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HomeMy WebLinkAboutMP23-117 yE BR 00 . 19 c C�c O VILLAGE OF RYE BROOK MAYOR 938 King Street, Rye Brook,N.Y. 10573 ADMINISTRATOR Jason A. Klein (914) 939-0668 Christopher J.Bradbury www.gyebrook.or� TRUSTEES BUILDING& FIRE INSPECTOR Susan R. Epstein Steven E. Fews Stephanie J. Fischer David M. Heiser Salvatore W. Morlino CERTIFICATE OF COMPLIANCE February 21,2024 Win Ridge Realty LLC c/o Alena Hakanjin 24 Rye Ridge Plaza Rye Brook,New York 10573 Re: 122 South Ridge Street, Rye Brook,New York 10573 Parcel ID#: 141.27-1-6 This document certifies that the work done under Mechanical Permit #23-117 issued on 7/26/2023 for the installation of a new rooftop HVAC unit has been satisfactorily completed. Sincerely, Steven E. Fews Building&Fire Inspector /to �E BRC��• w � • 1982 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 : / ZZ SD(.IY� I� I��'Q jTIL�� � DATE: ;6:;; - -2O4�Z PERMIT# I r 2 3 - 117 ISSUED: 716 lj SECT: 7;7 BLOCK: LOT: _ LOCATION: 200 �7 (/ C. IC �� ( N/ OCCUPANCY: ❑ Violation Noted THE WORK IS... Lil PASSED ❑ FAILED REINSPECTION ❑ SITE INSPECTION REQUIRED ❑ FOOTING ❑ FOOTING DRAINAGE ❑ FOUNDATION ❑ UNDERGROUND PLUMBING NOTES ON INSPECTION: ❑ ROUGH PLUMBING ❑ ROUGH FRAMING ❑ INSULATION ❑ Natural Gas J � PiPz /,j ❑ L.P. Gas ❑ FUEL TANK ❑ FIRE SPRINKLER ❑ FINAL PLUMBING ❑ CROSS CONNECTION [I,-FINAL ❑ OTHER QyE BR(�k• 1982 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 :— Z C_ �C�c i IrQ S � DATE: 2()Z �I PERMIT# M F' 23 - / 7 ISSUED: 7-2 6-2-3 SECT:1Y122 BLOCK: LOT: 6 LOCATION: ,00 SOP �"l�/7 C� J U'y 14 OCCUPANCY: ❑ Violation Noted THE WORK IS... ❑ PASSED LEI FAILED REINSPECTION ❑ SITE INSPECTION REQUIRED ❑ FOOTING ❑ FOOTING DRAINAGE ❑ FOUNDATION ❑ UNDERGROUND PLUMBING NOTES ON INSPECTION: ❑ ROUGH PLUMBING ❑ ROUGH FRAMING ❑ INSULATION 1` f ❑ Natural Gas ��e c F c°�` Q of� l-c,p U N ❑ L.P. Gas ❑ FUEL TANK ` / J S �4 �r S(•{PFO� ❑ FIRE SPRINKLER I�jj 1CQ_ ,r- ❑ FINAL PLUMBING ❑ CROSS CONNECTION FINAL ❑ OTHER ■ ■ � o N y F ■ a c4 � ■ fs. VUy v1 CIS CA aCA O G L7a bA L. M z o a v - O eel r�TQT E" o o,� s W emu' "ov tt � zr O G;en lu eq �� 3 w w Z p! W � W ' `~ -E ` U Cam. y 3 U s C:D 4. n U A V �' V ►0 vJ 0 H z Uz � b a c � w i „ p P a� FBI H W cia 1 j" o r/ A �M, W✓ f U UON UN I OC z z w - W b v O V M—i V W A Q � u0 OEM � �j Q H a o o F-, 40, H 3 z � o o V g ° U U w i o x W 8 a OE r� b �I � a a � ___ jaECIEME , I BUILDING Dr.1"ARTMENT JUL 2 5 2023 VIL nc.r o�Rvl: �kc>oK VILLAGE OF RYE BROOK 938 K[�c. ' .FT RYE BR t,NY 10573uI1.nING DEPARTMENT r ru APPLICATION FOR PERMIT TO INSTALL AND/OR REMOVE _HEATING, VENTILATION AND/OR AIR CONDITIONING EQUIPMENT FOR OrFIC'E USE ON[A' l>l ld m rl /�i ��3--1. 7 - Approval Date: 2 6 2023 Permit Fee: $ �U Approval Signature: Other: Disapproved: (ices are non-refundable) _REQUIREMENTS FOR RELEASE OF PERMIT&CERTIFICATE OF COMPLIANCE: 1. Properly completed& Signed Application. d 2. Site/Staging Plan if Required by the Building Inspector. 3. Copy of Licensed Contractor's Liability Insurance.(Village of Rye I3rotrk must be listed as eertificale holder,&Workers Compensation Insurance on a NYS Board form(Form#C 105.2 or Fomt it 1126.31 or NY State Workers Compensation Waiver) 4. Payment of Fees/Unit: RESIDENTIAL=$100.00/tinit• COMMERCIAL.