HomeMy WebLinkAboutMP23-079 Q�C 419
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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 20,2023
Donna Profeta&Maryann Profeta
62 BelleFair Road
Rye Brook,New York 10573
Re: 62 BelleFair Road, Rye Brook,New York 10573
Parcel ID#: 124.65-1-45
This document certifies that the work done under Mechanical Permit #23-079 issued on 5/23/2023 for the
installation of a new water heater has been satisfactorily completed.
Sincerely,
Steven E. Fews
Building&Fire Inspector
/to
-a
�2 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 : Q ' �0- 41 DATE: 1 ��
PERMIT# � � ISSUED: L� ECT: BLOCK: LOT:
LOCATION: `._.!; �d- e (N(!',`� �' �'� �� OCCUPANCY:
❑ Violation Noted THE WORK IS... Ld 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
D CROSS CONNECTION
FINAL
❑ OTHER
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VIL 'OF RY OOK MAY 2 3 2023
938 KING ET RYE BR -c ,NY 10573
,.. VILLAGE OF RYE BROOK
BUILDING DEPARTMENT
APPLICATION FOR PERMIT TO INSTALL AND/01z REMOVE
HEATING, VENTILATION AND/OR AIR CONDITIONING EQUIPMEN/�T
FOR OFFICE USE ONLY: PERMIT#: MA:9 2 J—07?
Approval Date: MAY Z 4 2 Z3 Permit Fee: $ O'
Approval Signature: Other:
Disapproved: Az�)
(fees are non-refundable)
REoulREMENTS 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#C 105.2 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, is hereby made to the Building Inspector of the Village of Rye Brook for a permit for the
installation and or retir&@ of he AC 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.
I. Address: 62 bellefair road SBL: )QW-&f&46 Zone:
2. Property owner: Donna Profeta Address: 62 bellefair road
Phone#: 914 260-9995 Cell#: email: postlgrad@icioud.com
3. Contractor: SILA LLC DBA Astacio Plumbing Address: 70 fort point street, Norwalk CT 06855
Phone#: 914 966-0800 Cell#: email: calvarado@sila.com
4. Scope of Work:New Installation( )•Replacement()o•Removal( )•Other( ):
5. List Equipment: FmPrnPnry - RPnlarPmPnt of a 7..9 nallnn nnwPr vent water heater
3/4 copper pipe
6. Location of Equipment: basement
7. Method of Installation/Removal(list all equipment needed to perform job): hand truck, 3/4 copper pipe, expansion tank,
mixing valve.
t
3/3/2023
STATE OF NEW YORK,COUNTY OF WESTCBESTER ) as:
/)f� b ,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 Master Plumber 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 16 Sworn to before me this
day of ' Yl 20 day of 20
Signature of Prro/perty O er Signature of Applicant
Print Name of Property Owner Print Name of Applicant
A-L C1,
otary Public XTZNota
SCOTTW CRAB Amanda_fluNob"PubMeofNowyork y Public-COW OcticutR�'NO. a390Sa7Commisio.n expires
COMMISSION EXPIRES 04/1&2027 Februar 28;2 26,
This application must be properly completed in its entirety and mus e notariz��c'i"sigr..ature(s) of.
the legal owner(s)of the subject property,and the applicant of record in the spaces provided. Applications
not properly completed in its entirety and/or not properly signed shall be deemed null and void and will be
returned to the applicant.
3/3/2023
BRADFORD WHITE
W A T E R H E A T E R S
TM
Residential Power Vent
Gas Water Heater
The TTW"Models Feature:
■ ENERGY STAR Qualified—Some models qualify for the September 1,2010
minimum ENERGY STAR"EF requirement, as well as most utility rebate programs.
■ Bradford White ICON System"—Intelligent gas control with spark to pilot ignition
system eliminates the constant burning pilot.This results in savings of pilot gas during
standby periods(120 V.A.C.).
— Enhanced Performance—Proprietary algorithms provide enhanced First Hour Delivery
ratings and tighter temperature differentials.
—Advanced Temperature Control System—Microprocessor constantly monitors and
controls burner operation to maintain consistent and accurate water temperature levels.
® —Intelligent Diagnostics—An exclusive green LED light prompts the installer during
start-up and provides ten different diagnostic codes to assist in troubleshooting.
