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HomeMy WebLinkAboutMP23-167 `yE BR �. O �4✓U�11. Y tc4 qua o�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.iyebrook.org TRUSTEES BUILDING & FIRE INSPECTOR Susan R.Epstein Steven E. Fews Stephanie J. Fischer David M.Heiser Salvatore W. Morlino CERTIFICATE OF COMPLIANCE December 11,2023 Randa Dreznick 7 Doral Greens Drive East Rye Brook,New York 10573 Re: 7 Doral Greens Drive East, Rye Brook, New York 10573 Parcel ID#: 129.35-1-9 This document certifies that the work done under Mechanical Permit#23-167 issued on 11/27/2023 for the installation of a new gas water heater has been satisfactorily completed. Sincerely, Steven E. Fews Building&Fire Inspector /to �yE BRC��• ,,/�' 19F�2• O 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 : OYC/-!G �j 2ti(�S UDC 1�C �. DATE: PERMIT# /w ISSUED://"Z7"2JSECT: BLOCK: / LOT: LOCATION: 01911 � �C� ��U�''J OCCUPANCY: 4;12/ U ❑ Violation Noted THE WORK IS... VFW PASSED ❑ FAILED REINSPECTION ❑ SITE INSPECTION REQUIRED ❑ FOOTING ❑ FOOTING DRAINAGE ❑ FOUNDATION ❑ UNDERGROUND PLUMBING NOTES ON INSPECTION: ❑ ROUGH PLUMBING ❑ ROUGH FRAMING ❑ INSULATION ❑ Natural Gas ? (/ C ��`'1��L z ❑ L.P. Gas ❑ FUEL TANK ❑ FIRE SPRINKLER ❑ FINAL PLUMBING \ ❑ ROSS CONNECTION 1 ff'FINAL ` ❑ OTHER QyE BRcbl O� 2m cu � • 1932 BUILDING DEPARTMENT ❑BUILDING INSPECTOR []-CSSISTANT 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:- � L Cz re e vs 72 . &�AA . DATE. /2 - 6 - Z O Z-3 PERMIT# /- o)-3 - l 6 7 ISSUED: //-1 7-6SECT: 3j-BLOCK: / LOT: 7 LOCATION: 1'411V A 4 Pd/10 e ZOSt / OCCUPANCY: ❑ Violation Noted THE WORK IS... ❑ PASSED FAILED REINSPECTION ❑ SITE INSPECTION REQUIRED ❑ FOOTING ❑ FOOTING DRAINAGE ❑ FOUNDATION ❑ UNDERGROUND PLUMBING NOTES ON INSPECTION: ❑ ROUGH PLUMBING ❑ ROUGH FRAMING ❑ INSULATION 11 / ❑ Natural Gas ❑ L.P.Gas AC'-,— ❑ FUEL TANK ❑ FIRE SPRINKLER ❑ FINAL PLUMBING n ✓/ ❑ CROSS CONNECTION lc ❑ Lj FINAL ❑ OTHER m N v � tu 07, W V] 0. tU � Py a 0 4 OA A4 :Y; 1■n� � "^` - a 9 Lq pALzO � w � O 0 � zt, CN Cc: z Zt-w0 ° W o Hoo Q O wv � � .. o V V I� o O '° w Cho - z W M ' A � � v a o I-j m - 00 hil �CIS � W p; z Zo x o m ■ V o � C Gin w m 04 vuZ U C � ��� y Q � ■ p �, C V [� oc '-. p v o v o w .. 14 �. d . �..� o U H ~ BUILD INC,DEPARTMENT MENT Q �� JD VILLAGE OF RYE:,ftoox I NOV 2 2 2023 938 DING STREET RYE BROPK,NY 10573 3 L— (914)939-0668 i VILLAGE_ OF Ryr- BROOK www.ryebreeko1rP- BUILDING DEPARTMENT APPLICATION FOR PERMIT TO INSTALL AND/OR REMOVE HEATING, VENTILATION AND/OR AIR CONDITIONING QEO UIPM)lEN`TJ FOR OFFICE USE ONLY: PERMIT#: / d `—/(D ! Approval Date: NOV 2 Permit Fee: $ Approval Signature: Other: Disapproved: i (fees are non-refundable) 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 REQUIREMENTS FOR RELEASE OF PERNUT&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#C105.2 or Form#U26.3/or NY State Workers Compensation Waiver) 4. Payment of Fees/Unit: RESIDENTIAL=$100.00/unit• COMMERCIAL a$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 required 7. Electrical work requires a separate Electrical Permit&Electrical Inspection. 8. Plumbing/Gas work requires a separate Plumbing Permit&Plumbing Inspection. Application dated, ��" �' is hereby made to the Building Inspector of the Village of Rye Brook for a permit for the installation and or 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, -` ( r� q 1. Address: - ! U<-C,1 ten' E)-"� G`'ti5� SBL: /o ?,3� ` / Zone: Gf6 2. Property Owner: RGin(ICt a05f% f Address: Phone#: 2p,1) - 5 U- H H H CJ Cell#: email: CU-0 C-i M'!