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HomeMy WebLinkAboutMP23-120 �yE DR o ti to, L� 19 4,JJ,GC Ut..+V O1C 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 gov TRUSTEES BUILDING& FIRE INSPECTOR Susan R. Epstein Steven E. Fews David M.Heiser Donald T.Krom,Jr. Salvatore W.Morlino CERTIFICATE OF COMPLIANCE July 14,2025 Fabio Marconi Goncalves de Arruda&Eleine Gomes Fernandes Pohdo 11 Carlton Lane Rye Brook,New York 10573 Re: 11 Carlton Lane, Rye Brook,New York 10573 Parcel ID#: 135.42-1-10 This document certifies that the work done under Mechanical Permit #23-120 issued on 8/1/2023 for the installation of a new condenser and coil has been satisfactorily completed. Sincerely, Steven E. Fews Building&Fire Inspector /to �yE BRC�j,�. o` Q �9fi2' BUILDING DEPARTMENT ❑BUILIIING INSIVECP1'OIt KA38INTANT BUILDING INISPECTOR VILLAGE OP RYE BROOK ❑Com ENFORCEMENT OFFICER 938 KING STRl3ET-RYE BROOK,NY 10573 (91.4) 939-0668 FAx (914)939-5801 www rnb oo or - - - - -- - - - - - - - - - - -- - - - INSPECTION REPORT - - - - - - - - - - - - - - - - - - - - L-� AnnRl�ss :�L it wL •� °� P,I:;It1VIITw YY1P20 Issul:n: SFCT: l3S_f�L BLOCK: -_,/LOT:_ /C� LOCATION: _^ i �, -�- _Qw S i �C.iG�F . -- OCCUPANCY: ❑ VIOLATION NOTED THE WORK Is... Q- AcCEPTE7D ❑ REJECTED/REINSPECTION ❑ SITE INSPECTION REQUIRED ❑ TOOTING ❑ FOOTING DRAINAGE ❑ FOUNDATION ❑ UNDERGROUND PLUMBING NOTES ON INSPECTION: ❑ ROUGH PLUMBING ❑ ROUGH FRAMING ❑ INSUL)V ION ❑ N GrRA_r..GAS ou J .do o C'0•� ,��2 ❑ L.I. n.ti ❑ FUEL TANK - ❑ FIRE SPRINKLEIt E� d ❑ FINAL PLUMBING ❑ CROSS CONNECTION - ou ��on�__- Jn2 FINAL - — TJ 0T1-1I1I2 A .v A C _ N LnIry M c o Ln w . L a' a 00 o\° w H ON Z a o a � 0.0 a O a a Ln 1 M ^ M $ a 44 O tt) w � .d F 3 u g v .. w 4-4 o 'C 0 1�1 (�i q W `� 010 a b 0 4-4w cn >' H o � o Q � � O AQQb � u -d 0, vi'b A z a .5 o co o z w N -l � v = ^ Z o p 0 z � v ° w 00 � U p�1 °U a u � q V.. 11 Z Uz b ° V1 00#4 it SO A a t U �••� M W C7 I� a3 u M v WA 0 '5' � 4. r`7 z z vw �E z � xIt 44 °a w a H off � v z 2uQ �/I p V 0 r. V ds w i � � o V c7 H q z q ti y O zQj q � Uov a O W 0 BUILDING-bEPARTMENT Im VILLAGE OF RYE$ROOK 938 KING STREET RYE BROOK,NY 10573 (914)939-066 (914)939-5801 oo ) APPLICATION FOR PERMIT TO INSTALL AND/OR REMOVE HEATING, VENTILATION AND/OR AIR CONDITIONING EQUIPMENT FOR OFFICE USE ONLY: PERMIT#: Approval Date: A U rOA,;2 Permit Fee:$ Approval Signature: Other: Disapproved: (fees are non-refundable) w,t********,t*,t******,t*w*«ww*******r,t,t*,t,t,t***w*r***r�**********�*,t*,t**,►**r******+r**,t**r�*************r,t*,t REQUIREMENTS 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, 06/29/2023 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. 