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HomeMy WebLinkAboutMP23-029 �yE DR . 19 4 J JJ, l7Vy y V VILLAGE OF RYE BROOK MAYOR 938 King Street,Rye Brook,N.Y. 10573 ADMINISTRATOR Jason A. Klein (914)939-0668 Christopher J.Bradbury www.r ebrooknygov TRUSTEES BUILDING & FIRE INSPECTOR Susan R.Epstein Steven E. Fews Stephanie J. Fischer David M. Heiser Salvatore W. Morlino CERTIFICATE OF COMPLIANCE September 10,2024 Stephen Effler&Deborah Carroll 274 North Ridge Street Rye Brook,New York 10573 Re: 274 North Ridge Street, Rye Brook,New York 10573 Parcel ID#: 135.27-1-8 This document certifies that the work done under Mechanical Permit #23-029 issued on 3/7/2023 for the installation of two new condensers and two new air handlers have been satisfactorily completed. Sincerely, Steven E. Fews Building&Fire Inspector /to �E 4Rcb. 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 : �)� / /vJ e i� f DATE: PERMIT# Mr Z 3 - O Z 1 ISSUED: SECT: BLOCK: LOT: LOCATION: A\ \ \ (_ C-� !) 4,A�(_r"`o__� 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 1 _ / // ❑ FIRE SPRINKLER �'N�Tq(„LQ 2. �4C. V'y I /ti LJ f7/G ❑ FINAL PLUMBING ❑ CROSS CONNECTION FINAL ❑ OTHER a . W N i Q M N w y C,�• N C W O 4 W V dd ,s O O 4 � 00 z A uiP. ON ° `� s Q 'p � � L z a °'a1 ,�o �q� ° (V W 0d a so- oob CO z z 4 Ems+ . O ) o O H a O a00 �✓ W Z W v z H ON4 cn GN p rn Cam r Ei 41 zo 00 CUJ V A O Cj I v © p �•y OC O v ICI F+ v `r' U � � w 0 v r✓ O W �.+ o z 10L. E v z C �tn o $ �o � ,y � � 14 BUILDING DEPARTMENT VILLAGE OF RYE BROOK MAR - 2 2023 ID 938 KING STREET RYE BROOK,NY 10573 (914)939-0668 VILLAGE OF RYE BROOK www.rye6r©ok.org BUILDING DEPARTMENT APPLICATION FOR PERMIT TO INSTALL AND/OR REMOVE HEATING. VENTILATION AND/OR AIR CONDITIONING EQUIPMENT FOR OFFICE USE ONLY: PERMIT#: /YA-2— 0,�) / Approval Date: MAR 2 C2 Permit Fee: $ - Ioo— Approval Signature: Other: Disapproved: _ (fees are non-refundable) REQUIREMENTS FOR RELEASE OF PERMIT&CERTIFICATE OF COMPLIANCE: 1. Properly completed& Signed Application. 2. Site/Staging Plan if Required by the Building Inspector. 3. Copy of Licensed Contractor's Liability Insurance. (Village of Rye Brook must be listed as certificate holder)&Workers Compensation Insurance on a NYS Board form(Form#C105.2 or Form#U26.3/or NY State Workers Compensation Waiver) 4. Payment of Fees/Unit: RESIDENTIAL=$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,3—t�>-a3 is hereby made to the Building Inspector of the Village of Rye Brook for a permit for the installation and or removal of the HVAC equipment as listed below.The applicant and property owner,by signing this document agrees that said equipment will be installed and/or removed in conformance with all applicable Local,County,State&Federal laws, codes,rules and regulations. L 1. Address: 7 rl 4SBL: c)7"1— Zone: 1-5 2. Property Owner: i ( Address: Phone#:��� 924 1/ Cell#: email: ,^ 3. Contractor: /)y��/ i�%/� "Address; Phone#: feCell#: email:S�9N�C1i,�C co 4. Applicant: `QA,I/5.7. ��rz�}� Address` G¢ � � 74� ' Phone#: /y 0!e 9 C? Cell#: email: 5. Scope of Work:New Installation( )•Replacement( )•Removal O•Other( }: 6. List Equipment: � 7ri �T 7. Location of Equipment: t�" j�2"e-- 8. Method of Installation/Removal(list all equipment needed to perform job): /truer r� f�� r t 8112no21 STATE OF NEW YORK, OUNTY OF WESTCHESTER ) as: S,�)Nl)o d 41 ;2�L ,being duly sworn,deposes and states that he/she is the applicant above named, (print name of individual signing as the pplicant) and further states that(s he is the legal owner of the property to which this application pertains,or that(s)he is the C,ON i�C/ 0 — 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. n Sworn to before me this Sworn to before me this day of J (P ,20 day of U C,1't 20, T Signature of Property Owner ignature of Applicant �ZZ S,gA1d 0,f1 J'4 Print Name of Property Oywne/ Print Name of Applicant Notary P&EIGRE60RY M.RIVERA Notary' RY M.RIVERAM.RIYERA Notary Public,State of New York Notary Public,State of New York No.01R16441398 No,01RIWI398 Qualified In Westchester County Qualified in Westchester Covntw Commission Expires September 26, Commission Expires September 26.1 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. 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 8/12/2021 Outdoor Unit Multi-z• • Ductless System Outdoor M• • ; • Submittal Data Job Data: Location: Buyer: Buyer P.O.#:I Carrier#: Unit Number: Model Number: Performance Data Certified By: Date: MULTI-ZONE STANDARD FEATURES P Features Outdoor: j � Connect up to 3, multiple style indoor units �9-.,'1 High Wall / % �� Cassette / _!M a` k Ducted �i - �/� -� ` Console ( f f �{Z\ j) 11) I •100%Heating Capacity at 5°F(-15°C) � Variable Speed(Inverter)Compressor `�````ti /; •Basepan Heater factory installed Quiet operation \ \ _ � •Aluminum Golden Hydrophilic pre-coated fins Cooling operating range-13°-122°F(-25°-50°C) Heating operating range-22°-86° F(-30°-30°C) r•-7 LIMITED WARRANTY* •10 year limited to original purchaser on compressor and parts upon timely registration,otherwise 5 years *For residential applications.See warranty for full details. Compatibility Table For matched compatibility see Product Data INDOOR UNIT 40MPHAQ09XA3 619PHAQ09XA3 DHMPHAQ09XA3 40MPHAQ12XA3 619PHAQ12XA3 DHMPHAQ12XA3 40MAQB09B--3 619PEQ009BBMA DHMSHAQ09XA3 High Wall 40MAQB12B--3 619PEQ012BBMA DHMSHAQ12XA3 40MAQB18B--3 619PEQ018BBMA DHMSHAQ18XA3 40MHHQ09---3 40MHHQ12---3 40MHHQ18---3 40MBQB09C--3 619REQ009CBM 40MBCQ09---3 Cassette 40MBQB12C--3 1619REQ012CBMM 40MBCQ12---3 40MBQB18C--3 619REQ018CBM 40MBCQ18---3 40MBQB09D--3 619REQ009DBM 40MBDQ09---3 Ducted 40MBQB12D--3 619REQ012DBM 40MBDQ12---3 40MBQB18D--3 619REQ018DBM 40MBDQ18---3 40MBQB09F--3 619REQ009FBM 40MBFQ09---3 Console 40MBQB12F--3 619REQ012FBM 40MBFQ12---3 40MBFQ18---3 Gopynght 20l8 CACBDP•7310 W.Morns St. Indianapolis,IN 46231 Edition Date.08/2018 Catalog No:38MGR-24-05SB SUBJECT TO CHANGE WITHOUT NOTICE Page 1 Replaces.38MGR-24-04SB Specifications Size 24 Operating Cooling Outdoor DB Min-Max °F°C -13-122 -25-50 System Outdoor Model 38MGRQ24C--3 Range Heating Outdoor DB Min-Max °F°C -22-86 -30-30 Max Number of Zones 3 Total Piping Length ft m 197 60 Energy Star YES Piping to furthest FCU ft(m) 98(30) Cooling System Tons 2.0 Piping Drop