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HomeMy WebLinkAboutMP23-104 DR . 19 t Q VoGG'V W V VILLAGE OF RYE BROOK MAYOR 938 King Street, Rye Brook,N.Y. 10573 ADMINISTRATOR Jason A. Klein (914)939-0668 Christopher J.Bradbury www.ryebrookny.g_ov TRUSTEES BUILDING&FIRE INSPECTOR Susan R. Epstein Steven E. Fews David M. Heiser Donald T. Krom,Jr. Salvatore W. Morlino CERTIFICATE OF COMPLIANCE February 3,2026 Maria Giampino 72 College Avenue Rye Brook,New York 10573 Re: 72 College Avenue,Rye Brook,New York 10573 Parcel ID#: 135.68-1-6 This document certifies that the work done under Mechanical Permit #23-104 issued on 7/11/2023 for the installation of new gas fired boiler has been satisfactorily completed. Sincerely, Steven E. Fews Building&Fire Inspector /to o ti� QR BUILDING D EPARTMEN T 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 : C.SU DATE• 1 Z z PERMIT# 1 v ISSUED: t I SECT � LOCK: LOT: LOCATION: 7V � �C � k rv'r-\gCCUPANCY: ❑ VIOLATION NOTED THE WORK IS...,,,A ACCEPTED ❑ REJECTED/ REINSPECTION ❑ SITE INSPECTION REQUIRED ❑ FOOTING ❑ FOOTING DRAINAGE ❑ FOUNDATION ❑ UNDERGROUND PLUMBING NOTES ON INSPECTION: ❑ ROUGH PLUMBING ❑ ROUGH FRAMING ❑ INSULATION ❑ NATURAL GAS ❑ L.P. GAS ❑ FUEL TANK ❑ FIRE SPRINKLER ❑ FINAL PLUMBING ❑ CROSS CONNECTION FINAL ❑ OTHER QyE BR1982 C�j�, 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.or - - - - - - - - - - - - - - - - - - - - INSPECTION REPORT - - - - - - - - - - - - - - - - - - - - l/ \ �\ V'� � I ZUZ� ADDRESS • DATE:M PERMIT# � ISSUED• 1 N • V YS � . 1 .� .��ECT. BLOCK. LOT. _ LOCATION: 1 OCCUPANCY: r� ❑ Violation Noted THE WORK IS... ❑ PASSED / FAILED REINSPECTION r. ❑ SITE INSPECTION REQUIRED ❑ FOOTING _ ❑ FOOTING DRAINAGE ❑ FOUNDATION ❑ UNDERGROUND PLUMBING NOTES ON INSPECTION: ❑ ROUGH PLUMBING ❑ ROUGH FRAMING �t 0 INSULATION ❑ Natural Gas } N�J 1�- 1 `' �1 C-�u ❑ L.P. Gas crKi J�V �_ 1 S ❑ FUEL TANK ❑ FIRE SPRINKLER ��� ❑ FINAL PLUMBING ❑ CROSS CONNECTION ❑ FINAL ❑ OTHER _ 1-2 0CC a i W J ea y r� U'1 Ow A . Lr) ,b s a Z O \ O A 00 W .i' o o o ob �I O � � M r/a � � � [� o O .� � •� r 01)0 If�T, ►-a E' u ^d v co Ln F N ;� QV ^G �? V0) ~ 0000 x U z v n 01% . o : W IQsloe aON C i Z O V .a 00 = 3 v e ON V v) .� v W 0 = V A0-4 w = M � ,, v3oa Rao Z Z zZ o � H V a a P-M z o ;4 0 0 W � .a -d D E C E� V BUILDING DEPARTMENT JUL - 6 2023 VIL AGE OF RYE BROOK 938 KING�ikEET RYE BRooK,NY 10573 VILLAGE OF RYE BROOK (914)939-0668 BUILDING DEPARTMENT www.rye6rook.ar8 APPLICATION FOR PERMIT TO INSTALL AND/OR REMOVE HEATING, VENTILATION AND/OR AIR CONDITIONING EQUIPMENT FOR OFFICE USE ONLY: PERMIT #: 3 Approval Date: JUL Pr4 Permit Fee: $ Approval Signature: Other: Disapproved: (fees are non-refundable) REQUIREMENTS FOR RELEASE OF PERMIT&CE_RTIFICATE OF COMPLIANCE: 1. Properly completed& Signed Application. 2. Site/Staging Plan if Required by the Building Inspector. 3. Copy of Licensed Contractor's Liability Insurance. (Village of Rye Brook must be listed as certificate holder) & Workers Compensation Insurance on a NYS Board form(Form#C105.2 or Form#U26.3/or NY State Workers Compensation Waiver) 4. Payment of Fees/Unit: RESIDENTIAL=$100.00/unit-COMMERCIAL= $350.00/unit. 5. Complete specifications for each unit being installed. 6. Inspection by the Building Department for removal and/or installation. (48 hour notice require,) 7. Electrical work requires a separate Electrical Permit&Electrical Inspection. 