22 II '' I. Address: 11 Carlton Lane SBL:JJ5,y'p2 1 10 Zone: —�a 2. Property Owner: Fabio Marconi Address: same Phone#: 914-559-8531 Cell#: email: 3. Contractor. Robison Oil Address: Phone#: 914-847-0295 Cell#: email: (weir@robisonoil.com 4. Applicant: Same as above Address: Phone#: Cell#: email: 5. Scope of Work:New Installation( )•Replacement(X)•Removal( )•Other( ): 6. List Equipment: Replacement of rnndPncer& Opil 7. Location of Equipment: Outside 8. Method of Installation/Removal(list all equipment needed to perform job): t 6/1/18 NEW TER �T�T Zov-1 ORKZCO�II;J�,Y�F WES g duly sworn, ) p: pp �}Y,�J t[l�,�j�('}'(u/((T/jJ�-}' being dui 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 legal owner of the property to which this application pertains,or that(s)he is the __ _ _ _ for the legal owner and is duly authorized to make and file this application. (indicate architect,contractor.agenC attorney,etc) 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 D7)i Sworn to efor me this '-7 day of _-4s I��`-, 0 a3 day of 0 Signature of Property Owner Si of t t Pant Name of Property weer me o pplic amanda K olmstead E1J1110 NOTARY PUBLIC,STATE OF NEW YO Nora 1 e• NEw or* No.0 1 OL6417632 No.O1ME6260063 Qualified in WF.STCHESTER Cnunt ry PubliC Qualified In Westchester County Commission Expires08/30/2025 Commission Expires January 29,2#Ll This application must be properly completed in its entirety and -list 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. z N N Ln p., Ln 7-4 Z W 6uJ n a A N p CW) VI �. M l z w x No v O �Z �., z a Ln 96 N UZ C44 i(. `n r- Ua� z U1 w - w H o o Z A W z WZO z , Z W V, > z O wG z oo ~" � � u V a 0 _ :- �.y p w z < , = w F z o > U G z w a z w za RECENED Angelo Zaccagnino �� dRC�v,� D.O.S: 12/1111968 BUIL EPz MENT AUG 3 0 2023 Company: �..,r Zaccagnino Electric ViL E OF RYE OK 81 Maple Avenue 938 KIN } -ET RYE B NY 10573 VILLAGE OF RYE BROOK BUILDING DEPARTMENT Rye,NY 10680 w 11i or �f P — 2 3' rZ tense No. 755 CCTRICAL PERMIT APPLICATIO :pires on:1213112023 MerBor'duccl ester County Master Electricians License quired FOR OFFICE USE ONLY �"� EP#: Approval Date: ?�� 1 Permit Fee: $ /-'�S 0� J Approval Signature: Other: Application dated, 8/30/23 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: 11 Carlton Lane SBL: 135.42 - 1 - 10 Zone: 2.Property Owner: Fabio Marconi Address: Phone#: 9145598531 Cell#: email: 3.Master Electrician: Angelo Zaccagnino Address: 81 Maple Ave, RVP NY 10580 Lic.#: 755 Phone#:9149213244 Cell#: email:Officeftzaecagnino.net Company Name: Zaccagnino Electric Address: 4.Proposed Electrical Work/Fixture Count: Wring of HVAC - Condenser and covenenience outlet atctke� $P= A? a3 -1 c) 5.31 Party Electrical Inspection Agency: SWIS STATE OF NEW YORK,COUNTY OF WESTCHESTER ) as: Anaelo Zaccagnino ,being duly swom,deposes and states that he/she is the applicant above named and does further (print name of individual signing as the applicant) state that(s)he is the legal owner of the property to which this application pertains,or that(s)he is the Electrician for the legal owner and is drily authorized to make and file this application. (indicate architect,contractor,agent,attomcy.etc.) The undersigned further states that all statements contained herein