Loading...
HomeMy WebLinkAboutMP23-023 t� �t`y�o wYi VILLAGE OF RYE BROOK MAYOR 938 King Street, Rye Brook,N.Y. 10573 ADMINISTRATOR Jason A. Klein (914) 939-0668 Christopher J. Bradbury ebrook.org TRUSTEES ACTING BUILDING& FIRE INSPECTOR Susan R. Epstein Steven E. Fews Stephanie J. Fischer David M.Heiser Salvatore W. Morlino CERTIFICATE OF COMPLIANCE April 10,2023 Washington Park Plaza Associates c/o Martha Levy 253 South Ridge Street Rye Brook,New York 10573 Re: 263 South Ridge Street, Rye Brook,New York 10573 Parcel ID#: 141.35-2-51 This document certifies that the work done under Mechanical Permit #23-023 issued on 2/22/2023 for the installation of a new rooftop HVAC unit has been satisfactorily completed. Sincerely, %00� Steven E. Fews Acting Building&Fire Inspector /to BRC�v� O Zm w � ,9a2 BUILDING DEPARTMENT ❑BUILDING INSPECTOR VILLAGE OF RYE BROOK 0 VILLAGE ENGINEER 938 KING STREET RYE BROOK,NY 10573 ❑ASSISTANT BUILDING INSPECTOR (914) 939-0668 FAx(914) 939-5801 - - - - - -- - - - - -- - - - - - - - - INSPECTION REPORT - - - - - - - - - - - - -- - - - -- - - ADDRESS: `+- ' -� ` \ - DATE: PERMIT# 15 FIX 2' L�--SHCI: ��� BLOCK: LOT: LOCATION: ` C �C U() OCCUPANCY: ❑ VIOLATION NOTED THE WORK Is.. ACCEPTED ❑ REJECTED/REINSPECTION ❑ SITE INSPECTION ��� REQUIRED 0 FOOTING ❑ FOOTING DRAINAGE 0 FOUNDATION 0 UNDERGROUND PLUMBING NOTES ON INSPECTION: 0 ROUGH PLUMBING ❑ ROUGH FRAMING 0 INSULATION ❑ NATURAL GAS 0 L.P. GAS 0 FUEL TANK 0 FIRE SPRINKLER ❑ FINAL PLUMBING ❑ FINAL ❑ OTHER a (VN a N N 066 W . E. v : M.,� G� C••r � v y".41 c X Ln o � x oCIA � 3 � h � y A ` It O �j 6ry f'is ~ h••i Q F v.. ae Gr U 0 v � v ,° 8 U w w � � � � 0141W W F o o � w a © H z UW z D u w 00 uw CA 0 j U © o V O © V �^ M z A � � ° F p w A O � ° - a to r"Si I a0 a w � rj) M p L C EE WE BUILDING DEPARTMENT FEB 15 2023 VILLAGE OF RYE BROOK 939 KING STREET RYE BROOK,NY 10573 VILLAGE OF RYE BROOK (914)939-0668 BUILDING DEPARTMENT APPLICATION FOR PERMIT TO INSTALL AND/OR REMOVE HEATING,VENTILATION AND/OR AIR CONDITIONING EQUIPMENT FOR OFFICE USE - -. I, .4x//,-)-3 0 Approval Date: FEB 2 2 Permit Fee: $ Approval Signature: Other: Disapproved: (fees are non-refundable) *te*,t*trir,kftir*ire,r,t,�*+rz,e,r+rx**ir**,trr�*,t*st*,t **sir*tr**fr****r�,t**ir*,r,ra**t�*:e,te:*irtir**+t,trt,t*kttir,ttr*kir**+kt�rxrr:.t,rs*t 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: -_3STDENTI/�,1=$100.00/unit•C01V2,)?E?CU-__+y=$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, S r�3 is hereby made to the Building Inspector of the Village of Rye Brook for a permit for the installation and or removal of the i3VAC equipment as listed below.The applicant and property owner,by signing this document agrees that said equipment will be installed and/or removed in conformance with all applicable Local,County,State&Federal laws, codes,rules and regulations. 1 1. Address: 17 SBL: I II �� 'd--' /Zone: 2. Property Owner: ,}'I IAA 1 F iZJ# ► OW ess: 1 �t Phone#: ' 1 q)q- ;�1 W Cell#: f email:_ mr �0�V3 oo J eo.,n 3. Contractor./UY1?11n-M Mechanical feryi ce lam_Address: ,t(57 Ma►i t1t 1��C5if!/il_�1✓la5f�G� Phone#: f qlI�� 1�f:1`�`r y 11 9 Cell#: email: �b6lffh rlJ Cal(?t�)F3[hWC,Ca-n 4. Applicant: (11f'll nu l Mff hanl fn f -.6yi ro Address: 14 h) RECUP ti 1C 514— Phone#: (if4 %;7 Cell#: email: L'laSYnrCFiC:► ,C(:J�L St7 hy'iaC CC++►� 5. Scope of Work:New Installation( •Replacement Y11•Removal( )•Other( ): 6. List Equipment: .