■ Power Vented Water Heater—Designed for installations where atmospheric units
cannot be used. Exhaust gases are vented under positive pressure directly out of the
building through the roof or the wall.
■ Powerful Blower Motor—Our significantly quiet design has greater resistance to
outside winds and the power to vent in many difficult venting situations.
—Ten Foot Power Cord—Included(120 VAC).
■ Horizontal and Vertical Venting—PVC,ABS or CPVC(Maximum equivalent vent
length on reverse side).
■ Advanced ScreenLok°Technology Flame Arrestor Design—Flame arrestor is
designed to prevent ignition of flammable vapor outside of the water heater(excluding
RG1 PV55H6N & RG2PV75H6N).
■ Flammable Vapor Sensor—Electronic sensor prevents burner operation if flammable
vapors are detected.The sensor will also prevent operation if there is ongoing
flammable vapor burn inside the combustion chamber(excluding RG1 PV55H6N&
RG2PV75H6N).
■ Maintenance-Free—No regular cleaning of air inlet openings or flame arrestor is
required under normal conditions(excluding RG1 PV55H6N&RG2PV75H6N).
■ Sight Window—Offers a view into the combustion chamber to observe the operation
..._ of the pilot and burner.
- ■ Factory-Installed HydrojeV Total Performance System—Sediment reducing device
that also increases first hour delivery of hot water while minimizing temperature build-
up in tank.
■ Vitraglas'Lining—An exclusively engineered enamel formula that provides superior
—�
- tank protection from the highly corrosive effects of hot water.This formula(Vitraglas)
is fused to the steel surface by firing at a temperature of over 1600°F(871°C).
■ Insulation System—Non-CFC foam covers the sides and top of the tank, reducing
Photo IS of heat loss.This results in less energy consumption, improved efficiencies, and jacket
RG2PV50H6N rigidity.
■ Water Connections-314"(19mm)NPT factory-installed true dielectric fittings extend
FEATURING: water heater life and simplify water line connections.
_ ■ 3/4"(19mm)NPT Side Connections—(RG2PV50H6N, RG1 PV55H6N, and
IcoN RG2PV75H6N only).
—System ■ Factory-Installed Heat Traps—Design incorporates a flexible disk that reduces heat
® loss in piping and eliminates the potential for noise generation.
il�r L.1V:Ji.l\ >' ■ Protective Magnesium Rod—(RG1 PV55H6N has 2).
■ T&P Relief Valve—Installed.
■ Thermostatic Mixing Valve(ASSE Approved)—Included(RG1 PV55H6N only).
■ Low Restriction Brass Drain Valve—Durable tamper-proof design.
6 or 10-Year Limited Tank Warranties/6 or 10-Year Limited Warranty on Component Parts.
SP® ® For more information on warranty, please visit www.bradfordwhite.com
For products installed in USA,Canada and Puerto Rico.Some states do not allow limitations on warranties.See complete
copy of the warranty included with the heater.
MANUFACTURED UNDER ONE OR MORE OF THE FOLLOWING U.S.PATENTS:5,682,666;7,634.976:5.660,165,5.954.492,6.056.542:6,935,280:5.372.185.5485,879,5,574.822,7.971,560;7,992.526:
6.684.821:6,442,178;7,334.419:7,866,168:7,270,087:7,007.748:5.596.952:6,142,216:7,699.026:5,341.770:7,337,517;7.665.211:7,665.210;7,063,132,7.063.133:7,559,293:7.900.589:5,943,984:
8,082,888;5,988.117:7,621,238;7,650.859:5.761,379;7.409.925:5,277,171;8,146,772;7,458,341:2,262,174.OTHER U.S.AND FOREIGN PATENT APPLICATIONS PENDING CURRENT CANADIAN PATENTS:
2.314,845:2,504,824:2.108,186:2,143.031,2,409,271:2,548,958;2,112,515;2,476.685:2,239,007:2,092,105:2,107,012.Defender Safety System',ScreenLokl,TTW',Vitraglas-and Hydrolet"are registered
trademarks of Bradford White"Corporation.