are true to the best of his/her knowledge and befief,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. Swom to this >Q Sworn to be me this Soo day of ,20z da o Y ,20 Cr. Signa a of Property O er Signataue of ppli ///(,Gry ,f G /dd Print Name S N Priiit Nafne-of Spplicant NOTARY pUBLI TAT OF NEW YORK Tf A ON NotaU Publ' 100238 Notary Pub 1c K ualified i esfchester County No. zg' 36 My Commission Expires October 14, 20�j� GU011fl@d@ster County My Commission Etober 14, IQ _ 6/23/2022 il • STATEWIDE INSPECTION Service With lwegriq 1:1 Main Street,Fishkill, NY 12524 1 email:• • . • SWIS JOB APPLICATION8. 1 914.219.1062 • • • Office Use Elect.Permit# /) \ Date Utility ID# Final Certificate`# d O► City/Village Zip Township ,` c�clit County Address i `y Cross Street Section � e�� Block Lot Owner Name/Address if different than above) � ;� i Contact Number ❑Basement ❑ 1 st Fl. ❑2nd FI. ❑3rd FI. ❑lvlore Than 3 FI. ❑Garage ❑Attic ❑Outside Residential ❑Commercial Receptacles Special Recept GFCI AFCI Switches Dimmers Smoke Alarms Carbon Monox Hood Trash Compact Amt Amps Range(s) Cooktop(s) Oven(s) Dishwashers Refrigerator Disposal Microwave Warm Draw Incandescent Fluorescent SERVICE Amperage Voltage 1 P 3P #Meters #Disconnect ❑Underground ❑New ❑Reconnect ❑Overhead ❑Change ❑Visual Re-Inspection ❑ Safety Re-Inspection ❑ Re-Inspection Additional Information D AUG 3 0 2023 VILLAGE OF RYE BROOK BUILDING DEPARTMENT This application is valid for one(1)year from the date received by WAS.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 tlrorized au 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. Inspector Date Finalized I or# Company Name _ Date S Address City/State h Zip Code License# Phone# D ka �(�] — ---- , State Wide Inspection Services 1080 Main Street JAN - 3 2024 Fishkill, NY 12524 I 845 202-7224 Phone SwumVILLAGE OF RYc BROOK 914-219-1062 Fax STATE WIDE INSPECTION SERVICES BUILDING D�I'AI-ZTiv1 Website: www.swisny.com Email: office(i1swisny.com Service With Integrity N BY THIS CERTIFICATE OF COMPLIANCE STATE WIDE INSPECTION SERVICES CERTIFIES THAT: Upon the application of: Upon Premises Owned by: Zaccagnino Electric Fabio Marconi Goncalves de Arruda Angelo P.Zaccagnino Eleine Gomes Fernandes Polido 81 Maple Avenue 11 Carlton Lane Rye, NY 10580 Rye Brook, NY 10573 Located at: 11 Carlton Lane, Rye Brook, NY 10573 Section: Block: Lot: Electrical Permit Number: EP23-186 135.42 1 to Certificate Number:2023-9377 Building Permit Number: MP23-120 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: 11 Carlton Lane, Rye Brook, NY 10573 The Basement& Exterior were 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 3`d Day of January 2024. Name Quantity Rating Circuit Type HVAC System 01 Convenience Receptacle 01 Officer: Frank J. 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. M ay id � x O:1 V .+ C rr L-upir r I = L � j ^Ja'a summand.Y.■.