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HomeMy WebLinkAboutBP23-161PERMIT #,01/ , )3— DATE: c�,i c�•3 SECTION 3 s CK TYPE OF WORK / JOB LOCATinlu i�i r_.. ��, /�-lr�a39 _ CONTRACTOR rQ �1'IC� El Q/ LC in )s 77- 765/ BEST. COST`` OC�� FE V CO FEES DATEj2LLJ aas TCO #� FEE DATE DATE FOOTING FOUNDATION FRAMING RGH FRAMING INSULATION PLUMBING I� RGH PLUMBING 0 GAS SPRINKLER ELECTRIC LOW -VOLT O ALARM O - AS QUILT LO _. FINAL tNSP zaa OTHER QyE BR(�v'�. iu G i J J� vy W v 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.ryebrook.org TRUSTEES BUILDING& FIRE INSPECTOR Susan R. Epstein Steven E. Fews Stephanie J. Fischer David M. Heiser Salvatore W. Morlino CERTIFICATE OF COMPLIANCE December 4,2023 Samuel Marcus&Audrey Marcus 12 Bobbie Lane Rye Brook,New York 10573 Re: 12 Bobbie Lane, Rye Brook,New York 10573 Parcel ID#: 135.35-1-36 Building Permit#23-161 issued on 9/25/2023 for a Rooftop Solar Array This certifies that the rooftop solar array,installed under the above captioned permit has been satisfactorily completed. Sincerely, Steven E. Fews Building& Fire Inspector /to ' v C�- C ' �33 For office use only: BUILDING&?*7 MENT = PERMIT# NOV —6 VIL `AOi OF RYE�IPOK ISSUED: 5 —old 938 KING STREtZ ttYE BROOK,4W YORK 10573 DATE: — VILLAGE OF RYE BROOK � 9 -066'$(_` FEE: -a�,�,� PAMA, BUIt_nNIO nFP/,RTf,!c�,! www l�o or CS c APPLICATION FOR CERTIFICATE OF OCCUPANCY,CERTIFICATE OF COMPLIANCE, AND CERTIFICATION OF FINAL COSTS TO BE SUBMITTED ONLY UPON COMPLETION OF ALL WORK, AND PRIOR TO THE FINAL INSPECTION iitRitR►■♦F4tRtFiit■rti►Rkrtkkkk4//tttttRtittittkiiRttiiit►■i4►kRiR►4k44Rk4tt/k/ttik/kttkt►i►►i►t►i►iitiititRRRi►kki►■4kkt4/i►► Address: 12 Bobbie Lane, Rye Brook, NY 10573 Occupancy/Use: Parcel ID#: 313 i ,�J�—/ —J�U Zone: —/ Owner: Samuel Marcus Address: 12 Bobbie Lane, Rye Brook, NY 10573 P.E./R.A.or Contractor: Address: Person in responsible charge: Thomas CattersonNenture Home Solar Address: 100 Charlotte Ave, Hicksville, NY 11801 Application is hereby made and submitted to the Building Inspector of the Village of Rye Brook for the issuance of a Certificate of Occupancy/Certificate of Compliance for the structure/construction/alteration herein mentioned in accordance with law: STATE OF NEW YORK,COUNTY OF WESTCHESTER as: Thomas Catterson/Venture Home Solar being duly sworn,deposes and says that he/she resides at 100 Charlotte Avenue (Print Name of Applicant) (No.and Street) in Hicksville ,inthecountyof Nassau in the State of NY ,that (City/Town/Village) he/she has supervised the work at the location indicated above,and that the actual total cost of the work,including all site improvements, labor,materials,scaffolding,fixed equipment,professional fees,and including the monetary value of any materials and labor which may have been donated gratis was:$ 23,672.00 for the construction or alteration of: Installation of Roof-Mounted Solar Panels. 22 Panels, System size: 8.80kW Deponent further states that he/she has examined the approved plans of the structure/work herein referred to for which a Certificate of Occupancy/Compliance is sought,and that to the best of his/her knowledge and belief,the structure/work has been erected/completed in accordance with the approved plans and any amendments thereto except in so far as variations therefore have been legally authorized,and as erected/completed complies with the laws governing building construction.Deponent further understands that it shall be unlawful for an owner to use or permit the use of any building or premises or part thereof hereafter created,erected,changed,converted or enlarged,wholly or partly,in its use or structure until a Certificate of Occupancy or Certificate of Compliance shall have been duly issued by the Building Inspector as per§250-10.A.of the Code of the Village of Rye Brook. Sworn to before me this 3rd Sworn to before me this 3rd day of November ,2023 day of November , 2023 Sawa g Nurcug- 7"G~Ak C4 fi9'i^Sr tV Signature of Property Owner Signature of Applicant Samuel Marcus Thomas Catterson Print Name of Property Owner Print Name of Applicant N S rEI 'JOHN LUISE 7R. STEPHEN JOHN LUISE JR N(YfARY PUBLIC STATE OF NEW YORK NOTARY PUBLIC,STATE OF NEW YOR� ge0tration Na 02LU6407287 12/2021 Qualified in S olk County Registration No.02LU6407287 on Expires !Y Z'K Qualified in Suffolk County MY My Commission Expires 3` •!P'•2-ti QyE BR1982.(�� BUILDING DEPARTMENT �UILDING 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:— 1 ��Q DATE: PERMIT# \ ISSUED:a L �ECT: BLOCK: LOT: LOCATION: / a, KJ OCCUPANCY: ❑ Violation Noted THE WORK IS... ❑rPASS ED ❑ 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 ❑ CROSS CONNECTION FINAL ❑ OTHER i s _ _ N N N a 1+1 \ \ ski •p m W M � C1 • y 91 � 1�I = s.r FBI F s� a � ►�.