8. Plumbing/Gas work requires a separate Plumbing Permit&Plumbing inspection. Application dated, 3 is hereby made to the Building Inspector of the Village of Rye Brook for a permit for the installation and or removal of the HVAC equipment as listed below.The applicant and property owner,by signing this document agrees that said equipment will be installed and/or removed in conformance with all applicable Local,County,State&Federal laws, codes,rules and regulations.v` � k 1. Address: �2 C. -roe Y ��-lr,` BK cO SBL: 13J/62 —1-6 Zone: 2. Property Owner: I,Gk V1 G1 E✓' a jVt 1���.� Address`:Z C o� ecie Phone#: It I,- 3 } - (DYE�q Cell#: Co7(o`1 email: G t 1'V PkAu 3. Contractor: F.CAA:k C Address: 1eVlq Phone#: `��y-{e�3�� �$fj Cell#: q 1q-'iQ email: ►nf%pelI ntCtcDIt._MULWAea��t (J 4. Scope of Work:New Installation(-j<Replacement( )•Removal( )•Other( ): ---)-D3 e-,o4,P)r--f7,1 Ck CQA 5. List Equipment: 7Tn Sin 1 \\!A P 6. Location of Equipment: jL1( � 7. Method of Installation/Removal(list all equipment needed to perform job): 1 3/3/2023 17 Fi-om: jennifer.martucci@plitnick.com Subject: Affidavit of Compliance Building Department of Rye Brook Date: Jun 27, 2023 at 1: 16:42 PM To: mlgiampino@yahoo.com Good afternoon, Attached you will find the Affidavit of Compliance for the Building Department of Rye Brook. Please sign and notarize this document per the instruction. ;` Kindest Regards, w Jenny BUILDING DErAR'rt11F.NT VILLAGE OF RYF..RROOK 938 KIN4r S'rRF.VT RYE BRrn)K,NY 10573 (914)93 9-11 6 6 8 Ir.e)l.nrbrnnk.urk . ....................................... AFFIDAVIT OF COMPLIANCE VILLAGE CODE 216- TO1tM SEWERS AND SANITARY SEWERS IRIS AFFIDAVIT/OUST BEAR THE NOTARIZED SIGNATURE OF THE LEGAL PROPERTY OWNER AND RE SUBMITTED ALONG WITH ANY RUILDING OR PLUMAING PERMIT APPLICATION• ANY BUILDING OR PI,UNW,, PERMIT APPLICATION SUBMITTED WITHOUT THIS COMPLETED AND NOTAR12E0 FORM WILL RE RETURNF_O TO THE hPPLIcANT. S'r/ATE OF NEW YYORK,COUNTY 01"WESTCHESTER residing at. bein g dui swum,do b Y poses and states that($)he is the applicant above named,and further stales That(s)hc is 111V legal owner of the PrOPerY to which this Affidavit of Compliance pertains al; /�7 � ( .Rye Brook,NY Further that all statcmenls contained herein are true,and that Io the best oorhis/hcr knowledge and belief,that Ihcrc arc nn known iltegUl crlrss-conncctnlns concerning either the storm sewer or sanitary sewer,and further thal Iherc an•Iro roast drains,sump pump,,nr usher Prohibited stornwalcr or groundwater connections or sources of Int1o.Y Ill inAhration of any kind into :Intl the s.nry tita solver from the Subject pr©Pcrty in accordance with all State, {Oln11l' IllAge Codch, JOHN M SUOTZO /L1{ f2 r A CC'l Alec Pr Ajt (1107ARY PUBLIC,STATE Or NEW VW Reglstratkln No.01 SU6070919 DuWifled In WBstchestar County Sworn 10 before me this / MN Commlasion EAlbas March 11,20M 9 I OF WESTCHESTER as; he/she is the applicant above named, STATE OF NEW YORy,COUNTY ) being duly swom,deposes and states that ° ". (prim name of. vidue1 ur)hg`s the Heating, Contractor for the legal owner and is duly and[mother states that(s)he is the Hcati°g,Ventilation and/or Air Conditioning erformed,Or use authorized to make and file this application. That all statements contained herein arc true to the in st of his/her conformance with knowledge details belief, set forth and contained in this application conducted at the above captioned property 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. r; Sworn to before me this Swom to before we this �t -- day,of ZO,� day of--- 20 Signature of Applicant Signature of Prope Owner Print Name of Applicant