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HomeMy WebLinkAboutMP23-008 �yE DR 19 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 CERTIFICATE OF COMPLIANCE March 13,2023 Kathleen Riley 6 Lee Lane Rye Brook,New York 10573 Re: 6 Lee Lane, Rye Brook,New York 10573 Parcel ID#: 135.66-1-25 This document certifies that the work done under Mechanical Permit #23-008 issued on 1/17/2023 for the installation of a new gas fired boiler has been satisfactorily completed. Sincerely, Steven E. Fews Acting Building&Fire Inspector /to �E BROvk 1982 BUILDING DEPARTMENT BUILDING INSPECTOR I ❑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 : C-1 DATE: '31 PERMIT# — n ISSUED: 1k-�"CT: ('�)4�BLOCK: LOT: LOCATION 20 S C -s ) s�) y,-� OCCUPANCY: l ❑ VIOLATION NOTED THE WORK IS... f`'' 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 ❑ SS CONNECTION INAL ❑ OTHER r _ 04 Lo O � 400 ■ N ! N � n.'a O � � � x � as fir. � ,� i••i s ■ • - � � O O , et \o p w C!1 ■ � � � � �i O w 3 � � y al: Q 1-4 11 0" PLO Aq00 tog O w 0 0*4% pJ O a zACN � v v v Q u M 00 H "z R ` w oZZx O ,woo ° ww a � v O H " 4 oiZ H w z a O � � o � b �I � � Cz+ i-•1 W x � � � a b ED BUILDING DEPARTMENT R C IE M VILL, E OF RVE BROOK JAN 13 2023 938 KING T RYE BROOK,NV 10573 ft 0668 VILLAGE OF RYE BROOK w%*W.r irook.org BUILDING DEPARTMENT APPLICATION FOR PERMIT TO INSTALL AND/OR REMOVE HEATING, VENTILATION AND/OR AIR CONDITIONING EQUIPMENT FOR OFFICL l;SE ONLY: 1 7 2U 3 PERMIT#: /:-/,/ 3—QO4 Approval Date: Permit Fee: $ Approval Signature: Other: Disapproved: (fees are non-refundable) REQUIREMENTS FOR RELEASE OF PERMIT&CERTIFICATE 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#C 105.2 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, f '2 2> is hereby made to the Building Inspector of the Village of Rye Brook for a permit for the installation and or removal of the fIVAC 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. l. Address: Q L e? e` UDL o e- SBL: ZS7 Zone:'e 0 2. Property Owner: Address: (i LCe- Lge-vc Phone#: Ct{t l -�►0 - l 2 BCo Cell#: email. 3. Contractor: M CL c Z 0 6r a r\-1 Address: l t;o G%M%.ZAc1('4g °C k Phone#:�'i_(14-590 - -)kQ, 3 Cell#: email:pecM.}s��Cac 4. Applicant: Cy,)CL C i o r u n i Address:Luo C1,c'cz�;Sl0 cvAs T_& Phone#: `�l� -S20- 1og3 Cell#: email: �ec(�ek�[ �C7rvcgr�rrtc.ca.,, 5. Scope of Work: New Installation( )-Replacement V)/• Removal( )•Other( ): 6. List Equipment: "Q\l(Crl bode cr 7. Location of Equipment: ti`J9Se e n 8. Method of Installation/Removal(list all equipment needed to perform job): 1 8/12/2021 STATE OF NEW YORK,COUNTY OF WESTCHESTER ) as; (:n(3-6 Q3 n�► being duly sworn,deposes and states that he/she is the applicant above named, (print name of individual signing as the applicant) and fi►rther states that(s)he is the legal owner of the property to which this application pertains,or that(s)he is the CAnV ro-r-k o r for the legal owner and is duly authorized to make and file this application. (indicate architect,contractor,agent.attorney,etc.) That all statements contained herein are true to the best of his/her knowledge and belief,and