=S350.00/unit. 5. Complete specifications for each unit being installed. 6. Inspection by the Building Department for removal and/or installation. (48 hour notice required) 7. Electrical work requires a separate Electrical Permit&Electrical Inspection. & Plumbing/Gas work requires a separate Plumbing Permit&Plumbing Inspection. Application dated, ZDE 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. U.t art. C,IEC�-M!/►- / I. Address: 4'11 50,,:Ti 44, 1I % 1D6IE: SST_ - SBL: Zone: 2. Property Owner: V`� VOL* 'N t uC Address: Z4- Alz Aft-6 PUN" Phone#: Cl 1+---Wt— Cell#: _ ema it:RH�K�1A?�1 N C -AJiI%►a t Y�E JF C 4�v1 3. Contractor: CC'0-5TefC— VVXCC.+tftktC'kL 5IW—Vp 1� �Pl• Address: o Phone M�" �� —-5 3 53 Cell#:t�. J O - &3`V 7 etnail: V O'C� tP►�. 4. Scope of Work:New Installation•Replacement( ) Removtial )-Other( ): 5. List Equipment: 'r1 _�tiC �S 1✓t C i? V0C4'*Cf:.%e; eTV C^-J �r 6 V) _ N Q+l tnn a 6 f'1)--T05115 V---V ; CND 6. Location of Equipment: CODE- TG4P A13C,V F.E e AuA C 4ctt:-*-a 7. Method of Installation/Removal(list all equipment needed to perfoim job): L?J / at habk,0e. 0--w{t 3/3/2023 A j STATE OF NEW YORK,COUNTY OF WESTCHESTER ) as: _ being duly sworn,deposes and states that he/she is the applicant above named, �'� �ti g Y P pp (print name of individual signing as the app icant) 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 Slate Uniform Fire Prevention&Building Code,the Code of the Village of Rye Brook and all other applicable laws,ordinances and regulations. �" Y Sworn to before me this 2,1) Sworn to before me this 3y�" day of Jv t''`�,20 2:3 day of ©-I ,20 Z3. i e of qoperty Oamcr� -r Signature of Applicant 'JAyG kftJ&u5l:} LevtD 61EST64)C-1Q-0 P�int e of Property Print Name of Applicant Notary Public tV ary Pt&ic E Ly SAMOLER Notary F' ic, c+ ate o' New York JOAN EMABET VASQUEZ RUMO$ NOTARYP+UBLIC Cualified in County MyCommisslonE>�tnsJuly31,2027 Cofrtmission Expirss Marche 9, 20b 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. 3/3/2023 j D [EC E-HWE D�j J U L 2 5 2023 ' VILLAGE OF RYE BROOK BUILDING DEPARTMENT The new degree of comfort'" Date: Jul 25 2023 Job: WINE CELLAR Mechanical Contractor: Coastal Mechanical Submitted By: Randy Winkler Equipment list for project: WINE CELLAR- Dated: Jul 25 2023 Units Tag No Model No Qty Description RGED: New platform gas heat and electric cool small commercial packages RTU-1 RGEDZT090ACG152AAAA0 1 Voltage: 208-230V-3PH-60Hz Factory Options:Two Stage, Non-communicating Economizer: None Accessories Tag No Field Model Description Notes Jul 25 2023 Performance Summary Tag: RTU-1 Model No: RGEDZT090ACG152AAAAO AHRI Ref:201841267 Project:WINE CELLAR City: BRIDGEPORT/IGOR I. State: CT Altitude: 16 Air Discharge: Downflow/Horizontal Cooling Performance AHRI Rating-Capacity: 85,000 EER: 11 IEER: 14.6 Gross Cap @ AHRI Rating Conditions(btuh)-Capacity: 88,385 Ambient Air(F)-Dry Bulb:84.4 Wet Bulb: 71.5 Airflow(CFM)-CFM: 3,000 SCFM: 3,000 System Entering Air(F)-Dry Bulb: 80 Wet Bulb: 67 % RH: 51.1 System Leaving Air(F)-Dry Bulb: 59 Wet Bulb: 56.9 Air Enthalpy(btu/Ib)-Entering:31.4 Leaving: 24.3 