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HomeMy WebLinkAboutMP23-060 (ta VILLAGE OF RYE BROOK MAYOR 938 King Street, Rye Brook,N.Y. 10573 ADMINISTRATOR Jason A. Klein (914) 939-0668 Christopher J. Bradbury www.ryebrook.org TRUSTEES BUILDING& FIRE INSPECTOR Susan R. Epstein Steven E. Fews Stephanie J. Fischer David M. Heiser Salvatore W. Morlino CERTIFICATE OF COMPLIANCE June 5,2023 Brian Zelesky&Alexandra Zelesky 26 Hawthorne Avenue Rye Brook,New York 10573 Re: 26 Hawthorne Avenue, Rye Brook,New York 10573 Parcel ID#: 135.83-1-29 This document certifies that the work done under Mechanical Permit #23-060 issued on 4/27/2023 for the installation of a new oil fired boiler has been satisfactorily completed. Sincerely, Steven E. Fews Building&Fire Inspector /to QyE[3R(�k, 1932 BUILDING DEPARTMENT �Q ifUILDING 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 - - - - - - - - - - - - - - - - - - -- S /2 ADDRESS: W 1 Q. DATE: PERMIT# �' ISSUED: CT: BLOCK: LOT: LOCATION: UC " ► \ CUPANCY: ❑ VIOLATION NOTED THE WORK IS... ACCEPTED ❑ REJECTED/REINSPECTION 3 ❑ 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 ■ mg 6'c O � a M Ncq C a F+� N N ~ � � � W ■ \ \ o �• � � 04 � a� �� � ,� MCI ■ " op *ID W sn 0. v W W r+ z04 q p OL`) �4 a p p V] O � �■■� W \ O E r A] � p � H a+ p ■ M w o O O b W00 � vo- 5- '04 CO o �o+3G, Z N +C1 © Au `e v C� V ICI a 0 � ~ cn M O 7• o 0 u 0 o : e� Q _ � . zz v Us. aa W. w a w O 1`p H Q .2 —V s z R ,� u d z w > o a sn � a+ v o v u b 'N a� a w x � � b BUILDJNC DEPARTMENT 3D VILI✓ E OF RYE $4POK APR 18 2023 938 KING _f"ET Rl'E BRQ NY 10573 ` la -0668 VILLAGE OF RYE BROOK .roa .'"r BUILDING DEPARTMENT APPLICATION FOR PERMIT TO INSTALL AND/OR REMOVE HEATING, VENTILATION AND/OR AIR CONDITIONING EQUIPMENT FOR OFFICE USE ONLY: PERMIT#: / /f c)3 W APR 2 123 7 Approval Date: Permit Fee: Approval Signature: Other: Disapproved: (fees are non-refundablei 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 he listed as certificate holder)& Workers Compensation Insurance on a NYS Board form(Form#C 105.2 or Fomt#U26.3/or NY State Workers Compensation Waiver) 4. Payment of Fees/Unit: RESIDENTIAL=$100.00/unit• COMMERCIAL =$350.00/unit. S. 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, e"-aI 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. 7 q I. Address: Z 1 a,7` 0� 'C, SBL:� �/�J�� / Zone: 2. Property Owner: E'X Qress: 2,05, D Phone#: ;_�(�_ ��/Cell#: -/�,�i y�j�email: r' 1'4 q,) C L-))'r 3. Contractor: Mc-ziG Address: Fri f. �1 S ri1© I 10 2 Phone#: Cell#: p,per ef4-r—©2or email:yh&;','g, 4. Scope of Work:New Installation( )•Re lacement�)•Removal( )•Other( ): 5. List Equipment: dr/P/_ gP271�'l&a- Lt--,q1 co- ,�joa ;�w 6. Location of Equipment: L?g S ej-i et 7. Chod of Install tion/Re Oval(list all equipm�nt needed to perfo job): m aJC� o o ( 61 1, t 3/3/2023 STATE OF NEW YORK,COUNTY OF WESTCHESTER ) as: id 60-o''7 /�eJ t G ,being duly sworn,deposes and states that he/she is the applicant above named, (print nfine of individual signing as the applicant) and further states that(s)he is the Heating,Ventilation and/or Air Conditioning Contractor for the legal owner and is duly authorized to make and file this application. 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 bef re me this ` day of ,2� day of NAt- ,20 Z 3 Signature of Property Owner Si ture of Applicant Pri Nam f Pr rty n Print Name of A t otary Publi Publ' AISLING GERAGHTY NOTARY PUBLIC,STATE OF NEW YORK t4r�8o�iQ S���O Registration No.01 GE6184245 srp See o �tS'j Qualified in Westche•ter Count FS Qsr`��'e My Commission Expires: 0 r This application mast be properly completed in its entirety and must include the notarized signature(s) ' the legal owner(s)of the subject property, and the applicant o#`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 3/3/2023 u erus ` -- G215 — G315 Cast Iron Residential Boilers a �' J e 7. r Design Advantage Superior Heating High Efficiency—AFUEs Above 86% Thermostream Design Eliminates Thermal Shock Flexible, Corrosion Resistant GL-180M Cast Iron Full Swing Burner Door for Excellent Serviceability 134.000 to 768,000 BTU/Hr Output Comfortable. Efficient. Intelligent Heating. B u d e ru s 6215 - 6315 l Superior Design Buderus boiler sections are assembled with beveled, surface profiled push nipples for