* K u a N — 7 ' zo 0 am0 u m C _ W cu *w :D r'1 w � � pR i u a, 3734 Q40; I 'IRON PIN S 1 SET 1 1 13.1 1. Q39� o It N. IRON PS a°.s N� x x CNAN x LINK FENCE l.p' p /W 1 rocr E 1R�pm do S.V.R.W. � � g 0. o CONCRETE PAYER (1'� _Ea• POOL E(%I. PATIO I.?' 5ET I Dot• � POOL t47� x 1 Y CONCRETE PAYER }{yI N S} C RET.WALL x CONCRETE PAYER L'GVCRE/E PAWN PA110 PATp CONDHELL NET.WALL RAf= SUPS x OW EC BRIO XK4' STOCKADE I CNAINEr R FENCE• > ` E4y1 I ATE WALK T.�' " N/le x Y+vn rcr ' 46; O �48� as ff ONE 5TORY FRAME Q 0 BASEMENT DWEWNG 5i0 E LRB H � I AAiaw I7 Lo1fm L•r,• O W I I TSJ' EQ 1 ® UAnlf• PLAT &1YTM SLATE {� SIM < SLATE IIWL = Ak L11 a = y m oaf° ' STEPS REC E NE Z JAN 3 0 M3 VILLAGE OF RYE BROO , BUILDING DEPARTMEN •�R= 250.00' 0 =20°44 2 L =90.49' I- 187.3�� -- ASPHALT cum C A R L T O N L A � F • THE PREMIUM rinmSHOWN ECTIOHEREON DEBKINATED OW.MAI LOT N047 ON A LLMUNS N, SURVEY OF PROPERTY MAP ENTRED'SECTION TWOPNIE RIDGE',MADE M RlISSE1.L MUNSON, DATED APRR 2%IZ AND FILED IN THE OFFICE OF THE COUNTY CLERK- DlVVWNOF LAND RIECORDSON NOV.te.1 BUT Ae MAP NO.iIW?• SITUATE IN THE • PREMISES ARE DESIGNATED ON THE TAX MAPS FOR THE TOWN OF RYE TOWN OF RYE VILLAGE OF RYE BROOK VILLAGE OF RYE BROOK SECTION:135.42 BLOCK:1 LOT:10 WESTCHESTER COUNTY AREA:14,925 Sq.Ft/0.3426 Acres • SURVEY IS SUBJECT TO ANY STATE OF FACTS WHICH AN UP-TO-OATE TTTLE NEW YORK EXAMNIATION MAY DISCLOSE. • THE OFFSETS SHOWN HEREON ARE FOR INFORMATIONAL PURPOSE ONLY. SCALE:1-20' OFFSETS ARE NOT INTENDED TO ESTASLISH PROPERTY LMES FOR THE ERECTION OF FENCES.STRUCTURES OR ANY OTHER IMPROVEMENr. SURVEYED:AUGUST 19.199• • ENCROACHMENTS BELOW GRADE ANDIOR SUBSURFACE FEATURES.IF ANY, SURVEY UPDATED:AUGUST 31.2010 NOT LOCATED OR SHOWN HEREON. SURVEY UPDATED:APRIL 30.2016 • LIN1LLTHORIZED ALTERATION OR ADDITION TO A SURVEY MAP SEARING A SURVEY AMENDED TO SHOW NEW FENCE 6 TREES:SEPTEMBER 1.2M UCBNlD LAND SURVEYOR'S SEAL IS A VIOLATION OF SECTION 7205, SURVEY REVISED 6 PROPERTY MARKERS SET:NOVEMBER 3,2022 SUBDIVISION 2.OF THE NEW YORK STATE EDUCATION LAWS. • ONLY COPIES FROM THE ORIGINAL OF THIS SURVEY MARIED WITH AN ORKNNAL OF THE LAND SURVEYOR'S REAL SHALL BE CONSIDERED TO SE TRUE Link VALID COPES. • THIS MAP WAS PREPARED FROM AN ACTUAL FIELD BURY"CONDUCTED ON THE DATE SHOWN AND THAT SAID SURVEY WAS PERFORM IN ACCORDANCE Land S O/S P.C. WITH THE EXISTING'CODE OF PRACTICE FOR LAND SURVEYS'ADOPTED BY THE NEW YOM STATE ASSOCMTION OF PROFESSIONAL LAND SURVEYORS. 21 C*k -B N N.Y.10541 PREPARED FOR DOCUMEn A, eNDs FABK)MARCONI,GONCALVES do ARRUDA a ELEINE DOMES FERNANDES POLIDO THE JUDICIAL TITLE INSURANCE AGENCY,LLC WELLS FARGO NA.M sucommom wKVor BaB1, Be dmk InEeR•Bb may appw RI D REBIRL comes"The first thing that % The 110sc,IDS Family was designed for homeowners that w • mind when reliable�IVAC Sys, ant a em,that will Produce exce and efficient heating nd PtiOnal with a I think of Bosch is warrant Year 4 c0ohng Year round backed quality, reliability • comfort, plus they off er the best jjj�� systems • Al I I I I 1 11111 11111 1I