OD above ID ft m 49 15 Cooling Rated Capacity Btu/h 24,000 Lift(OD below ID) ft(m) 49(15) Cooling Cap.Range Min-Max Btu/h 7880-33510 Pie Connection Size-Liquid in mm 1/4`3 6.35.3 SEER 23 Pipe Connection Size-Suction in mm 3/8`3 9.52'3 Performance EER 12.5 Type R410A Non-Ducted Heating Rated Capacity 47°F Btu/h 23,000 Refrigerant Charge Ibs k 6.17 2.8 Heating Maximum Capacity 5°F Btu/h 23,000 Metering Device EEV Heating Cap.Range Min-Max Btu/h 6010-36180 Voltage,Phase,CycleTV/Ph/Hz 208/230-1-60 Indoor unit powered HSPF 10 Electrical Power Supply from outdoor unit COP 47°F W/W 3.9 MCA A. 25 COP 5°F W= 2.1 MOCP-Fuse.Rating A. 35 Energy Star YES Type R410A Cooling System Tons 1.9 Model ATF235D22UMT Cooling Rated Capacity Btu/h 23,000 Compressor Oil Type ESTER OIL VG74 Cooling Cap.Ran a Min-Max Btu/h 7765-31955 Oil Charge FI.Oz. 23.58 Performance SEER 21 Rated Current RLA 15 Combination EER 12.5 Unit Width in mm 41.22 1047 Ducted and Heating Rated Capacity 47°F Btu/h 22,000 Unit Height in mm 31.88 810 Non-Ducted Heatin Maximum Ca aci 5°F Btu/h 22,000 Outdoor Unit Depth in mm 17.91 455 Heating Cap.Range Min-Max Btu/h 5980-36190 Net Weight Ibs k 149.9 68 HSPF 9.4 Airflow CFM 2130 COP 47°F W= 3.85 Sound Pressure dB(A) 63.4 COP 5°F W/W 2.03 Energy Star YES Cooling System Tons 1.8 Cooling Rated Capacity Btu/h 22,000 Cooling Cap.Range Min-Max Btu/h 7650-30400 SEER 19 Performance EER 12.5 Ducted Heating Rated Capacity 47°F Btu/h 21,000 Heating Maximum Capacity 5°F Btu/h 21,000 Heating Cap.Range Min-Max Btu/h 5950-36200 HSPF 8.8 COP 47°F W/W 3.8 COP 5°F W/W 1.96 Gopyhght 2018 CACBDP.7310 W.Morris St. Indianapolis,IN 46231 Edition Date:08/2018 Catalog No:38MGR-24-05SB SUBJECT TO CHANGE WITHOUT NOTICE Page 2 Replaces:38MGR-24-04SB Construction View Outdoor Model: 38MGRQ24C--3 37.64(956 • I PE Master Valve Master Valve Gas Line I iquld LinecocpdinI P6 A I 0 a M ri 26.50(673) 3.19(81) � 37.24(946) 6.7 (172 40.71(1034) 0 1.22 (1047 2.87(73) 18.15(461) 0 0.47 12) c N n V O O M < _ v 0.95 (24 — ui 0)Li, CS Copyright 2018 CACBDP•7310 W.Moms St. Indianapolis,IN 46231 Edition Date:08/2018 Catalog No:38MGR-24-05SS SUBJECT TO CHANGE WITHOUT NOTICE Page 3 Replaces:38MGR-24-04S8 Ducted Style Heat Pump Ductless System Indoor • • - 1 w Submittal Data Job Data: Location: Buyer: Buyer P.O.#: Carrier#: Unit Number: Model Number: Performance Data Certified By: Date: STANDARD FEATURES �! Modes:Cool, Heat,Dry, Fan,Auto Vertical or Horizontal Installation 70 Rear or Bottom Return Outside Air Intake Condensate Lift pump shipped with the unit Follow Me(senses temperature at handheld remote) Heating Setback(46°F Heating Mode) Quiet indoor operation Anti-corrosive fin coating Controls: Wireless Remote Controller included with indoor unit Optional Wired Remote Controller(Timer Function) Wired Remote Controller KSACN0501AAA(7 Day programmable)included with indoor unit LIMITED WARRANTY' •10 year limited to original purchaser on compressor and parts upon timely registration,otherwise 5 years 'For residential applications.See warranty for full details. System Size 12 Face Area Sq.Ft. 1.18 y Indoor Model 40MBDQ12-3 No.Rows Indoor Coil 