-t 3. Contractor: iAmw%X Nkacy o►CCA k Address: 26 \.) (V-Mr)d r*-e- Phone#: C{1 '(,�10 1� Cell#: email: 10(1L[ QQ(? l%--rx 1 -C yl 4. Scope of Work:New Installation(�•Replacement( }•Removal( )•Otheeir,( ): 5. List Equipment: L004 e 6. Location of Equipment: 7. Method of Installation/Removal(list all equipment needed to perform job): 1 10/30/2023 3/3/2023 STATE nOF�NEW YORLK,,COUNTY OF WESTCHESTER ) as: r"�"� LOV. ,being duly sworn,deposes and states that he/she is the applicant above named, Game of individual 91bmi as the applicant) and further states that(s)he is the Master Plumber for the legal owner and is duly authorized to make and file this application. That all statements contained herein are true to the best of his/her knowledge and belief,and that any work performed,or use conducted at the above captioned property will be in conformance with the details as set forth and contained in this application and in any accompanying approved plans and specifications,as well as in accordance with the New York State Uniform Fire Prevention& Building Code,the Code of the Village of Rye Brook and all other applicable laws,ordinances and regulations. Sworn to before me this /4/k Sworn to before me this q 4k day of NovemW ,20� day of ILemr ,20 23 atnn,A 62&ngkA -'� Signature of Property Owner Signature o pplicant lidOCAa RasvleY fir,"- 4hlEy Print Name of Property Owner Print Name of Applicant Notary Public b . - JENNIFER RIVERA JENNIFER RIVERA Notary Public-state of New York Notary Public-State of New York NO.01 R16388056 NO.OIR16388056 Qualified in Bronx County Qualified in Bronx County My Commission Expires Feb 25, 2027 MY Commission Expires Feb 25, 2027 This applica in its entirety and mu (s) of the legal owner(s) of the subject property, and the applicant of record in the spaces provided. Applications not properly completed in its entirety and/or not properly signed shall be deemed null and void and will be returned to the applicant. -2- 10/30/2023 BUILD, MENT VIL E OF RY9, OOK 938 KING ITT RYE BR NY 10573 4 _0 WV AFFIDAVrIT OF COMPLIANCE VILLAGE CODE 4216 • STORM SEWERS AND SANITARY SEWERS THIS AFFIDAVIT MUST BEAR THE NOTARIZED SIGNATURE OF THE LEGAL PROPERTY OWNER AND BE SUBMITTED ALONG WITH ANY BUILDING OR PLUMBING PERMIT APPLICATION. ANY BUILDING OR PLUMBING PERMIT APPLICATION SUBMITTED WITHOUT THIS COMPLETED AND NOTARIZED FORM WILL BE RETURNED TO THE APPLICANT . STATE OF NEW YORK, COUNTY OF WESTCHESTER ) as: 3S, lw o d a IW O C K _, residing at, I)Lx u &v-eev-6 > �� (print namc) (Address where you live) being duly sworn, deposes and states that(s)he is the applicant above named,and further states that(s)he is the legal owner of the property to which this Affidavit of Compliance pertains at; G fef'_J) atd , Rye Brook, NY. (]oh Address) Further that all statements contained herein are true, and that to the best of his/her knowledge and belief, that there are no known illegal cross-connections concerning either the storm sewer or sanitary sewer,and further that there are no roof drains, sump pumps,or other prohibited stormwater or groundwater connections or sources of inflow or infiltration of any kind into the sanitary sewer from the subject property in accordance with all State, County and Village Codes. (Atk� Alcl� (Signature of Property Ownen s)1 � q V1 d C1 IZ (Print Name of Property Owner(s)) Sworn to before me this 1.q Ph JENNIFER RIVERA day of 20 Notary Public-State of New York NO,01 R16388056 Qualified in Bronx County My Commission Expires Feb 25,1027 (Notary Public/ -3- 8/12/2021 BRADFORD MMITE`' W A T E R H E A T E R S Residential Atmospheric Vent High Input Gas Water Heater The Atmospheric Vent High Input Models Feature: ■ Bradford White ICON System"*—Intelligent gas control with proven millivolt powered technology and built-in piezo igniter.A standard,off-the-shelf