Illillllllllillill IIIiI Barry C.Owner,Comfort Technology,Braintree,MA • I iillllllilllllllll �IIIIII, System & Technical Information BOSCH IDS FAMILY DESCRIPTION&DIMENSIONS' BOVB18 OUTDOOR CONDENSING SECTION BOVB-36HDN1-M18M 36 kBTU/hr(3 ton) 8733955036 29.125 24.9375 29.125 BOVB-60HDN1-M18M 60 kBTU/hr(5 ton) 8733955037 29.125 33.1875 29.125 INDOOR AIR HANDLER BVA•24WNI-MI5 24 kBTU/hr(2 ton) 8733955038 19.625 46.5 21.625 BVA-36WN1-MI5 36 kBTU/hr(3 ton) 8733955039 19.625 46.5 21.625 w BVA-48WNI-MI5 48 kBTU/hr(4 ton) 8733955040 22.0 54.5 24.0 Air Handler BVA-60WN1-M15 60 kBTU/hr(5 ton) 8733955041 22.0 54.5 24.0 BOVA20 OUTDOOR CONDENSING SECTION BOVA-36HDN1-M20G 36 kBTU/hr(3 ton) 8733952437 29.125 24.9375 29.125 t rara NIIirI BOVA-60HDN1-M20G 60 kBTU/hr(5 ton) 8733952438 29.125 33.1875 29.125 I p P." 31 d1ippl�1'��� INDOOR HANDLER H i ili]0 NU BVA-24WN1-M20 24 kBTU/hr(2 ton) 8733952439 19.625 46.5 21.625 BVA-36WN1-M20 36 kBTU/hr(3 ton) 8733952440 19.625 46.5 21.625 BVA-48WN1-M20 48 kBTU/hr(4 ton) 8733952441 22.0 54.5 24.0 w Candensmg Section BVA-60WN1-M20 60 kBTU/hr(5 ton) 8733952442 22.0 54.5 24.0 IDS FAMILY FIELD INSTALLED ELECTRIC HEAT KITS MODEL • • EHK-05B 7739832075 5 kW Electric Strip Heater EHK-08B 7739832076 7.5 kW Electric Strip Heater EHK-106 7739832077 10 kW Electric Strip Heater EHK-15B 7739832078 15 kW Electric Strip Heater EHK-20B 7739832079 20 kW Electric Strip Heater ��� � �. iR• � •n\`.OEM w � � � a r in �. •� ^ ' � `AIV. ti�.�'-`.•Yid �J. 4 rfi. �ytr s �.,.�,�'C•t2 4�ri �►;. � �-`�'r � � w r< �^s4n��'�� A. ,4nfi:� .�, n oy! �. ; ''g �A` ',� 3Adk ��'y{�, �AiM. -..'nvi A• I�A - ?t' (\A/ y AMR,*-, ,1�5• Or .t \O _� !r!` my ♦• 94 �! ♦.1 t ac' «• e�rd • +' •• ar `. §t�f /< } r n:!?,,y::�'%'t,i'. 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VJ Y i..rLLJ ao 4-o �r = 0 z za r Y, cC C3 y O 1•(�`v, r , y N -_ v` 1 i�� O h y O O �O°2"•' np \ /N <to»a ;a •-'�i; 1 1�::::o-,_'_'may,^^«: _ !r aa5?;>_ %�J,{�l�y Illll�+,,y� =,,1,1���+� ; ; .1,►1,1+�y1,;, t , yl:• rl �I�+•, ��1 ►11114 s a } 1/ i `8 �.T/Ai ♦• j1I n , �n 41 �F}f ♦♦ alA4�t 1//111 $ A 1 � p ;:r0 ,� �Wzl n a a "' r � ` V A r •• O�t '�� t nt i�° tOtF;(� S��tit1 •�tfi4r` '37t�t � � tiW+ d/+� �l.r ` ' rrr.; i',r.Vr'-� �'`j-v-�u��yr`�r.�h r'��\q`"t�'a��'��rt'?�rl J��:� +�(1��4' �r i. llr,�-t� f tom.;:.:• � I AC`�® DATE(MMIDD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 12/27/2022 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: Matthew Moraski,CISR Arthur J.Gallagher Risk Management Services, Inc. PHONE 18568663252 ac No:856-273-3663 4000 Midlantic Drive, Suite 200 E-MAIL Mount Laurel NJ 08054 ADDRESS: matthew moraski AJG.com INSURERS AFFORDING COVERAGE NAIC 8 INSURER A:New York Marine And General Insurance Company 16608 INSURED SINGHOL-02 INSURER B: Singer Holding Corporation 55 South Main Street,4th Floor INSURER C: Port Chester NY 10573 INSURERD: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:1284557956 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. 