} 7. Location of Equipment: 9W4 ) f)lid 8. Method of Installation/Removal(list all equipment needed to perform job): Poo a o maier}p 1 I 1 1 k be �I�.) to remove old Inr and in loll aff,2 Uni t 8/12f2o21 I STATE OF NEW YORK,COUNTY OF WESTCHESTER ) as: rQ being duly swom,deposes and states that he/she is the applicant above named, (print name o individual signing as tileISWapplicant) i f p w pp p f and further states that she is the o e o w t lieation pertains,or that she is the for the legal owner and is duly authorized to make and file this application. (indicate archirect,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 Wore me this SwozAto before me this day of 20 I f ZL� ,2Signature of Prope Own natu 9 r Print Name of Property Owner Print Na a of pplicant CAROLYN MARIE CANNISTF--<AFc(J J' i Public Notary Public-St�,'.c Ot f 'Yu`k Notary blic No.O1CA6177060 MICHELLE ORTEGA Qualified in Westcfne-.t-r County �023 Nulary puUlic-State of New York My Commission Expires N :5,� NO.01t3N6437255 C nimlified in Westchester County My COIT1110',Sion Expires Aug 1, 2026 This aiTolication must be proper y completed in its h :r entirety and-must include tLle notai.% the legal owner(s)of he subject propcity, and the applicant of record in the spaces provided. Any applit anon not properly completed in its entirety and/or not properly signed shall bee�eenzec null and will lie retirxned to the applicant. CAROLYN MARIE CAl,1NISTRAR0 Notary Public-Slate of New York No.OI CAb 17 7080 Qualified in VVcstchester County My Commission Expires Nov.b,2C21 3 8/1212021 I f ' ' 48FC 04-07 WEATHERMAKER® SERIES WITH ECOBLUETm TECHNOLOGY SINGLE PACKAGE ROOFTOP GAS HEAT/ELECTRIC COOLING UNITS - PERFORMANCE DATA CERTIFIED DIMENSION PRINTS - CERTIFIED ROOF CURB DETAILS Manufacturer reserves the right to discontinue,or change at any time,specifications or designs without notice and without incurring obligations. Printed in U.S.A. Form 48FC-4-7-02SB Pg 1 3-19 Replaces:48FC-4-7-01 SB JOB NAME: LOCATION: BUYER: BUYER PO#: CARRIER#: UNIT NUMBER: MODEL NUMBER: PERFORMANCE DATA CERTIFIED BY: DESCRIPTION 48FC units are single-packaged electric cooling, gas heating unit that are pre-wired and pre-charged with Puron�'(R-410A)ETC refrigerant.The units are factory tested in both hearing and cooling modes. Sizes 04-06 models use single-stage cooling capacity control.Size 07 models use two-stage cooling capacity control. FEATURES Standard Base Unit Cabinet • Puron(R-410A)HFC refrigerant Access panels with easy grip handles • SEER of 14.0(3 to 5 Ton) Innovative, easy starting, no-strip screw feature on unit • IEER of 15.0 access panels • Meets or exceeds ASHRAE 90.1 energy efficiency levels Pre-painted exterior panels and primer-coated interior pan- Rated in accordance with AHRI Standards 210/240 for els tested to 500 hours salt spray protection sizes 04 to 06 and 340/360 for size 07 Fully insulated cabinet • Designed in accordance with Underwriters Laboratories Tool-less filter access door Std 1995 Refrigerant System • Listed by UL and UL-Canada AcutrolTM refrigerant metering system on 04 to 06 models, • Single-stage cooling capacity control on 04 to 06 models, TXV on 07 models two-stage on 07 models Liquid line filter drier • Corrosive resistant composite sloping design;side or cen- Scroll compressors