thermopile converts heat energy from the pilot flame into electrical energy to operate the gas valve and microprocessor. No need for external electricity. —Enhanced Performance—Proprietary algorithms provide enhanced First ORP Hour Rating and tighter temperature differential. —Advanced Temperature Control System—Microprocessor controls burner operation for consistent and accurate water temperature levels up to 160°F(71°C). —Intelligent Diagnostics—Exclusive multicolor LED light indicates operation status/service required. ■ Factory-Installed Hydrojet®Total Performance System—Sediment reducing device that also increases first hour rating of hot water while minimizing temperature build-up in tank. ■ Vitraglas Lining with Microban®—An exclusively engineered enamel formula that provides superior tank protection from the corrosive effects of water;and with Microban antimicrobial product protection to help prevent the growth of bacteria, mold and mildew on the surface of the tank lining. ■ Side Connections-3/4" (19mm) NPT tappings that allow easy connections for space heating applications(potable water only). ■ Insulation System—Non-CFC foam covers the sides and top of the tank, reducing heat loss.This results in less energy consumption, improved efficiencies, and jacket rigidity. ■ Pedestal Base (except RG21001-16N). ■ Water Connections—Factory-installed true dielectric fittings extend water 1 heater life and simplify water line connections. ' ■ Hand Hole Cleanout—Allows inspection of tank interior and facilitates the removal of sediment deposits(RG2100H6N models only). f+ ■ Protective Anode Rod—Provides added protection against corrosion for ` long-term,trouble-free service. ■ 4" (107mm) "Snap Lock"Draft Diverter. ■ T&P Relief Valve—Installed. �� �_■^ I j ■ Low Restrictive Brass Drain Valve—Durable tamper proof design. ■ Thermostatic Mixing Valve(ASSE Approved)—Included with RG255H6N only. Photo is of ■ NOx Emissions—Less than 40 ng/J. RG255H6N FEATURING: 'May vary by region ---�lSystem Micr 0113nn' 6 or 10-Year Limited Tank Warranties/6-Year Limited Warranty on Component Parts. For more information on warranty,please visit www.bradfordwhite.com For products installed in USA,Canada,and Puerto Rico.Some states do not allow limitations on warranties.See complete copy of the warranty included with the heater. S�• ® MicrobanO antimicrobial product protection helps prevent the growth of bacteria,mold and mildew that may affect the product.The built-in antimicrobial properties do not protect users or others from disease-causing organisms.Microban®is a registered trademark of Microban Products Company. MANUFACTURED UNDER ONE OR MORE OF THE FOLLOWING U.S.PATENTS:5,682,666,7,634,916,5,660,165,5,954,492,6,056,542,6,935,280,5,312,185,5,485,819,5,514,822,7,971.560,7.992,526.6.684,821; 7,334419,7,866,168;7,270,087;7.007,748,5,596,952;6,142,216.7,699,026;5,341,770,7,331,517;7,GG5,211,7,665210:7,063.132.7,063,133.7,559293,7,900,589,5,943,984;8,082,888,5.988,117;7,621.238; 7,650.859;5,761,379;7,409,925;5,277,171,8.146,772,7,458.341,2,262,174,OTHER U.S.AND FOREIGN PATENT APPLICATIONS PENDING.CURRENT CANADIAN PATENTS.2,314,845;2,504,824;2,108,186;2,143,031; 2.409.271:2,548,958;2,112,515,2,476.685,2,239,007;2.092.105.2.107.012.Vitraglas'and Hydrojet•are registered trademarks of Bradford White'Corporation. 