that any work performed,or use conducted at the above captioned property will be in conformance with the details as set forth and contained in this application and in any accompanying approved plans and specifications,as well as in accordance with the New York State Uniform Fire Prevention&Building Code,the Code of the Village of Rye Brook and all other applicable laws,ordinances and regulations. Sworn to before me this 13 Sworn to before me this day of day of C1 � 20 23 ignr P Opel wrier ign a of Applicant Print Name of Property Owner Print Name of Applicant Notar u is DIANE M KEMPTER Notary Public-State of New York DIANE M KEMPTER NO,01 KE6391666 PNotary Public-State of New York Qualified in Westchester County NO.01KE6391666 My Commission Expires May 13. 2023 alified in Westchester County mmission Expires May 13, 2023 This application must be properly completed in its entirety and must 1 cue ie notartz.e sigt a r (s) of the legal owncr(s)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 8/1 212 02 1 2 NCB-H High-Efficiency Condensing Combination Boiler—Submittal Sheet Overhead View 19, E • 1.5'(38In" 14.3"(364 mm) a E E E E e E E N .5'(115 miry, 6.7'(170 mm) a C Supply Connections o l� 4 O Q Supply Connections 10 ( 0 • D6SCA on _ DIemM�r .. �• 4 A jPressure Relief Valve Adapter %in Zo j • �•� • B Air intake 2 in C Eftust Gas Vent 21n D Heating Supply 1 in • • •• E Domestic Hot %in F Gas Connection -%In G Domestic Cold -%in 2.7'(68 RsN 3.5' 3.3" 2.V 2.5' H Aub Feeder Inlet(Make-up Water) h in (88 mm) (85 mm) (74 mm) @3 mm) I lCondensate Outlet X in J lHealing Return 11 in 9.6'(244'"") 17.3 (440 mm) Navim Combbodon Bohr Other Specillicadons Domestic Hot water winiga Heating In ut(BTU/H) Model Number Water Minimum Flow Rate 770F DHW Supply DHW Return Min Max Pressure Flow Rate (43"C)Temp Rise Connection Size Connection Size NCB-190/060H 10,700 160,000 3.7 GPM(14.0 L/m) NCB-190/090H 10,700 160,000 0.5 GPM NCB-240/110H 13,300 199,900 15-150 PSI (1.9 L/m) 4.7 GPM(17.8 L/m) 3/4"NPT 3/4"NPT NCB-240/130H 13,300 199,900 NCB-250/1501­1 1 14,000 210,000 14.9 GPM(18.5 L/m) Navien Condensing Boger OdwrSpod icalbits Spam Heating Ratings _..eating lnyut BTU/H) Heating Net AHRI Water Model Number Capacity Rating Water AFUE I%) Water Pressure Connection Sze Water Min Max (MRH) (MRH) (Supply,Return) Volume NCB-190/060H 11 60 56 49 95.0 NCB-190/080H 11 80 74 64 95.0 NCB-240/110H 13 "0 102 89 95.0 12-30 psi 1"NPT 1.5gallons NCR 2401130H 13 130 120 1. 1.0 NCB-250/150H 14 150 1 138 1 120 95.0 20 Goodyear, Irvine, CA 92618 13 949.420.0420 ® 949.420.0430 © Navieninc.com © Nav�eN NCB-H High-Efficiency Condensing Combination Boiler Submittal Sheet ❑ Model NCB-1901060H(60,000 Btu/hr. space heating and 160,000 Btu/hr. DHW) ❑ Model NCB-1901080H(80,000 Btu/hr. space heating and 160,000 Btu/hr. DHW) ❑ Model NCB-2401110H(110,000 Btu/hr. space heating and 199,900 Btu/hr. DHW) ❑ Model NCB-2401130H(130,000 Btu/hr. space heating and 199,900 Btu/hr. DHW) ❑ Model NCB-2501150H(150,000 Btu/hr. space heating and 210,000 Btu/hr. DHW) Job Name: Location: Engineer: Wholesaler: Sales Rep: Contractor: Model: _ Gas Type (NGILP): Notes: Boiler Standard Features Boiler Optional Accessories Controls • SS Dual Heat Exchangers SS Primary Manifold Kit Smart Controls with LCD • Cold-rolled Carbon Steel Condensate Neutralizer Kit Display, Quick Dial Wheel and Casing Zone Controller Setup Wizard • 95%AFUE Universal Temperature Sensor Built-in 3 zone pumps and 3 • DHW 15:1 TDR NaviLink Control System zone valves powered • Heating up to 11:1 TDR Ready-Link Racking System connections • 30 PSI ASME Relief Valve NaviClean Magnetic Filter Manual Reset LWCO • Direct Spark Ignition NaviCirc for Recirculation Manual Reset High Limit • Variable Speed Blower HotButton and Wall Plate Freeze Protection • Dual Venturi Mixing System Outdoor Reset • Negative Pressure Gas Valve Venting Warm Weather Shutdown • Cascaded with up to 15 NPEs Direct Exhaust Sidewall or Air Handler Interface • Common Vented with up to 7 Roof Vent 4 Circulator Outputs NPEs Direct Exhaust Inside Air NaviLink Mobile Application • Wall Mounting Bracket Venting • High Altitude NG and LPG 2" PVC, CPVC, PP, SS up to Warranties Conversion Kits 65 ft. 10 yrs. Residential HX • Outlet & Inlet Temp Sensors 3" PVC, CPVC, PP, SS up to Warranty • Outdoor Temperature Sensor 150 ft. 5 yrs. Residential Parts • Flue gas Temperature Sensor Vent Termination Caps Warranty • Condensate Trap Wall Flanges 1 yr. Labor Warranty • Mixing and Water Adjustment Valves 20 Goodyear. Irvine, CA 92618 © 949.420.0420 © 949.420.0430 0 Navieninc.com M n o ate. 00 CL u W Qr cn a ��J ►-r zON v �n � x ,o Q o as F O z o z Z � coo O W oo zLLI O w V o ru z (> H � � a� � a zz w ca 0 a 0.0 ,♦ F W c z z 2 �I O a V og ►-a �' H Q z A o � �-' 0.0 w U p �C�COMC - DD JAN 13 2023 BUIL E MENT V>1, E OF RYE OK VILLAGE OF RYE BROOK 938 KIN , ET RYE BI NY 105 BUILDING DEPARTMENT W , :or PLUMBING PERMIT APPLICATION FOR OFFICE USE ONLY - — W PI>#: 03 C-00 Approval Date: d 7 Permit Fee: $ / 75 1 �J Approval Signature: Other: Disapproved: (fees are non-refundable) **************** ********************************************************************************* Application dated, \ 2 2 3 is hereby made to the Building Inspector of the Village of Rye Brook NY, for the issuance of a Permit to install and/or remove Plumbing as per detailed statement described below.The applicant&property owner,by signing this document agree that said plumbing work will be in conformance with all applicable Federal,State,County and Local Codes. I.Address:LQ Lee Car,C_ SBL: haS.fo(o- 25 Zone:,e /o 2.Proposed Work: 3.Property Owner:�0.-NA:te t\ "-K,A e y Address: (,o Lee- LQn t- Phone#: C114-`(l1 12810 Cell#: email: K�t'c�`ey V'tG!'MQ% CCM 4.Master Plumber: M olc io n v n Address: l o o C1 c QSS\Qn ZS 2Z . Lic. #: L_Vl Phone Cell#: email:pecM�kS�\Jruegn.�ne.coc+i Company Name: CC1('-\{]tS� Address: \pp INDICATE FIXTURES&LINES TO BE INSTALLED AS PER THE FOLLOWING SCHEDULE: Location Water Urinals Drinking Sinks Showers Bath Laundry Domestic Fire Sanitary Natural/ Other* Total Closets Fountains Tubs 'rubs Service Service Sewer LP Gas Basement otlC(- st Floor 2nd Floor 3`d Floor 4"Floor 5"Floor Exterior 5.