3 Voltage,Phase,Cycle VlPh/Hz 208/230-1-60 Fins per inch 18 Electrical Power Supply Powered from outdoor unit Circuits 3 MCA A. 1.11 Unit Width in(mm) 27.56(700) Controls Wireless Remote Controller('F/'C Convertible) Standard Unit Height in(mm) 7.87(200) Wired Remote Controller('F/'C Convertible) Standard Unit Depth in(mm) 19.92(506) Operating Cooling Indoor DB Min-Max °F(°C) 62-90(17-32) Net Weight Ibs(kg) 43.56(19.8) Range Heating Indoor DB Min-Max °F(°C) 32-86(0-30) Number of Fan Speeds 3 Indoor Piping Pipe Connection Size-Liquid in(mm) 1/4(6.35) Airflow(lowest to highest) CFM 176/282/353 Pipe Connection Size-Suction in(mm) 1/2(12.7) Sound Pressure(lowest dB(A) 35/37/39 to highest) Max Static Pressure In.WG. 0.2 For Compatibility See Product Data Field Drain Pipe Size O.D. in(mm) 1 (25.4) Performance may vary based on the outdoor unit matched to.See compatible outdoor units pages for Performance Data. Accessories KSACN0101AAA Optional Wired Remote Control with Timer Function KSACN0501AAA Shipped with the unit Wired Remote Control 7 day Programmable KSAIF0401AAA Wi-Fi-Kit KSAIC0101230 24V Interface Kit 208/230V 53DS-900-008 Insulated 25'Line Set-1/4"x 3/8" 53DS-900-090 Wireless Remote Control Locking Mount Kit Copynght 2018 CAC/BDP•7310 W.Morris St. Indianapolis,IN 46231 Edition Dale:03/2018 Catalog No.40MBDQ-12-3-01 SB SUBJECT TO CHANGE WITHOUT NOTICE Page 1 Replaces.NEW Construction View Indoor Model: 40MBDQ12---3 Air inlet from rear side Air filter e �} e i 1 MEIN4-install hanger Test mouth& Test cover Outside air intake .� — Electric control box- 0-98in (25mm) Drain �0.98in(25mm) connecting pipe (for lift pump) o " Drain vbe _ Gas connection iquid connectio I a L 2 � Air fitter Air inlet from bottom side Unit inch mm A 27.6 700 OUTLINE DIMENSIONS B 7.9 200 C 19.9 506 D 17.7 450 E 5.4 137 AIR OUTLET OPENING SIZE F 21.1 537 G 1.2 30 H 6 152 1 23.6 599 AIR RETURN OPENING SIZE J 7.3 186 K 2 50 HANGER BRACKERS L 29.2 741 Cus M 14.2 360 H1 3.3 84 REFRIGERANT LOCATIONS H2 5.5 140 PIPE W 1 3.3 84 W2 3.3 84 OPERATING WEIGHT Ib(kg) 40 18.1 Copyright 2018 CACBDP a 7310 W.Mortis St. Indianapolis,IN 46231 Edition Date:03/2018 Catalog No:40MBDQ-12-3-01 SB SUBJECT TO CHANGE WITHOUT NOTICE Page 2 Replaces:NEW r M N _ .- 00 �t CA p' W 00.0 z AA A p W z a v x i. ow 0-4 mw 0-4 Ln 00 v v 4+ � z PAW z cr, � � O � z � oo M w w a x E 14 • Z w a o z zzo Z o � g i V W z n z w o o c � u N °w" w a v a a �I 0 a a 0-4 Vol = � • , p EC IEVIE BUILDING DEPARTMENT ID VILLAGE OF RYE BROOK APR 17 2023 938 KING STREET RYE BROOK,NY 10573 VILLAGE OF RYE BROOK (914)939-0669 4 BUILDING DEPARTMENT www.ryehrook.or,_, ELECTRICAL PERMIT APPLICATION Westchester County Master Electricians License Required FOR OFFICE USE ONLY B�#'� /� �0 EP#: C:D 3—Q /"S APR 1 _ ,Q Approval Date: Permit Fee: $ ��� / Approval Signature: Other: Application dated, '7 7-4 3 is hereby made t e Building Inspector of the Village of Rye Brook NY,for the issuance of a Permit to install and/or remove electrical equipme ,wiring, fixtures, or to perform other high or low voltage electrical work as per the detailed statement described below. By signing this document, the applicant & property owner agree that all electrical work performed will be in conformance with all applicable Federal,State,County and Local Codes. 