1108-H-0723 Residential Atmospheric Vent High Input Gas Water Heater High Input Models Meet or exceed ASHRAE 90.1b(current standard)C.E.C.Listed NATURAL GAS AND LIQUID PROPANE GAS Recovery efficiency ranging up to 80% Model Nominal Recovery at Model Nominal Recovery at Number Gal. DOE 901 Rise' Number Liter DOE 50'C Rise* Capacity Rated First Capacity Rated First Storage LP Hour Uniform LP LP Storage LP Hour Uniform LP U,S. Imp. Volume BTU/Hr. BTU/Hr. Rating Energy U.S. Imp. U.S. Imp. Volume kW kW Rating Energy Liters/ Liters/ Gal. Gal. (Gal.) Input Input (Gal.) Factor GPH GPH GPH GPH (Liters) Input Input (Liters) Factor Hour Hour RG250H6N 48 40 46 65,000 65.000 106 0.63 70 35 70 35 RG25OH6N 182 174 19.0 17.9 401 0.63 265 265 RG255H6N 1 55 46 55 78,000 78,000 117 0.61 84 70 84 70 RG255H6N 208 208 22.9 22.3 443 0.61 318 318 RG275H6N 1 75 63 72 76,000 76,D00 135 0.59 82 68 82 68 RG275H6N 284 273 1 22.3 22.3 477 0.59 310 310 RG2100H6N 1 100 83 95 80,000 80.000 157 0.57 85 71 85 71 RG210OH6N 379 360 1 23.4 23.4 519 0.57 1 322 322 Model A B C D E F G H J K L M R S Approx. Number Floor to Jacket Vent Floor to Floor to Floor to Floor to Depth C/L Floor to Floor to Water Space Gas Shipping Flue Dia. Size T&P Gas Top of Water of Water Space Heating Space Heating Conn. Heating Conn. Weight Conn. Conn. Conn. Heater Conn. Conn. Inlet Outlet NPT Conn.Sue Size in, in, in. in. in, in. in. in. in, in. in. in. in. in, lbs. RG250116N 60'h 22 4 49"/, 13 56`A 57'/a 251; 11 13'/ 491''F6 314 31, /; 189 RG255H6N 58'1, 24 4 48 A 13/. 547, 56'/, 27'h 8 13'h 481a 74 31, h 210 RG275H6N 1 62`7a 26 4 1 51Ile 15 1 59`/a 60'h6 2974 11 16519 1 5198 1 N, h 240 RG2100H6N 71'h 281, 4 1 59'l F 15 Y., 65'N 66'h 31 A 16 17'/a 50% 17, 14 1 h 413 Model A B C D E F G H J K L M R S Approx. Number Floor to Jacket Vent Floor to Floor to Floor to Floor to Depth C/L Floor to Floor to Water Space Gas Shipping Flue Dia. Size T&P Gas Top of Water of Water Space Heating Space Healing Conn. Heating Conn. Weight Conn. Conn. Conn. Heater Conn. Conn. Inlet Outlet NPT Conn.Size Sae mm. mm4 mm. mm. mm. mm. mm. mm. mm, mm. mm. mm. mm. mm. kg. RG25OH6N 1527 559 102 1268 330 1438 1457 648 279 341 1268 19 19 1 13 86 RG255H6N 1486 607 102 1222 333 1391 1435 657 203 343 1222 19 19 13 95 RG275H6N 1591 660 102 1 1318 381 1514 1526 743 279 422 1318 1 25 19 13 109 RG2100H6N 1816 718 1 102 1 1507 1 389 1659 1689 806 406 448 1286 1 32 19 1 13 187 Propane models feature a Titanium Stainless Steel propane burner. For Propane(LP)models change suffix"N"to"X". For 10 year models,change suffix from"6"to"10"(Not available o on RG255H6N). p Based on manufacturer's rated recovery efficiency. T-+„ O -� Uniform Energy Factor and First Hour Rating is based on the H latest AHRI directory listings. QB H -I r c �Cr R—� R—$} A A G D8L G F F s DaL s ( ®R—A ( O � T A K E o0 o K E RG250H6N/RG255H6N/RG275H6N RG2100H6N General: Meets NAECA or EPACT Requirements,as applicable. All gas water heaters are certified at 300 PSI test pressure(2068 kPa)and 150 PSI working pressure(1034 kPa).All gas connections are 112" (13mm). All models design-certified by CSA International(formerly AGA/CGA),ANSI Z21.10.3 and peak performance rated(except RG250H6N=ANSI Z21.10.1). Dimensions and specifications subject to change without notice in accordance with our policy of continuous product improvement. Suitable for Water(Potable)Heating and Space Heating. Toxic chemicals,such as those used for boiler treatment,shall NEVER be introduced into this system.This unit may NEVER be connected to any existing heating system or component(s)previously used with a non-potable water heating appliance. -BRADFORD WHITE IS- AMR=-RICAN Sales:800-523-2931 ■Fax 215-641-1612 STRONG- 2417 Technical Support 800-334-3393■Email techservc@bradfordwhite.com Products made by Bradford White are manufactured in the United States using the finest raw materials and components from around the world. Built to be the Best' 1108-H-0723 ©2023,Bradford White Corporation,USA.All rights reserved. Printed in U.S.A. wbk Ia. a; � io C LO O 5t cc m11ni 'a CA 4- Cc 6 .N•. � '�': •mac �' ° L" •° � �F=�� C Ncn , 9LO O W cM U awn U N �' 'AO • » Q w o a �otection >� Qv r Q LL W c w; O o p o LLJ» ' O W LL u) 3 w o � w co w r N c� O i L.v nr 2 x' w z y . IL CLco . 