* List Other Equipment/Provide Details: (Notarized Signatures Required Next 2 Pages) sn 2/202 F STATE OF NEW YORK,COUNTY OF WESTCHESTER ) as: Mac I cL, ,being duly sworn,deposes and states that he/she is the applicant above named, (print name of individual signing as the applicant) and further states that(s)he is the legal owner of the property to which this application pertains,or that(s)he is the P�U c- for the legal owner and is duly authorized to make and file this application. (indicate architect,contractor,agent,attorney,etc.) That all statements contained herein are true to the best of his/her knowledge and belief,and that any work performed,or use conducted at the above captioned property will be in conformance with the details as set forth and contained in this application and in any accompanying approved plans and specifications,as well as in accordance with the New York State Uniform Fire Prevention&Building Code,the Code of the Village of Rye Brook and all other applicable laws,ordinances and regulations. Sworn to before me this V-Z-- Sworn to before me this k 2 day of �J—ZnQa ,20 Z3 day of 20 Si nat a of Property Own e ASigna pplicant Print Name of Property Owner Print Name of Applicant N DIANE M KEMPTER DIANE M KEMPTER Notary Public-State of New York Notary Public-State of New Yprll N0.01KE6391666 NO.OIKE6391666 Qualified in Westchester County Qualified in Westchester County My Commission Expires May 13,2023 My commission Expires May 1 1, 2023 This c ton mus e properly completed in its entirety and must inclffdTtfre f the legal owner(s) of the subject property, and the applicant of record in the spaces provided. Applications not properly completed in its entirety and/or not properly signed shall be deemed null and void and will be returned to the applicant. -2- 8/12/2021 BUIL MENT V11L OF RY OOK 938 KING ET RYE BR ,NY 10573 4 -0 AFFIDAVIT OF COMPLIANCE VILLAGE CODE �216 • STORM SEWERS AND SANITARY SEWERS THIS AFFIDAVIT MUST BEAR THE NOTARIZED SIGNATURE OF THE LEGAL PROPERTY OWNER AND BE SUBMITTED ALONG WITH ANY BUILDING OR PLUMBING PERMIT APPLICATION. ANY BUILDING OR PLUMBING PERMIT APPLICATION SUBMITTED WITHOUT THIS COMPLETED AND NOTARIZED FORM WILL BE RETURNED TO THE APPLICANT . STATE OF NEW YORK,COUNTY OF WESTCHESTER ) as: �, Q-k�'1��en e y , residing at, (0 Lee 'Lac-, (fruit mantel (Address�\here\ou Ine) being duly sworn, deposes and states that(s)he is the applicant above named, and further states that(s)he is the legal owner of the property to which this Affidavit of Compliance pertains at; (p Le,.- Llan-P, , Rye Brook,NY. Doh AJdress) Further that all statements contained herein are true, and that to the best of his/her knowledge and belief,that there are no known illegal cross-connections concerning either the storm sewer or sanitary sewer,and further that there are no roof drains,sump pumps,or other prohibited stormwater or groundwater connections or sources of inflow or infiltration of any kind into the sanitary sewer from the subject property in accordance with all State, County and Village Codes. I . nuturK of honerl� M\ner(sn (limit Name of Propert?,Uwnei-is)) Sworn to before me this t 2 ENotary M KEMPTER day of �QC1 QQ CN{ 20 2 Star a 16 New Yoi k, 1KE6391000 Wetchester OLMIL023 Expires May 13, -3- S/12/2021 2 NCB-H High-Efficiency Condensing Combination Boiler—Submittal Sheet Overhead View � T • 151(38 mot) 14.3"(364 mm) e c E E E E cV • E � E i. .5'(115 6.7"(170 mm) �i v in i Supply Connections I. Supply ConnectionsE ® ( Desaiption-- ._._................. 