long, trouble-free watertight operation. Flueways of Buderus boilers are sealed gas tight with tongue and groove section design and elastic high temperature resistant sealing rope.This seal is fully pressed into the groove during assembly to allow positive pressure operation. A permanent dry door gasket ensures repeated positive sealing off of the full swing burner door, producing a proven gas tight seal. Heating my home is never an issue 1. standardsI materials,such as 7their patented GL1:0 flexible cast iron with tightly joined and sealed sections with profiled, -j. 1beveled steel push nipples. r- yearsI perwhen it matters most. formance - Special compounds provide a gas-tight seal for safe and efficient operation.And,thanks to the Putting Energy to Work GL-180M cast iron's amazing Buderus developed a full three-pass system which increases the efficiency of the boilers. flexibility,this boiler resists thermal With single-pass boilers,the flue products have only one chance to heat the water. Buderus shock under conditions of rapidtemperature change. three-pass boilers triple this opportunity.The unique way heat flows through the G215 and G315 boilers allows the water to be heated three separate times.The full 3"thick thermal insulation helps to maintain a higher water temperature even after the boiler has gone into standby mode. GL-180M Gray Cast Iron Buderus GL-180M silicone injected, gray cast iron has excellent corrosion resistance, exceptional casting characteristics, 40% greater flexibility and elasticity as well as high thermal conductivity. Buderus developed the special substances that are impregnated during the casting process to improve the mechanical properties of cast iron.The graphite precipitates into smaller, modified flakes which produce GL-180M cast iron with 40% greater elasticity and a high silicone barrier for corrosion protection. Gray cast iron obtains its superior material characteristics primarily from a high carbon(graphite)and silicone content.Additional elements further enhance the properties of the GL-180M.The graphite appears in two different forms in the microstructure: nodular form producing excellent tensile strength and great elasticity and graphite flakes producing excellent corrosion resistance against acidic combustion products. G215 — G315 Cast Iron Residential Boilers 00 --� Residential Thermostream Boilers Thermostream Design These Buderus boilers can be shipped fully assembled or the G315 can be shipped The Buderus developed knocked down.This option makes the G215 and G315 models ideal for everything Thermostream Principle for cast from the most straightforward new-home installations to challenging refurbishments iron boilers,is proven to improve of vintage homes.To increase efficiency the boilers are designed with precision system reliability and increase made sectional construction as well as a unique "tongue and groove" design for efficiency in heating systems for any size home.Cool return flue side sealing.With this distinctive construction the boilers are sealed gas tight, water mixes internally and is eliminating lost heat.This dramatic increase in boiler efficiency affects a similarly preheated with supply water impressive decrease in your heating costs. before being exposed to directly heated surfaces.This process The attractive blue enameled jacket hides a full 3" of thermal insulation and flexible eliminates the risk of damage GL-180M cast iron with silicone "barrier skin." To streamline the appearance of the caused by thermal shock, "hot and cold spots"developing.The boilers, the supply and return connections are located at the rear of the G215 and Thermostream design allows G315 models.These boilers have minimal stack losses and increased efficiency; for continuous low temperature they are for hot water space heating use and run with either oil or gas. operation under normal conditions without maintaining a minimum Whether you heat by baseboard, panel radiators, hydro-air systems or radiant boiler temperature.Superb flooring, our advanced heating systems will provide man reliability through excellence in g y p y years of exceptional comfort and economy. product design! A better way to heat your home Buderus Thermostream boilers are designed and built to the highest industry Design Benefits standards.They extract and deliver more heat from every fuel dollar.Acknowledged 1 Eliminates"hot and cold spots"in as the leader in high-efficiency, low-emission hydronic heating, Buderus offers the boiler innovative design, quality manufacturing, exceptional efficiency and performance. 