1261-13-1216
Residential Power Vent Gas Water Heater
Power Vent Models Meet or exceed ASHRAE 90.1b(current standard)C.E.C.Listed
NATURAL GAS AND LIOWD PROPANE GAS 80%Recovery Efficiency
Model Capacity Recovery at Model Capacity Recovery at
Number 90°F Rise' Number 50°C Rise'
Nat. LP 1st Hour Nat. Nat. LP LP Nat. LP 1st Hour Nat. LP
U.S. Imp. BTU/Hr. BTU/Hr. Rating Energy U.S. Imp. U.S. Imp. kW kW Rating Energy Liters/ Liters/
Gal. Gal. Input Input (Gal.) Factor GPH GPH GPH GPH Liters Input Input (Liters) Factor Hour Hour
RG1PV40S6N 40 33 40,000 38,000 72 066 43 36 41 34 RG1PV40S6N 151 11.7 11.1 273 0.66 163 155
RG1PV50S6N 50 42 40.000 38,000 86 0.65 43 36 41 34 RG1PV50S6N 189 11.7 11,1 326 0,65 163 155
*RG2PV4OS6N 40 33 40,000 38000 72 0.67 43 36 41 34 *RG2PV4OS6N 151 11.7 11.1 273 067 163 155
*RG2PV50S6N 50 42 40,000 38,000 84 0.67 43 36 41 34 *RG2PV50S6N 189 11.7 11.1 326 0.67 163 155
*RG2PV4OT6N 40 33 40,000 40,000 72 0.70 43 36 43 36 *RG2PV4OT6N 151 11.7 11.7 273 0.70 163 163
*RG2PV50T6N 50 42 40,000 40.000 86 0.70 43 36 43 36 *RG2PV50T6N 189 11.7 11.7 326 0.70 163 163
*RG2PV5OH6N 48 42 65.000 WOOD 112 0,70 70 58 62 52 *RG2PV50H6N 182 19.1 17.0 424 0.70 265 235
RG1PV55H6N 55 46 78,000 78,000 N/A N/A 84 70 84 70 RG1PV55H6N 208 22.9 22.9 NA N/A 318 317
RG2PV75H6N 75 62 76.000 75,500 N/A NIA 82 68 81 67 RG2PV75H6N 284 22.3 22.1 NIA N/A 310 307
Model A 8 C 0 E F H J K L M Approx.
Number Floor to Jacket Vent Floor to Floor to Floor to C/L Floor to Depth Floor to Floor to Shipping
Vent Dia. Size T&P Gas Top of of Water Water Space Heating Space Heating Weight
Conn. Conn. Conn. Heater Conn. Conn. Inlet Outlet
in. in. in. in. in. in. in. in. in. in. in. lbs.
RG1PV40S6N 575/16 20 2 or 3 40 11314 471/2 8 49 243/4 N/A N/A 140
RG1PV50S6N 58V4 22 2or3 405/s 11'A 481/4 8 50112 263/4 N/A N/A 166
*RG2PV4OS6N 575/te 22 1 2 or 3 40 113/4 1 471/2 8 49 263/4 N A N/A 142
*RG2PV50S6N 581/4 24 2 or 40V8 113/4 481/4 8 50'/3 283/4 N/A N/A 168
*RG2PV4OT6N 667,18 20 2 or 3 50 113/4 563/4 8 58 243/4 N/A N/A 146
*RG2PV50T6N 667/8 22 2 or 3 50 113/4 563/4 8 58 263/4 NA N/A 173
*RG2PV5OH6N 66'/e 22 3 or 4 501/e 113/4 563/8 11 573/4 263/4 131/2 5040 187
RG1PV55H6N 643/16 22 3or4 4715/ie 11V2 545/a 1 8 1 56 263/4 133/9 4715/1e 219
RG2PV75H6N 69'/16 26 3 or 4 1 511/2 1 13112 59'/2 1 11 1 60'/4 303i4 13`3 1 51'12 260
Model A B C D E F H J K L M Approx.
Number Floor to Jacket Vent Floor to Floor to Floor to C/L Floor to Depth Floor to Floor to Shipping
Vent Dia. Size T&P Gas Top of of Water Water Space Heating Space Heating Weight
Conn. Conn. Conn. Heater Conn. Conn. Inlet Outlet
mm. mm. mm. mm. mm_ mm. mm. mm. mm. mm. mm. kg.