'r1: ♦, ¢ ::�'� cz Cd co •ter L [r7 •C U � d K U w N ' •_l � U C) Vi � � • cn Cl. (o)s y z_ 1/�. •�`_. _ O 'Y1JJmm" "+WWM44Y :M' N•�((__(���.,wyf�fy%%,tyl� I.. 'y. • ..ice' - 'v. r .�' .• .. _ \ ... � 3'.._ � `.y ._ :,•. ` .•; k ,acoR�® CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 0 3/1 612 0 2 3 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 LuAnn Silano NAME: BNC Insurance Agency PHONE (914)937-1230 (Ax (914)937-1124 AIC No E:t: A/C,No): 90 S Ridge St Ste UL-2 E-MAIL s: Isilano@bncagency.com INSURER(S)AFFORDING COVERAGE NAIC# Rye Brook NY 10573-2836 INSURER A: Stillwater Property&Casualty Insurance Company 16578 INSURED INSURER B Phoenix Mechanical Corp INSURER C 26 Vreeland Avenue INSURER D: INSURER E Elmsford NY 10523 INSURER F COVERAGES CERTIFICATE NUMBER: CL2331410872 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 AUUL15UbK1 POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER MM/DD/YYYY MM/DD/YYYY LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE Fx—]OCCUR PREMISES Ea occurrence $ 100,000 X Contractual Liability MED EXP(Any one person) $ 10,000 A Y MPGR3802-01 03/16/2023 03/16/2024 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER. GENERAL AGGREGATE $ 2,000,000 POLICY PRO ❑LOC PRODUCTS-COMP/OP AGG $ 2,000,000 JECT OTHER I $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000 Ea accident X ANYAUTO BODILY INJURY(Per person) $ A OWNED SCHEDULED BAGR3802-01 03/16/2023 03/16/2024 BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY Per accident BACEE $ X UMBRELLA LIAB OCCUR EACH OCCURRENCE $ 5,000,000 A EXCESS LIAB CLAIMS-MADE XSGR3802-01 03/16/2023 03/16/2024 AGGREGATE $ 5,000,000 DED I X1 RETENTION $ 10,000 $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY y/N STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE ❑ N/A E.L.EACH ACCIDENT S OFFICER/MEMBER EXCLUDED? (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101.Additional Remarks Schedule,may be attached if more space is required) Village of Rye Brook is included as an additional insured when required under written Contract or Agreement. 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 p 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 . Workers' e ...ti STATE C01npei'1Sati£I!1 . �, Board NYS OF 9 NYS WORKERS' COMPENSATION INSURANCE COVERAGE 1 a.Legal Name&Address of Insured(use street address only) 1 b.Business Telephone Number of Insured ADP TotalSource DE IV,Inc. 9146901000 5800 Windward Parkway Alpharetta,GA 30005 1c.NYS Unemployment Insurance Employer uCiF: Registration Number of Insured Phoenix Mechanical Corp. 46-051340 9 26 VREELAND AVE SUITE B Elmsford,NY 105230000 1 d. 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) 133934943 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 3b.Policy Number of Entity Listed in Box"1 a" 938 King Street WC 034299107 NY Rye Brook,NY 10573 All worksite employees working for Phoenix Mechanical Corp. 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 ®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"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 bog"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: David McElroy (Print name of authorized representative or licensed agent of insurance carrier) Approved by: 1 1/0912 0 2 3 (Signature) (Date) Title: CEO North America Telephone Number of authorized representative or licensed agent of insurance carrier: 800-743-8130 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