1 Minimizes stresses normally caused by rapid temperature A Thermostream boiler is ideal for new installations or as a replacement for changes virtually any make or model of boiler. This innovative technology eliminates thermal I Operates at low return water shock, increases product reliability and lowers heating costs.The G215 and temperatures G315 are compatible with most hot water tanks and offer a variety of convenient 1 Balances water flow through all installation options. Constructed with superior materials and designed by the boiler sections industry's top engineers, a Buderus Thermostream boiler is an ideal choice for any residential installation. i 6215 - 6315 Energy Savings The ENERGY STAR program recognizes Intelligent Heating—by design products that meet or exceed an energy- Buderus, the world leader in heating technology, manufactures the highest quality efficiency level set by the EPA.Energy boilers based on centuries of experience.With its innovative design and quality star ratings for boilers are based on an Annual Fuel Utilization Efficiency manufacturing, a Buderus boiler will outlast and out perform virtually any other (AFUE)rating,which is a ratio of the residential hot water system in the world. heat produced to the energ y gy consumed on an annual basis.This high efficiency translates into dollars saved as well as improved environmental quality. Not only are the Buderus G215 and G315 boilers energy efficient,but they also include the following installation and maintenance features: 1 Rear tappings and flue connection to 4 streamline appearance 1 Baffles and clips for adjusting stack t temperatures k. 1 Heavy gauge blue enameled jacket for V durability and attractiveness The G215 and G315 are designed in Europe,where fuel costs are significantly 1 Full swing burner door hinged on either higher and environmental regulations are more stringent. Established in 1731, the left or right allowing for easy access Buderus uses state-of-the-art techniques in the design and manufacturing of its 1 Front access plugs permit flushing of boilers.The G215 and G315 are designed to maximize the heating value of every the boiler's interior ounce of fuel and built of the highest quality materials. These features allow for easy installation and thorough,proper cleaning in a Constructed without a heat consuming refractory or target wall, service and fraction of the time it takes with a maintenance calls are minimized,while fuel efficiency and heat transfer is maximized. conventional boiler. The full 3" thermal insulation around the boiler, including underneath, increases efficiency by virtually eliminating standby and stack temperature losses. Manufactured with the patented Buderus GL-180M flexible cast iron, the sections are tightly joined together and sealed by profiled, beveled steel push nipples,ensuring a long life with no leakage. Special compounds provide a gas-tight seal for safe and efficient operation.And,thanks to the GL-180M cast iron's amazing flexibility,this boiler resists thermal shock under conditions of rapid temperature change. A Complete your system for added comfort to your home! Once you have a Buderus boiler you can add a Buderus indirect fired hot water tank, C C. ' an optional Buderus Logamatic control or both.The Logamatic control maximizes your comfort and fuel savings, it will also accommodate specialized heating applications such as radiant flooring. Combined, this premium heating system will provide years of exceptional comfort and economy. . . for little more than the cost of a standard replacement components. - - r The Three-Pass Boiler is Designed for 1 Optimized combustion with positive pressure-fired boilers and tailored chamber geometry—no need for a _ heat-consuming refractory or target wall eliminating the need for costly repairs. 1 Minimal stack losses with the modified three-pass flue design's large heat transfer areas. z , _ 4 1 Low standby losses with a full 3/s"to 4"jacket of thermal insulation around the entire block evenunderneath } the boiler! 