t Name of Property e terry Public Notary Public SHARI MEt.ILL0 Notary Pubtle,State of New York No.01ME6160063 qualtMed In Westchester County. Commisslon Expires January 29,2V_( This application must be properly completed in its entirety and must include the notarized signature(S)of the legal owner(s)of the subject property,and the applicant of record in the spaces provided.Any application not properly completed in its entirety and/or not properly signed shall be deemed null and void and will be returned to the applicant. a 3r312023 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 t 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 Sworn to before me this day of as 20'D3 _ day of 201} Signature of Property Owner Signature or Applicant Print Name of Property Owner Print Name of Applicant Notary Public Notary Public '9 uuj..0, RLA. o This application must be properly completed in its entirely and must include: the notarized sis;�t the legal owner(s) of the subject property, and the applicant of record in the spaces provided. 1)(s��'�9Vfg�g>)�tv��.•`' 4,,,unrurNr� not properly completed in its entirety and/or not properly signed shall be deemed null and void .Intl evils he returned to the applicant. -2- 3 3 2023 _ s e' M v a W = o _ � cn x u ► 00 v O a w � M w 1 a W CA x ao z v � O Lr)Z Zo `� N C F3 W O w oa H s n Q A� � ONO V) 0-4 rn oo CYo a � W W Q 00, T." >- o A o A a z m z a ° a Z w = � * }4141to47;4-4t -;444tt4fi= 47;V.,474toy c;4";4.4;414:444 4410.ti ;43-4164tato4 oC4.4to4CA D �C� FP' BUILDING DEPARTMENT j ID VILLAGE OF RYE BROOK NOV - 1 2023 938 KING STREET RYE BROOK,NY 10573 VILLAGE OF RYE BROOK (914)939-0668 BUILDING DEPARTMENT www.rycbrook.org ELECTRICAL PERMIT APPLICATION Westchester County Master Electricians License Required FOR OFFICE USE ONLY -90*V 3 EP#: 3-- Approval Date: �` 4 Y Permit Fee: $ �� �Z4 Approval Signature: Other: ************************************************************************************************** DO NOT START WORK or CONSTRUCTION UNTIL A PERMIT HAS BEEN ISSUED BY THE BUILDING INSPECTOR THE ADMINISTRATIVE FEE FOR WORK PROGRESSED OR COMPLETED WITHOUT A PERMIT IS 12%OF THE TOTAL COST OF CONSTRUCTION WITH A MINIMUM FEE OF$750.00 Application dated, I I I I Z 3 is hereby made to the Building Inspector of the Village of Rye Brook NY,for the issuance of a Permit to install and/or remove electrical equipment,wiring, fixtures, or to perform other high or low voltage electrical work as per the detailed statement described below. By signing this document, the applicant & property owner agree that all electrical work performed will be in conformance with all applicable Federal,State,County and Local Codes. 1.Address: -1 Z Cox\e 5� Art-- Zone:�L 2.Property Owner: m G c 1 Q Q) ► u yy-1 P)n O Address: '1 Z C cj 1 l e,:i _ A y-&, Phone#: 11`f -9 37 " to g 7-9 Cell#: email: 3.Master Electrician/Licensed Installer: coay'-sonx- Tq,. Address: QC'VC Pu.-c-1'10v- 0'q r Lic.#: \3\% Phone#:?lq-6Z9-3b1`} Cell#: 9)4 (029-382q email: 13ae-415 p cfJ+-Ov- It✓tie.: rt4--+ Company Name: Address: 4.Proposed Electrical Work/Fixture Count: tt�� (� J r 5-*G,\\ _y�-+e�� . S�r1 v,�- o�� Sw }c 1. `-& h2.