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HomeMy WebLinkAboutMP19-162PERMIT #� SECTION TYPE OF WORK JOB LOCATION . ►,rl► too � � ' �`(IJ Rai:��A.7��.i�/�fat...�a�...-... •-�__- ...-- INSrEQT10N RECORD DATE INSP FOOTING FOUNDATION FRAMING RGH FRAMING INSULATION PLUMBING O — RGH PLUMBING/ GAS SPRINKLER ELECTRIC ® �►'�/ LOW -VOLT O -- ALARM C� AS BUILT O FINAL OTHEf2 APPROVALS ARB k�f 943-�-10-8317 PP Iq-Iq(,/PaTFick Gre9or� PIum61r�-+-i-ice.+►r� �P 19~R4a/Nort easf Genermfor of CT �yE BRnv� tt�wJtiVJ V c c �J+ivy 198 VILLAGE OF RYE BROOK MAYOR 938 King Street,Rye Brook,N.Y. 10573 ADMINISTRATOR Jason A. Klein (914)939-0668 Christopher J.Bradbury www.ryebrookny.gov TRUSTEES BUILDING &FIRE INSPECTOR Susan R. Epstein Steven E. Fews Stephanie J. Fischer David M. Heiser Salvatore W. Morlino CERTIFICATE OF COMPLIANCE September 19,2024 Benjamin Sheer&Carlen Sheer 4 Concord Place Rye Brook,New York 10573 Re: 4 Concord Place,Rye Brook,New York 10573 Parcel ID#: 135.44-1-51 Mechanical Permit#19-162 issued 9/16/2019 for a New Generator This certifies that the 16kw LP gas fired generator,installed under the above captioned permit has been satisfactorily completed. Sincerely, Steven E. Fews Building&Fire Inspector /to �yE BRC�k cu � 1932 BUILDING DEPARTMENT ❑BUILDING INSPECTOR .0 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 : Ll `— C _ & DATE: PERMIT# �� I� ISSUED: SECT: <t�`% BLOCK: LOT: LOCATION: "'/\ � � , � �� I 'u � OCCUPANCY: ❑ VIOLATION NOTED THE WORK IS... ® ACCEPTED ❑ REJECTED/REINSPECTION ❑ SITE INSPECTION REQUIRED ❑ FOOTING ❑ FOOTING DRAINAGE ❑ FOUNDATION ❑ UNDERGROUND PLUMBING NOTES ON INSPECTION: ❑ ROUGH PLUMBING ❑ ROUGH FRAMING ❑ INSULATION ❑ NATURAL GAS ❑ L.P. GAS ❑ FUEL TANK ❑ FIRE SPRINKLER ❑ FINAL PLUMBING ❑ CROSS CONNECTION FINAL ❑ OTHER QyE BRC��, O� ym cu � 1982 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 :- 7 L_O/j C(ord ILL DATE: / - c) - Z d L 7 PERMIT# 42 / / -Z b Z ISSUED:9-/6-/ SECT:/3-`,-`/ BLOCK: / LOT: 5 LOCATION: I Q t J J e n-( �V US e OCCUPANCY: 210 ❑1 Violation Noted THE WORK IS... [IPASSED 19/ FAILED REINSPECTION 9---SITE INSPECTION REQUIRED ❑ FOOTING ❑ FOOTING DRAINAGE ❑ FOUNDATION ❑ UNDERGROUND PLUMBING NOTES ON INSPECTION: ❑ ROUGH PLUMBING ❑ ROUGH FRAMING ❑ INSULATION ❑ Natural Gas ❑ L.P. Gas ❑ FUEL TANK ❑ FIRE SPRINKLER ❑ FINAL PLUMBING ❑ CROSS CONNECTION ❑ FINAL ❑ OTHER cu � 1982 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 : ` �1 LQ DATE: �2 1 2' 0'2—(�. PERMIT# 1� ISSUED: `� I l SECT: ' ` BLOCK: I LOT: LOCATION: h11 � ��� -� 1�� OCCUPANCY: l ❑ VIOLATION NOTED THE WORK IS... ❑ ACCEPTED ❑ REJECTED/REINSPECTION ❑ SITE INSPECTION UIRED ❑ FOOTING ❑ FOOTING DRAINAGE ❑ FOUNDATION ❑ UNDERGROUND PLUMBING NOTES ON INSPECTION: ❑ ROUGH PLUMBING ❑ ROUGH FRAMING ❑ INSULATION ❑ NATURAL GAS ❑ L.E GAS ❑ FUEL TANK ❑ FIRE SPRINKLER ❑ FINAL PLUMBING ❑ CROSS CONNECTION ❑ FINAL [ OTHER �::5 ' s ��Raj�. 2m cu � BUILDING DEPARTMENT ,�,❑,/BUILDING INSPECTOR ASSISTANT BUILDING INSPECTOR VILLAGE OF RYE BROOK /�J❑CODE ENFORCEMENT OFFICER 938 KING STREET • RYE BROOK,NY 10573 (914) 939-0668 FAX (914) 939-5801 www ryebrook.ors - - - - - - - - - - - - - - - - - - - - INSPECTION REPORT - - - - - - - - - - - - - - - - - - - - ADDRESS: l C C11�C DATE: i 1� PERMIT# i ISSUED: SECT: BLOCK: LOT: LOCATION: t, OCCUPANCY: ❑ VIOLATION NOTED THE WORK IS... ❑ ACCEPTED ❑ REJECTED/ REINSPECTION ❑ SITE INSPECTION REQUIRED ❑ FOOTING ❑ FOOTING DRAINAGE ❑ FOUNDATION ❑ UNDERGROUND PLUMBING NOTES ON INSPECTION: ❑ ROUGH PLUMBING ❑ ROUGH FRAMING ❑ INSULATION _ ❑ NATURAL GAS `r �'; n ( [�fcQ✓ � ❑ L.P.GAS ❑ FUEL TANK ❑ FIRE SPRINKLER ❑ FINAL PLUMBING ❑ CROSS CONNECTION ❑ FINAL ❑ OTHER �s i i S t -ti r 11 L..,, A . `cam C4 '0 to ti C4 Vi Z 41 Old 16 Now to how t;- LLI kn ow Woo sOC -t Q CGS, to co 0 �d to Now 0 to tn IX CA OIN ;r to Z moo U Q V) C4) woo ti- t; to w v < Moo rw 61. z to 16 to 4 U 4 U 46 4A 46 4A U 4 U 44 IEEED BUILDING DEPARTMENT c v VILLAGE OF RYE BROOK ' O 2019 938 KING STREET RYE BROOK,NY 10573 Fi v (914)939-0668 FAx(914)939-5801 VILLAGE OF RYE BROOK www.ryebrook.org 13UILDING DEPARTMENT ELECTRICAL PERMIT APPLICATION Westche tteerr County Master Electricians License Required FOR OFFICE USE ONLY )wMe I /-I EP#: SEP 1 1 1019 Approval Date: Permit Fee: $ Approval Signature: Other: Disapproved: (fees are non-refundable) ************************************************************************************************** Application dated, e, (lis hereby made to the Building Inspector of the Village of Rye Brook NY, for the issuance of a Permit to install and/or rem ve 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 with all applicable Federal, State,County and Local Codes. 