Design Net Cooling Capacity(btuh)-Total:96,100 Sensible: 68,100 Latent:28,000 Design Gross Capacity(btuh)-Capacity:97,200 Sensible:69,200 Total Power-Watts:8,048.4 KW:8 Heating Performance Gas Heating Values(btuh)-Input: 150,000 Output: 121,600 Heating Airflow(CFM)-CFM:3,000 Air Dry Bulb(F)-Outdoor: 15.8 Entering Air:70 Leaving Air: 107.5 Air Temperature Rise(F)-Rise: 37.5 Air Moving System Characteristics External Static Pressure(inches WG)-ESP: 0.7 Blower Speed or Speed Tap-RPM: 786 Drive: Belt Motor Characteristic(watts&BHP)-Power: 1,280.1 Electrical Supply Power Supply(Volt/Hz/Ph)-Volt/Hz/Ph: 208-230/60/3 Minimum Ampacity(amps)-Ampacity:44 Max Overcurrent Protection(amps)-Fuse: 60 HACR Breaker: 60 Dimensions, Weight & Clearances Dimensions-Length:88-5/8 Width: 57-1/2 Height:49-1/2 Weight(lb)-Weight:820 Clearances(inches)-Front:48 Cond. Coil: 18 Duct Side: 12 Clearances(inches)-Evap End: 36 Top:60 Product Submittal#: 232093ab-Od 1 c-4530-a5a6-5175f26ed69c Submittal Printed on: 7/25/2023 2:41:00 PM For Model: RGEDZT090ACG152AAAAO In keeping with its policy of continous progress and product improvement,reserves the right to make changes without notice. Gross capacity does not include the effect of motor heat.AHRI rating is net capacity and includes the effect of fan motor heat.All net capacities also accounts for the effect of motor heat. ASHRAE Weather Data©2009 American Society of Heating,Refrigerating and Air-Conditioning Engineers,Inc.,Atlanta,GA,USA.www.ashrae.org All rights reserved.Used by permission in this program. Model: RGEDZT090ACG152AAAAO i TIER COMPARISON Single-Stage Two-Slage 2018 DOE Efficiency 2023DOE Efficiency VFD Cooling Cooling I Standards Compliant Standards Compliant Technology HumidiDryTM Commercial Prestige*Series(RGEDZT) X X X X X(Optional) Commercial Classic Plus-Series(RGEDZS) X X X(Optional) X(Optional) Commercial Classic*Series(RGEDZR) X X Not Available Not Available RGED STANDARD FEATURES INCLUDE: • Factory charged with R-410A HFC refrigerant • PlusOnel Diagnostics with Dual 7-Segment LED Display • Wired and run tested • One-piece top cover and one-piece base pan with drawn • Scroll compressors with internal line break overload and high supply and return opening pressure protection • Two-piece control door • Model RGEDZR has a single-stage compressor • 1/a turn fasteners on filter access door • Models RGEDZS and RGEDZT have two-stage compressor • Color-coded and labeled wiring • Convertible airflow-vertical down flow or horizontal side • External lockable gauge ports flow • TXV refrigerant metering system • Single-point electrical connections • Solid-core liquid line filter drier • Forkable base rails for easy handling and lifting • High pressure and low pressure/loss of charge protection • Cooling operation up to 125OF ambient • Insulation encapsulated throughout entire unit • Two-stage gas heat input with direct spark ignition system, e High performance belt drive motor with variable pitch pulleys solid state furnace controls,and optimized induced draft and quick adjust belt system combustion • Variable Frequency Drive(VFD)blower is standard on Model • MicroChannel evaporator and condenser coil RGEDZT and optional on model RGEDZS • PlusOne•ServiceSmart package includes: • New product footprint with matching connections • PlusOne®ServiceSmart package includes: • Improved factory lead times Qwik-Change Flex-Fit Rack Qwik-Slide Blower Assembly Qwik-Clean Drain Pan With Standard Overflow Switch Model: RGEDZT090ACG152AAAAO 57 7/e" [1470 mm] 89" [2261 mm] CONTROLACCESS SERVICE DISCONNECT KNOCKOUT 150 MODEL ACCESS PANEL COMPRESSOR W. [1524 mm) 090 THRU 120 MODELS 50" [1270 mm] 7s/d [196 mm) II!