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HomeMy WebLinkAboutMP23-082 CB 4" t,b t � 19 4 Ja4G'yl'�V K 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 13,2023 Philip Guerin& Katherine Guerin 9 Loch Lane Rye Brook,New York 10573 Re: 9 Loch Lane, Rye Brook,New York 10573 Parcel ID#: 136.21-1-5 This document certifies that the work done under Mechanical Permit #23-082 issued on 6/1/2023 for the installation of a new gas fired boiler has been satisfactorily completed. Sincerely, Steven E. Fews Building&Fire Inspector /to QyE BRC�k. • �9a2 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 Uebrook.org - - - - - - - - - - - - - - - - - - - - INSPECTION REPORT - - - - - - - - - - - - - - - - - - - - ADDRESS: DATE: PERMIT# Q� � "�SSUED: r SECT:_BLOCK: LOT �r A (6 LOCATION: N C� 'l9 \ lr' OCCUPANCY: ❑ Violation Noted THE WORK IS... ❑ PASSED ❑ FAILED 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 d` a N © 'n M o o w w a N W a 4 2 y v W do ° z LS) CJ 1 0 0 © o "O 1-4 � W H W z w -r. 0 y 14 T CINco W W y o 'er 00 (> u o a H Cl") C1i or- �. cn W 0 ) v � �, p v OEM oll H 3 z cn gyp+ 44 - a A W Al � � cpi' v Q W QH •� �� .� BUILDING DEPARTMENT U E C E� V E VILLAGE OF Ri`E BROOK MAY 3 0 2023 DD 938 DING STREET RYE BROOK,NY 1057 (91.1)939-0668 VILLAGE OF RYE BROOK Nvww.rNehrook.ot-2 BUILDING DEPARTMENT I APPLICATION FOR PERMIT TO INSTALL AND/OR REMOVE HEATING, VENTILATION AND/OR AIR CONDITIONIN�G_EQUIPMENT FOR OFFICE USE ONLY: PER -%l11 Na1 3 - Approval Date: Permit Fee: $ Approval Signature: Other: Disapproved: (fees are non-refundable) **h*hh**hit*h****hit:F*:YhYc*Yr**1:**r.hhz**h*hh**ar*Yr**Yr**ir**:4 h*h*hie iFR*Yk'**kYc*#Yk fi*C9S ewwwww*'M***ikw RRR*1FP**w'�`w*** REQUIREMENTS FOR RELEASE OF PERM17 &CF:RTIFICA l'F.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. I Village of Ryc Brook 111LIM be 11SIClt eta certiticate holder)& Workers Compensation Insurance on a NYS Board form aoTm ff C 105_2 or dorm 4 l Q6.3;or NY State Workm 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. *** r�tw�th*wit**h*sr **sr.�thhxhhxhwe,�,vxwxc,�x�trth�h�t*nth t��whww**w***w*wx***>i>E*xR*w�x,:�wxwwwwwwrxwwwr Application darted, Z� is hereby made to the Building Inspector ofthe Village ol'Rye Brook for a permit for(lie installation and or rem val o the.HVAC equipment as listed bc1ow. 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 refit tions. /n ff T I. Address: 6) SBL: � �2_1 —5 z0111A 2. Property wner: ! r• n Address: Phone#: Cell#: email: 3. Contractor: t'1 cyxah�arl Address: 2.0 bnoo \ Phone 4: � ! 4 �l l I3 e, (/Id ell#: 0+ 6 1�, T'��fl email:�lY1 o c all V (ybJ � a 4. Scope of Work:New Installatic Replacement 40—Removal( }•other( }: 5. List Equipment: LD& t Wcx r— + V i� C, 6 o t k ac H,1 6. Location of Equipment: Q5rwnk- C- 7. Method of Installation/Removal(list all equipment needed to perform job): i 3 12023 ST C)F NEW Y ,COUNTY OF WESTCHESTER ) as: S �kr%-" ,being duly sworn,deposes and states that he/she is the applicant above named, (print name of individual signing as the applicant) and further states that(s)he is the 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 rand regulations. Sworn to before me this ,� Sworn to before me this c�r7 day of r 20 11<1 day of ,20 Signature F�p/erkyOwner Signature ofApplicant J rin of Property Owner ,,' WZGER '' Print 1A ,\ '� STATE •d STAT 'OF N�FtK', O E Notary Public X, NOTARY uB�t� ;o N�, zced in a Qualitrad isx r Cv Cl , Putnam County i Putnam County ,ti +?