� a O O O 4 a �f c� o a � o '15 a v 'n � u� A cV r+ I con F+� rrQ�� N u o�lv a. Q. O G1 M LOg�g � 3 J � a _ W N M �-' a 3 ° 'CL 0 O! 2 = - co 00 z a A �A � 0*4 o ca � " � w ■ �J 04 Q O c� Uz °' " a o � � � I--�I rl)s o M W 4, W v� 6 a. Z v �a aa N V a p, _ x � Cq -� 1>1 as o Cl) a. OZ P N 0 ] v o oi oG F" ° 79 P. Z z _ Q O w O '_' : BUIL T TMENT D VII h' 0 RY 1 938 DING >E:H;f Ri't',B ,NY 10573 AUG 2 S 2023 ° or VILLAGE OF RYE BROOK BUILDING DEPARTMENT FOR OFFICE USE ONLY:Approval Date: SEP 23 rmit# Mc),346 1 Application# "Ob/8 Approval Signature: ARCHITECTURAL REVIEW BOARD: Disapproved: : Date: BOT Approval Date: —Case# : Chairman: PB Approval Date: Case# Secretary: ZBA Approval Date: Case# Other: 22 Application Fee: Permit Fees:. APPLICATION TO INSTALL PHOTOVOLTAIC SOLAR ARRAY Application dated: is hereby made to the Building Inspector of the Village of Rye Brook,NY,for the issuance of a Permit for the installation of a Photovoltaic Solar Array as per detailed statement described below. Bobbie Lane Q— 1, Job Address: 12 L SBL: �. Zone: 2 Type,kW&Location of Array,(use additional sheets if necessary): Installation of 22 roof mounted solar modules and inverters. No structural. 8.8kW 3.Property Owner: Samuel Marcus Address: 12 Bobbie Lane, Rye Brook NY 10573 Phone#(914) 643-6239 Cell# e-mail sammarcus57@gmail.com 4.Applicant: Gina Napomoceno Address:327 Captain Lewis Drive Southington, CT 06489 Phone#203-577-7651 Cell# e-mail gina.napomoceno@venturesolar.com 5. Design Engineer: Patrick Bussett Address:327 Captain Lewis Drive Southington, CT 06489 Phone#860-919-3093 Cell# e-mail gins.napomoceno@venturesolar.com 6.Solar Contractor: Venture Solar Address:327 Captain Lewis Drive Southington, CT 06489 Phone#203-577-7651 Cell# e-mail gina.napomoceno@venturesolar.com 7. Occupancy;(I-Fam.,2-Fam.,Commercial.,etc...)Pre-construction: 1-Fam Post-construction: 1-Fam 8. If building is located on a corner lot,which street does it front on: 9, N.Y.State Construction Classification: N.Y. State Use Classification: 10. Construction Type&Location:()Typical Western Lumber Frame;()Timber Frame[TC];()Wood Truss[TT]; O Pre-engineered wood [PW];Located;O Floor Framing[F];O Roof Framing[R];O Floor&Roof Framing[FR];Other: 11. Number of stories: Roof Style:(hip,shed,mansard,etc...) 12. Will a New Roof Be Installed: No X Yes ❑ (a separate roofing permit is required to re-roof an existing building) 13. Roofing Material&Number of Layers: I 8/12/2021 14. Will the proposed project disturb 400 sq.ft.or more of land,or create 400 sq,ft.or more of impervious coverage requiring a Stormwater Management Control Permit as per§217 of Village Code? No: 1A Yes: ❑ Area: 15. Will the proposed project require a Site Plan Review by the Village Planning Board as per§209 of Village Code? No: d Yes: ❑ (If yes,applicant must submit a Site Plan Application.&provide detailed drawings) 16. Will the proposed project require a Tree Removal Permit as per§235 of Village Code?No: 91 Yes: ❑ (If yes,applicant must submit a Tree Removal Permit Application) IT Does the proposed project involve a Home-Occupation as per§250-38 of Village Code? No: d Yes: El Indicate:TIER L—TIER If:—TIER III:_ (if yes.a Home Occupation Permit Application is required) 18. What is the total estimated cost of construction: S 24,000 (Note:The estimated cost shall include all site improvements,labor,material,scaffolding,fixed equipment,professional fees,including any material and labor winch may be donated gratis.if the final cost exceeds the estimated cost,an additional fee will be required prior to issuance of the CIO). 19. Start Date: Completion Date: This application must bear 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. Please note that application fees are non-refundable. STATE OF NEW YORK,COUNTY OF WESTCHESTER ) as: 1, &M Kkorv\gee f10 ,being duly sworn,deposes and states that he/she is the applicant above named, (print name of indi dual 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, Q*f)4 for the legal owner and is duly authorized to make and file this application. (indicate architect,contractor,agent,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 q 6(—'c Sworn to before me this 10 il day of 20 day of U�S 20 a 3 A__4� 0 JQ Z-�— TNotblic Notary ublic /4; c'C A'roperty Owner S of Applicant 511a,m Z./6 L P - >M AtC J S "wo. N pomocevla Print Name of Property Owner Print Name of Applica t DIANNE ROJAS Nicole Dow Notary Public-State of New York , Notary Public,State of Connecticut No.01RO6127547 Qualified in Westchester County My Commission Expires OW3112027 My Commission Expires May 23,2025 8/1 212 02 1 f � O ' N N ON c z m v vi ■ `qy W pp P-W v ,C T ice-. a, W N.y M OO � °� W -- tox z . M Uco F 3 rrr:► A 0 10 � - O un ' CIL cc �I ^ 3o C w Q M > O 12 w z V u Z �j, V C� Q� = oa z cc � z w H H