1.Address: W'ola D6e S � SBL: • Z- — Zone: t-1 2.Property Owner: — gm Cho lL- Address: 2 Phone#:(11K) q 33-? 161 t Cell#:Llt, -fk 5 email: 3.Master Electrician/Licensed Installer: N__V J n Address: L ���- Lic.#: _Phone#: Cell#: 932m email: CMWA Company Name:�Q401���( _ Address:11, Lj_�_510 4.Proposed Electrical Work/Fixture Count: j)16.xr Z 5.31 Party Electrical Inspection Agency: STATE OF NEW YORK,CCOUNTY OF WESTCHESTER ) as: being duly swom,deposes and states that he/she is the applicant above named,and does further (print name of individual signing as the app1 ant) state that(s)he is the P)^ t� �IL�for the legal owner and is duly authorized to make and file this application. (Master Electrician/Licensed Installer) 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 Swom t before roe this day of 120 day, ,20 Signature of Property Owner ignature of Xpplicrnt NS Print Name of Property Owner ame of App tc Notary Public Notary Public,State of New York No,01ME6160063 Quallfled In Westchester County 'commiss"Lcplres January 29.20� 3/3/2023 STATE WIDE INSPECTION SERVICES, INC.', CAO Service Witli Integrity 0•0 • • SWIS JOB APPLICATION0. • Office Use Elect. Permit# Date Li Bldg Permit# T 7 O Z Sq Ft Z Plumbing Permit# Final Certificate# City/Village `- Zip; �\ Building Dep AV County Address Cross Streetyov - Z� Block Lot Owner Name/Address(If different than ve _ o Number ` 4 n Q Basement ❑ 1st FI. ❑2nd FI. 3rd FI. ❑ An.Than ❑Garage ❑Attic utside RFtesidential ❑Commercial Receptacles Special Recept GFCI AFCI Switches Dimmers Smoke Alarms C/0 Detector Hood Trash Compact Amt Amps t Range(s) Cooktop(s) Oven(s) Dishwashers Refrigerator Disposal Microwave Luminaires Generator Transfer Switch SERVICE Amperage #Panels 1P 3P # Meters # Disconnect ❑Underground ❑ New ❑ Reconnect ❑ Repair ❑Overhead ❑ Upgrade ❑ Disconnect Utility ID# ❑Con Ed ❑ NYSEG ❑Central Hudson ❑ Orange/Rockland PHOTOVOLTAIC SYSTEM PV Modules Inverters AC Disconnect ]unction Box Combiner Box Load Center PV Monitor Energy Storage System DC Disconnect ❑Legalization ❑ Safety Inspection ❑Consultation Z rh(L RD APR 17 2023 LLAGE OF RYE BROOK BUILDING DIING 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 anytime 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. Email Address C t _C� Name License# Date Signature 03.Address _ City/Stite I Zip Code Company L _ J Phone# D� !C �FE �V/ [Ej State Wide Inspection Services cr" 3D 1080 Main Street Fishkill, NY 12524 a APR 2 6 2023 845 202-7224 Phone `, 914-2194-219-1062 Fax STATE WIDE INSPECTION SERVICES y IL GE OF RYEBROOK Email: office@swisny.com BUI DING DEPARTMENT Website: www.swisny.com Service With Integrity BY THIS CERTIFICATE OF COMPLIANCE STATE WIDE INSPECTION SERVICES CERTIFIES THAT: Upon the application of: Upon Premises Owned by: Your Choice Electric LLC Stephen Effler& Deborah Carroll 16 Greenhaven Road 274 North Ridge Street Poughquag, NY 12570 Rye Brook, NY 10573 Located at: 274 North Ridge Street, Rye Brook, NY 