0 - Q FAn re Relief Valve Adapter %in • • '�' ke 21n st Gas Vent 2 In g Supply 1 Instic Hot A inonnection *in stic Cold %in 2.7'(88 RxN 3.5' 3.3" 2.9' 2.5' eeder Inlet(Make-up Water) Ain (8s mrl ley mm) 04 mN (63 mN at,Outlet 14 in J Healing Return 1 in s.s (24a mr) 17.3'(440 MM) Navien Combination Boiler r Other Specifications Domestic Hot Water Ratings Heating Input(BTU/H) Water Minimum Flow Rate 77°F DHW Supply DHW Return Model Number Min I Max Pressure Flow Rate (43°C)Temp Rise Connection Size Connection Size NCB-190/060H 10,700 160,OD0 3.7 GPM(14.0 L/m) NC8-190/080H 10,700 160,DD0 0.5 GPM NCB-240/110H 13,300 199,900 15-150 PSI (1.9 L/m) 4.7 GPM(17.8 L/m) 3/4'NPT 3/4"NPT NCO-240/130H 13,300 199,900 NCB-250/150H 14,000 210,000 4.9 GPM(18.5 L/m) Navien Condensing Boiler OfheYS{ac(flc4dmSls Space Heating Ratings tleatin 1 ut 8TU/H Heating I Net AHRI Water water Model Number (:apacky Rating Water AFUE(%) Water Pressure Connection Size Volume Min Max (MBH) (MBH) (Supply.Return) NCO-190/060H 11 1 60 56 49 95.0 NCB-190/0e0H 11 eo 74 64 95.0 NCB-240/110H 13 110 102 89 95.0 12.30psi 1"NPT 1.5 gallons NCO 240/130H 13 130 120 104 95.0 NCB-250/150H 14 150 138 1 120 I cKn 20 Goodyear, Irvine, CA 92618 ©949,420,0420 0 949,420,0430 0 Navieninc.com MNavieN NCB-H High-Efficiency Condensing Combination Boiler Submittal Sheet ❑ Model NCB-1901060H(60,000 Btu/hr, space heating and 160,000 Btu/hr. DHW) ❑ Model NCB-1901080H(80,000 Btu/hr, space heating and 160,000 Btu/hr. DHW) ❑ Model NCB-2401110H(110,000 Btu/hr. space heating and 199,900 Btu/hr. DHW) ❑ Model NCB-2401130H(130,000 Btu/hr. space heating and 199,900 Btu/hr. DHW) ❑ Model NCB-2501150H(150,000 Btu/hr. space heating and 210,000 Btu/hr. DHW) Job Name: Location: Engineer: Wholesaler: Sales Rep: Contractor: Model: Gas Type (NG/LP): Notes: Boiler Standard Features Boiler Optional Accessories Controls • SS Dual Heat Exchangers SS Primary Manifold Kit Smart Controls with LCD • Cold-rolled Carbon Steel Condensate Neutralizer Kit Display, Quick Dial Wheel and Casing Zone Controller Setup Wizard • 95%AFUE Universal Temperature Sensor Built-in 3 zone pumps and 3 • DHW 15:1 TDR NaviLink Control System zone valves powered • Heating up to 11:1 TDR Ready-Link Racking System connections • 30 PSI ASME Relief Valve NaviClean Magnetic Filter Manual Reset LWCO • Direct Spark Ignition NaviCirc for Recirculation Manual Reset High Limit • Variable Speed Blower HotButton and Wall Plate Freeze Protection • Dual Venturi Mixing System Outdoor Reset • Negative Pressure Gas Valve Venting Warm Weather Shutdown • Cascaded with up to 15 NPEs Direct Exhaust Sidewall or Air Handler Interface • Common Vented with up to 7 Roof