c!) Q � � cy<� � 0 . CA d o $ CL W U U � o W o 3 a d w � C H8 v � " x CA o a- WIE BUIL E MENT VIL E OF RYE OK AUG 2 8 2023 938 KIN ET RYE B ,NY 10 � VILLAGE OF RYE BROOK .or BUILDING DEPARTMENT ELECTRICAL PERMIT APPLICATION Westchester County Master Electricians License Required? FOR OFFICE USE ONLY BP tD 'S ) b /SEP 2 EP#: � �Approval Date: Permit Fee: $ Approval Signature: Other: Application dated, 8—c 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: 12 Bobbie Lane SBL: /316- 1 3Co Zone//o 2.Property owner: Samuel Marcus Address: 12 Bobbie Lane, Rye Brook NY 10573 Phone#: (914) 643-6239 Cell#: email: sammarcus57@gmail.com 3.Master Electrician: Jason Sampogna Address: 327 Captain Lewis Drive Southington, CT 06489 Lic.#: 1403 Phone#: 845-518-3239 Cell#: email: gina.napomoceno@venturesolar.com Company Name: Venture Solar Address: 327 Captain Lewis Drive Southington, CT 06489 4.ProposedElectrical Work/FixtureCount: Installation of 22 roof mounted solar modules and inverters. No structural. 8.8kW 5.31 Party Electrical Inspection Agency: SWIS STATE OF NEW YORK,COUNTY OF WESTCHESTER ) as: )0.Son SGrhP0C-,Y1 C% ,being duly swom,deposes and states that he/she is the applicant above named,and does further (print name of individual siong4s the applicant) •� - state that(s)he is the legal owner of the property to which this application pertains,or that(s)he is the CoMracipr for the legal owner and is duly authorized to make and file this application. (indicate architect,contractor,agent,attorney,etc.) 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 IUD day of 20 day of Aucwsl20 a 3 Signature of Property Owner 2 Si re of 'cant So In SG►M o ok Print Name of Property Owner Print Nartye_af-Appliaent__ Notary Public Notary u Ilrc ----ter Nicole Dow { Notary Public,State of Connecticut My Commission Expires 08131/2027 STATE WIDE INSPECTION SERVICES, INC. CAD Service With Integrity 0•0 • • APPLICATIONSWIS JOB 0. • Office Use Elect. Permit# Date 'S Bldg Permit# -��'� Sq Ft Plumbing Permit# Final Certificate# City/Village 1 r K zlp `lc)5�3 Building Dept. ,I��'1 G e �{ F�}C County t 1eS��heS f Address 13 b, Lc.n e Cross Street Section Block Lot Owner Name/Address(If different than above) JQ�U�\ - -((U S Contact Number �y _ l 3— 6a 3'I(p� ❑Basement ❑ 1st Fl. ❑2nd Fl. ❑3rd Fl. ❑More Than 3 Fl. ❑Garage ❑Attic ❑Outside P 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 0 Safety Inspection Consultation InS�gllatioy,) of as roU� ry)oUr R� SC)IGr (Vy-)8U les c„e,d i r\Vf r-K(s . No S� ECEMED AUG 2 8 2023 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 atany 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 to 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 2 ,nG - Name ev) C, License# U 3 Date Signature, Address G kAl J; )\! City/State \\_ Zip e C C) Company 1�• lJ� tit` Phone# DE C LE 11 v State Wide Inspection Services CA� i 1080 Main Street OCT 2 7 2023 ` Fishkill, NY 12524 S%Vuts 845 Phone 914-2194-219-1062 Fax STATE WIDE INSPECTION SERVICES VILLAGE OF RYE BROOK Email: office@swisny.com BUILDING DEPARTMENT 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: Venture Home Solar Samuel Marcus 327 Captain Lewis Drive 12 Bobbie Lane Southington,CT 10804 Rye Brook, NY 10573 Located at: 12 Bobbie Lane, Rye Brook, NY 10573 Section: Block: Lot: Electrical Permit Number: EP 23-209 135.35 1 36 Certificate Number: 2023-7804 Building Permit Number: BP 23-161 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: 12 Bobbie Lane, Rye Brook, NY 10573 The Photovoltaic System 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 25' Day of October 2023. Name Quantity Rating Circuit Type PV Modules 22 Inverters 22 AC Disconnect 01 Combiner Box 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. !R, vent re sot r Village of Rye Brook Building Department NOV - 3 2023 11/1/2023 938 King Street VILLAGE OF RYE BROOK Rye Brook, NY 10573 BUILDING DEPARTMENT Re:Solar Panel Post Installation Certification Letter To whom it may concern, I, Patrick Bussett, certify the installation of the solar panels for the building located at 12 Bobbie Lane, Rye Brook, NY 10573, have been reviewed,are true and accurate, and are in conformance to the village of Rye Brook approved plans, the 2020 Residential Building Code of New York State, and the provisions of ASCE 7-16. Permit#: BP 23-161 SBL#: 135.35-1-36 Best, �P.A OF NEW � �` BUSS r � Patrick Bussett, PE yr Email: patrick.bussett@venturesolar.com 105278 �'��FESSIONP� :sauou u S . 