10573 Section: Block: Lot: Electrical Permit Number: EP 23-093 135.27 Certificate Number: 2023-2824 Building Permit Number: MP 23-029 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: 274 North Ridge Street, Rye Brook, NY 10573 The Exterior was inspected in accordance with the NYS and NFPA 70-2017 and the detail of the installation, as set forth below,was found to be in compliance on the 21st day of April 2023. Name Quantity Rating Circuit Type HVAC Systems 02 Exterior GFCI 01 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. A�® CERTIFICATE OF LIABILITY INSURANCE FDATE(MM/DD/YYYY) 03/03/2023 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: ANA C EUGENIO Albert Palancia Agency, Inc. PHONE UV�No•ExO; (914)898-1373 ��;(914)898-0125 116 Mamaroneck AvenueADDREs ana@palanclainsurance.com Mamaroneck, NY 10543 INSURERS AFFORDING COVERAGE NAIL• INSURERA: MERCHANTS INSURANCE GROUP 12901 INSURED INSURERS: PROGRESSIVE COMMERCIAL 24260 SANROZ HEATING 8r AIR CONDITIONING, INC. INSURER C: HARTFORD ACCIDENT AND INDEMNITY Co 22357 32 LAKESIDE DR INSURERD: ShelterPoInt Life Insurance Company KATONAH, NY 10536-1610 INSURERE: INSURER F: COVERAGES CERTIFICATE NUMBER: 10008319-402330 REVISION NUMBER: 41 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. INSRR TYPE OF INSURANCE AD L UBR POLICPOLICY NUMBER MM1DDDY EFF POM/LDIDY EXP rrfM LIMITS A X COMMERCIAL GENERAL LIABILRY CTRIO07228 12/29/2022 12/29/2023 EACH OCCURRENCE $ 2,000,000 CLAIMS-MADE OCCUR PREMISES(Ea-RENTED occurrence $ 500,000 MED EXP(Any one person) $ 5,000 X LIABILITY PERSONAL&ADV INJURY t 2,000,000 GEML AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 4,000000 X POLICY�E O- LOC PRODUCTS-COMP/OP AGG $ 4,000,000 OTHER: $ B AUTOMOBILE UABIU Y 01978152-2 04/01/2022 04/01/2023 ECOMBINED a accident)SINGLE LIMIT : 1,000,000 ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED AUTOS ONLY X AUTOS BODILY INJURY(Per accident) _ HIRED NON-OWNED PROPERTY DAMAGE : IX X AUTOS ONLY AUTOS ONLY Per accident i UMBRELLA LIM OCCUR EACH OCCURRENCE $ EXCESS LIAO HCLAIMS-MADE AGGREGATE : DIED I I RETENTION $ C WORKERS COMPENSATION 16WECAR8F8L 06/01/2022 05/01/2023 STATUTE ER 500,000 ANY AND ROPRIEERS'LIABILITY Y ECUTNE Y/N OFFICERWEMBER EXCLUDED? FY-1 N/A E.L.EACH ACCIDENT $ 100,000 (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE S 100,000 yes,describe under D E.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS below D DISABILITY D664028 05/01/2022 05/01/2023 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 VILLAGE OF RYE BROOK THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN BUILDING DEPARTMENT ACCORDANCE WITH THE POLICY PROVISIONS. 938 KING STREET RYE BROOK, NY 10573 AUTHORIZED REPRESENTATIVE ` ACE ©1988 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD Printed by ACE on 03/03/2023 at 11:21AM N'W Workers' CERTIFICATE OF STATE Compensation NYS WORKERS' COMPENSATION INSURANCE COVERAGE Board la Legal Name&Address of Insured(use street address only 1 1 b Bus,ness Teiephore Number of Insured SANROZ HEATING 8 AIR CONDITIONING INC (914)943-8908 32 LAKESIDE DR KATONAH NY 10536-1610 I NYS Unemployment Insurance