1.Address: /7 C O N C d 2 iD PL A �C L SBL: —I—,r�l Zone: Q 2.Property Owner: C A R L A:�N 57A l-L'1Z Address: •A/►� Phone#: /`' CD V 8 �0 c Cell#: — — email: C A(Z L r�iJ, 5 H E E2 A/'1�4- 3.Master Electrician: Fc A^,K (Y)A(LK%,'T Address: (daS-�H,j ST &�T CT 0660 Y'Cd M Lic.#: (OS-3 Phone#: Cell#:Zd-? " V/6—8319 email: FM A R k-IT (! rVv e+ e.9 S-r Company Name: Nt✓�M 5 T GQr 09 Address: SA V"c 6'eN trw+V -, cc M 4.Proposed Electrical Work/Fixture Count: Tr,J5 -nd 1(0 Kw pap4A4 IitryA art 2--co 4iile ZITA STATE OF NEW YORK,COUNTY OF WESTCHESTER ) as: FAA N K M tN R 1<v T being duly sworn,deposes and states that he/she is the applicant above named,and does further (print name ofindividual 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 C d k. CTo for the legal owner and is duly authorized to make and file this application. (indicate architect,contractor,agent,attorney,etc.) The undersigned further states that all statements contained herein are true to the best of his/her knowledge and belief,and that any work performed,or use conducted at the above captioned property will be in conformance with the details as set forth and contained in this application and in any accompanying approved plans and specifications,as well as in accordance with the 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 x7 t+ Sworn to before me this '2(0 da �vKt►it ,20 day of u c,i t'f ,20 j 4ature o Property Owner Signatur f Applicant Print N e of Property Owner Print Name of Applict Notary Publi'OSETH A. SHEER f4otary Public Notary Public, State of New York No. 02SH4606662 RENA C PIOSELLI Qualified. in Westchester County Notary Public Commission Expires March 30,2(T7-1' Connecticut Emv mmission Expires Jun 30IW /21/19 INSPECTIONSTATEWIDE SWISJOB APPLICATION tel 845.202.7224 1 fax 914.219.1062 1 SWISNY.com I SWISTraining.com Office Use Elect.Permit# IG /�� rl Date ermit# t, Utility ID# Final Certificate# City/Village K Zip %O S Township Kfe/mock County W6*l-a Address 9 C40 A.-tot A P44 U Cross Street A( K f), Section Block Lot Owner Name/Address(If different than above) A `N f�514 Cea Contact Number 17/y_/_ * 0, Basement ❑ 1 st Fl. ❑2nd Fl. ❑3rd Fl. ❑More Than 3 Fl. ❑Garage Attic ❑Outside Residential ❑Commercial Receptacles Special Recept GFCI AFCI Switches Dimmers Smoke Alarms Carbon Monox Hood Trash Compact Amt Amps Range(s) Cooktop(s) Oven(s) Dishwashers Refrigerator Disposal Microwave Warm Draw Incandescent Fluorescent SERVICE Amperage Voltage 1P 3P #Meters #Disconnect ❑Underground ❑New ❑Reconnect ❑Overhead ❑Change ❑Visual Re-Inspection ❑ Safety Re-Inspection ❑ Re-Inspection Additional Information (2�PIA K�Jr✓� k y R Kpillip-� . 2�� AmP pT5 Wt New Co►�J t LELLAGEOF RYE BROOKU►LC !VG DEPARTMENT This application is valid for one(1)year from the date received by SWIS.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.The applicant declares that there is no open applications for the above address with any other inspection company.The applicant,owner or authorized agent agrees to all the above terms and conditions as set forth for the application. Inspector Date Finalized Inspector# Company Name Date Signature Address City/State Zip Code �� f License# Phone# crkDll State Wide Inspection Services 1080 Main Street U TO I W- - l � 02-F2l, 12524 845 202-722424 Phone %IAI[WIDE IN%Vt( T'(.IN St RV I(1 914-219-1062 Fax Email: office@swisny.com Service With Integrity Website: www.swisny,com BY THIS CERTIFICATE OF COMPLIANCE STATE WIDE INSPECTION SERVICES CERTIFIES THAT: Upon the application of: Upon Premises Owned by: Northeast Generator Carlen Sheer Frank Markut 4 Concord Place 625 John Street Rye Brook, New York 10573 Located at:4 Concord Place Rye Brook, New York 10573 Certificate Number: 2019-6430 Electrical Permit Number: 19-242 Section:135.44 Block:1 Lot:51 BDC:844 Building Permit Number: 19-162 A visual inspection of the electrical system was conducted at the Residential occupancy described below. The