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OOK AUG 8 2023 938 KING N;r RYE BR ,NY 10573 4 4 9 9-0 VILLAGE 0 OF RYE BROOK BUILDING DEPAR T 11MENT ARCHITECTURAL REVIEW BOARD CHECK LIST FOR APPLICANTS This form must be completed and signed by the applicant of record and a copy shall be submitted to the Building Department prior to attending the ARB meeting. Applicants failing to submit a copy of this check list will be removed from the ARB agenda. Job Address: 12 Bobbie Lane Date of Submission: Parcel ID#: Y-�5 _ 3-"�- `— o e: Q" 0 Proposed Improvement(Describe in detail): Installation of 22 roof mounted solar modules and APPLICANT CHECK LIST: inverters. No structural. MUST BE COMPLETED BY THE APPLICANT The following items must be submitted to the Building Depart nt by the applicant-no exceptions. Property Owner: Samuel Marcus I. ( ompleted Application 2. ( Two(2) sets of sealed plans. (one full size(maximum Address: 12 Bobbie Lane, Rye Brook NY 10573 allowable plan size=36-x 42-I and one I I"xl7") Phone#(914) 643-6239 3. ( )Two(2)copies of the property survey. 4. ( ) wo(2)copies of the proposed site plan. Applicant appearing before the Board: 5. ( One electronic/disc copy of the complete Venture Solar plication materials. 6. (VI Filing Fee. Address:327 Captain Lewis Drive Southington, CT 06489 7. ( ) Any supporting documentation. 8. ( ) PeA approval letter. (i/'applicable) Phone# 203-577-7651 9. ( Photographs. Architect/Engineer: Patrick Bussett 10.( ) Samples of finishes/color chart. (a sample board or Phone# 860-919-3093 model may be presented the night of the meeting) By signature below, the owner/applicant acknowledges that he/she has read the complete Building Permit Instructions& Procedures, and that their application is complete in all respects. The Board of Review reserves the right to refuse to hear any application not meeting the requirements contained herein. Sworn to before me this Gt-+ Sworn to before me this 10' day of r 20_�—� d AU 1S- " 1200 3 ignature of Property Owner St ture of Applicant Print Name of Property Owner Print Name of Applica Not ry Public Notary Public DIANNE ROJAS Notary Public-State of New York No.01RO6127547 Nicole Dow Qualified in Westchester County Mn Expires May 23,2025 Notary Pudic,State of ConnectiaR y Commissio My Commission Expires 0ti/3112027 8/ 2/2021 UR(�v� Village of Rye Brook IX Agenda 0 t�. ` W Z Architectural Review Board Meeting � CC te"J J V C`t`�y VL Wednesday, September 20,2023 at 7:30 PM >J Village Hall,938 King Street 1. ITEMS: 1.1. ARB23-090 (Consent Agenda) Volkert Braren&Maureen Braren 262 North Ridge Street Rooftop solar array. 1.2. ARB23-101 (Consent Agenda) Thomas Mariam&Alyce Mariam 89 Country Ridge Drive 4'high& 6'high white vinyl fence. 1.3. ARB23-102 (Consent Agenda) Jonathan Starr&Shanen Starr 20 Paddock Road 4'high black aluminum fence and gates. 1.4. ARB23-103 (Consent Agenda) Samuel Marcus&Audrey Marcus 12 Bobbie Lane Rooftop solar array. Consent Agenda Approvals: Motion Second_Abstention Aye; Nay; � Adjournment; Notes 1.5. ARB23-023 (Amendment to Prior Approval) Ervin Gomez&Maria Gomez 59 South Ridge Street Rear 2nd story addition. Approvals: Motion Second Abstention Aye; Nay; Adjournment; Notes Architectural Review Board September 20,2023 1.6. ARB23-104 Vanderlei Carvalho&Ehane Carvalho 770 King Street Roof over existing terrace. Approvals: Motion Second Abstention Aye; Nay; Adjournment; Notes 1.7. ARB23-105 Suresh Shanmugam&Anisha Mathur 259 North Ridge Street Enclose existing rear patio w/ steps to grade. Approvals: Motion Second Abstention Aye; Nay; Adjournment; Notes 1.8. ARB23-106 Lorenzo De Roni&Christine De Roni 16 Jennifer Lane New walkways and retaining walls,install SWM system. Approvals: Motion Second Abstention Aye; Nay; Adjournment; Notes 1.9. ARB23-107 Win Ridge Realty LLC 104 South Ridge Street New sign. "Mama Mia Dessert Bar" Approvals: Motion Second Abstention Aye; Nay; Adjournment; Notes Page 2 of 4 • Architectural Review Board September 20,2023 1.10. ARB23-108 Frank Nunziato&Kristina Nunziato 30 Argyle Road 2nd floor addition and interior alterations. Approvals: Motion Second Abstention Aye; Nay; Adjournment; Notes 1.11. ARB23-109 Washington Park Plaza Associates LLC 243 South Ridge Street New sign. "Wells Fargo" Approvals: Motion Second Abstention Aye; Nay; Adjournment; Notes 1.12. ARB23-110 Jing Xie&Margaret Chung 141 North Ridge Street Renovate existing deck. Approvals: Motion Second Abstention Aye; Nay; Adjournment; Notes 1.13. ARB23-111 Sooah Park 47 Bonwit Road New rear patio,retaining wall and fencing. Approvals: Motion Second Abstention Aye; Nay; Adjournment; Notes Page 3 of 4 Architectural Review Board September 20,2023 1.14. ARB23-112 Lake Development Co LLC 11 Old Orchard Road Legalize and renovate existing deck. Approvals: Motion Second Abstention Aye; Nay; Adjournment; Notes NEXT MEETING: October 18,2023 Page 4 of 4 vent re sot r 8 07/27/2023 B3muel Marcus 12 Bobbie Lane Rye Brook, New York 10573 Re: -%Iar Panel Installation Dear Mr./Ms. Marcus At your request, Pat rick Bussett of Venture Solar LLC(NY