�J -71I f trl Q c-e 5.3'Party Electrical Inspection Agency: 4-e-w c)e ��nS lae�- S42 r./i L,zs l 'STATE OF NEW YORK,COUNTY OF WESTCHESTER ) as: W 1��V4YY1 6 r-orw-. r .being duly sworn,deposes and states that he/she is the applicant above named,and does further (print name of individual stgmng as the applicant) state that(s)he is the Ws\1 l G yn 6arc;C^k-If for the legal owner and is duly authorized to make and file this application. (Master Electrician/Licensed Installer) The undersigned further states that all statements contained herein are true to the best of his/her knowledge and belief,and that any work performed,or use conducted at the above captioned property will be in conformance with the details as set forth and contained in this application and in any accompanying approved plans and specifications,as well as in accordance with the New York State Uniform Fire Prevention&Building Code,the Code of the Village of Rye Brook and all other applicable laws,ordinances,and regulations. Sworn to before me this Sworn to before me this day of 120 day of 20 Signature of Property Owner Signature of Applicant Print Name of Property Owner Name of Applic t Notary Public No ary b lc, tate of New York No.01M E6160063 10/30/2023 Qualified In Westchester County Commission Expires January 29,20Z-� STATE WIDE INSPECTION SERVICES, INC. ••• • • SWIS JOB APPLICATION •2.7224 1 fax 914.219.1062 1 SWISNYcoml SWISTRAINING.COM Office Use Elect. Permit# Date 11 .I I I LE Bldg Permit# '"Plzz) 3—. /v y Sq Ft Plumbing Permit# Final Certificate# City/Village r Zip ' 0 �1 �, Building Dept. County 1. + Address 2- +I Cross Street Section Block Lot Owner Name/Address(If different than above) Contact Number ❑Basement ❑ 1st FI. ❑2nd Fl. ❑3rd FI. ❑More Than 3 FI. ❑Garage ❑Attic ❑Outside ❑Residential ❑Commercial Receptacles Special Recept GFCI AFCI Switches Dimmers Smoke Alarms C/0 Detector Hood Trash Compact Amt Amps Range(s) Cooktop(s) Oven(s) Dishwashers Refrigerator Disposal Microwave Luminaires Generator Transfer Switch SERVICE Amperage #Panels 1P 3P # Meters # Disconnect ❑Underground ❑ New ❑ Reconnect ❑ Repair ❑Overhead ❑ Upgrade ❑ Disconnect Utility ID# ❑Con Ed ❑ NYSEG ❑Central Hudson ❑ Orange/Rockland PHOTOVOLTAIC SYSTEM PV Modules Inverters AC Disconnect Junction Box Combiner Box Load Center PV Monitor Energy Storage System DC Disconnect ❑Legalization ❑ Safety Inspection ❑Consultation t-iacc FNOV - 1 2023 .______j VILLAGE OF RYE BROOK BUILDING DEPARTMENT This application is valid for one(1)year from the date received by SWIS.This application is intended to cover the above listed items to be inspected,if at any time of inspection additional items have been installed,you are authorized to make the inspection and adjust the fee for the additional items inspected.The applicant declares that there is no open applications for the above address with any other inspection company.The applicant, owner or authorized agent agrees to all the above terms and conditions as set forth for the application. Email Address U 5 Li k 5 0 j On 1 trv-e . Ylc+ Name J)Okv, /J ( oyx- TV- License# , -2 1$ Date I Z Signature L Address City/State Zip Code cY 5"A, j �l r i�ly p ► Gsl 1 Company l r , Phone# 14 6 L c7 — 3$ L 4 < C1 State Wide Inspection Services C—A� NOV 2 0 2023 1080 Main Street Fishkill, NY 12524 SIN%V a t 845 2 Phone 914-219-119-1062 Fax STATE WIDE INSPEC71ON SERVICES Email: officeCabswisny.com Website: www.swisny.com Service With Integrity BY THIS CERTIFICATE OF COMPLIANCE STATE WIDE INSPECTION SERVICES CERTIFIES THAT: Upon the application of: Upon Premises Owned by: Gargone Electric Maria Giampino PO Box 546 72 College Avenue Purchase, NY 10577 Rye Brook, NY 10573 Located at: 72 College Avenue, Rye Brook, NY 10573 Section: Block: Lot: Electrical Permit Number: EP 23-233 135.68 1 6 Certificate Number: 2023-8445 Building Permit Number: MP 23-104 A