electrical system consisting of electrical devices and wiring is located in/on the premises at:4 Concord Place Rye Brook, New York 10573 The Basement and Exterior were inspected in accordance with the NYS and NFPA 70-2014 and the detail of the installation, as set forth below,was found to be in compliance on the loth day of December 2019. Name Quantity Rating Circuit Type Generator 01 23KW ATS 01 200AM P Officer: Frank J. Farina This certificate may not be altered in any way and is validated only by the presence of a seal at the location indicated.This certificate is valid for work performed on the date of inspection only. �o o, °s N Ch I�j rQ i-V a a w w ao aar F29 CIO Q .. • �" a 8z co w T � Q z � C1, o � oFc � •• Q m OQ. yI U ►, O � r� W O � r .. � a• w a. v a � BUILDING DEPARTMENT DDD) VILLAGE OF RYE BROOK OCT 16 2019 938 KING STREET RYE BRopx,NY 10573 (914)939-0668 FAX(914)939-5801 VILLAGE OF RYE BROOK www,ryebrook.org BUILDING DEPARTMENT PLUMBING PERMIT APPLICATION FOR OFFICE USE ONLY19— . PP Approval Date: V VA A' Permit Fee: $_A75D4 Approval Signature: A Other: Disapproved: (fees are non-refundable) Application dated, is hereby made to the Building Inspector of the Village of Rye Brook NY,for the issuance of a Permit to install and/or remove 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,�Counnty and Local Codes. 1.Address: L l C o n f o r c1 P 1- SBL: _I- �J�( 1-51 Zone: 11—I 2.Proposed Work: ✓ dell Q r v. -C ✓" 3.Property wner: P, Address: -I C o C Phone#: — '� Q Cell#: 7 u (Vqe' 7 DV/y email: 4.Master Plumber: �a k r -i C 6 f e v. d� -} Address: la < < V e \,-j 10 V✓� Ci� Lic.#: Phone#:%I "`()V-j�1X Cell#: email: w0 j�I 1-`1-@ m u 1 G Jm Company Name:6 i C 1-S�Dtv a!.o+-\ IP C 0 -T-r. L- Address: 1 1 Q r 2 C j E4 011 _""GA 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 Tubs Service Service Sewer LP Gas Basement 1st Floor 2nd Floor 3`d Floor 4`"Floor 5'Floor Exterior ) I V 5.*List Other Equipmcnt/Providc Dctails: (Notarized Signatures Required Next 2 Pages) 3/21/19 TATE OF NEW YORK,COUNTY OF WESTCHESTER ) as: 0.A r`,07� L v e oy r 1 ,being duly sworn,deposes and states that he/she is the applicant above named, (print name of individual signing as the app'cant) 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 `J k-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 Sworn to before methis �'fh day of fib ,20 day of �'� 201� Si of o er Signature of pp c t Gr-n ZZ4�_ �c 0\6 11 Print Name d Property Owner Print Name of Applicant Notary Public SETH A. SHEER otary Pub Notary Public, State of New York L�XANDRA H.FRANK /1'1"") No. 02SH4606662 Notary Public,State of New York No.Qualified in Westchester Count Qualifieedd i n Westchester Count Commission Expires March 30,20 Z Wy Commission Expires August 28,26L . This application must be properly completed in its entirety and must include the notarized signature(s) of 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. -z- 3/21/19 BUILDING DEPARTMENT �C IE Q " MED VILLAGE OF RYE.BROOK OCT 16 2019 938 KING STREET RYE BROOK,NY 10573 (914)939-0668 FAX(914)939-5801 VILLAGE OF RYE BROOK wrvw ryebirook.ore BUILDING DEPARTMENT AFFIDAVIT OF COMPLIANCE VILLAGE CODE §216 • STORM SEWERS AND SAMTARY 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 F NEW YORK, COUNTY OF WESTCHESTER ) as: n p 31, el'Wryii n S�UW , residing at, "� (i>9✓tl�+N� r ( int naru.) (Address%+here you ll�Q) 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; ,4- . ( , Rye Brook, NY. i.lob nddresi 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. (Sign of �- nS Ske e24 (Print Name of Property Owncr(s)) Sworn to before me this STµ day of 0 C +A4, , 20P_ �/�' otary Public) SETH A. SHEER Notary Public, State of New York No. 02SH4606662 Qualified in Westchester County Commission Expires March 30,202z _3_ 3/21/19 GENERAC® 16/20/22 kW GUARDIAN® SERIES Residential Standby Generators Air-Cooled Gas Engine INCLUDES: • True Power" Electrical Technology Standby Power Rating Models GO07036-1,G007037-1 (Aluminum-Bisque)-16 kW 60 Hz • Two Line LCD Multilingual Digital Model G007035-1 (Aluminum-Bisque) 6 kW 6 Evolution'"Controller(English/Spanish/ Models G007039-1,G007038-1 (Aluminum-Bisque)-20 kW 60 Hz French/Portuguese) Models GO07043-2,G007042-2(Aluminum-Bisque)-22 kW 60 Hz • Two Transfer Switch Options Available: 100 Amp,16 Circuit Switch or 200 Amp Service Rated Smart Switch. - See Page 5 for Details. • Electronic Governor • Standard Wi-Fi" Remote Monitoring �- • System Status&Maintenance Interval LED Indicators • Sound Attenuated Enclosure • Flexible Fuel Line Connector GENERAC —— • Direct-To-Dirt Composite Mounting Pad —� • Natural Gas or LP Gas Operation • 5 Year Limited Warranty• Listed and Labeled by the Southwest Research Institute allowing COUS Q�I ry installation as close as 18"(457 mm)to a structure.