with internal line-break overload ter drain condensate pan.Meets ASHRAE Standard 62 o protection(one-stage on 04 to 06 models, two-stage on F • Standard cooling operating range from 40 up to 115 F 07 models) (4°C up to 46°C). Field installable accessory extends the Copper tube, aluminum fin coils with optional corrosion minimum down to—20°F(-29°C) resistant coils • Field convertible from vertical to horizontal airflow for Top cover removable gage line plugs for reading refriger- slab mounting—no special kits required ant pressure with unit panels in place • Two-inch disposable return air filters • Thru-the-bottom power and gas entry capability Gas Heat • Single point gas and electric connections IGC solid-state gas heat exchanger control for on-board • 24-volt control circuit protected with resettable circuit diagnostics,anti-cycle protection,LED error code designa- breaker tion, burner control logic and energy saving indoor fan • Direct Drive - EcoBlueTM technology indoor fan system motor delay uses vane axial fan design and electronically commutated Gas efficiencies up to 81% motor Inducted draft combustion — Shall have inherent automatic-reset thermal overload Redundant gas valve,with 2 stages of heating protection Flame roll-out safety protector — Shall require no fan/motor belts for operation, adjust- Solid-state electronic direct spark ignition system ments,and/or initial fan speed setup Dedicated 3 to 5 ton "low NOx" models available that meet California Air Quality Management NOx require- -Shall be internally protected from electrical phase rever- ment of 40 nanograms/joule. Low NOx models include sal and loss stainless steel heat exchangers. —Shall have slow ramp up to speed control capabilities to Standard Limited Parts Warranty help reduce sound and comfort issues 15-year gas heat exchanger parts-Stainless Steel —Shall be a slide-out design with two screw removal 10-year gas heat exchanger parts-Aluminized —On 07 size model with two stage cooling capacity con- 5-year compressor parts trol,the indoor fan speed is automatically controlled to 5-year factory installed Ultra Low Leak Economizer meet the code compliant 66%low fan speed and 100% 3-year SystemVuTM controls at full fan speed 1-year parts • Totally enclosed condenser motors with permanently lubri- cated bearings • Low-pressure and high-pressure switches • Full perimeter base rail with built-in rigging adapters and fork truck slots • Centralized terminal board facilitating simple safety circuit troubleshooting and simplified control box arrangement • New unit control board with intuitive quick fan speed adjustment 2 FIELD-INSTALLED ACCESSORIES(CONT) NOTE:48FC 07 models use two-speed indoor fan logic,the two-position damper and manual dampers are designed for single- speed motor control.See Application Tip"ROOFTOP-18-01"for further guidance when using this unit. ❑ Power exhaust—prop fan design ❑ Time Guard H compressor anti-cycle protection ❑ Two-position motorized outdoor air damper ❑ Thermostats and sensors ❑ Manual outside air damper 25% NOTE:Size 07 model has two-stage cooling ❑ Manual outside air damper 50% thermostat;use appropriate thermostat. ❑ Roof curb—14 inch(356mm)tall ❑ Condensate overflow switch ❑ Roof curb—24 inch(610mm)tall ❑ Non-powered 115-volt(20 amp)convenience outlet ❑ Thru-the-bottom connections,electrical only ❑ Side access