1 How It Works Domestic Hot Water Tanks The flame fires into the first chamber. The Buderus indirect fired domestic hot water tanks are designed Then the flue products flow through to fit any specialized need.To maximize space,you are able the second pass to the front of the to pair the LT-tanks with the G215 stacked on top. For greater boiler.From there they reverse direction again—moving through the third pass to recovery rates, you have the option of pairing the boilers with the back,and finally exiting via the flue vertical model tanks.These tanks increase boiler efficiency, connection into the chimney.Because system longevity and minimize the need of service calls,when the gases are held in the boiler longer paired with a Buderus boiler.The tanks are designed with many this allows the cast iron to absorb the features to aid in maintenance, such as easy access ports for maximum amount of heat,resulting in cleaning the tank's interior, extra thick Magnesium anode rods and a lower stack temperature and ahigher efficiency. Thermoglaze®interior tank coating to protect against corrosion and aid in cleaning. To help maximize efficiency the tanks are so well insulated against heat loss, they lose less than a t/a°F per hour. .._ Convenient Logamatic Control The Buderus Logamatic Controls, designed to work 40 a 40 with all Buderus boilers, significantly increase the efficiency of your heating system. The Controls maintain a comfortable environment y 1, by measuring indoor and outdoor temperatures in order to automatically and effectively regulate the temperature of the boiler.This allows the boiler to use less fuel while keeping your home exactly as warm as you want it.The Logamatic Controls also include the convenience of a setback feature for nighttime as well as a domestic hot water priority option. So, no matter how hard the heating has to work on a cold day, there will always be hot water for showers.All control functions are able to be customized by you.Additionally, the Buderus Logamatic R2107 is designed with a built-in self diagnostic system to aid in maintenance and reduce service costs. G215 D.O.E Heating Capacity(MBH) 134 171 207 256 294t Net IBR Rating(MBH) 117 149 180 223 256 Oil Firing Rate(GPH) 1.1 1.4 1.7 2.1 2.5 AFUE(%) 86.3 86.2 86.1 86.0 86.7' Number of Sections 3 4 5 6 7 -- --- Vent Connection Size 6" 6" 6" 6" 8" Supply 1 rh" 1 1/e" 1 '/:" 1 '/2" Return 11/2 11/:" 11/2 11/2 11/:1, Overall Boiler Length(L) 26 1A" 31" 35 8A" 40 1/z" 451h" Boiler Block Length(LK) 22" 261/4" 31'h" 361A" 41" Minimum Boiler Block Width 18" 18" 18" 18" 18" Boiler Width 23 1/z" 231/2" 23'h" 23 1/z" 23 1/2" Minimum Boiler Height 33'/z" 33'/2" 33'/z" 331/2" 33'/2" Boiler Height 34 1/2" 34'/z" 34 Vz" 34'h" 341/z" Boiler Feet Spacing 13 1/4" 18" 22'/z" 211A" 32" Fire Box Depth(T) 16'A" 21 Vz" 36 1/4" 31" 351/4" Fire Box Volume(cu.ft.) 1.35 1.73 2.10 2.48 2.86 Dry Weight(lbs.) 400 500 600 700 800 Approx.Water Content(gal.) 12.9 16.1 19.3 22.5 25.6 Recommendended Sidra 15" 15" 15" 15" 15" bf W W 20" 20" 20" t IBR Gross Output Combustion Rating Approvals and Certifications z. '. _. . .. MEA 463-99-E LT160 42 Gallon CRN No#6248.7C LT200 53 Gallon LT300 79 Gallon K Mounting hardware to secure G215 Boilers on top of LT Tanks, must be purchased separately. i k plugged) Min.2 " ® L, - 2 W I�.•.`� G215 - G315 Cast Iron Residential Boilers 6315 Gross Output MBH 350 454 559 663 768 Operational Requirements #of Sections 5 6 7 8 9 of the G315 Max.Input Gas MBH 433 556 678 801 924 Max.Input Oil 3.0 3.85 4.7 5.6 6.4 1 The boiler must be placed on a Net IBR MBH 304 395 486 577 668 smooth,level concrete base, Boiler HP 10.4 13.6 16.6 19.8 22.9 33'/2"wide. Max.Operating Pressure(psi) 87 87 87 87 87 1 Cement in the base(or place on Combustion Efficiency Oil 86.8% 86.9% 87% 81.1% 81.1% its top)either 4"x 1/4"flat steel Combustion Efficiency Gas 84.2% 84.3% 84.4% 84.4% 84.4% plates or 4"x 2"x'/4"angle irons Thermal Efficiency Oil 83.3% 84.3% 84.9% 85.4% 85.7% for boiler support. Thermal Efficiency Gas 80.8% 81.8% 82.4% 82.8% 83.1% 1 Set boiler high limits above 122"F Number of Sections 5 6 7 8 9 (149°F for modulating gas burner) for safe boiler operation. Vent Connection Size 7" 7" 7" 7" 7" 1 Low fire setting must be at least Supply 3" 3" 3" 3" 3„ 60%of full fire for a LHL burner. Return 3" 3" 3" 3" 3" 1 Maintain minimum of 158°F in the boiler in case of ice water return Overall Boiler Length(LG) 441/4" 501/i' 563/4" 631/4" 69'/2" temperatures. Boiler Block Length(LIQ 381/4" 441/2" 501/4" 57" 631h" Boiler Door Thickness 5" 5" 5" 5" 5" 1 Buderus recommends the use Minimum Boiler Width(BE) 28" 28" 28" 28" 28" of customized Beckett or Riello Height 401/4" 401/4" 401/4" 401/e" 401/1' F series burners when firing the G315 with oil.