Vent 4 Circulator Outputs NPEs Direct Exhaust Inside Air NaviLink Mobile Application • Wall Mounting Bracket Venting • High Altitude NG and LPG 2" PVC, CPVC, PP, SS up to Warranties Conversion Kits 65 ft. 10 yrs. Residential HX • Outlet& Inlet Temp Sensors 3"PVC, CPVC, PP, SS up to Warranty • Outdoor Temperature Sensor 150 ft. 5 yrs. Residential Parts • Flue gas Temperature Sensor Vent Termination Caps Warranty • Condensate Trap Wall Flanges 1 yr. Labor Warranty • Mixing and Water Adjustment Valves 20 Goodyear. Irvine, CA 92618 13 949.420.0420 © 949.420.0430 Navieninc.com ' \ `'� i�.r`.. .1 ••�.._ f �./ rr r .t,...�;'.',:C�,,,tti'`�s1,l";•:l f;l•iriQ.a.t^rA.5')�4.1;5`;�:A,`�af)ck�v.r.;,...;,•�..„"�,th.,r'..l,bn;„{a G�.—o !%r.f 4.f�`;R,•ti-\'i�'•�`;�..:.5fi�,''+"<�t.'�;";�. dK.r;;R.:\•a�.t:... .a.\{�; A !h: Owl, , PRO, : �`{ c,,�'.�•};p Y/:g{tY,'..'..:r:.F,fqS..�3,,. • ' �,ga,��7:�La.?�,;•,G't�{11 �It�?',,;�... ;�7 . ..:,J.�• rr;c. 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UY maai?�bl� GJ N . ka�1' h _ 3 .,j,'� 'r:.r r ;--,� •c�•- t ,y <lm y•~.-"'?rSf��_a,�•y+ •rs,. �'. .�'• n'°�°;• .:�' �(?l�suDD,�• '� �'�..� �Bt s,� {141 .:;.,�'.'•ry�`'*`�'{ !r} "' r , , `H I�: 1�rz, � t :xe 11j;; !•{ 0/�{ fy'fd lr {', r, 'k Of00t ,F ,r'a,. ,r'relltr 7mr ' • �� J t(;rr;v�l` ,?„�0.. �.I�000 �.B} "�z4"'t.r,•000i, ��T�,� .r.;��_, 7i �� h�l•,�Mv lY.�;�1;f- �'�'r�O:I`�,, t,r fl �,F '1�{I p{ �}�'�•,��.•,': "�� y`'I�Si, r�,�' y�f�Uy�. .. �r�i,c'^Y�LXO�u1t� S �. i �.��'�a�.`�.,.�.{ :���Y;'Yr4.hl�� �5 �.;i2�,�1T((��,. 1' .�;5r,rt�' � � S 1 e 111 t�'�U"'..,Yba� 7 1� l r 75V'<�,'yY ,r ��,,• .;'t) .h1.M v f.£ �t{��. t� �.,.tiY�.2;n '�'.r?'.',t�re�'I;J'�,�>.7�s,¢If'{Vr>�lf.l. .e.•.' A�7:i.•' �• �' ��.'�1�.�, >e",^:riZ-� �1 vi ������ �'�}., o:(�u41Ar;'??<S�b':' !b ':Y:�rt.yi 3t' \+�:'J•'�'r�37%.^.:lS�Y^ arj,5;"�?%`si:::i;'<{:'// .�t'�,'�r:"o'F,T•,�•tS`ai!ilS.� 'iiu�%:;,cf,r>��yp yr 'i�J�.7j','a'�.�'p:/ty�r•;.r.,ijl,., '�rt, a,-�y4,.iit. �>'�� d�r,l' �7t�j��t� la�,.�"rY.����.•C .)'.-3,+J�°�.• ���✓f�;),..\ rl��l. y� tote�,r�ta ,�t�`�fri..��v � hfi .>C}p����S..rC)�'•+.1 Al CERTIFICATE OF LIABILITY INSURANCE DATE11/13/D/YYYY) 11/132022 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 endorsements. PRODUCER CONTACT FEDERATED MUTUAL INSURANCE COMPANY NAME: CLIENT CONTACT CENTER HOME OFFICE: P.O. BOX 328 A C, . Ext:888-3334949 A/c No):507-4464664 OWATONNA, MN 55060 ADDRIESS:CLIENTCONTACTCENTER FEDINS.COM INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:FEDERATED MUTUAL INSURANCE COMPANY 13935 INSURED 287-972-4 INSURER B: BRUNI AND CAMPISI PLUMBING AND HEATING, INC. INSURER C: 100 GRASSLANDS RD ELMSFORD, NY 10523-1110 INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:37 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 ADDL SUER POLICY NUMBER POLICY EFF POLICY EXP LIMITS LTR INSR WVD MMIDDIYYYY MM/DD/YYYY X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $1,000,000 CLAIMS-MADE DAMAGE TO RENTED $100,000 - X -,OCCUR PREMISES Ea occurrence MED EXP(Any one person) $5,000 A Y N 6119957 01/01/2023 01/01/2024 PERSONAL&ADV INJURY $1,000,000 CEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $2,000,000 X POLICY ❑JECT ❑LOC PRODUCTS-COMPIOP AGO $2,000,000 OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $1,000,000 Ea ticciden X ANY AUTO BODILY INJURY(Per person) OWNED AUTOS ONLY SCHEDULED A AUTOS N N 6119957 01/01/2023 01/01/2024 BODILY INJURY(Per accident) HIRED AUTOS ONLY NON-OWNED PROPERTY DAMAGE AUTOS ONLY Per accident X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $5,000,000 A EXCESS LIAB CLAIMS-MADE N N 6119958 01/01/2023 01/01/2024 AGGREGATE $5,000,000 DED I X I RETENTION$10.000 WORKERS COMPENSATION OTH- AND EMPLOYERS'LIABILITY Y N PER STATUTE ER / ANY PROPRIETORIPARTNER/EXECUTIVE E.L.EACH ACCIDENT OFFICERIMEMBER EXCLUDED? N I A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE yes,describe under D E.L DISEASE-POLICY LIMIT DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS 1 LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached it more space is required) THE CERTIFICATE HOLDER IS AN ADDITIONAL INSURED SUBJECT TO THE CONDITIONS OF THE ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS - AUTOMATIC STATUS WHEN REQUIRED IN CONSTRUCTION AGREEMENT WITH YOU ENDORSEMENT FOR GENERAL LIABILITY. CERTIFICATE HOLDER CANCELLATION 287-972-4 37 0 VILLAGE OF RYEBROOK 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 REPRESENTATIVE © 1988-2015 ACORD CORPORATION.All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD DocuSign Envelope ID:DCB22B4E-5D9E4960-8FA3-D7C23886CCED Yo K Workers' CERTIFICATE OF STATE Compensation NYS WORKERS' COMPENSATION INSURANCE COVERAGE Board 1 a.Legal Name&Address of Insured(use street address only) 1 b.Business Telephone Number of Insured BRUNT AND I PLUMBING AND HEATING, 100 Grasslandsds Rd 1 c.NYS Unemployment Insurance Employer Registration Number of Rd ELMSFORD,NY10523 Insured Work Location of Insured(Only required it coverage is specifically limited to 1 d.Federal Employer Identification Number of Insured or Social Security certain locations in New York Slate,i.e.,a Wrap-Up Po/icy) Number 132999646 2.Name and Address of Entity Requesting Proof of Coverage 3a.Name of Insurance Carrier (Entity Being Listed as the Certificate Holder) Indemnity Insurance Co.of North America VILLAGE OF RYE BROOK 938 KING STREET 31b.Policy Number of Entity Listed in Box"ta" RYE BROOK,NY 10573 C51623769 3c.Policy effective period 10/1/2022 to 10/01/2023 3d.The Proprietor,Partners or Executive Officers are included.(Only check box If all partners/officers Included) ❑ all excluded or certain partners/officers excluded. This certifies that the insurance carrier indicated above in box"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 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 t 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: Lex Smith Docusi(7pgt4rame of authorized representative or licensed agent of insurance carder) Approved by: dam^^ 9/12/2022 (Signature) (Date) Title: Assistant Program Manager Telephone Number of authorized representative or licensed agent of insurance carrier: 214-721-6248 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) Acct#:2809046 www.wcb.ny.gov