hinged filter door kit ❑ Thru-the-bottom connections,electrical and gas ❑ Horn/Strobe annunciator ❑ Condenser hail guard,louvered style Economizer Sensors ❑ Flue shield ❑ Single dry bulb control ❑ Flue discharge deflector ❑ Differential dry bulb control ❑ Liquid propane(LP)conversion kit ❑ Single enthalpy control ❑ High altitude conversion kit ❑ Differential enthalpy control ❑ Phase monitor(loss of phase/phase reversal) ❑ CO2—wall mounted ❑ Winter start kit,down to 250F(-4°C) ❑ COz—duct mounted ❑ Fan/Filter status switch ❑ CO2—unit mounted ❑ Low ambient head pressure controller, down to 0°F(-18°C) ❑ Low ambient head pressure controller, down to —20°F(-29°C) 7 zzzz IM Y w g J s g $ �21 OF m Mn -- _ � � c Z 15 o Tz � g E W �' 4= � V 0 72 co �. L4 I LL $Yo = = = MERtz I = lfzz� Y S _ � e o g , � § ---- -.0 NNE ■ ■ ■ ■ ■ ■ §2kkk))) � .-._._._._._. . . . . . . . . . � -- -- - - - - - -.._..j I I gg � I • I ) &§#_ ■-. / � o . _ k� , a2 `© ® � ° I � � • ' I � � � cn Z � o LU ) E � ( o � b W ~ / U _=22 2 _ % E 0 MT 2 . M. � ®■-. « . � Ms- »B■2!§ � } � \ kkk( $ 9 gs U m V �3 m aao — U d s H ` O O � z � Q o c 0F13 a W m 0 - N �W LL j J u C co O W � LLK 1� RT W V M IlL • a m o . 10 ¥§ ){ @ 22 & f , 0 / . )\ � k� iz a[ E 2 � E i �i ! ; n _ ! | 0 } } §] [ ( ( ( ( N } � ! CD H\ q ® O ( K \ J �§ §a � . f§ e! « !7 Im ± /§ !)_ () \ / \/ O \\\ \� m; 7 !Lu / k§ a60 2 ��10 I EU|E ¥§!:§ 0,I �� _� »z z � ¥/! !_ ()) ) ! § ® �k �! 6{ !1 ©Carrier Corporation 2019 Manufacturer reserves the right to discontinue,or change at any time,specifications or designs without notice and without incurring obligations. Printed in U.S.A. Form 48FC-4-7-02SB Pg 12 3.19 Replaces:48FC-4-7-01 SB KMIER 66 1 RMTER SO PARCEL 00 L AREA = 217,009 50 6' 4 R WO 4- C!!p 4 0 5 6 WL" won-now Sow* COIOEIE 'PASS ty. Retail Stores (I Story Brick) Restaurant I CONC 3 (I Sty. Masonry) Cm WKW11 Sul PAD 75 S-1v OF \- A A A x I X�x x x X-X X-X-X-X-x BIT -T- AL -7' 6 7 11 12 13 1�� 1;4�� 14 4 3 4 8 9 10 NOW OR FORMERLY VILLAGE OF R7 BROOK CAMBALD1 PARK "MAP OF SLIM ON OF PROPERTY BELONGING TO LUICI SCAGUONE* FILED 1,1AP NO. 2459 o te Place (NOT DEVELOPED) D Lc FEB 15 2023 FILE COPY VILLAGE OF RYE BROOK k BUILDING DF=PARThAFK1T '�tr>• # .5� .' '. `� �7.`•��"J."fw _ ,#.;:•.-., .3 �� , ". r a 3 /:. 7 � f•;�` •.t � J.'`i f Y�"'9Frnca ;Yr.`•''.•;... '•II � ;G°an.,t�� i I g5•ti. •.� i 5� •� x- �•��',.� � a� -"' o ri r a f � 3y -"r"ysA""�[¢ r61�e•`��� m � `• F y yai i a�R aka �� �v•♦ @ a A'" ♦�+ a y q♦ �., .��� • •�' '��n.y. '.+i# �1 +f1f_�c �:+-:•.4+1 { � �-% ; ,e. �d {f!�-.. '9::+N ?I:z•s.+ p �_e' -.�%:,.p �;t .��in��S���/ x- u Oyy cL� N l'Y `• I ,•;�+mod o Q, •� � � CN :�� � ;"• "• ca cG O CO �i t` •� u � a� O a•",acaLs)e� a ti.�/•b�� � W j, Ci 0 .2 3 U S — Oo tiec - � L/i/t� 1. 0 2 O W d�lr8 2C1 rh. � f '8 0 �rLit�)a'7hLLJ � z If 01 f.' ma's'• }ter � v N fa•_ h��z•• ":e•ins G •� Ua '0 � �.m„ �f�)j• iF�<to» '�.�^..•e ! �'f �,,: IS + � {°++f� _ ,l�Fe�4'+'+' � sr wi4TP. i w • u, o• /+ gig W.7 /1 / J ^ef_,$yv'•t �i A. �f§� 'N;� Air17�•�.i„�'�$.,i,�iei? (�A S� A�+s,(q,•+( 3fAi� •f{ A ♦ i +�F' :4-, �i�" .77y _"�'1 l�` �h� �t�����ZY �•I,''+f�,h�SFrvrr� .A ?�.1�5���}eaf ^ ��y'3� �tis��n +► S •� f t�4F ^ �a%`� •L��;_ A it :5� •�' `•'`� i �{{�.6. g�. .� t �� '���f15�'�'"' �® ,s,�o .,o ..g{ j�yy, � � ����p(,h�S;�, a,,���li�'��. `�,` � �ti -c r`���� .:�o•���_�i�i`'� ii//,+►�"ai � 1.v®�! i - \ ��MIIl'd i-V, s v �•s �'�1� �� d .