RG1PV40S6N 1456 508 51or76 1016 298 1207 203 1245 629 N/A N/A 64
RG1PV50S6N 1480 559 51or76 1032 298 1226 203 1283 679 NA N/A 75
*RG2PV4OS6N 1456 559 51or76 1016 298 1207 203 1245 679 NIA N/A 64
*RG2PV5OS6N 1480 610 51or76 1032 298 1226 203 1283 730 N/A N/A 76
*RG2PV4OT6N 1699 508 51or76 1270 298 1441 203 1473 629 N/A N/A 66
*RG2PV5OT6N 1699 559 51or76 1270 298 1441 203 1473 679 N/A N/A 78
*RG2PV5OH6N 1680 559 76 or 102 1273 298 1432 279 1467 679 343 1273 85
RGiPV55H6N 1630 559 76or102 1218 279 1388 203 1422 679 340 1218 99
RG2PV75H6NI 1764 660 76 or 102 1 1308 343 1511 279 1543 781 340 1 1308 118
Propane models feature a Titanium Stainless Steel propane burner. For Propane
(LP)models change suffix "N"to"X". For 10 year models, change suffix from "6" 1 I_c
to"10"(Not available on RG1 PV55H6N). 'Based on manufacturer's rated recovery
efficiency. 120 VAC Required for Power Venting / 120 VAC 60HZ 3.1 Amperes.
Energy Factor and First Hour Rating is based on the latest AHRI directory listings.
*=ENERGY STAR"Qualified.® K B
RG2PV40S6N RG1PV50S6N RG2PV5OH6N ^H
RG2PV50S6N RG2PV40T6N 2" 3" RG1PV55H6N 3" 4"
RG1PV40S6N RG2PV50T6N Vent Pipe Vent Pipe RG2PV75H6N Vent Pipe Vent Pipe
Max.Equivalent Length t50 ft. ft 20 ft. Max Equivalent Length t50 ft t180 ft. J
Min.Equivalent Length 7 ft. 15 ft. Min.Equivalent Length 7 ft. 15 ft. A
Number 1 45 ft 115 ft Number 1 45 ft. 175 ft.
of 2 40 ft. 110 ft. of 2 40 ft. 170 ft. F
90`Elbows 3 35 ft. 105 ft. 90°Elbows 3 35 ft. 165 ft. o&M
Subtract 511.for each additional 90'elbow
tFor high altitude installations,consult the installation instructions. On
General:All gas water heaters are certified at 300 PSI(2068 kPa)test pressure and 150 PSI(1034 kPa)working I m
pressure.All water connections are 3/4" NPT(19mm),all gas connections are 12" (13mm).All models design- E o
certified by CSA International(formerly AGA/CGA),ANSI Z-21.10.1 and/or 10.3 and peak performance rated. o 0
Dimensions and specifications subject to change without notice in accordance with our policy of continuous product improvement.
Suitable for Water(Potable)Heating and Space Heating.Toxic chemicals,such as those used for boiler treatment,shall NEVER be introduced into this
system.This unit may NEVER be connected to any existing heating system or component(s)previously used with a non-potable water heating appliance.
For U.S.and Canada field service,contact your professional installer or local Bradford White sales representative.
BRADFORD"ITE' Sales 800-523-2931•Fax 215-641-1670/Technical Support 800-334-3393•Fax 269-795-1089•Warranty 800-531-2111•Fax 269-795-1089
W Ambler,PAR0 Intemabonal:Telephone 215-641-9400•Telefax 215-641-9750/www.bradfordwhfte.com
BRADFo D WHITE-CA NADW INC. Sales/Technical Support 866-690-0961/905-238-0100•Fax 905-238-0105/www.bradfordwhfte.com
Built to be the BeStTM
1261-B-1216 02016,Bradford White Corporation.All rights reserved. Printed in U.S.A.