license#105278), has carefully reviewed t he exist i ng roof framing and the proposed connection of the panels to the roof for the building referenced above. The following building codes were used in conjunction with the 2020 Residential Code of New York Sate to generate pertinent design criteria: A,9--E7-16—Minimum Design Loadsfor Buildingsand Other Sructures International Residential Code 2018 Edition(IRC) National Design Specification for Wood Construction 2018 Edition (NDb) Design Criteria: Design Gravity Load: Show/Live Load=30 Ibs/ft2, Dead Load=12 psf Design Wind Load: V,,,t=116 mph; Exposure B, Rsk Category I I *Wind loads exceed seismic loads and therefore govern the design Field observations identified thefollowing conditions: The new solar panelswill impose an additional dead load of approximately 3 psf. The roof consists of asphalt shingles over plywood sheathing supported by 2x6 rafters at 16" o.c.The rafters are sloped at a 27' pitch and have a maximum projected horizontal span of 12'-0"±.The framing is assumed to be Douglas Fir#2 graded or better. The calculations determined that the existing framing has adequate capacity to support the PV panels as shown in our PV panel layout plan with no structural upgrades required. I therefore certify that this installation complies with the applicable codes and is acceptable for approval. Rease feel free to contact me if you have any questions or concerns. Best, �PZEOF Nrg,), �c�\CK Bps 0 _ S c ac Patrick Bussett, PE y —� Email: patrickbussett@venturesolar.com c�� 105278 �V A��FfSS10Na�'� vent re sot r Letter of Authorization / Property Owner Authorization Form I, Samuel Marcus, am the owner of the property located at address: 12 Bobbie Lane, Rye Brook, New York 10573 1 hereby authorize Venture Home Solar, LLC dba Venture Solar Power of Attorney to handle dealings associated with the successful interconnection and application for obtaining local building and other permits from the Authority Having Jurisdiction as required for a Solar Photovoltaic System located on my Property. I further authorize you to release my account information for the prior twelve (12) months, including electrical usage and demand history. Venture Solar agrees to keep this information confidential and use it only for the purposes of designing, installing, and interconnecting my photovoltaic system, obtaining incentives on my behalf, and establishing interconnection agreements, proper metering, and approvals. Print Name: Samuel Marcus SaxueE 7llaneua Owner Signature: 07/25/2023 Date: Print Name: Samuel Marcus Sa.Kuel 7llaau�a Utility Bill Owner Signature: 07/25/2023 Date: Venture Solar August 7, 2023 To whom it may concern, This letter is to inform you that Gina Napomoceno, Permit Coordinator at Venture Solar, LLC, may use my HIC License #WC-35078-H22 for the permit needed at: 12 Bobbie Lane, Rye Brook, New York 10573 Printed Name:Alex Yackery, 203-577-7651 r powered by Quality I� . . • � , w Controlled PV • , TOVRheinland • � www.tuv.com ID 1111232615 •' YR Q TOP BRAND PV 51 ASSEMBLED IN THE IMURM ' USA Warranty 2021 0 CELLS P.o &Pere«- Yizld Security a_ BREAKING THE 20%EFFICIENCY BARRIER n/I Ilnll�I� Q.ANTUM DUO Z Technology with zero gap cell layout boosts module efficiency up to 20.9%. THE MOST THOROUGH TESTING PROGRAMME IN THE INDUSTRY _ Q CELLS is the first solar module manufacturer to pass the most comprehen- sive quality programme in the industry:The new"Quality Controlled PV"of w the independent certification institute TUV Rheinland. INNOVATIVE ALL-WEATHER TECHNOLOGY Optimal yields,whatever the weather with excellent �J low-light and temperature behavior. _ ENDURING HIGH PERFORMANCE Long-term yield security with Anti LID Technology,Anti PID Technology',Hot-Spot Protect and Traceable Quality Tra.QTMt. EXTREME WEATHER RATING High-tech aluminum alloy frame,certified for high snow(5400 Pa)and wind loads(4000 Pa). A RELIABLE INVESTMENT Inclusive 25-year product warranty and 25-year linear performance warranty2. S BUSBAR 12 BUSBAR `APT test conditions according to IEC/TS 62804-1.2015,method A(-15C0 V,96h) CELL TECHNOLOGY CELLTECHNOLOGY 'See data sheet on rear for fu,ther information. THE IDEAL SOLUTION FOR: (10 Rooftop arrays residential buildings Engineered in Germany OCELLS MECHANICAL SPECIFICATION Format 74.0in x 41.1in x 1.26in(including frame) (1879mm x 1045mm x 32mm) 2a.a•t16°mml a1.e'1308°mml L5.6'(095.6 mm) Weight 48.5lbs(22.Okg) Front Cover 0.13in(3.2mm)thermally pre-stressed glass wit anti-reflection technology a.G« oDo a0 8"N°mml Back Cover Composite film Frame Black anodized aluminum Cell 6 x 22 monocrystalline Q.ANTUM solar half cells C3 .1•(lwemm) Junction Box 2.09-3.98in x 1.26-2.36in x 0.59-0 71in (53-101mm x 32-60mm x 15-18mm),IP67,with bypass diodes °'�� =w1 nlsommt Cable 4mm2 Solar cable;(+)>49.2in(1250mm),(-)>49.2in(1250mm) e.a=w.nwY j 4.Mw,Wp MMETWA) + Connector Staubli MC4;IP68 +��L16'(31 mm) DEINLA C.83'lle 1 0.96";1as mml I�10.33'(a.e mml ELECTRICAL CHARACTERISTICS POWER CLASS 385 390 395 400 406 MINIMUM PERFORMANCE AT STANDARD TEST CONDITIONS,STC'(POWER TOLERANCE+5W/-0 W) Power atMPPI PM,n [W] 385 390 395 400 405 Short Circuit Current' ISC [A] 11.04 11.07 11.10 11.14 11.17 E E Open Circuit Voltage' VO,; IV] 45.19 45.23 45.27 45.30 45.34 c Current at MPP IM,V [Al 10.59 10.65 10.71 10.77 10.83 Voltage at MPP V.