�� p i Fi 2089 n'3 ' 01F16402069,%N N,N�+", 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 nul I and void and will be returned to the applicant. z 31/2023 HIGH - EFFICIENCY CONDENSING GAS COMBINATION BOILERS SMART ■ - � �i� rrrf • r .. . .. ; r � � r r r � I • I I% NCIBLIF fAINW111Li Ilk 9 5% (A.-IRS CERTIFIER AFUE EFFICIENCY ,Hsi Q A�P �yC Lo z L Q' f Q� ^^ 9,y PARTS SAP ! na va- DESIGNED*EN41NLERED*ASSEMBLED HIGH EFFICIENCY BOILERS&WATER HEATERS USA A 40 rw A Game-Changer In Combi Water Heating Lochinvar has long been the innovation leader in commercial boilers—and now it's bringing that engineering excellence to residential combi boilers. Lochinvar's legendary reliability and performance are now available for apartments and homes,where the combi boiler's next-generation fire tube design can provide hot water supply and space heating faster and more efficiently than ever before. The NOBLE'*combi boiler provides a space-saving choice for builders and specifiers,lowering installation costs by reducing the mechanical equipment needed to provide rapid,reliable hot water supply and efficient space heating.It also gives plumbing contractors a money-saving alternative for single- family housing with 1 or 2 bathrooms. cTf = Advanced Electronic Controt The backlit,user-friendly LCD display provides diagnostic information and system status in real words,not codes.The Set-Up Wizard display makes it simple to set system parameters in just minutes,including: CsItW++�f�t�iL"',t Space Heat Set Point(Coldest Day) Domestic Hot Water Set Point Maximum Space Heat Set Point Space Heat Rate Limiting ® Auto Reset High Limit Outdoor Temperature/Warm Weather Shutdown What Makes NOBLE The Best Combi Boiler? DELIVERS MORE HOT WATER BETTER TECHNICAL SUPPORT AND TRAINING It's sized large enough to quickiy meet domestic hot water(DHW) Answers are accessible whether online or on-campus.LochinvarU.com toad.Provides DHW from 2.6(NKC110)to 4.8 gpm(NKC199)at a 777 is always on,2417 for technical support.And Lochinvar University is temperature rise. the industry's best-equipped training certe . FASTER DHW RESPONSE TIME 10:1 TURNDOWN RATIO With many cornbi boilers when you turn on a hot water faucet,you Ope ates as low as 10`s,of the maximum firing rate,preventing on/off initially get hot water and then a brief burst of cold water before the hot short cvr,iinF at the lowest DFIW demands or small heating demands. water resumes.Thanks to its patent-pending control technology,this combi boiler eliminates this cold water"sandwich." AIR HANDLER INTERLOCK Prevents cool cm circutat`on in I lydro-Air installations when the QUIET OPERATION appliance is making DHW, Operates so silently that you often have to look at the user-friendly interface to see if is running. CONSUMER FINANCING AVAILABLE EASIER TO INSTALL AND PROGRAM Check with your local Sales Representative for additional information. With our Set-Up Wizard,you can program the boiler in less than two minutes.The user-friendly