(Available from Fire Box Depth(LF) 31" 371/2" 431/4" 50" 561/4" Buderus.) Fire Box Diameter 15'/4" 151/4" 151/4" 151/4" 15'/4" Fire Box Volume(cu.ft.) 539 6.39 Z59 8.79 9.99 1 Use Power Flame or Riello for gas Dry Weight(lbs.) 1,197 1,391 1,585 1,779 1,973 firing.(Available from Buderus.) Water Content(gal.) 37.8 45.2 52.6 60.0 67.4 Operating Weight(Ibs.) 1,512 1,768 2,024 2,280 2,545 Approvals and Certifications MEA 356-98-E u CRN No#616.TC c&sli j J us1En K Re ���►: T- ir �.N -77 V. v w A ---i r-0--1 F== -� 1- 6215 — G315 Cast Iron Residential Boilers A Tradition of Excellence • The World's leader in heating technologies since 1825,Buderus produced the world's first low- temperature hydronic heating systems.Today,Buderus products are JOP acknowledged as the world standard in high-efficiency,low emissions hydronic heating.All Buderus products w► are designed to meet strict safety and environmental regulations. duo Buderus boilers are quick and easy to install and will outlast and outperform virtually any other hot water heating system.They are designed for easy access and service.With appropriate maintenance,Buderus boilers deliver the _ highest possible efficiencies throughout a the lifespan of operation. _ R "ter In 2008 Buderus became a member a of the Bosch Group,representing o the Bosch,Buderus and FHP brands Maintenance and Service Convenience t with products that are designed to Stack temperature is easily adjustable with the removable baffles. A full swing improve efficiency ,cy,reliability and o; reversible burner door allows maximum accessibility, and allows the boiler to are environmentally friendly. Bosch be located almost anywhere. Buderus boilers are designed to be fully serviced Thermotechnology offers floor-standing ° from the front without disassembly and thus can be serviced in half the time of and wall hung boilers,water heaters, competitor's boilers. The Buderus GL-180 cast iron breaching ensures a long, solar systems,heat pumps,control CO systems and tankless water heaters. o problem-free life. 0 pT� O O Quick-FitTM' Modular Piping System The Quick-Fit System takes only minutes to connect and includes all the piping, E valves, circulating and control elements to feed both radiant floor heating zones and conventional high-temperature heating zones. Not only will a Quick-Fit system save o y time and money on any boiler installation it also eliminates incorrect valve or motor o o so installations.Additionally it ensures a clean, finished and professional installation. cN The Quick-Fit system consists of three main components, the Quick-Mix Mixing Station for radiant flooring applications, the Quick-Pump Station for high-temperature zones and the Quick-Header Manifold for multi-temp heating systems.The Quick-Fit System can be used to connect virtually any piping arrangement. Bosch Thermotechnology Corp. 50 Wentworth Avenue,Londonderry, NH 03053 Tel: (603)552-1100 Fax: (603)584-1672 www.buderus.us MEJIPLU-01 GCOHAN CERTIFICATE OF LIABILITY INSURANCE DA4/15/2023 ) 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 NOMTACT Gerry Cohan Cohan Associates,Inc. PHONE 27 Cleveland Street (A/C,No,Ext):(914)422-0500 A/C No):(914)220-1440 Valhalla,NY 10595 a DRIE ,CohanAssociates@OptonIine.net INSURER(Sl AFFORDING COVERAGE NAIC# INSURER A:Utica First Insurance Company 15326 INSURED INSURER B: Mejia Plumbing,Corp. INSURER C: 182 Fremont St INSURER D: Harrison,NY 10528 INSURER E INSURER F: COVERAGES CERTIFICATE NUMBER: 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 ADDUSUBR POLICY EFF POLICY EXP T TYPE OF INSURANCE IN D I WVD', POLICY NUMBER MI D/YYYY MMI /Y LIMITS A X COMMERCIAL GENERAL LIABILITY j EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE '- OCCUR X 'ART3000227250 5/29/2022 5/29/2023 PR MGE TO R(EaENTED occurrence) $ SO,QQQ MED EXP(Any one arson $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 �E o 1,000,000 X POLICY 7, LOC PRODUCTS-COMP/OP AGG $ MOTHER: $ A COMBINED SINGLE LIMIT 1,000,00Q AUTOMOBILE LIABILITY nt $ ANY AUTO X IART3000227250 5/29/2022 5/29/2023 BODILY INJURY Perperson) $ OWNED EOS ONLY X SCHEDULED SULEDp BODILY INJURY Per accident S X AUTOS ONLY X AUOTOS ONLY Pe0acE,ciCentDAMAGE $ i $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION PTAT T ORH AND EMPLOYERS'LIABILITY Y I N ANY AFFICER/MEMBER EXCLUDED?ECUTIVE ❑ NIA E.L.EACH ACCIDENT $ (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ i DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Additional Insured:Village of Rye Brook 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 9 y ACCORDANCE WITH THE POLICY PROVISIONS. 938 King St Rye Brook,NY 10573 AUTHORIZED REPRESENTATIVE ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD oRK Workers' CERTIFICATE OF --��aTl~ Compensation Board NYS WORKERS' COMPENSATION INSURANCE COVERAGE 1a. Legal Name&Address of Insured(use street address only) 1 b. Business Telephone Number of Insured Mejia Plumbing Corp. 914-844-0208 182 Fremont St 1c. NYS Unemployment Insurance Employer Registration Number of Harrison, NY 10528 Insured Work Location of Insured (Only required if coverage is specifically limited to 1 d. Federal Employer Identification Number of Insured or Social Security certain locations in New York State, i.e., a Wrap-Up Policy) y Number 61-1712038 2.Name and Address of Entity Requesting Proof of Coverage 3a. Name of Insurance Carrier (Entity Being Listed as the Certificate Holder) Travelers Insurance Company Village of Rye Brook 3b. Policy Number of Entity Listed in Box"la" 938 King Street UB-008M255279 Rye Brook, NY 10573 3c. Policy effective period 11/17/2022 to 11/17/2023 3d.The Proprietor, Partners or Executive Officers are included.(Only check box if all partners/officers included) �✓ all excluded or certain partners/officers excluded. This certifies that the insurance carrier indicated above in box"3"insures the business referenced above in box"1 a"for workers' compensation under the New York State Workers'Compensation Law. (To use this form, New York(NY) must be listed under Item 3A on the INFORMATION PAGE of the workers'compensation insurance policy). The Insurance Carrier or its licensed agent will send this Certificate of Insurance to the entity listed above as the certificate holder in box"2". The insurance carrier must notify the above certificate holder and the Workers' Compensation Board within 10 days IF a policy is canceled due to nonpayment of premiums or within 30 days IF there are reasons other than nonpayment of premiums that cancel the policy or eliminate the insured from the coverage indicated on this Certificate. (These notices may be sent by regular mail.)Otherwise,this Certificate is valid for one year after this form is approved by the insurance carrier or its licensed agent,or until the policy expiration date listed in box"3c",whichever is earlier. This certificate is issued as a matter of information only and confers no rights upon the certificate holder.This certificate does not amend, extend or alter the coverage afforded by the policy listed, nor does it confer any rights or responsibilities beyond those contained in the referenced policy. This certificate may be used as evidence of a Workers' Compensation contract of insurance only while the underlying policy is in effect. Please Note: Upon cancellation of the workers'compensation policy indicated on this form, If the business continues to be named on a permit, license or contract issued by a certificate holder,the business must provide that certificate holder with a new Certificate of Workers' Compensation Coverage or other authorized proof that the business is complying with the mandatory coverage requirements of the New York State Workers'Compensation Law. Under penalty of perjury, I certify that 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: Gerald B Cohan (Print name of authorized representative or licensed agent of insurance carrier) Approved by: �' 4/15/2023 (Signature) (Date) Title: Licensed Insurance Agent Telephone Number of authorized representative or licensed agent of insurance carrier: 9 1 4-422-0500 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