- [VI 36.36 36.62 36.88 37.13 37.39 Efficiency' rl I%] >-19.6 t19.9 >20.1 >--20.4 >>-20.6 MINIMUM PERFORMANCE AT NORMAL OPERATING CONDITIONS,NMOT2 Power at MPP Pu„ [W] 288.8 292.6 296.3 300.1 303.8 E Short Circuit Current Isc [A] 8.90 8.92 8.95 8.97 9.00 E Open Circuit Voltage Voc IV] 42.62 42.65 42.69 42.72 42.76 c f Current at MPP I.- [Al 8.35 8.41 8.46 8.51 8.57 Voltage at MPP Vurr IV] 34.59 34.81 35.03 35.25 35.46 'Measurement tolerances P_±3%;IS,;V,,±5%at STC:1000 W/m2,25±2°C,AM 1.5 according to IEC 60904-3.2800 W/m2,NMOT,spectrum AM 1.5 a CELLS PERFORMANCE WARRANTY PERFORMANCE AT LOW IRRADIANCE --r-----r-----I-----I------ � At least 98%of nominal power during first year.Thereafter max.0.5%U3 z LL$ rIiii -------- --- degradation per year.At least93.5% Y ye -- -----i---- ' of nominal power up to 10 years.At w u a z least 86%of nominal power up to '" ' z J Y Z , I 1 , Z. ------------ 25 years. - az i i i o All data within measurement toleranc- es.Full warranties in accordance with b o the warranty terms of the Q CELLS aeo we eY rRRaanNcarywrn n o r sales organisation o`you,respective a' U a Y Y Y Y country. YEARS Typical module performance under low irradiance conditions in o comparison to STC conditions(25°C,1000 W/m2) o TEMPERATURE COEFFICIENTS o Temperature Coefficient of IS;, a [%/K] +0.04 Temperature Coefficient of Vac D [%/K] -0.27 � s Temperature Coefficient of P_ y (%/K] -0.34 Nominal Module Operating Temperature NMOT [°F] 109±5 4(43±3°C) m 0 PROPERTIES FOR SYSTEM DESIGN a Maximum System Voltage Vs,, IV] 1000(IEC)/1000(UL) PV module classification Class II o b Maximum Series Fuse Rating [A DC] 20 Fire Rating based on ANSI/UL 61730 TYPE 2 m Max.Design Load,Push/PUII3 [Ibs/ft2j 75(3600 Pa)/55(2660Pa) Permitted Module Temperature -40°F up to+185°F o Max.Test Load,Push/Pull3 [Ibs/ft'] 113(5400 Pa)/84(4000 Pa) on Continuous Duty (-40°Cupto+85°C) u 'See Installation Manual 2 QUALIFICATIONS AND CERTIFICATES PACKAGING INFORMATION lc n UL 61730,C-c-compliant. 53' Quality Cont•dletl PV-Tl1V Rneinlantl. p-Q IEC 61215:2016,IEC 8,7302018, U.S.Petert Nc.9.893,215(sdar cells). S�• E .w.,++..;a Horizontal 76.4 in 43.3in 48.Oin 1656lbs 24 24 32 C US C ® packaging 1940mm 1100mm 1220mrn 751kg pallets pallets modules _s UL 61730 N In'11A1P N Note:Installation Instructions must be followed.See the installat on and ope,ating manual or contact our technical service department for further information on approved installation and use of this product. Hanwha O CELLS America Inc. 400 Spectrum Center Drive,Su to 1400,Irvine,CA 92618,USA I TEL+1 949 748 59 96 1 EMAIL inquiryQus.c-cells.com I WEB www.q-cells.us f, IENPHASE IQ8 and IQ8+ Microinverters Our newest I08 Microinverters are the industry's first microgrid-forming,software- defined microinverters with split-phase power conversion capability to convert DC power to AC power efficiently.The brain of the semiconductor-based microinverter Easy to install is our proprietary application-specific integrated circuit(ASIC)which enables the Lightweight and compact with microinverter to operate in grid-tied or off-grid modes.This chip is built in advanced plug-n-play connectors 55nm technology with high speed digital logic and has super-fast response times Power Line Communication to changing loads and grid events,alleviating constraints on battery sizing for home (PLC)between components energy systems. • Faster installation with simple two-wire cabling Enphase •��• High productivity and reliability 25 Produce power even when the year limited grid is down More than one million cumulative Part of the Enphase Energy System,I08 Series 108 Series Microinverters redefine reliability hours of testing Microinverters integrate with the Enphase IQ standards with more than one million Battery,Enphase IQ Gateway,and the Enphase cumulative hours of power-on testing, Class II double-Insulated App monitoring and analysis software. enabling an industry-leading limited warranty enclosure of up to 25 years. Optimized for the latest high- powered PV modules Microgrid-forming CERTIFIED Complies with the latest advanced grid support Connect PV modules quickly and easily to 108 Series Microinverters are UL Listed as Remote automatic updates for 108 