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HomeMy WebLinkAboutMP23-081 QyE I1R �'. t'CC wUJJV G C V V vv� 4 JJCKi Vy�V O �9 VILLAGE OF RYE BROOK MAYOR 938 King Street, Rye Brook,N.Y. 10573 ADMINISTRATOR Jason A. Klein (914) 939-0668 Christopher J. Bradbury www.tyebrook.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 #23-081 issued on 6/1/2023 for the installation of a new condenser and a new air handler has been satisfactorily completed. Sincerely, Steven E. Fews Building&Fire Inspector /to �E BR��• • �9�2 BUILDING DEPARTMENT 0 BUILDING INSPECTOR ❑ASSISTANT BUILDING INSPECTOR VILLAGE OF RYE BROOK ❑ 938 Kin Street• Rye Brook NY 10573 CODE ENFORCEMENT OFFICER g y � (914) 939-0668 FAx (914) 939-5801 www ryebrook.org - - - - - - - - - - - - - - - - - - - - INSPECTION REPORT - - - - - - - - - - - - - - - - - - - - ADDRESS: �l DATE: PERMIT# (" L J ' ISSUED: �I E ICT: B LOCK: -LOT: - -? LOCATION: 4 6(a�AiCCUPANCY: ❑ Violation Noted THE WORK IS... Zf 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 ❑ OSS CONNECTION INAL ❑ OTHER oG ° O N 6i Or O'' bD log a v v en p PL( \ enR'i d A ° o 04 W w° MCA 4 o en d � c 11 Ell °0 ROW, eo W+ ^ w z z p - � � M cn � m u CA ;D Wfz G � � � � � � o y p Vz a >' �' � 1 u v 0o a 0-4 a " " .. v U D EC ENE BUILDING DEPARTMENT MAY 3 0 2023 VILLAGE OF RYF,BROOK 938 KING STREET RYE BRooK,NY 10573 VILLAGE OF RYE BROOK (914)939-0668 BUILDING DEPARTMENT rsyVN%.rvehrc okmrg, APPLICATION FOR PERMIT TO INSTALL AND/OR REMOVE HEATING, VENTILATION AND/OR AIR CONDITIONING EQUIPMENT FOR OFFICE: USE ONLY: PERMIT#: Imil Q,3-0gl Approval Date: J UN Q O Permit Fee:$ Qao AD Approval Signature: Other: Disapproved: (Dees are non-refundable) REO uIREMENTS 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 ol`Etye Brook must be listed as certificate holder)& Workers Compensation Insurance on a NYS Board form(Form#C105.2 or Fonn#U26.3/or NY State Workers Compensation waiver) 4. Payment of Fees/Unit: RESIDENTIAL. =S100.00/unit• COMMERCIAL —$350.00/tlnit. 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, duets 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 regulatiioons. 1 I. Address: 1 t SBL: �LO' �~ r Zone: 2. Property Owner: f 1 e-r 1 Address: y ar —, - Phone#: �L�— ZItoceII#: email: 3. Contractor:: 1 Address: 2-C> Phone#: 4 '459—V6(3 Cell#: email: VY)Vi-jn[a-G �r0°1L1 ^ 1, 4. Scope of Work:New Installation )• Replacement 0•Removal{ )•Other{ ); 5. List E uipment: �'�i 1� �� 4 r a d Cfto be 6. Location of Equipment: 7. Method of Installation/Removal(list all equipment needed to perform job): 1 3/3/2023 STATE OF NEW YORK,COUNTY OF WESTCHESTER ) as: ,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 and regulations. Sworn to before me this 0Q.- Sworn to before me this 6As, day of 20 —OS day of 4a .20_,9,3 Signature of Propertykowner Applicant PfVt�lu�.r 8 Czu6A r ti x ame of Pr perty Owner (� Notary Public-' ,..�" G FIT GF �.---..� .F9 �.. 9q! �or SrArE''`9Cp� STATE '.Q ,•OF NEW YORIC NOTAf?PUBLK !;NOTARs g 16' ;�� :o p4QUalifrp��n�l[' _ K Oualrfied in ° is 2�' Q i,am c� �?�'• �16q d • Putnam County ;N` � •, Q Q8g�.`��� 01F16402089 PI This application must be pr"6}i'2t'l�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 3/312023 . . - �� � SERIES ��������� � Air Conditioning&Heating 8� D�c MULTI-SPEED, MULTI-POSITION, /v/�/-� �PEED/ E[M-ur���� n/� HANDLER �x � Ah �ND!ER INTERNAL /^^ v T��L/ 1 Y To 5 TONS Contents Air Handler Nomenclature —'---..