visual inspection of the electrical system was conducted at the Residential occupancy described below.The electrical system consisting of electrical devices and wiring is located in/on the premises at: 72 College Avenue, Rye Brook, NY 10573 The Basement was inspected in accordance with the NYS and NFPA 70-2017 and the detail of the installation, as set forth below,was found to be in compliance on the 20`h day of November 2023. Name Quantity Rating Circuit Type Emergency Shut Off Switch 01 ;;7- too- - Officer: Frank]. Farina This certificate may not be altered in any way and is validated only by the presence of a seal at the location indicated.This certificate is valid for work performed on the date of inspection only. NHB-150 P.taauts'tj4d9f Nlja,�&M'MIS I5u i iek i rtanly � load NHB- 150 �4"" - HIGH EFFICIENCY CONDENSING HEATING BOILER 1 t L w NOx • Super condensing efficiency • Dual stainless steel heat exchangers • SCH40,2"PVC venting up to 60' • '/2"Gas pipe up to 40' • TDR up to 15:1 • Integrated controls Credits&Rebates Finder t rebate up to$600> Find Sales Rep Enter Zip Code See other models» 1/6 NHB-150"MOW ��'y[Ig-,Qg. NNe-1 SO vii- I QuScxFffictg I Warraosr I t d 1 Acce�sjrirs ' NB' 2"venting up to 65'; NHB integrated control 3'up to 150'(including schedule \ provides industry-leading 40 PVC). options and features including adjustable heat capacity,temp boost for outdoor reset control, adjustable anti-cycle timer and M freeze protection ar•r 'W aa� Thee condensing technology of --- - the dual stainless steel heat exchangers saves energy, reduces greenhouse gasses 1l2"gas pipe capability up to 24'(sub)ect to local codes) Cuts installation time,no need to AMIN install new gas lines for retrofit applications 'r 1 4' The sophisticated gas flow control system provides a high turndown ratio which reduces energy waste and excessive boiler cycling NFi . 150 QuickFacts Dimensions Certification Summary Ratings 2A NHB-150 I QYickFact$ I « y l w l d I A e�son s Y.te4usL5'Ikle1�'Nlfa$6/ie6�Nrae-tso Model' NHB-150 Heating Input Min 10,000 BTU/h Max 150,000 BTU/h Heating Capacity2 138,000 BTU/h Net AHRI Rating,Water-3 120,000 BTU/h AFUE2, % gs.o t Ratings are the same for Natural Gas models converted to Propane use. 2 Based on U S Department of Energy(DOE)lest procedures a The NET AHRI Water Ratings Shown are based on a piping and pickup Allowance of 1 15 Consul[Navien before selecting a boiler for Installations having unusual piping and pickup I equirements,such as intermittent system operation,extensive piping systems,otc Specifications Item NHB-150 Dimensions 17 0"W x 24.0"H x 13.0"D(43.2cm W x 61.0cm H x 33 Ocm 0) Boller weight 80 Ibis(36 3 kg) Installation type Indoor wall-hung Venting type Forced draft direct vent Ignition Electronic ignition Natural gas supply pressure(from source) 3 5"WC to 10 5.1VC Propane gas supply pressure(from source) B"WC to 13"WC Natural gas manifold pressure -0.4"wC Propage gas manifold pressure -0.3"WC Connection sizes Gas Inlet 3/4"NPT(hembra) Power supply Main supply 120V AC,6OHz Maximum power consumption Less than 1OA Materials Casing Cold rolled carbon steel Heat exchangers Primary and secondary heat exchangers:stainless steel Venting Exhaust 2"or 3"PVC.CPVC,approved polypropylene(see installation manual for more details)2"or 3"special gas vent type BH(Class III 4 HH'I Vent clearances 0"to cvmbu0stAft ' c AC4R ® CERTIFICATE OF LIABILITY INSURANCE r ATE(MMIDD/YYYY) 10/4/2022 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 MVR