Employer Registration Number of Insured I Work Location of Insured(Only required it coverage is specifically limited to ld Federal Employer Identification Number of Insured or Social Security certain locations in New York State i o a Wrap-Up Policy) Number 20-1655977 2 Name and Address of Entity Requesting Proof of Coverage _ 3a Name of Insurance Carrier (Entity Being Listed as the Certificate Holder) Hartford Accident and Indemnity Co VILLAGE OF RYE BROOK BUILDING DEPARTMENT 938 KING STREET 3b Policy Number of Entity Listed in Box 1a" RYE BROOK NY 10573 16WECARBF8L 3c Policy effective period 05/01/2022 to 05/01/2023 3d The Proprietor Partners or Executive Officers are EJ included ioniv cncrk box it an partners otricers ocwam [] 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 IWM 33A on the INFORMATION PAGE of the workers'compensation insurance policy). T he Insurance Carrier or its licensed agent will send this Certificate of Insurance to the entity listed above as the certificate holder in box 2' The insurance carrier must notify the above certificate holder and the Workers Compensation Board within 10 days IF a policy is canceled due to nonpayment of premiums or within 30 days IF there are reasons other than nonpayment of premiums that cancel the policy or eliminate the insured from the coverage indicated on this Certificate (These notices may be sent by regular mail)Otherwise,this Certificate is valid for one year after this form is approved by the insurance carrier or its licensed agent,or until the policy expiration date listed in box"3c",whichever is earlier. This certificate is issued as a matter of information only and confers no rights upon the certificate holder This certificate does not amend extend or alter the coverage afforded by the policy listed. nor does it confer any rights or responsibilities beyond those contained in the referenced policy This certificate may be used as evidence of a Workers'Compensation contract of insurance only while the underlying policy is in effect Please Note: Upon cancellation of the workers'compensation policy indicated on this form, if the business continues to be named on a permit, license or contract issued by a certificate holder,the business must provide that certificate holder with a new Certificate of Workers'Compensation Coverage or other authorized proof that the business is complying with the mandatory coverage requirements of the New York State Workers'Compensation Law. Under penalty of perjury, I certify that I am an authorized representative or licensed agent of the insurance carrier referenced above and that the named insured has the coverage as depicted on this form. Approved by JOSEPH T.PALANCIA iprot name of authorized representative r((orensed agent i)i insurance carrier) �l Approved by ` {D -9aW /. /oaZut- L_ —7¢ signature 1 Date) Title Title AGENT Telephone Number of authorized representative or licensed agent of insurance carrier 914-698-1373 Please Note: Only insurance carriers and their licensed agents are authorized to issue Form C-105.2 Insurance brokers are NOT authorized to issue it. C-105.2(9-17) www wcb ny gov