* LISTED �l *Must be located away from doors, windows, and fresh air Note:CUL certification only applies to unbundled units and units packaged with intakes and in accordance with local codes. limited circuit switches.Units packaged with the Smart Switch are UL certified in https://assets.swri.org/libraryIDirectoryOfUstedProducts/ the USA only. Constructionlndustry1973DoC_204_13204-01-01_Rev9,pdf FEATURES U INNOVATIVE ENGINE DESIGN&RIGOROUS TESTING are at the heart of Generac's U SOLID-STATE,FREQUENCY COMPENSATED VOLTAGE REGULATION: success in providing the most reliable generators possible.Generac's G-force engine This state-of-the-art power maximizing regulation system is standard on lineup offers added peace of mind and reliability for when you need it the most.The all Generac models.It provides optimized FAST RESPONSE to changing G-Force series engines are purpose built and designed to handle the rigors of load conditions and MAXIMUM MOTOR STARTING CAPABILITY by extended run times in high temperatures and extreme operating conditions. electronically torque-matching the surge loads to the engine. Digital voltage regulation at±1%. 0 TRUE POWER" ELECTRICAL TECHNOLOGY: Superior harmonics and sine wave U SINGLE SOURCE SERVICE RESPONSE from Generac's extensive dealer form produce less than 5%Total Harmonic Distortion for utility quality power.This allows network provides parts and service know-how for the entire unit,from the confident operation of sensitive electronic equipment and micro-chip based appliances, engine to the smallest electronic component, such as variable speed HVAC systems. O TEST CRITERIA GENERAC TRANSFER SWITCHES: Long life and reliability are PROTOTYPE TESTED NEMA MG1-22 EVALUATION synonymous with GENERAC POWER SYSTEMS. One reason for this SYSTEM TORSIONAL TESTED MOTOR STARTING ABILITY confidence is that the GENERAC product line includes its own transfer systems and controls for total system compatibility. Q MOBILE LINK'" REMOTE MONITORING: FREE with every Guardian Series Home GENERAC _ standby generator.Allows you to monitor the status of our generator from anywhere in the Y Y 9 Yw = • , w c � world using a smartphone,tablet,or PC.Easily access information such as the current � PROMISE �®' 0 operating status and maintenance alerts.Connect your account to your authorized service _ v dealer for fast,friendly and proactive service.With Mobile Link,you are taken care of before the next power outage. 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 smartphone,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. G007038-1.G007039-1 G007042-2.G007043-2 G007037-1 (16 kW) (20 kW) (22 Il Rated Maximum Continuous Power Capacity(LP) 16,000 Watts' 20,000 Wafts* 22,000 Watts* Rated Maximum Continuous Powel 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 i 81.3 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 60Hz 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)irVmm 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 6/ Sound output in cli at 23 If(7 m)with generator in 0uiel-Test'"low-speed exercise mode'* 55 55 57 Exercise duration 5 min 5 min 5 min Engir Type o'Eng;-� GENERAC G-Farce 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(m,/hr) 112 Load 218(6.17) 204(5 78) 2281 Full Load 309(8.75) 301(8 52) 327 1Liquid Propane fill(gal/hr)(I/hr1 112 Load 74(2.03)[7.70] 87(2.37)[8.991 92(2.53)[9.571 Full Load 107(2.94)[11.111 130(3.56)[13.48] 142(3.90)[14.77) Note.Fuel pipe must be sized for full load.Required fuel aressure to generator fuel inlet al all load ranges-3.5-7 water column(7-13 mm mercury)for natural gas 10-12 water column 119-22 mm mercury) for LP gas For BTU content,multiply 0/hr x 2500(LP)or It/hr x 1000(NG).For Megejoule content,multiply m3/hr x 93.15(LP)or m3/hr x 37.26 ING) 