\ 38 Ve" [967 mm] FLUE RETURN COVER OUTLET DRAIN PAN SUPPLY COVER GAS ENTRY ACCESS PANEL (SIDE SUPPLY) BLOWER Ilatlon ACCESS PANEL ST-A1273-01_B-00 HEAT EXCHANGER RECEPTACLE FILTER POWER ACCESS PANEL ENTRY INDOOR COIL 323/4" ACCESS PANEL [832 mm] 0 29+/4" / [743 mm] Y 33/4' [97 mm] 4Vs" [110 mm] SERVICE 90l/e" PORT DOOR [2289 mm) Illusbow 59+/2" ST-Al273-01_D-00 [1511 mm] [ 1 Designates Metric Conversions Model: RGEDZT090ACG152AAAAO SUPPLY AND RETURN DIMENSIONS FOR HORIZONTAL APPLICATIONS 61/e" 13' 31/2' [156 mm] ( 0 mm] (89 mm] RETURN 53 m (953 mm] AIR 15" SUPPLY AIR " [381 mm] 5'/i 51/s" [133 m [130 mm) OE 291/2' [749 mm] [505 mm] 57/e" 21 7/s" 1149 mm] (555 mmj 593/e" Illushatlan (1510 mm] ST-A1273-01-F SUPPLY AND RETURN DIMENSIONS FOR DOWNFLOW APPLICATIONS [2289 mm] 14• 11/i 356 mm [32 mm] 63/4" 143/e" [171 mm] 55/e. (365 mm] [1407 mm] j 371/2' [953 mm] 281/2' [724 mm] SUPPLY 591/z' [1511 mm] if 51h' 1/ (140 mm] 4-1 RETURNm)[u] L 81/2' [165 mm] 2' (W/i [51 mm] (2203 mm] [224 mm] [105 mm] TYP.(3)SIDES 593/d [1507 mm) Illustmft ST-Al273-01 J1-00 I I Designates Metric Conversions Laura Petersen From: Bill Jenkins <bjenkins@coastal-mechanical.com> Sent: Wednesday,July 26, 2023 8:59 AM To: Laura Petersen Subject: Wine Cellar RTU Attachments: Wine Cellar RTU.pdf Hi Laura, Please find attached submittal for the roof top unit that is meant for the Wine Cellar. It is an exact replacement for the existing unit. This unit will be placed on the original curb with no curb adapter or roof flashing needed. The crane will rig the unit from the side of the building near the red sidewalk. The crane will leave the premises before 8 am. Joane, the bookkeeper from my office forwarded our certificate of insurance and workman's comp information to you. Is there anything else I will need to send to you for the approval? Thank you, Bill Jenkins Sales Engineer Coastal Mechanical Services Inc. Coastal Energy Services Inc. 40 Hathaway Drive, Stamford, CT 06615 tel. 203.953.3732 cell. 203.814.6347 HTG.0385667-S 1 i a l � ' • slow So rj7 _ _ , .yy,,y{y{��� mil�•A, --,�.-- �L2 - •DIG pos e t Chop' tsv 1 talbuC,4k t pl�IlyHott Salo;'^� `t �� om e y i + 1 IffPnag Cantlsatr!'Copernscus" 4- : go C% � COASMEC-02 TSALLER ACORO CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 7/20/2023 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 %W.CT Paul A.Suzio AssuredPartners New England,Inc. acoNN, ; 203 5147863 FAX No;203 51 -7863 100 Beard Saw Mill Road Shelton,CT 06484 IM38.Poul.SuzloJr@MsuredPartners.com INSURE S AFFORDING COVERAGE NAIC 0 INSURERA:American Fire&Casuaft Co. 2A66 INSURED INSURER B:Ohio Security Insurance Company 24082 Coastal Mechanical Services,Inc. INSURERC:Ohlo Casual Ins.Co. M74 40 