Load 107(2.94)(11.11] 130(3,56)(13.48] 142(3.90)[14.771 Note:Fuel pipe must be sized for full load.Required fuel3pressure to generator fuel inlet at all load ranges-3.5-T'water column(7-13 mm mercury)for natural gas.10-12"water column(19-22 mm mercury) for LP gas.For BTU content,multiply ft3/hr x 2500(LP)or It/hr x 1000(NG).For Megajoule content,multiply m3/hr x 93.15(LP)or m3/hr x 37.26(NG) Controls Two-Line Plain Text Multilingual LCD Display Simple user interface for ease of operation. Mode Buttons:Auto Automatic Start on Utility failure.7 day exerciser. Manual Start with starter control.unit stays on.If utility fails,transfer to load takes place. Ott Stops unit.Power is removed.Control and charger still operate. Ready to Run/Maintenance Messages Standard Engine Run Hours Indication Standard Programmable start delay between 2-1500 seconds Standard(programmable by dealer only) Utility Voltage Loss/Return to Utility Adjustable(Brownout Setting) From 140-171 V/190-216 V Future Set Capable Exerciser/Exercise Set Error Warning Standard Run/Alarm/Maintenance Logs 50 Events Each Engine Start Sequence Cyclic cranking:16 sec on,7 rest(90 sec maximum duration) Starter Lock-out Starter cannot re-engage until 5 sec after engine has stopped. Smart Battery Charger Standard Charger Fault/Missing AC Warning Standard Low Battery/Battery Problem Protection and Battery Condition Indication Standard Automatic Voltage Regulation with Over and Under Voltage Protection Standard Under-Frequency/Overload/Stepper Overcurrent Protection Standard Safety Fused/Fuse Problem Protection Standard Automatic Low Oil Pressure/High Oil Temperature Shutdown Standard Overcrank/Overspeed(@ 72 Hz)/rpm Sense Loss Shutdown Standard High Engine Temperature Shutdown Standard Internal FaulUlncorrect Wiring Protection Standard Common External Fault Capability Standard Field Upgradabie Firmware Standard "Sound levels are taken from the front of the generator.Sound levels taken from other sides of the generator may be higher depending on installation parameters.Rating definitions-Standby:Applicable for supplying emergency power for the duration of the utility power outage.No overload capability is available for this rating.(All ratings in accordance with BS5514.IS03046 and DIN6271).*Maximum kilovolt amps and current are subject to and limited by such factors as luel Btu/megajoule content.ambient temperature,altitude,engine power and condition,etc.Maximum power decreases about 3.5 percent for each 1,000 feet(304.8 meters)above sea level.and also will decrease about 1 percent for each 6'C(10'l above 16'C(60T). GENERAC" 16/20/22 kW switch options Limited Circuits Switch Features Model G007036-1(16kW) — • 16 space,24 circuit,breakers not included. No.of Poles 2 • Electrically operated,mechanically-held contacts for fast,positive Current Rating(Amps) 100 Voltage Rating(VAC) 120/240,10 connections Utility Voltage Monitor(Fixed)* • Rated for all classes of load,100%equipment rated,both inductive and -Pick-up 60% resistive. -Dropout 65% • 2-pole,250 VAC contactors. Return to Utility* approx 15 sec r • 30 millisecond transfer time. Exercises bi-weekly for 5 minutes* Standard • Dual coil design. ULListed standard • Rated for both copper and aluminum conductors. Total circuits available 24 • Main contacts are silver plated or silver alloy to resist welding and sticking. Tandem Breaker Capabilities 8tandems • NEMA/UL 3R aluminum outdoor enclosure allows