Insurance Agency PHONE 477 Ashford Ave LAIC.No Ext) 914-693-3500 I I'A"IC.Not:914-693-3980 Ardsle NY 10502 I- E Y no D r tEss: aoelkers(c7)_mvrage�c r.com _ INSURER(S)AFFORDING COVERAGE NAIC M INSURER A:Selective Insurance Company Of America INSURED PLITPLU•01 INSURERB:Selective Insurance Company Of South Carolina Plitnick Plumbing&Heating Inc. — ------ --- 59 Main Street INSURERC: Dobbs Ferry NY 10522 INSURER 0: INSURER E: INSURER F COVERAGES CERTIFICATE_NUMBER:1286001571 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 POLICY EFF POLICY TR POLICY NUMBER MMIDO M/DD LIMITS A X COMMERCIAL GENERAL LIABILITY Y S2509446 9/29/2022 9/29/2023 EACH OCCURRENCE $1,000,000 CLAIMS•MAOE I X1 OCCUR DAMAGE TO RENTEU PREMISES Fa occurrence $500,000 MED EXP(Anyone person) i 15.000 T PERSONAL&ADV INJURY $1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $3,000,000 POLICY PRO- ----- JECT LOC PRODUCTS-COMPIOP AGO $3,000,000 OTHER: $ A AUTOMOBILELL481LITY S2509446 9/29/2022 9/29/2023 COMcci entSINGLE LIMIT $1,000,0D0 X ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED -- AUTOS ONLY AUTOS I BODILY INJURY(Per accident) $ X HIRED X NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY Per accident A X UMBRELLA LIAB X OCCUR I S2509446 9/29/2022 9/29/2023 EACH OCCURRENCE $2,000,000 EXCESS LIAB CLAIMS-MADE �— AGGREGATE $2,000,000 DED I X 1 RETENTIONS in $ B WORKERS COMPENSATION WC909739300 9/29/ 0022 9/29/2023 PER OTH- AN PROPRIYERSPART ERRITY YIN STATUTE ER ANYPROPRIE TOR/PARTNERIEXECUTI VE OFFICERIMEMBEREXCLUDED7 N/A E.L.EACH ACCIDENT s 1,000,0D0 (Mandatory In NH) If yea,describe under E.L.DISEASE-EA EMPLOYEE,11,000.000 DESCRIPTION OF OPERATIONS but. E,L.DISEASE•POLICY LIMIT 11.000.000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached If more space is required) Certificate holder to be included as Additional Insured regarding general liability per CG730ONY(attached) 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 ©1988-201 S ACORD CORPORATION. All rights reserved. ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD NARK Workers' CERTIFICATE OF STATE Compensation NYS WORKERS' COMPENSATION INSURANCE COVERAGE Board 1a.Legal Name&Address of Insured(use street address only) 1b.Business Telephone Number of Insured Plitriick Plumbing&Heating Inc. 914-693-1885 59 Main Street Dobbs Ferry,NY 10522 1c.NYS Unemployment Insurance Employer Registration Number of Insured Work Location of Insured(Only required if coverage is specifically limited to 1d.Federal Employer Identification Number of Insured or Social Security certain locations in New York State,i.e.,a Wrap-Up Policy) Number 13-4098078 2.Name and Address of Entity Requesting Proof of Coverage 3a.Name of Insurance Carrier (Entity Being Listed as the Certificate Holder) Selective Insurance Company of South Carolina City of Rye 3b.Policy Number of Entity Listed in Box"1 a" 1051 Boston Post Road WC909739300 Rye, NY 10580 3c. Policy effective period Q9/29/2Q22-_ _. to 09/29/2023 3d. f he Proprietor,Partners or Fxecutive 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"l 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 serid 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: Angela Oelkers (Print name of authorized representative or licensed agent of insurance carrier) Approved by: --~��_ _ 10/04/2022 (Signature) (Date) Title: Commercial Lines Account Executive Telephone Number of authorized representative or licensed agent of insurance carrier: 914-693-3500 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