Hathaway Dr. INSURERD: Stratford,CT 06615 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 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 I TYPE OF INSURANCE ADDL SUB POLICY NUMBER POLICY EFF POLICY EXPLTR LIMBS A X COMMERCIAL GENERAL LIABS.ITY EACH OCCURRENCE 1,000,000 CLAIMS-MADE "- OCCUR X BKA58336167 12/17/2022 12/17/2023 DAMAGES(RENTED 300,000 MED EXP(Any oneperson) 15,000 PERSONAL 6 ADV INJURY 1,000,000 GENL AGGREGATE pLIMIT APPLIES PER: GENERAL AGGREGATE 2,000,000 X POLICY❑JECT F LOC PRODUCTS-COMPIOP AGG S 2,0001000 OTHER: III B AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT 1,000,000 (Ea acciden X ANY AUTO X BASS8336167 12/17/2022 12/17/2023 BODILY INJURY Per arson OWNED - - SCHEDULED AIURRTE�O��S ONLY _ AUTOS SSW Ep BODILY INJURY ersock Wrt X AU70S ONLY X AUUQ%S ONNLV PPer M AGE C UMBRELLA LIAS X OCCUR EACH OCCURRENCE 2,000,000 X EXCESS UAS CLAIMS-MADE X US058336167 12J1712M 121172023 AGGREGATE 2,000,000 DED I X I RETENTION$ 10,000 C WORKERS COMPENSATION X PER OTH- AND EMPLOYERS'LIABILITYSTATUTE FIR — ANY PROPRIETOR/PARTNER/EXECUTNE YIN XW058336167 12H/2022 1?H/2023 E.L.EACH ACCIDENT 500,000 OFFICER/MEMgER EXCLUDED? ❑ N/A (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE 500,000 If yes,describe under 500 000 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 apace Is required) Additional Insured- The Wine Cellar 122 South Ridge Street Rye Brook,NY 10573 CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Village of Rye Brook THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN g y ACCORDANCE WITH THE POLICY PROVISIONS. 938 King Street Rye Brook,NY 10573 AUTHORIZED REPRESENTATIVE j ✓K/I�.f..�OJA !I ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD PORK Workers' CERTIFICATE OF STATE Compensation Board NYS WORKERS' COMPENSATION INSURANCE COVERAGE 1a.Legal Name&Address of Insured(use street address only) 1b. Business Telephone Number of Insured Coastal Mechanical Services,Inc. (203)9533732 0 Hathaway Dr. 1c. NYS Unemployment Insurance Employer Registration Number of Insured Strafford,CT 06615 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 06-1450112 2.Name and Address of Entity Requesting Proof of 3a. Name of Insurance Carrier Coverage(Entity Being Listed as the Certfcate Holder) Ohio Casualty Ins.Co. Village of Rye Brook 3b. Policy Number of Entity Listed in Box"1a" 938 King Street XWO58336167 Rye Brook,NY 10573 3c. Policy effective period 1211/2022 to 12/1/2023 3d. The Proprietor,Partners or Executive Officers are ❑ Included.(Onty check box if all partners/officers included) Dail excluded or certain partners/officers excluded. This certifies that the insurance carrier indicated above in box"T'insures the business referenced above in box"1 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 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 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: Paul Suzio Jr. (Print name of authorized representative or licensed agent of Insurance carrier) Approved by: (Signature) (Date) Title: Account Executive Telephone Number of authorized representative or licensed agent of insurance carrier:(203)514-7863 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.