1�7R TYPE OF INSURANCE ADDL SUBR POLICY NUMBER MM DDPOLICY/YYYY MM DD/YYYY LIMITS A X COMMERCIAL GENERAL LIABILITY PK202200020101 12/31/2022 12/31/2023 EACH OCCURRENCE $1,000,000 DAMAGE TO RENTE15— CLAIMS-MADE a OCCUR PREMISES Ea occurrence $100,000 MED EXP(Any one person) $5,000 PERSONAL d ADV INJURY $1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $2,000,000 X POLICY PRO- JECT LOC PRODUCTS-COMP/OP AGG $2.000,000 OTHER: $ A AUTOMOBILE LIABILITY AU202200017525 12/31/2022 12/31/2023 EOaB`INeDt SINGLE LIMIT $1,000,000 IX ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY Per accident $ AUTOS ONLY AUTOS ( ) HIRED X NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY Per accident A UMBRELLA LIAB X OCCUR EX202200001405 12/31/2022 12/31/2023 EACH OCCURRENCE $5,000,000 X EXCESS LIAB CLAIMS-MADE AGGREGATE $5,000,000 DED RETENTION$ $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY Y/N STATUTE ER ANYPROPRI ETOR/PARTNE RIEXECUTIVE OFFICER/MEMBER EXCLUDED? ❑ N/A E.L.EACH ACCIDENT $ (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space Is required) Village of Rye Brook Building Department is named as an additional insured with respect to the above General Liability Policy,if required by a written contract executed prior to services performed. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Village of Rye Brook Building Department 938 King Street Rye Brook NY 10573 AUTHORIZED REPRESENTATIVE 1 (� ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD sTArki Compensation CERTIFICATE OF Board~ NYS WORKERS' COMPENSATION INSURANCE COVERAGE 1 a.Legal Name&Address of Insured(use street address only) Ib.Business Telephone Number of Insured ADP TotalSource FL XVII,Inc. 9143455700 5800 Windward Parkway Alpharetta,GA 30005 1 c.NYS Unemployment Insurance Employer LIC/F: Registration Number of Insured Singer Holding Corporation 45-04510 a 1 Gateway Plaza 4th Floor Port Chester,NY 10573 Id.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) 133121491 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 Building Department 3b.Policy Number of Entity Listed in Box"1 a" 938 King Street WC 034298819 NY Rye Brook,NY 10573 All worksite employees working for Singer Holding Corporation paid under ADP TOTALSOURCE,INC's payroll,are covered under the above stated policy. 3c. Policy effective period 07/01/2023 to 07/01/2024 3d.The Proprietor,Partners or Executive Officers are 2 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 boa"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"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 reyui rements 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 ofautlicirized representative or licensed agent of insurance carrier) Approved by: �-f�7as =-a• 23-APR-2023 (Signature) (Date) Title: CEO North America Telephone Number of authorized representative or licensed agent of insurance carrier: eoa743-8130 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