��� �r�•.�•�. \ ��511�5bi.:"• -^QJ(n.'"� v �'`}lv`y`` '•Lv' -+X�''v�'�.'.'' 'n'� ��., _••:��: i •,.. : V t• '� '�i�� AC�® DATE(MM/DD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 2/1/2023 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: Janke Caldararo John M. Glover Agency PHONE FAX Insurance Services • 914-829-9077 Alc No:203-274-9471 45 Knollwood Road ADDRESS: 'caldararo 'ohnm lover.com Elmsford NY 10523 INSURER(S)AFFORDING COVERAGE NAIC if License#:PC-904790 INSURER A:NGM Insurance Company 14788 INSURED URBIMEC-02 INSURERB:Merchants Preferred Insurance Company 12901 Urbina's Mechanical Service Corporation 1457 Main St INSURERC: Peekskill NY 10566-3112 INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:1352875531 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 TYPE OF INSURANCE ADDL SUBR POLICPOLICY NUMBER MM DDY EFF POLICY EXP MM DD/YYYY LIMITS LTR B X COMMERCIAL GENERAL LIABILITY CTRIO09271 7/30/2022 7/30/2023 EACH OCCURRENCE $1,000,000 DAMAGE TO RENTEU_ CLAIMS-MADE F_�_I OCCUR PREMISES Ea occurrence $500,000 MED EXP(Any one person) $5,000 PERSONAL&ADV INJURY $1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $2,000,000 POLICY PRO ❑ LOC PRODUCTS-COMP/OP AGG $2,000,000 X JECT OTHER: $ A AUTOMOBILE LIABILITY BlP1776T 4/16/2022 4/16/2023 COMBINED SINGLE LIMIT $100,000 Ea accident ANY AUTO BODILY INJURY(Per person) $ OWNED X SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS X HIRED X NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY Per.accident UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB HCLAIMS-MADE AGGREGATE $ DED I I RETENTION$ $ WORKERS COMPENSATION AND EMPLOYERS'LIABILITY Y/N STATUTE I ER ANYPROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ OFFICER/MEMBEREXCLUDED? ❑ N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS/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 ACCORDANCE WITH THE POLICY PROVISIONS. Village of Rye Brook 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 NEW Workers' RK STA E Compensation CERTIFICATE OF Board NYS WORKERS' COMPENSATION INSURANCE COVERAGE 1a. Legal Name and address of Insured (use street address only) 1b. Business Telephone Number of Insured URBINA'S MECHANICAL SERVICE CORP (914)907-2449 1457 MAIN ST PEEKSKILL NY 10566-3112 1c. NYS Unemployment Insurance Employer Registration Number of Insured Work Location of Insured (Only required if coverage is specifically 1 d. Federal Employer Identification Number of Insured or limited to certain locations in New York State, i.e. a Wrap-Up Policy) Social Security Number 47-4069120 2. Name and Address of the Entity Requesting Proof of 3a. Name of Insurance Carrier Coverage (Entity Being Listed as the Certificate Holder) Hartford Casualty Insurance Company VILLAGE OF RYE BROOK 29424 938 KING ST 3b. Policy Number of Entity Listed in Box"la": PORT CHESTER NY 10573-1226 76 WEG AD1BM8 3c. Policy effective period: 03/12/2022 to 03/12/2023 3d.The Proprietor, Partners or Executive Officers are Included. (Only check box if all partners/officers included) X 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: 4'6nL�Pi'.^ ��n..ti,� 02/15/2023 (Signature) (Date) Title: Operations Manager Telephone Number of authorized representative or licensed agent of insurance carrier: (866)225-7966 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