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.It utility fails.transfer to load takes place. Off Stops unit.Power is removed.Control and charger still operate. Ready to RurVMaintenance 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/Mainlerlance Logs 50 Events Each Engine Start Sequence Cyclic cranking 16 sec on,7 rest(90 sec maximum duralior' Starter Lock-oul Starter cannot re-engage until 5 sec after engine has stopped. Smart Battery Changer 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 Prdedion Standard Automatic Low Oil Pressure/High Oil Temperature Shutdown Standard Overcrank/Overspeed(@ 72 Hzyrpm Sense Loss Shutdown Standard High Engine Temperature Shutdown Standard Internal Fauloncorrect Wiring Protection Standard Commcr Exlemal Fault Capability Standard Field Upgradable Firmware Standard "Sound levels are taken from the front of the generator Sound levels taken tom other sides of the generator maybe higher depending on installation parameters Rabng 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 fuel Btu/megaloule content.ambient temperature.alfitude engine power and condition.etc Maximum power decreases about 3 5 per cent for each 1.000 feet(304 8 meters)above sea level.and also will decrease about 1 percent lot each 6 C(10 F)above 16 C(60 F) GENERAC' 16/20/22 kW switch options_ Li d Circuits Switch Features Model G007036-1(16kW) • 16 ce,24 circuit,breakers not included. No.or Poles 2 Current Rat ng(Amps) 100 • Electric operated,mechanically held contacts for fast,positive Voltage Rating(VAC) 120/240,10 ConnectlOnS Uldily Voitage Monllor(Fixed)' • Rated for all clas of load,100%equipment rated,both inductive and -Pick-up eo , resistive. -Dropout 65 w • 2-pole,250 VAC contacto Retumto utility' approx.15 sec , • 30 millisecond transfer time. Exercises b,-weekly for 5 minutes• Standard • Dual coil design. ULLlsted Standard • Rated for both copper and aluminum con tors. Total Circuits Available 24 • Main contacts are silver plated or silver alloy list welding and sticking. Tandem Breaker Capabilities 8tandems • NEMA/UL 3R aluminum outdoor enclosure allows 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 AFC akers from *Function of Evolution Controller Siemens,Murray,Eaton and Square D for the most flexible and co ffective 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 mm 679.4 764.3 266.7 343.0 175.4 Wire Ranges Conductor Lug Neutral Lug I Ground Lug DEPTH W2 1/0-#14 2/0-#14 1 210-#14 Service Rated Smart Switch Features Model G007037-1(16 kW)/GO07039-1(20 kW)/ • Includes Digital Power Management Technology standard(DPM). No.of Poles 0007043-2(22 kW) • Intelligently manages up to four air conditioner loads with no additional Current Rating(Amps) 200 hardware. Voltage Rating(VAC) 1 0 • 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' approx.13 sec tive. Exercises bi-weekly for 5 minutes' Standard UL Listed Standard • 2-pole,250 VAC contactors. Enclosure Type NEMA/UL 3R • Service equipment rated,dual coil design. Circuit Breaker Protected 22,000 • Rated for both aluminum and copper conductors. Lug Range 250 MCM-#5 • Main contacts are silver plated or silver alloy to resist welding and sticking. • NEMA/UL 3R aluminum outdoor enclosure allows for indoor or outdoor mount- Function of Evolution Controller Exercise can be set to weekly or monthly ing flexibility. Dimensions - W' 200 Amps 120/240,1 e , Open Transition Service Rated "r Height Width Depth �A H2 HI H1 H2 W1 W2 in 1 26.75 30.1 10.5 13.5 6.91 mm 679.4 764.3 266.7 343.0 175.4 L DEPTH i W2 GENERAC 16/20/22 kW available accessories Model# Product Description s The Wi-Fi enabled LP fuel level monitor provides constant monitoring of the connected LP fuel tank.Mon j 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 I unexpected power failure.Status alerts are available through a free application to notify when your LP tank is in need of a refill. ' �.G(305819-0 26R Wet Cell Battery Every standby generator requires a battery to start the system.Generac offers the recommended 26R wetl I cell battery for use with all air-cooled standby product(excluding PowerPact@). It 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). i G007102-0 Oil Warmer Oil warmer slips directly over the oil filter.Recommended for use if the temperature regularly falls below 0 Ti (-18°C). G007103-1 Breather Warmer The breather warmer is for use in extreme cold weather applications.For use with Evolution controllers I only in climates where heavy icing occurs. � 005621-0 Auxiliary Transfer Switch The auxiliary transfer switch contact kit allows the transfer switch to lock out a single large electrical load G Contact Kit you may not need.Not compatible with 50 am y y p p 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 I G005703-0-Bisque Paint Kit future corrosion.The paint kit includes the necessary paint to properly maintain or touch up a generator I enclosure. 