interface uses real words—not confusing codes—to guide the installer In setting Up vital system parameters. Raising the Bar in Combi Boiler Design Removing the front panel provides convenient access to the combustion system, control panel and key components. This simple-to-install-and-service combi boiler is making an impact on the industry. The unique fire tube heat exchanger design is what enables NOBLE to 2 produce the results users deserve and have come to expect from Lochinvar, i 1 ADAPTER-FREE FLUE CONNECTION r hlult;-material connector allv,rs either PVC, CPVC,polypropylene or stainless steel connection directly to the appliance without adapters.NOBLE also has a built-in combustion Z analyzer port. 3 2 DIRECT VENTING UP TO 100 FEET Offers five venting options for tremendous installation flexibility.It permits direct vent air intake and exhaust tuns up to 100 equivalent feet using either PVC,CPVC,polypropylene or ,; AL?9-4C Ili i!ess steel vent pipe. e 3 ADVANCED NEGATIVE REGULATION TECHNOLOGY Safelv ar.; c 'ably operates with.supply gas pressure as low as 4 inches water column.Its negative regulation(neg!reg) technology eliminates mechanical dampers as it automatically adjusts fan speed to ensure the correct volume and mix of fuel and air throughout the firing range. 4 INNOVATIVE FIRE-TUBE HEAT EXCHANGER The fire tube design can produce a higher heat transfer coefficient than traditional fire tubes. �{ 5 BRAZED PLATE HEAT EXCHANGER Stainless Stee(Hea=.Exchangeri that quickly 1 Y transfers heat from the boiler system to the domestic water satisfying DHW load. 6 WATER CONNECTIONS FOR EASY INSTALLATION NPT water connections make installation easy, 5 especially with Our optional Isolation valves. 6 6 lh-product images shohn are for illustration purposes unit' and may nn!be an enact representation of the prndurt. NOBLE Dimensions and Specifications Q FRONT NKC 150-199 R c TOP E lee 1 r K 6 H C j �L— f NKC110 _...._ _P H N TOP BOTTOM NOBLE Comm BOILER DIMENSIONS AND SPECIFICATIONS Heating NetAHRI Model InputCapacity Number1 NKC110N 110 11 95.0 102 89 32.1/2" 17.114" 18" 14-3/4" 2-3/4" 6-1/2" 2-3/4" NKG50N 150 15 95.0 139 121 32-1/2" 18.3/4" 18" 6.3/4" 2-3/4" 6-3/4" 11-3/4' NKC199N 199 19.9 95.0 185 161 32-1/2" 18-3/4" 18" 5-1/2" 2-3/4" 6-3/4' 11-1/2' DIMENSIONS AND SPECIFICATIONS rr PR Gas Water Air Vent Ship Conn. 2" 3-1/2" 8-3/4" 13-1/7 2-3/4" 9" 10-1/2" 5" 14-1/2" 12.3/4" 5" 1/2" 1" 3" 3" 139 2-1/2" 6-1/4" 2.3/4" 13-1/7' 3" 9" I1-1/2" 5" 6-1/4" 13-3/4" 6" 1/2" 1" 3" 3" 142 2-1/4" 5-1/7' 2.3/4" 13-1/2" 2-3/4' 9-1/2" 10-1/2" 2-3/4" 5-1/2" 13" 5.1/4" 1/2" 1" 3" 3" 159 Notes:Indoor installation only.All information subject to change.Change'N"to-i"for LP gas models. 'The Net AHRI Water Ratings shown are based on a piping and pickup allowance of 1.15. 