-2 Heater Kit Nomenclature......................2 PmductSpecificatiuns---------3 Dimensions............................................4 Airflow Data...........................................5 HeatKit Data..........................................7 Wiring Diagram......................................9 Accessories..........................................12 Product Features ° Internal factory-installed thermal expansion ° RigidSmartFrame-cabineg valves for cooling and heat pump applications ° Horizontal o/vertical ° Direct drive, multi-speed E[IVI blower motor configuration capabilities ° All-aluminum evaporator coil ° 21''depth for easier attic access ° Coil mounting track for quick repositioning ° DecaRD[free thermoplastic drain ° Optimized for use with R'410A refrigerant pan with secondary drain connections ° Cabinet air leakage less than 2.096at 1.0 inch H20 ° Screw-less sides and back helps to reduce con- when testedinaccondancewithASHRA[standand193 densation when installed in humid locations ° Cabinet air leakage less than 1.496at0.5 inch H'O ° Foil-faced insulation covers the internal when tested in accordance with ASHRAE standard 193 casing to reduce cabinet condensation ° AHR|certified; ETLlisted ° Galvanized,leather grain-embossed finish ° Glue-less cabinet insulation retention ° Tool-less filter access ° Field Installed 3 kVV-25 kVV electric heater kits available PARTS � L/m/rso | 10 | YEAR w^""^"`,�| By OW ��r� ~~' 'u '~^ ~``~~' -�' BBB ^c"mpl.*warranty details available from p.'local dealer°,*°°°gDmni""=w=m,*receive Elie m+ea,Parts un..w Warranty,online registration must be completed within 60 class winstallation.Online registration.no(required~California or Quebec. SS-GAx4ST wmw.Koodmanmfgmm 06/22 NOMENCLATURE A M s T 36 B U 1 4 05 A 1 2 3 4 S,6 7 8 9 10 11,12 13,14 Product Engineering' A Corporate Air Handler Major/Minor Revisions A Initial Release D Daikin Air Handler B 1st Reviswn Electric Heat KW Unit Application 5=5kw C Ceiling Mount 8=8kw M Multi-Positional 10=1Okw W Wall Mount F Fit Compatible Multi-Positional Refrigerant H Horzontal Discharge 3-R32 Compatible Multi-Positional 4-R410A 6-R410A or R22 Motor Electrical S MS-ECM 1 208/240 V,1 Phase,60 Hz V VS-ECM Communicating Expansion Device Cabinet E Electronic Expansion Valve N-Uncased F Flowrator P-Painted T Thermal Expansion Valve U Unpainted Nominal Capacity Range Cabinet Width 12=1 Ton 36=3.0 Tons AC*Series AM*Series AW*Series 18=1.5Tons 42=3.5Tons M=43.25" B=17.51, S=20.2" 24=2.0 Tons 48=4.0 Tons L =49.25" C =21.0" L=24.0" 30=2.5Tons 60=5.0Tons D =24.5" *DENOTES AHRI WILD CARDS HKS X 03 X A AA 1 2 3 4 5 6,7 Unit Type Revisions HKS Heat Kit for Engineering Revisions Air Handlers Phase Circuit Breaker A Single Phase 208 V E Three Phase 240 V X No circuit breaker B Single Phase 240 V F Three Phase 208/240 V C Circuit Breaker C Single Phase 208/240 V G Three Phase 460 V D Three Phase 208 V Heating Capacity @ 240 Volts H Special case 208 V 03 3.0 kW 15 14.4 kW Cabinet Size(MAX) 05 4.5 kW 19 19.2 kW wth 150F limit C C Cabinet 06 6.0 kW 20 19.2 kW with 170F limit D D Cabinet 08 8.0 kW 25 25.0 kW X All Cabinet Sizes 10 