1 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. I Smart Management Module Smart Management Modules are used in conjunction with the Automatic Transfer Switch to increase its-1 G006873-0 power management capabilities.It provides additional power management flexibility not found in any other (50 Amps) power management system. dimensions & UPCs Dimensions shown are approximate.Refer to installation manual for exact dimensions.DO NOT USE THESE DIMENSIONS FOR INSTALLATION PURPOSES. 1218 mm 637.6 mm -- 1".0 In] { [25.1 In] -- Model UPC rJ G007035-1 696471074161 G007036-1 696471074154 72�.2 mm '}! G007037-1 696471 7417 In] j 0 8 G007038-1 696471074185 G007039-1 696471074192 ar7 4, G007042-2 696471074208 G007043-2 696471074215 1232 mm - 125 5 ink 148.5 kj y LF=T SIDE VIER FRONT VIEW GENERAC Generac Power Systems,Inc. • S45 W29290 HWY.59,Waukesha,WI 53189 • generac.com ©2018 Generac Power Systems.Inc.All rights reserved.All specifications are subject to change without notice.Pad No.10000000194-H(8/01/18) Building Permit Check List&Zoning Analysis Address: _.O o ca a ►� :�—,L SBI_ .144 Zone:_72--k Use: 2 t Const.Type: Other. Submittal Date: 5 1 ( 0 L S Revisions Submittal Dates: Applicant: _C14 C F_(,,- Nature of Work: 1 u 3-,ALL 1 6-, -F,­,1c,�-�n i-- rt4� ::E2EEt-,4Cf2 'F—x t j no 4 Reviews:ZBA: PB: BOT: Other. NE�F OK ( ) FEES:Filing. 7S-� BP: 13�•��'P'' C/O: Legalization: ( ) (L-YAPP: Dated ✓ Notarized: `--"SBL. Truss I.D. Cross Connection: H.O.A.: ( ) ( ) Scenic Roads: Steep Slopes: Wetlands: Storm Water Review: Street Opening. ( ) ( ) NVIRO:Long. Short: Fees: N/A: ( ) (�ITE PLAN:Topo: Site,Protection; S/W Mgmt.: Tree Plan: Other. ( ) (-?"SURVEY:Dated O S' Current: ✓Archival: Sealed: Unacceptable: ( ) (�PLANS:Date Stamped. Seal d 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 20I7 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 mtg.date: approval: notes: ( )PB mtg.date: approval: notes: APP�n� REQUIRED EXISTING: PROPOSED NOTES !�{ lE1,D Area: Dab; JJ CC rr" 20 1 n J Circle: Frontage Front: Front: Sides: Rear. Main Cov Accs.Cor. Ft.H Sb: Sd.H Sb: GFA: Tot.imp: Ft.Im : PP Height/Stories: notes: TrrLE NO. W 90362 F,A- W o s rlTU�LPrPrlocPcPclr�f7rPcPcPrPr�cPcPcPrJ'r rPcPrJ�k�PU'tcfEPcP[PrJ'orPCPrricPP �nrrrnr�rnrsu�u�u�uu��mnrr�r�nr.�r�an�rcnrr�uu�cnrr�nu� i a ARISTOTLE BOURNAZOS, P.C. 5 5 This is to certify that I have surveyed LAND SURVEYORS - PLANNERS 5 5 LGT G ,9S .S.s'OWAI -OA/ iPESUBO/✓/S/D�1/ 5 5 20 CEDAR STREET OF A POiPT/Dif/ of lflAf DF P/OGE LICENSED IN MONO e , SECT/o✓ 2 /N TiYE TD/1/,y/ OF NEW ROCHELLEa NEW JERSEY 5NEWYORK 10801CONNECTICUT 5 5 (914)633-0100 15 Filed in the Westchester County Clerk's Office,Division of Land Records iv/,y'.2/, /967 as Map IV-F /5,270. S I have located all existing buildings and lines of possession and have shown their positions hereon. 5 SSurvey completed: A414. Z4, 000/ S Map Drafted: Aue. Z9, -ao/ on scale of one inch to 20 feet. ..................................................... ...................._......................... I hereby certify this survey to OoN M. 6` JEN�1//FC.2 C. STNR,2 N.Y. c. 49586 S 5 Ci7/M aRTGNG6-, /.VC. F/,SST AME.P/C'pN T/TLE /NSUrP�9.VCE CO. 5 N£W FENCE SuevEYEO:06-07-Zo05 5 �Si 5 5 S y ,' CORNf� SO/o/(J /V✓r Yc ✓/MYL 5 FfNCf ; S dins Ffwcf LLJ• —r 5 14 5 5 ` > Ile' N i •— 5 5 `V Cw,ei7Ge o'^s F,t.9ME 5 � i/. yousE 5 5 p p aW /6,0 5 o Viol/ 67 5 n D SEp 10 2�'g O�l/CO,eO Rz- IfCE 5 OK S S 5 EYE pAR-�MENY .. gU1LDINV 5 unauthorized alteration or additions to this survey map is a viotation of section 7209 sub-section 2,of the New York State Education Law. No guarantee is implied by this map as to the existence or non-existence of any easements of record that would aHtxl subject property,untesa 5 surveyor has been furnished a complete copy of the title report. Dimenstons shown from structures to properly fines are not fntenoed to be used for construction of fences,structures or other improvements. [hM01099 L1112 oPt-k�PL1'rcPc1"rc.r� cP f.