Series Microinverters using the included PV Rapid Shut Down Equipment and conform the latest grid requirements Q-DCC-2 adapter cable with plug-n-play MC4 with various regulations,when installed connectors. according to manufacturer's instructions. Configurable to support a wide range of grid profiles ©2021 Enphase Energy.All rights reserved.Enphase,the Enphase logo.I08 microinverters, Meets CA Rule 21(UL 1741-SA) and other names are trademarks of Enphase Energy,Inc.Data subject to change. requirements 108SP-DS-0002-01-E N-US-2021-10-19 IQ8 and IQ8+ Microinverters INPUT DATA IOCI 108-60-2-USr:• Commonly used module pairings' W 235-350 235-440 Module compatibility 60-cell/120 half-cell 60-cell/120 half-cell and 72-cell/144 half-cell MPPT voltage range v 27-37 29-45 Operating range V 25-48 25-58 Min/max start voltage v 30/48 30/58 Max input DC voltage v 50 60 Max DC current'[module Iscj A 15 Overvoltage class DC port II DC port backfeed current mA 0 PV array configuration 1x1 Ungrounded array;No additional DC side protection required;AC side protection requires max 20A per branch circuit Peak output power VA 245 300 Max continuous output power VA 240 290 Nominal(L-L)voltage/range' V 240/211-264 Max continuous output current A 1.0 1.21 Nominal frequency Hz 60 Extended frequency range Hz 50-68 Max units per 20 A(L-L)branch circuit' 16 13 Total harmonic distortion <5% Overvoltage class AC port III AC port backfeed current mA 30 Power factor setting 1.0 Grid-tied power factor(adjustable) 0.85 leading-0.85 lagging Peak efficiency % 97.5 97.6 CEC weighted efficiency % 97 97 Night-time power consumption mw 60 MECHANICAL DATA Ambient temperature range -400C to-600C(-40OF to.1401F) Relative humidity range 4%to 100%(condensing) DC Connector type MC4 Dimensions(HxWxD) 212 mm(8.3")x 175 mm(6.9")x 30.2 mm(1.2") Weight 1.08 kg(2.38lbs) Cooling Natural convection-no fans Approved for wet locations Yes Acoustic noise at 1 m <60 dBA Pollution degree PD3 Enclosure Class II double-insulated,corrosion resistant polymeric enclosure Environ.category/UV exposure rating NEMA Type 6/outdoor i CA Rule 21(ILL 1741-SA),UL 62109-1.UL1741/IEEE1547,FCC Part 15 Class B,ICES-0003 Class B,CAN/CSA-C22.2 NO.107.1-01 Certifications This product is UL Listed as PV Rapid Shut Down Equipment and conforms with NEC 2014.NEC 2017.and NEC 2020 section 690.12 and C22.1-2018 Rule 64-218 Rapid Shutdown of PV Systems,for AC and DC conductors,when installed according to manufacturer's instructions. (1)No enforced DC/AC ratio.See the compatibility calculator at https://Iink.enphase.com/ module-compatibility(2)Maximum continuous input DC current is 10.6A(3)Nominal voltage range can be extended beyond nominal if required by the utility.(4)Limits may vary.Refer to local requirements to define the number of microinverters per branch in your area. 108SP-DS-0002-01-EN-US-2021-10-19 0 t r .� AH = � � � 1 ;; • it All . 0,iiA Rr EMO off?AO y ; ;�,>; lam n v6 ti MM- MEMO r .I tit .. �� �.re.•, - - t 46 --,r- wnture solar ,: Solcr for • n�^�� �• $0 Down ., 6 .� 4*1 .4/ �� f s)<) �,� � . e . �- Ira• �, ��� Ail ri •.` .~ <. �r' .\ •c . .;. +�M� ,�% .. 'd�. R�. _ a.�.:�� air,. ap �: mil.. •r+�. �,• +�;#�!! �M. _ �,� ', '' f �„ e.. �''��� Y i .�♦ fir �� �� }ice •, '!� ,��y'�,tea- 'R^.. ,���'*'•� i ���� � �, �i'��.�T sl �- 1.4��f. 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"`4 • �+ V J W _J > co r... rn OCD I'G'•y�... .- v r,,erction LD ' h 4K c, O U �- N r✓ arL t2 � • � Z 0 CL � ^ CD 'w Ali V � _t' '�. cn fA s:l . ,If \=.-T^.ref 1.,-. 1 1t - t a ;*s' �r �,r-+��s-�','--�.•-•- .�r ) C. l(0)) ,�*.•'-"�is�,f!'+ / — �. •)4yr �J.H�✓ �11)/fJ t T �t f �;'� •„1 f 4�� dA1 .• .. �dwi 1 �,•v, a�z�.°�� �� +f., fl4, y..�'il�+'a •f�+)l):r '. to ss�sl,S w •♦ w Awl 1 .� fi3y.gii ^ 4' Ol .. A� 11/2a/2022 Y) CERTIFICATE OF LIABILITY INSURANCE DATE(MM/ ozz 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 Heather Ryan NAME: Protection Plus Associates Inc PH CONEo (973)579 6776 FAX N Ext: C No (973)579-0111 AI AI PO Box 4 E-MAIL h an SBOnelnsurance.com ADDRESS: ry 96 US Hwy 206 North INSURER(S)AFFORDING COVERAGE NAIC# Augusta NJ 07822 INSURER A: Southwest Marine&General Ins Co 12294 INSURED INSURER B: Endurance American Insurance Company 10641 Venture Home Solar LLC,Venture Solar Electric, INSURER c: AMGuard Insurance Company Venture Solar Capital LLC INSURER D: Selective Insurance Company 327 Captain Lewis Drive INSURER E: NJ Manufacturing Southington CT 06489-1170 INSURER F: COVERAGES CERTIFICATE NUMBER: 22/23 Master#4 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 AUUL1SUI5R POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER MM/DD MM/DD LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 2,000,000 CLAIMS-MADE DAMAGE TO RENTED ®OCCUR PREMISES Ea occurrence $ 100,000 