for indoor or outdoor Circuit Breaker Protected Available RMS Symmetrical 10,000 mounting flexibility. Fault Current @ 250 Volts • Multi listed for use with 1"standard,tandem,GFCI and AFCI breakers from *Function of Evolution Controller Siemens,Murray,Eaton and Square D for the most flexible and cost effective Exercise can be set to weekly or monthly install. Dimensions w' Height Width Depth Ht H2 Wt W2 in 26.75 30.1 10.5 13.5 6.91 H2 H1 mum 679.4 764.3 266.7 343.0 175.4 Wire Ranges Conductor Lug Neutral Lug I Ground Lug DEPTH L—w2 1/0-#14 210-#14 2/0-#14 Service Rated Smart Switch Features Model G007037-1(16 kW)/G007039-1(20 kW)/ • Includes Digital Power Management Technology standard(DPM). G007043-2(22 kW) • No.of Pales 2 Intelligently manages up to four air conditioner loads with no additional Current Rating(Amps) 200 hardware. voltage Rating(VAC) 120/240,10 • Up to four more large(240 VAC)loads can be managed when used in Utility Voltage Monitor(Fixed)* conjunction with Smart Management Modules(SMMs). -Pick-up 80% • Electrically operated,mechanically-held contacts for fast,clean connections. -Dropout 65% • Rated for all classes of load,100%equipment rated,both inductive and resis- Return to Utility* approlt.13 sac five. Exercises bi-weekly for 5 minutes* Standard UL Listed standard • 2-pole,250 VAC contactors. Enclosure Type NEMANL 3R • Service equipment rated,dual coil design. Circuit Breaker Protected 22,WO • Rated for both aluminum and copper conductors. Lug Range 250 MCM-#6 • Main contacts are silver plated or silver alloy to resist welding and sticking. *Function of • NEMA/UL 3R aluminum outdoor enclosure allows for indoor or outdoor mount Evolution Controller Exercise can set to weekly or monthly ing flexibility. Dimensions w' 200 Amps 120/240,1 e Open Transition Service Rated Height Width Depth H2 Mt H1 H2 W1 W2 in 26.75 30.1 10.5 13.5 6.91 mm 679.4 764.3 266.7 343.0 175.4 DEPTH L w2 GENERAC 16/20/22 kW available accessories Model# Product Description The Wi-Fi enabled LP fuel level monitor provides constant monitoring of the connected LP fuel tank.Mon- G007005-0 Wi-Fi LP Fuel Level Monitor itoring the LP tank's fuel level is an important step in making sure your generator is ready to run during an unexpected power failure.Status alerts are available through a free application to notify when your LP tank is in need of a refill. ' r G005819-0 26R Wet Cell Battery Every standby generator requires a battery to start the system.Generac offers the recommended 26R wet cell battery for use with all air-cooled standby product(excluding PowerPact(k). G007101-0 Battery Pad Warmer The pad warmer rests under the battery.Recommended for use if the temperature regularly falls below 0°F(-18`C).(Not necessary for use with AGM-style batteries). G007102-0 Oil Warmer Oil warmer slips directly over the oil filter.Recommended for use if the temperature regularly falls below 0°F (-18°C). G007103-1 Breather Warmer The breather warmer is for use in extreme cold weather applications.For use with Evolution controllers only in climates where heavy icing occurs. G005621-0 Auxiliary Transfer Switch The auxiliary transfer switch contact kit allows the transfer switch to lock out a single large electrical load Contact Kit you may not need.Not compatible with 50 amp pre-wired switches. Fascia Base Wrap Kit The fascia base wrap snaps together around the bottom of the new air cooled generators.This offers a G007027-0-Bisque (Standard on 22 kW) sleek,contoured appearance as well as offering protection from rodents and insects by covering the lifting holes located in the base. If the generator enclosure is scratched or damaged,it is important to touch up the paint to protect from G005703-0-Bisque Paint Kit future corrosion.The paint kit includes the necessary paint to properly maintain or touch up a generator enclosure. G006485-0 Scheduled Maintenance Kit Generac's scheduled maintenance kits provide all the hardware necessary to perform complete routine maintenance on a Generac automatic standby generator. Smart Management Module Smart Management Modules are used in conjunction with the Automatic Transfer Switch to increase its G006873-0 (50 Amps) power management capabilities.It provides additional power management flexibility not found in any other power management system. dimensions & PCs Dimensions shown are approximate.Refer to installation manual for exact dimensions.DO NOT USE THESE DIMENSIONS FOR INSTALLATION PURPOSES 1216 mm 637.E mm I [16.0 in] f2E.1„] Model UPC G007035-1 696471074161 G007036-1 696471074154 smm 0007037-1 696471074178 r1EA M] G007038-1 696471074185 G007039-1 696471074192 o a 0 0 G007042-2 696471074208 G007043-2 696471074215 R5b in] 7232 mm NE.6 kp LEFT SIDE VIEW FRONT VIEW GENERAC Generac Power Systems,Inc. • S45 W29290 HWY.59,Waukesha,WI 53189 • generac.com u2018 Generac Power Systems,Inc,All rights reserved.All specifications are subject to change without notice.Part No.10000000194-H (8/01/18) I Building Permit Check List&Zoning Analysis Address: Z 2 n-,S Fz S too F Lv l SBL• ( 3 S r S( -- L —3 Zone: 2 - Z Use: Const.Type: Other. Submittal Date: Z t Revisions Submittal Dates: Applicant: Nature of Work. LAD �A L (-Z�, Reviews:ZBA: SEP 5 2018 PB: BOT: Other. NEED OK y _� ( ) FEES:Filing. BP: l C/O: Legalization: ( ) ( 4-APP: Date Stamped. ✓Properly Signed.' ­SBL Verified I.O.A.Approval• ( ) ( ) Scenic Roads: Steep Slopes: Wetlands: Storm Water Review: Street Opening: ( ) ( ) ENVIRO:Long. Shore Fees: N/A: ( ) ( ) SITE PLAN:Topo: Site Protection S/W Mgmt.: Tree Plan: Other. ( ) ( ) SURVEY:Dated Current Archival: Sealed Unacceptable: ( ) ( ) PLANS:Date Stamped Sealed Copies: Electronic Other. ( ) ( ) License: Workers Comp: Liability Comp.Waiver. Other. ( ) ( ) CODE 753#: Dated N/A: ( ) (. HIGH-VOLTAGE ELECTRICAL:Plans: Permit N/A: Other. ( ) ( ) LOW-VOLTAGE ELECTRICAL:Plans: Permit: N/A: Other. ( ) ( ) FIRE ALARM/SMOKE DETECTORS:Plans: Permit: H.W.I.C.:_Battery._Other. (� ( ) PLUMBING Plans: Permit: Nat. Gas: LP Gas: N/A/: Other: ( ) ( ) FIRE SUPPRESSION:Plans: Permit: N/A: Other. ( ) ( ) H.V.A.C.: Plans: Permit N/A: Other. ( ) ( ) FUEL TANK.Plans: Permit: Fuel Type: Other. O O 20I6 NY State ECCC: N/A: Other. ( ) ( ) Final Survey Final Topo: RA/PE Sign-off Letter. As-Built Plans: Other. ( ) ( ) BP DENIAL LETTER: C/O DENIAL LETTER: Other. ( ) ( ) Other. ( )ARB mtg.date: approval notes: ( )ZBA rntg.date: approval notes: ( )PB mtg.date: approval• notes: REQUIRED EXISTING PROPOSED NOTES APPrwv4QO,B Area DATE; Circle: Fn2ntage Front: Front: Sides: Rear. Main Cor. Accs.Cor. Ft.H Sb: Sd.H Sb: GFA: Tot : ELkn : Paz Height/Stories: notes: Westchester County Electrical Licensing Board . Westchester County Consumer Protection Master Electrician License 2018 Angelo Zaccagnino D.O.B: 12/1111968 Company: Zaccagnino Electric 81 Maple Ave Rye,NY 10580' '+ , License No. 755 Expires on:12/31/2018 PeWBorducci .aco