�f�C.l7 Ln tlo QQ ML("] Field Book No. Page No. Office Map No. Certificate No. Survey No. C'01_ J eq ACO® CERTIFICATE OF LIABILITY INSURANCE FDATE(MMIDOIYYYY) o8/21/2019 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: Sheila DelPrete - Merit Insurance,Inc PAHONfE o. at (203)367-5328 FAX No): (203)331-8608 One Enterprise Drive. -ADDRESS: : sdelprete@meritinsurance.com Suite 310 INSURER(S)AFFORDING COVERAGE NAIC 0 Shelton CT 06484 INSURERA; Twin City Fire Insurance Company 29459 INSURED INSURER B: Charter Oak Fire Insurance Company 25615 Northeast Generator Company of CT Inc INSURER C: Farmington Casualty Insurance Company 41483 625 John Street INSURER 0: Travelers Property Casualty Company of America 25674 INSURER E: Bridgeport CT 06604 INSURER F COVERAGES CERTIFICATE NUMBER: CLI962810447 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 CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAYBE 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 ADDLSURRPOLICY FF LICY EXP LTR TYPE OF INSURANCE I POLICY NUMBER MMIDD/YYYY MMIDOIYYYY LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1.000.000 300.000 CLAIMS-MADE X OCCUR DAMAGE TO RENTED PREMISES Ea occurrence s MED EXP(Any one person) s 10,000 A 310ESOA8232 07/01/2019 07/01/2020 PERSONAL BADVINJURY s 1.000.000 GEN.LAGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE g 2,000,000 POLICY ❑X JE 0 LOC PRODUCTS•COMP/OP S 2,000,000 _C T OTHER $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT g Ea accident 1.000,000 JX ANY AUTO BODILY INJURY(Per person) SOWNED SCHEDULED 810-7NB35259 07/0112019 07/01/2020 BODILY INJURY(Per accident) AUTOS ONLY AUTOS S HIRED Ix NON-OWNED PROPERTY DAMAGE AU70S ONLY AUTOS ONLY Per accident $ S UMBRELLA LIAR X OCCUR EACH OCCURRENCE s 5,000,000 A X EXCESSLIAB CLAIMS-MADE 31XSON2059 07/01/2019 07/01/2020 AGGREGATE s 5,000.000 DED I X1 RETENTION S 0 s WORKERS COMPENSATION PER OTH• AND EMPLOYERS'LIABILITY YIN X STATUTE ER ANY PROPRIETORIPARTNERIEXECUTIVE 0EL.EACHACCIDENT 1,000,000C OFFICER/MEMBER EXCLUDED? aNIA UB-7N942317 07/0112019 07/01/202 IMandalory in NH) E L.DISEASE-EA EMPLOYEE s 1.000,000 If yes describe under DESCRIPTION OF OPERATIONS below E L DISEASE-POLICY LIMIT S 1,000,000 Instal lation/ Stored Material S300,000 C Inland Marine 660-8N121875 07/01/2019 07/01/2020 Per Location/Site: $300,000 Leased/Rented Equip: $300,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) 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 REPRESENTATIVE Rye Brook NY 10573 ©198888-200115ACORD CORPORATION. All rights reserved. ACORD25(2016/03) The ACORD name and logo are registered marks of ACORD STATE OF NEW YORK WORKERS' COMPENSATION BOARD CERTIFICATE OF NYS WORKERS' COMPENSATION INSURANCE COVERAGE Ia. Legal Name& Address of Insured(Use street address only) lb. Business Telephone Number of Insured Northeast Generator Company of CT 203-335-4204 625 John Street Ic. NYS Unemployment Insurance Employer Bridgeport,CT 06604 Registration Number of Insured Work Location of Insured (Only required if coverage is specifically limited to certain locations in New York State, i.e., a Id. Federal Employer Identification Number of Insured Wrap-Up Policy) or Social Security Number 061046634 2.Name and Address of the Entity Requesting Proof of 3a. Name of insurance Carrier Coverage(Entity Being Listed as the Certificate Holder) Farmington Casualty insurance Company 3b. Policy Number of entity listed in box"ia" Village of Rye Brook UB-7N942317 938 King Street Rye Brook,NY 10573 3c. Policy effective period 07/01/2019 to 07/01/2020 3d. The Proprietor, Partners or Executive Officers are included. (Only check box if all partners/officers included) all excluded or certain partners/officers excluded. This certifies that the insurance carrier indicated above in box "3" insures the business referenced above in box "la" for workers' compensation under the New York State Workers'Compensation Law.