9.6 kW 2 www.goodmanmfg.com SS-GAMST PRODUCT SPECIFICATIONS is :D .0D NOMINAL RATINGS Cooling(Btu/h) 24,000 36,000 36,000 36,000 42,000 48,000 48,000 60,000 BLOWER Diameter 10" 10" 10" 10" 10" 10" 10" 11" Width 6" 6" 6" 8" 8" 10" 10" 10'. COIL CONNECTIONS Liquid 3/8" 3/8" 3/8" 3/8" 3/8" 3/8" 3/8" 3/8" Suction 3/4" 3/4" 3/4" 3/4" 3/4" 7/8" 7/8" 7/8" Coil Drain Connect(FPT) 3/4" 3/4" 3/4" 3;14" 3/4" 3/4" 3/4" 3/4" ELECTRICAL DATA Voltage 208/230 208/230 208/230 208/230 208/230 208/230 208/230 208/230 Minimum Circuit Ampacity 5.8/5.8 5.6/5.6 5.6/5.6 7.1/7.1 5.9/5.9 7.1/7.1 8.6/8.6 8.6/8.6 Max.Overcurrent Device 1S/15 15/15 15/1S 15/15 15/15 15/15 1S/15 15/15 (Amps) Minimum VAC 197 197 197 197 197 197 197 197 Maximum VAC 253 253 253 253 2S3 253 253 253 Blower Motor Full Load Amps(FLA) 4.6 4.S 4.5 S.7 4.7 6.9 6.9 6.9 Horsepower(HP) '/< % N '/. '/. '/, '/ SHIP WEIGHT(LBS.) 112 129 129 153 153 153 155 167 'Airflow rate @.3 static Note:kssumes dry coil;SUM co,rection for wet coi =4%(208V/240V) SS-GAMST www.goodmanmfFr.com 3 GSX13 Air Conditioning& Heating COOLING CAPACITY.' 18,000-60,000 BTU/H ENERGY-EFFICIENT SPLIT SYSTEM AIR CONDITIONER 13 SEER / 1 '2 To S TONS Contents Nomenclature........................................2 Product Specifications...........................3 Expanded Cooling Data.........................4 Wiring Diagrams .................................20 Dimensions..........................................22 Accessories..........................................22 z #' Standard Features Cabinet Features • Energy-efficient compressor • Heavy-gauge galvanized-steel cabinet • Factory-installed filter drier with louvered sound control top • Copper tube/aluminum fin coil • Attractive Architectural Gray powder-paint • Service valves with sweat connections finish with 500-hour salt-spray approval and easy-access gauge ports • Steel louver coil guard • Contactor with lug connection • Single-panel access to controls with space • Ground lug connection provided for field-installed accessories • AHRI Certified; ETL Listed 1 A PARTS I � � co.-. CGMMDrrM „ f V LIMITED C �g WA4TV SVSIFM FXVMONMEMtLL,4V GL GEPT�D BY D/IV GL GFAlilEO BY ONV GL xEAA WOk"AMIY .e0- vl ,-- Intertek B.411r. "Complete warrarty details avadable from your local dealer or at www.goodmanmfg cam.To receive the 10-vear Parts Limited Warranty,online reeistrarior must be completed within 60 days of installation.Online registration is not required in California or Quebec SS GSX13 www.goodmanmfg.com 05/22 supersedes OV22 NOMENCLATURE G 5 X 13 036 1 AA 1 2 3 4,5 6,7,8 9 10,11 Brand Engineering G Goocrmr`Brand Major&Mi^or Revisions (not used for inventory or ordering) Product Category Electrical S Split System 1 208/230 V,1 Phase,60 Hz 2 220/240 V,1 Phase,50 H, Unit Type 3 208/230 V,3 Phase,60 Hz X Condenser R-410A Z Heat Pump R-410A Nominal Capacity 018 1%Tons 030 2/:Tons 042 K,Tons Efficiency 019 1%Tons 031 2i2 Tons 043 377 Tons 13 13 SEER 16 16 SEER 024 2 Tons 036 3 Tons 048 4 Tons 14 14 SEER 19 1R SEER 025 2 Tons 037 3 Tons 060 5 Tons 2 www.goodrnanmfg.com SS-GSX13 PRODUCT SPECIFICATIONS 1 0181EH 1 1 1 1 1 14 1.1 0. CAPACMES Nominal Cooling(BTU/h) 18,000 18,000 18,000 23,000 30,000 30,000 36,000 42,000 48,000 60,000 60,000 SEER/EER 13/11 13/11 13/11 13/11 13/11 13/11 