777 >Low Voltage Terminal Strip >Condensate Trap Air Handler Interlock >Other Features Flow Switch Contacts Automatic Reset High Limit Low-Water Cutoff Connection Adjustable High Limit w/Manual Reset System Sensor Contacts Built-in Circulating Pump Outdoor Air Sensor Contacts Walt-Mount Bracket Cascade Contacts Zero Clearances to Combustible Materials >Time Clock for Data Logging 10-Year Warranty *77°F Temperature Rise Last 10 Lockouts (See Warranty for Details) >Low-Water Flow Safety Control&Indication 5-Year Parts Warranty >Password Security OPTIONAL EQUIPMENT SMART CONTROL" FEATURES >Built-in Cascading Sequencer for Low-Water Cutoff w/Manual Reset&Test >SMART CONTROL Digital Operating Control up to 8 units Concentric Vent Kit LCD Display with words not codes STANDARD FEATURES Condensate Neutralization Kit Sidewall Vent Termination >Outdoor Reset Control with Outdoor Air Sensor >ENERGY STAR Most Efficient Recognition Floor Stand >Programmable System Efficiency Optimizers >95%DOE AFUE Efficiency Wireless Outdoor Sensor DHW Response Time >Modulating Burner with 10:1 Turndown Nat to LP Gas Conversion Kit DHW Pre Heat Direct-Spark Ignition Isolation/Flush Valves Outdoor Air Reset Curve Low-NOx Operation >ASME Stainless Steel Heat Exchanger FIRING CODES >Two Pump Control >M9 Standard Construction/California Code System Pump 50 psi Working Pressure wJASME Relief Valve >Vertical&Horizontal Direct-Vent Boiler Pump 'Lochinvar should be consulted before selecting a boiler for >High-Voltage unction BOX PVC, 100 f Polypropylene or SS Venting installations havingunusual piping and pickup re uirements,such 1 up to 100 feet p g p p a 120 VAC/60 Hertz J 1 Phase Power Supply as intermittent system operation,extensive piping systems,etc. *The ratings have been determined under the provisions governing forced draft burners. -hinva lJ t of Sa\ A Ij ME HIGH E"(IU flFCV 301LCkS&wArF:N L++EATERS 910®Q Luchinvar.com 44 AWIDIL N `` ff+/+ 1 •y �" `.f4 }>a Y ";'� a�s1�1 f1w)M - �....+ '` 3:a. k i�-. >z•.'�_.ds��•+s.G i ...fir� „i+`.+`,► �„ +!lNip*y3� . ..— * __._ -`__—_ --- ...._. _. � _.............w- ._ .-..�•tr'� a G ��•� b u `n :� N I•� n;; y � 0 4+ _ O �! C) t �; 9�� -.. . � a -o � cam.. M •r .; E c c o ti � • �_.� 09in di v O ^< = b v o . � uv U '� ? v � .f. Y� I _ I�1 •~ x CJ Z o !. tJ ZCtion c c uj ! 4Zj„/ � ��r lL J Z z tA C > W p W anw o Vr r.+ U N O H f _ 4•. O -s 06 f It v i N I �.( LO U of ci a E"' ML �, ,w. ; ,+t+ � ._ -�t� :���+i«I���� 7 �� .i�'yt141f�+•4� t• •'+�;1�1+°t, �":: n� ,kt`y�jtilt � �F,�t,►+t'+11+�+ ,� ,jf 't:�ff/ j+�3. �`�`, ' �w� ?� f.� f*♦ �;�#�.►�� "�#i1••' � wf+��s ta1�f� � h@ydtpw���¢ �'f"GOO A■, dX,q;4�na6a`*' ,.y� ; `, 40T1 f. :c.'Jel r'hi -.. -r "F IF 'yx. ., < 1 .010 .,w ..NF.,f�''•,3+-Y T', ,. 'R -i .�.3�ir�'. ,.-.N �;a Na% '' .. <, •�' +y�""s�+,�*"�,`.�t,4. `v +r 'b'v✓,,r �i't ' ♦ ,w ACORN CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDD/VYYY) 9/15/2022 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 endorserrient(s). PRODUCER CONTACT NAME: -_Soraya Plmentel Arthur J. Gallagher Risk Management Services, Inc PHONE — FAX -- -- 300 Madison Avenue WC,Na.F_4)�212-530-7504_ _ ------- (A/C No):212 981-3386 E-MAIL ---- 28th Floor ADDRESS_ soraya SAIT1entID a' .COm — New York NY 10017 INSURER(S)AFFORDING COVERAGE NAICA INSURER A-:--Selective Insurance_Company of America 12572 INSURED YOST&CA-01 INSURER B Yost&Campbell, Inc. 20 Brookdale Place I-NSURERC: Mt. Vernon. NY 10550 INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:1070757288 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 SUER POLICY EFF POLICY EXP LIMITS LTR POLICY NUMBER MM/DDIYY MMIDD A X COMMERCIAL GENERAL LIABILITY S2390242 