(To use this form,New York(NY)must be listed under Item 3A on the INFORMATION PAGE of the workers' compensation insurance policy). The insurance Carrier or its licensed agent will send this Certificate of insurance to the entity listed above as the certificate holder in box"T'. The Insurance Carrier will also notify the above certificate holder within 10 days IF a policy is canceled due to nonpayment ofpremiums 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 Ilse insurance carrier or its licensed agent, or until lire policy expiration date listed in box "3c whichever is earlier. Please Note: Upon the cancellation of the workers' compensation policy indicated on this form, if the business continues to be named on a permit, license or contract issued by a certificate holder, the business must provide that certificate holder with a new Certificate of Workers' Compensation Coverage or other authorized proof that the business is complying with the mandatory coverage requirements of the New York State Workers'Compensation Law. Under penalty of perjury, I certify that I am an authorized representative or licensed agent of the insurance carrier referenced above and that the named insured has the coverage as depicted on this form. Approved by: Robert Cal ell t name of ri d representative or licensed agent of insurance carrier) Approved by: 8/21/19 (Signature) (Date) Title: Area Vice President HEw (Workers' CERTIFICATE OF INSURANCE COVERAGE f-- s1 t (ompensation Board DISABILITY AND PAID FAMILY LEAVE BENEFITS LAW PART 1.To be completed by Disability and Paid Family Leave Benefits Carrier or Licensed Insurance Agent of that Carrier la.Legal Name&Address of Insured(use street address only) 1b.Business Telephone Number of Insured NORTHEAST GENERATOR COMPANY 625 JOHN STREET 203-336-3031 BRIDGEPORT.CT 06604 1c.Federal Employer Identification Number of Insured or Social Security umber Work Location of Insured(Only required 6 coverage is specifically limited to certain locations in Neiv York State,i e, Wrap-Up Policy) 061046634 2.Name and Address of Entity Requesting Proof of a Name of Insurance Carrier Coverage(Entity Being Listed as the Certificate Holder) Village of Rye Brook HARTFORD LIFE AND ACCIDENT 938 King Street 3b Policy Number of Entity Listed in Box"I a" Rye Brook, NY 10573 LNY725221 c Policy effective period 07-01-2019 to 06-30-2020 4.Policy provides the following benefits: R A.Both disability and paid family leave benefits. B.Disability benefits only. C.Paid family leave benefits only. 5.Policcovers: [✓ A.All of the employer's employees eligible under the NYS Disability and Paid Family Leave Benefits Law. B.Only the following class or classes of employer's employees. 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 NYS Disability and/or Paid Family Leave Benefits insurance coverage as described above. Date Si ned 08-21-2019 re&g- (Signature of Insurance urriees autttodzed representative or NYS Licensed Insurance Agent of that insurance carrier) Telephone Number (212)553-8074 Name and Title:Elizabeth Tello-Assistant Director,Statutory Services IMPORTANT: If Boxes 4A and 5A are checked,and this form is signed by the insurance carrier's authorized representative or NYS Licensed Insurance Agent of that carrier,this certificate is COMPLETE. Mail it directly to the certificate holder. If Box 46,4C or 56 is checked,this certificate is NOT COMPLETE for purposes of Section 220,Subd.8 of the NYS Disability and Paid Family Leave Benefits Law. It must be mailed for completion to the Workers'Compensation Board,Plans Acceptance Unit, PO Box 5200,Binghamton,NY 13902-5200. PART 2.To be completed by the NYS Workers' Compensation Board (Only if Box 4C or 56 of Part 1 has been checked) State of New York Workers' Compensation Board According to information maintained by the NYS Workers' Compensation Board,the above-named employer has complied with the NYS Disability and Paid Family Leave Benefits Law with respect to all of his/her employees. Date Signed By (Signature of Authorized NYS Workers Compensation Board Employee) Telephone Number Name and Title Please Note:Only insurance carriers licensed to write NYS disability and paid family leave benefits insurance policies and NYS licensed insurance agents of those insurance carriers are authorized to issue Form DB-120.1.Insurance brokers are NOT authorized to issue this form. DB-120.1 (10-17) III' I!�!!111111111°°!4!1111!°Iill IH