13/11 13/11 13/11 13/11 13/11 Decibels 75 75 75 75 73 74 74 75 76 77 72 COMPRESSOR RLA 6.7 6.7 6.0 7.7 12.8 10.5 13.6 17.9 19.9 25.0 26.4 LRA 41 37.5 37.5 37 64 47 79 112 109 134 134 Stage Single Single Single Single Single Single Single Single Single Single Single Type Rotary Rotary Rotary Rotary Scroll Rotary Scroll Scroll Scroll Scroll Scroll CONDENSER FAN MOTOR Horsepower 1/8 1/8 1/8 1/8 1/8 1/8 1/4 1/4 1/-1 1/4 1/4 FLA 0.7 0.65 0.65 0.65 0.65 0.7 1.4 1.4 L 1 1 A 1.3 REFRIGERATION SYSTEM Refrigerant Line Size' Liquid Line Size('O.D.) W. W. W. '/: 3/8, W. '/e' Suction Line Size("O.D.) '/," ;" '/." W. 1%." %:' Refrigerant Connection Size Liquid Valve Size("O.D.) W. 'rG" %." %." Y:' W. W. Y. %:' '%" W, Suction Valve Size("O.D.)a s /•• 3/•• �••• W. y•• %•a y"s '/: s Y. s �/ Valve Type Sweat Sweat Sweat Sweat Sweat Sweat Sweat Sweat Sweat Sweat Sweat Refrigerant Charge 44 58 58 60 60 68 62 80 91 94 111 Shipped with Orifice Size 0.051 0.051 0.051 0.055 0.061 0.067 0.070 0.076 0.080 0.086 0.086 ELECTRICAL DATA Voltage(60 Hz) 2081230 208/230-60 208/230-60 208/230 2081230 208/230-60 20812.30 208/230 208/230 208/230 208/230 Minimum Circuit Ampacity z 9.1 9.1 8.2 10.3 16.7 13.8 19.0 23.8 26.3 32.7 34.3 Max.Overcurrent Protection 3 15 amps 15 amps 15 amps 15 amps 25 amps 20 30 amps 40 amps 45 amps 50 amps 60 amps Min/Max Volts 197/253 197/253 197/253 197/253 197/253 197/253 197/253 197/253 197/253 197/253 197/253 Electrical Conduit Size %"or''/." A"or S"or Z or'/." %z"or% A"or Y" 14"or 1;" A"or W v."or%" A"or%" %"or EQUIPMENT WEIGHT(LBS) 102 102 102 103 115 138 118 171 175 184 211 SHIP WEIGHT(LBS) 117 1 117 117 120 132 153 1 135 189 193 202 233 Line sizes denoted for 25'line sets,tested and rated in accordance with AHRI Standard 210/240.For other line-set lengths or sizes,refer to the installation&Operating instructions and/or the long line-set guidelines. ' Wire size should be determined in accordance with National Electrical Codes;extensive wire runs will require larger wire sizes 3 Must use time-delay fuses or HACR-type circuit breakers of the same size as noted. • Installer will need to supply X"to Y."adapters for suction line connections. s Installer will need to supply%."to 1'A."adapters for suction line connections. NOTES • Always check the S&R plate for electrical data on the unit being installed. • Unit is charged with refrigerant for 15'of%"liquid line.System charge must be adjusted per Installation Instructions rinal Charge Procedure. • This product may not be installed in the Southeast(including Hawaii)or Southwest Regions as of Jan.1,2015. SS-GSX13 www.goodmanmfg.com 3 'C5007 1 r .00•om ,r..Oolot.re s o � paaq"ano 1 r- 4 i p poom CC) m i x * k a food � 1 u 2 �. uIsDA If-7mo uJ'roq V31DJ IX:E qnS vans ' a volff c I# 107 ►GUJBU e ya ol _�-------x �--- a41 fi nS vZ1ZVE6vt6t vzLzK6bt6 C19t-lo'f.ZZ.ZAeLV OW 'e:�-w ~ G' Sit � 4► i9 X11b IkIw1 �Z�.. v is �} r '{� �f •.r ;t,- � J, � T v� �? N., , � ixEt�k`�{ 'F�s*r, ..� 7n:&� �� { l TIM ,d 16. v �► )p� N O o � u p k• N P "� (� U t,.., u� r E C C � ! f e ca ' 7_ L { ' p C) ..r Q LJ to �j t vvv`����177y7JJJ,"',,,` ��I1 11 J O [^y "� QJ` ♦�,.�' 4 p �W YO W i V L d r f y i Y' mo 0 0 , o ` e a0 fie ., Ot =� :. Cq 06 X �0 )31 G> ' O a, +-{ p Q i N H cc b L V S C. y.