o� CERTIFICATE OF LIABILITY INSURANCE FDATE(MM4/2018 IDD/YYYY) 0 4/2 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: Joseph$alVatOre BNC Insurance Agency,Inc. PHONE (914)93 lvator FAx AIC No Ext: A/C No: ADDRESS: @nca (914)937-1124 90 South Ridge Street E-MAIL jsalvatore b com 9enc Y� INSURER(S)AFFORDING COVERAGE NAIC N Rye Brook NY 10573 INSURER A: Merchants Mutual Insurance Company 23329 INSURED INSURER B. Merchants Preferred Insurance Company 12901 Sterling Electrical Contracting Inc. INSURER C dba Zaccagnino Electric INSURER D: 81 Maple Avenue INSURER E Rye NY 10580-1583 INSURER F COVERAGES CERTIFICATE NUMBER: CL1842483004 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 LTR TYPE OF INSURANCE IN SD WVD POLICY NUMBER MM/DD/YYYY MM/DD/YYYY LIMITS X COMMERCIAL GENERAL LIABILITY 1,000,000 EACH OCCURRENCE $ CLAIMS-MADE a OCCUR PREMI-E TO RENTED SES Ea occurrence g 500.000 X Contractual Liability 500,00 IVIED EXP(An one person) $ A BOP9095053 05/18/2018 05/18/2019 PERSONAL SADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 JE ❑LOC PRODUCTS-COMP/OPAGG $ POLICY ❑X 2,000,000 OTHER: Employment Practices $ 100,000 AUTOMOBILE LIABILITY 60MBM1E 68M/GH61-1MIT $ 1,000,000 X ANYAUTO Ea accident BODILY INJURY(Per person) $ B OWNED SCHEDULED CAP8662546 05/18/2018 05/18/2019 BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS X HIRED X NON-OWNED PROPERTY DAMAGE AUTOS ONLY iAUTOS ONLY Per accident $ $ X UMBRELLA LIAB CUR2,000,000 EACH OCCURRENCE $A EXCESS LIAR AIMS-MADE CUP9139391 05/18/2018 05/18/2019 AGGREGATE 2,000,000 g DED X RETENTION$ 10,000 WORKERS COMPENSATION $ PER AND EMPLOYERS'LIABILITY YIN 'TA TU ERTE ER ANY PROPRIETORlPARTNER/EXECUTIVE $ OFFICER/MEMBER EXCLUDED? ❑ NIA E.L.EACH ACCIDENT (Mandatory In NH) If yes,describe under E.L.DISEASE-EA EMPLOYEE $ DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached If more space Is required) village of rye brook as additional insured. 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 rye brook ny 10573 AUTHORIZED REPRESENTATIVE ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD YORK Workers' s c �TISTATE Compensation CERTIFICATE OF R004 Board NYS WORKERS' COMPENSATION INSURANCE COVERAGE 1a. Legal Name and address of Insured (use street address only) 1b. Business Telephone Number of Insured STERLING ELECTRICAL CONTRACTING (914) 921-3244 INC DBA ZACCAGNINO ELECTRIC 1c. NYS Unemployment Insurance Employer Registration Number 81 MAPLE AVE of Insured RYE NY 10580 1d. Federal Employer Identification Number of Insured or Social Security Number Work Location of Insured (Only required if coverage is specifically 272148891 limited to certain locations in New York State, re, a Wrap-Up Policy) 2. Name and Address of the Entity Requesting Proof of 3a. Name of Insurance Carrier Coverage(Entity Being Listed as the Certificate Holder) Sentinel Ins Co LTD 3b. Policy Number of Entity Listed in Box"l a": VILLAGE OF RYE BROOK ,6 WEG Z04525 938 KING ST 3c. Policy effective period: RYE BROOK, NY 10573 05/08/2018 to 05/08/2019 3d. The Proprietor, Partners or Executive Officers are included. (Only check box if all partners/officers included) 7 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 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: " � clull 4/27/2018 (Signature) (Date) Title: Operations Manager Telephone Number of authorized representative or licensed agent of insurance carrier: 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