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Site.Services LLC
0 Fort point Sireet
Norwalk,CT 06asS
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EXP'res OtIm-1213-1/2023
co CERTIFICATE OF LIABILITY INSURANCE DATE(MM/2D/YYYV)
04/25/2023
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 NAME:CONTACT
CLIENT CONTACT CENTER
FEDERATED MUTUAL INSURANCE COMPANY PHONE i
HOME OFFICE: P.O.BOX 328 (A/C,No,Ext):SM333-4949 w,Mel:507-4464664
OWATONNA, MN 55060 E-MAIL CLIENTCONTACTCENTER FEDINS.COM
INSURERS AFFORDING COVERAGE NAIC#
INSURER A:FEDERATED MUTUAL INSURANCE COMPANY 13935
INSURED 194-905-6 INSURER e:FEDERATED SERVICE INSURANCE COMPANY 28304
SILA SERVICES, LLC DBA ASTACIO PLUMBING &HEATING INSURER C:
70 FORT POINT STREET
NORWALK,CT 06855- INSURER D:
INSURER E:
INSURER F:
COVERAGES CERTIFICATE NUMBER:3685 REVISION NUMBER:0
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 SU POLICY NUMBER IhPO Y IFFY, POUCYDo, EXPYYY1 LIMITS
X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $1.000,000
CLAIMS-MADE ❑X OCCUR AMAGE TO ENTED PREMISES $100,000
MED EXP(My one Person) EXCLUDED
B Y N 6126484 08/26/2022 08/26/2023 PERSONAL s ADV INJURY $1,000.000
GEN L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE
X ECT ❑LOC PRODUCTS 6 COMPIOP ACC S2,000,000
POLICY IF -
OTHER:
AUTOMOBILE LIABILITY E,.BCN,ED4SINOLE LIMIT $1,000,000
X ANY AUTO BODILY INJURY(Per Penton)
B OWNEDAUTOS ONLY AUTOSULED N N 6126484 08/26/2022 08/26/2023 BODILY INJURY(Per Accident)
HIRED AUTOS OWNLY NON-OWNED PROPERTY DAMAGE
AUTOS ONLY
X UMBRELLA LIAB tAIMS-MADE
CUR EACH OCCURRENCE $20,000,000
B EXCESS LIAB N N 6126487 08/26/2022 08/26/2023 AGGREGATE $20,000,000
DED I RETENTION
WORKERS COMPENSATION X PER STATUTE DTHER
AND EMPLOYERS'LIABILITY YIN
ANY PROPRIETORIPARTNER;EXECUTIVE E.L EACH ACCIDENT S500,000
A OFFICERIMEMBEREXCLUDED? N/A N 1807146 08/26/2022 08/26/2023
(Mandatory in NH) E.L DISEASE EA EMPLOYEE $500,000
It yes,describe undw
DESCRIPTION OF OPERATIONS bolow E.L DISEASE•POUCY LIMIT S500,000
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101.Additional Remarks Sdndule,may be attached If more space is required)
THE CERTIFICATE HOLDER IS AN ADDITIONAL INSURED SUBJECT TO THE CONDITIONS OF THE ADDITIONAL INSURED - STATE OR POLITICAL
SUBDIVISIONS - PERMITS ENDORSEMENT FOR GENERAL LIABILITY.
CERTIFICATE HOLDER CANCELLATION
194-905-6 3685 0 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED
VILLAGE OF RYE BROOK
938 KING ST BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN
RYE BROOK, NY 10573-1226 ACCORDANCE W1TH THE POLICY PROVISIONS.
AUTHORIZED REPRESENTATIVE � L�
0 1988-2015 ACORD CORPORATION.All rights reserved.
ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD
YaRtc Workers` CERTIFICATE OF
Compensation
�`— Baird NYS WORKERS COMPENSATION INSURANCE COVERAGE
1a.Legal Name&Address of Insured(use street address only) 1b. Business Telephone Number of Insured
#194-905-6 (610)491-9400
SILA SERVICES,LLC DBA ASTACIO PLUMBING&HEATING
70 FORT POINT STREET
NORWALK,CT 06855 1c. NYS Unemployment Insurance Employer Registration Number of
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) Number
85-1645781
2.Name and Address of Entity Requesting Proof of Coverage 3a Name of Insurance Carrier
(Entity Being Listed as the Certificate Holder) Federated Mutual Insurance Company
#3685
Village Of Rye Brook 3b Policy Number of Entity Listed in Box"1a"
938 King St 1807146
Rye Brook NY 10573-122
3c.Policy effective period
0812 6/2 0 2 2 to 0 812 612 0 2 3
3d.The Proprietor,Partners or Executive Officers are
Q Included.(Only check box if all partnerslofficers 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"1a"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 carder 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, 1 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 Jessica Mundt
tPnnt nerne of authorized representative or licensed agent of insurance carrier)
Approved by: � ���-r 04/25/2023
— '��
(Signature) (Date)
Title: Authorized Representative
Telephone Number of authorized representative or licensed agent of insurance carrier: (888)333-4949
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