� Ln � o = '� • 71 ; rwr qi' 3 Ix t ",�A,yii� t i ffl�j : � itwk� i♦ J► t i♦ �w� fib �r**ppi +"WAww' r�i�. .a ry,. 'j�' ..r �"'�:�9AY(,� ,•.'M '�'�:'�+ �. .��y .b,Mn'4:" 1�>'� �i1R�'�t4 •:Y� t�, ,S"b`F'.-.;v�,f • DATE(MM/DD/YYYY) �coRo CERTIFICATE OF LIABILITY INSURANCE 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 endorsement(s). PRODUCER CONTACT NAME: Soraya Pimentel Arthur J. Gallagher Risk Management Services, Inc PHONE FAx 300 Madison Avenue n IC.No.Ext)1 212-530-7504 (wc No):212-981-3386_ 28th Floor ADDRESS: soraya_pimentel@ajg.com New York NY 10017 INSURERS AFFORDING COVERAGE NAIC III INSURER A:Selective Insurance Company of America 12572 INSURED YOST&CA-01 INSURER B: Yost&Campbell, Inc. INSURERC: 20 Brookdale Place - Mt.Vernon, NY 10550 INSURERD: 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 SUBR POLICY EFF POLICY EXP LIMBS LTR POLICY NUMBER MM/DD/YYYY MWDD/YYYV A X COMMERCIAL GENERAL LIABILITY S2390242 9/15/2022 9/15/2023 EACH OCCURRENCE $1,000,000 CLAIMS-MADE �OCCUR DAMAGE T RENTED PREMISES Ea occurrence E 500,000 MED EXP(Any one person) $15,000 PERSONAL&ADV INJURY $1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $2,000.000 _ POLICY❑JET a LOC PRODUCTS-COMP/OP AGG $2,000,000 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT : Ea a.denl ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY Per accident $ UMBRELLA L AB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED I I RETENTIONS S WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY Y/N STATUTE ER - . ANYPROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ OFFICER/MEMBEREXCLUDED? ❑ NIA (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 REPRESENTATIVE USA ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD STATE CERTIFICATE OF Board NYS WORKERS' COMPENSATION INSURANCE COVERAGE la. Legal Name&Address of Insured(use street address only) 1 b.Business Telephone Number of Insured ADP TotalSource FL XVI,Inc. 5800 Windward Parkway Alpharetta,GA 30005 1 c.NYS Unemployment Insurance Employer L/C/F: Registration Number of Insured Yost&Campbell Heating,Cooling,and Generators,LLC. 47.35300 2 20 Brookdale PI Mount Vernon,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 WC 053456189 NY RYE BROOK,NY 10573 All 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 07/01/2023 3d.The Proprietor,Partners or Executive Officers are 2 included.(Only check box if all partners/officers included) ❑all excluded or certain partnerstoffiicers excluded. This certifies that the insurance carrier indicated above in box"3"insures the business referenced above in box"la"for workers'compensation under the New York State Workers'Compensation Law.(To use this form,New York(NY)must be listed under Item 3A on the INFORMATION PAGE of the workers'compensation insurance policy).The Insurance Carrier or its licensed agent will send this Certificate of Insurance to the entity listed above as the certificate holder in box"T'. The insurance carrier 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 boa"3c",whichever is earner. 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 ncensed 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 au korized representative or licensed agent of insurance carrier) Approved by: �. Jry� - tin,=-•. 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.ny.gov