MED EXP(Any one person) $ 5,000 A Y Y GL202200012768 11/15/2022 11/15/2023 PERSONAL&ADV INJURY $ 2,000,000 MGEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 4,000.000 POLICY PECT LOC PRODUCTS-COMP/OPAGG $ 4,000,000 OTHER: Per Proj capped agg limit $ 5,000,000 AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000 Ea accident ANYAUTO BODILY INJURY(Per person) $ C OWNED �/ SCHEDULED Y Y VEAU371260 08/22/2022 08/22/2023 BODILY INJURY(Per accident) $ AUTOS ONLY /� AUTOS IX HIRED �/ NON-OWNED PROPERTYDAMAGE $ AUTOS ONLY /� AUTOS ONLY Per accident Un/Underinsured $ 1,000,000 UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 1,000,000 B X EXCESS UAB CLAIMS-MADE Y Y EXC30000854804 11/15/2022 11115/2023 AGGREGATE $ 1.000,000 DED RETENTION$ $ WORKERS COMPENSATION PER H- OT EMPLOYERS'LIABILITY y/N STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE ❑ NIA E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ Commercial Auto Combined Single Limit $1,000,000 D Scheduled Auto(7) S2467549 08/22/2022 08/22/2023 Un/Uninsured Motorist $1,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Description of Operations:Solar Panel Installation Certificate holder is included as an Additional Insured to the above captioned General Liability Policy for on-going&completed operations on a primary&non-contributory basis;Additional Insured to the Automobile Policy for work the insured is performing provided a written contract exists requiring such a status. Per the terms of the policy,coverage for an additional insured is contingent upon an underlying written contract with the named insured requiring such coverage. There is a Waiver of Subrogation included in the General Liability,Business Auto,& Umbrella if required by written contract. Umbrella is follow form. 30day notice of cancellation except 10 for non payment of premium. 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 AUTHORIZED REPRESENTATIVE Rye Brook NY 10573 �` ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD YOR Workers' CERTIFICATE OF STATE I Compensation Board NYS WORKERS' COMPENSATION INSURANCE COVERAGE 1a.Legal Name Address of Insured(use street address only) 1b.Business Telephone Number of Insured Progressive Employer Management Company III,LLC Labor Contractor,for (718) 398-2259 leased workers to: Venture Home Solar,LLC.,dba:Venture Solar Electric 1c.NYS Unemployment Insurance Employer Registration Number of insured 100 Charlotte Ave Hicksville,NY 11801 1d.Federal Employer Identification Number of Insured or Social Security Work Location of Insured(Only required if coverage is specifically limited to certain Number locations in New York State,i.e.,a Wrap-Up Policy) 47-4266827 12.Name and Address of Entity Requesting Proof of Coverage(Entity Being 3a.Name of Insurance Carrier Listed as the Certificate Holder) American Zurich Insurance Company ,Village of Rye Brook 31b.Policy Number of Entity Listed in Box Ia" 938 King Street WC 10-18-880-04 3c.Policy effective period Rye Brook, NY 10573 4/1/2023 to 4/1/2024 3d.The Proprietor,Partners,or Executive Officers are included.(Only check box if all partners/officers inclued) all excluded or certain partners/officers excluded. This certifies that the insurance carver indicated above in box"3 insures the business referenced above in box"la"for workers'compensation under the New York State Workers'Compensation Law.(To use this form,New York(NY)must be listed under Item 3A on the INFORMATION PAGE of the workers'compensation insurance policy).The Insurance Carrier or its licensed agent will send this Certificate of Insurance to the entity listed above as the certificate holder in box 7. 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,licese 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 refernced above and that the named insured has the coverage as depicted on this form. Approved by: Douglas Jones (Print name of authorized representative or licensed agent of insurance carrier) Approved bv: � �L ,,� 4/3/2023 (Signature) (Date) Title: Vice President Telephone number of authorized representative or licensed agent of insurance carver: (480)951-4177 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) ww.wcb.ny.gov Mv O I m 10 rr.-j � h (IQ CD E a a e. f 0 Iro 'd z➢ CJi P W N Q "o W -] Q� ',A m �1 0 tr7 N CD (P l �'. Q • 3 O O O z O O O w IQ g' a M W ro z z CD (I CL M --` d d d m n. .� cr o. 0CD ' o CD 0 0 0 0 0 o m m m o N 0 0 o p p po p p ' CD p o p Qp� O CJl O O W O pN O S O O O 00 O o O O O O , ` j— ril o< ti O ~ c y 0 00 c,n O O O ►tz� .p O N W �00 00 M 00 W W f - y J w^ 7 0 � x ., r Ngj h= 2a � •gyp i�• yv ilk � y�ii,�, any ups y „ lit" 4 -c tv 7 1' y vs / op . aCL d /�// � ZI U3 7t r � T C �� Pd C 0 o - < o �- N y 0 cn 0 (D `!). 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