9/15/2022 9/15/2023 EACH OCCURRENCE $1,000,000 CLAIMS MADE OCCUR DAMAGE TO RENTED PREMISES a occurrence $500,000_________ MED EXP(Any one person) $15,000 PERSONAL&ADV INJURY $1,000,000 GENT AGGREGATE LIMIT APPLIES PER: GENERAL_AGGREGATE $2,000,000 POLICY JET [�]LOC PRODUCTS-COMP/OP AGG $2,000,000 OTHER --_--- $ - AUTOMOBILE LIABILITY COMBINED SINGLE $ _fa accidentl_-__ ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY(Per accident) $ HIRED NON-OWNED PROPERTYDAMAGE $ AUTOS ONLY AUTOS ONLY Per accident $ UMBRELLA LIAR HOCCUR EACH OCCURRENCE $ EXCESS LU1B CLAIMS-MADE AGGREGATE $ DED ' RETENTION$ $ WORKERS COMPENSATION PIER TH- AND EMPLOYERS'LIABILITY Y/N STATUTE ER ANYPROPRIETOR/PARTNERIEXECUTIVE N/A E.L.EACH ACCIDENT $ OFF ICER/MEMBER EXCLUDED? (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under -- DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101.Additional Remarks Schedule,may be attached if more space is required) Village of Rye Brook is included as Additional insured for general liability as per written contract and as per policy terms.conditions and exclusions 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 Rye Brook NY 10573 AUTHORIZED REPRESENTATIVF USA t4!�7____ ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD(Tame and logo are registered marks of ACORD <� 1+1848 STATE :: COMPenSafi0f) CERTIFICATE OF Board NYS WORKERS' COMPENSATION INSURANCE COVERAGE 1a. Legal Name&Address of Insured(use street address only) 1b. Business Telephone Number of Insured ADP TotalSource FL XVI,Inc. 58W 1110indward Parkway Alpharetta,GA 30005 1c.NYS Unemployment Insurance Employer L/C/F: Registration Number of Insured Yost&Campbell Heating,Cooling,and Generators,LLC. 4735300 2 20 Brookdale PI Mount Vemon,NY 10550 1d.Federal Employer Identification Number of Insured or Social Security Number Work Location of Insured(Only required if coverage is specifically limited to certain locations in New York State,i.e., a Wrap-Up Policy) 132866714 2.Name and Address of Entity Requesting Proof of Coverage 3a. Name of Insurance Carrier (Entity Being Listed as the Certificate Holder) New Hampshire Insurance Co. VILLAGE OF RYE BROOK 3b.Policy Number of Entity Listed in Box"1 a" 938 KING STREET We 053456189 NY RYE BROOK,NY 10573 Ali worksite employees working for Yost&Campbell Heating,Cooling,and Generators LLC. paid under ADP TOTALSOURCE,INC's payroll,are covered under the above stated policy. 3c. Policy effective period 12/25/2022 to 07101/2023 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"la'for workers'compensation tinder 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 Carver 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 EF 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 went,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 rcfcrencetl 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: Michael Price (Print name of aut oozed representative or licensed agent of insurance carrier) Approved by: - tom ' - 11-APR-2023 (Signature) (Date) Title: CEO North America Telephone Number of authorized representative or licensed agent of insurance carrier: 800 743-8130 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) Certificate Number: www.wcb.iiv.gov