HomeMy WebLinkAboutMP23-163 DR �. tC 4n J o' V � w 1�V4 Vint 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.aebrook.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 Roy Tumpowsky 64 Winding Wood Road Rye Brook,New York 10573 Re: 64 Winding Wood Road, Rye Brook,New York 10573 Parcel ID#: 135.34-1-14 This document certifies that the work done under Mechanical Permit#23-163 issued on 11/16/2023 for the installation of a new condenser,new gas furnace and coil has been satisfactorily completed. Sincerely, Steven E. Fews Building&Fire Inspector /to E BRC��. i-- '982 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 : '� ' �\ DATE: PERMIT# `I ISSUED: �14"SECT: BLOCK: LOT: LOCATION: ( ',3 r i y " ! 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 ❑ Natural Gas ' ❑ L.P. Gas ❑ FUEL TANK .�'_ T ❑ FIRE SPRINKLER ❑ FINAL PLUMBING ❑ CROSS CONNECTION [� FINAL ❑ OTHER m M ' o Vr M v e m TI N id a� ¢ Qa : a M r x 0 x W W O U 3 a pa fv P-r 11 'h4 w ] �D � ¢� cw U, (' �O �• w O r+ H 4-4 . a H (110 O rr Z ,0 O w I s 1 O 4.4 O A Cn ..tea. _ MM J-� 7 �"� q a y a v .% co Q . �T w wx ° ` � �' 76 U = '" a o O z ° 2 W W O U F, oa � � v a W z o Uzvvao v, = 0 1--1 Z M `� W .; Q cn W F � alNO cup �• . � ^ w PQ © � V c 00 rn W A z 94dvan. � . fn V L L 102 U GG U4 o Z � C4 OFF A H o Z z , v � O v � z � W O p O � •� �� a -b I O W �I a� P-4 041 a w x � � b i BUILD TMENT V E OF RYE BROOK NOV 13 2QZ3 938 KING ET RYE BR004 ,NY 10573 2 4 939-066$� k APPLICATION FOR PERMIT TO INSTALL AND/OR REMOVE HEATING, VENTILATION AND/OR AIR CONDITIONING QEO UIPME/NT FOR OFFICE USE ONLY: PERMIT#: Approval Date: NOV Permit Fee: $ � —1 Approval Signature: Other: Disapproved: (fees are non-refundable) xxxxxxxxxxx*xx**x+xxxxxxxxxxx*x,a*x*x**xx**x*xx,tax*x�xx*xxxx,►xxx,xtx*xx,�,r***x**xt**xxxxxxxx*x*xxxxx,txxx,tx 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 fHE TOTAL COST OF CONSTRUCTION WITH A MINIMUM FEE OF$750.00 REOUtREMENTS 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. 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. akir kir�cxfe*itxiexxx*xx#xxxxxx*il'dex*xirxxxxxx,txxx,txxxxtF*xxx,tx,t*xxxxx*,tkx,k,txksYxltkyksksF9e'kit+k+Fdr+kkkMk+°r�rx4rsrkxkkis Application dated,Z/3 c_)X3 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. / I. Address: G9 � LAY-6i ln9 W'0d R� SBL: ��J`J,-34/ ��� Zone: 2. Property Owner: `��t�n�exl ,�tc� Address: Wood 91� Phone#: C'I1 H - 9%- 2C)6q Cell#: email: +k"P Q yG�=._-00o, ,,,r 3. Contractor: ,� �`� 1; �(`C,f�IC'�` Address:�2P1G� �liC� kL �'T Phone#: GM '6C©'tam Cell#: email: 4. Scope of Work: New Installation( )•Replacement(4•Removal O-Other( ): 5. List Equipment: Q&Ab U< AMC,5 S©to 050► CP 1 L 04P IPA 4ahC 1 S �Y' Pt��Cb13 Nab !D 6. Location of Equipm nt: J r C �--; Cv d �if- 7. Method of Installation/Removal(list all equipment needed to perform job): r 10/30/2023 STATE OF NEW YOM COUNTY OF WESTCHESTER ) as: - ,being duly sworn,deposes and states that he/she is the applicant above named, (print name of individual signing as the applicant) 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 State Uniform.Fire Prevention& Building Code,the Code of the Village of Rye Brook and all other applicable laws,ordinances and regulations. fA Sworn to before me this 4 Sworn to before me this �day of Kem� ,20 73 day of J4bQ6rriber ,20� I, Signatrire of Pr perty Owner ature o Applicant ion N)�SStyt0l Print Name of Property Owner Print Name of Applicant Notary Pub 't; Notary Pu is JENNIFER RIVERA .}EMNIFER RIVERA Notary Public-state of New York Notary Public-Stato of Now 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 application must be properly completed in its entirety and must include the notarized signature(s)of the legal owncr(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. 2 10/30/2023 C3 C J Q 0CL y r u 1 � J - ' Street 11• Photo of Heating 8 o//on A M9S80/A C9S80 ff Waar HEATING INPUT:40,000-120,000 BTU/H SINGLE-STAGE, MULTI-SPEED ECM, MULTI-POSITION GAS FURNACE 80%AFUE Contents Nomenclature........................................2 Product Specifications...........................3 Dimensions............................... 5 Airflow Data...........................................7 Wiring Diagrams..................................19 Accessories..........................................20 Minimum Filter Sizes ..........................20 Standard Features Cabinet Features • Heavy-duty stainless-steel,dual- Installation: diameter tubular heat exchanger — AM9S80-upflow, • Single-stage gas valve horizontal left or right • Durable Hot-surface igniter — AC9S80-downflow, • Quiet,single-speed draft induced horizontal left or right • Self-diagnostic control board • Convenient left or right connection • Color-coded low-voltage terminals for gas and electrical service • Multi-speed ECM blower motor • Heavy-gauge steel cabinet with durable baked-enamel finish • California Low NOx emissions models available • Foil faced insulated heat exchanger • Can no longer be installed in California's South Coast Air Quality Management District (SCAQMD)on or after October 1,2019. • AHRI Certified;ETL Listed • UAUV Y VATN i0i V1V AL SY DUIRED By$rEM ENVpDNMF By V"GLA CERIIRED$Y ONV DL CENTiIED BY DNV CL �M •1H09001• =1801�W1= Intertek 'Complete warranty details available from your local dealer or at www.amana-hac.com.To receive the Lifetime Heat Exchanger Limited Warranty(good for as long as you own your home),2-Year Unit Replacement limited Warranty and 10-Year Parts Limited Warranty,online registration must be completed within 60 days of installation.Online registration is not required In California or Quebec SS-AM9S80/AC9S80 www.amana-hac.com 8/21 Amana•is a trademark of Maytag Corporation or its related companies and used under license to Goodman Company,L.P.,Houston,Texas. AM9S80 PRODUCT SPECIFICATIONS HEATING CAPACITY Input 40,000 60,000 60,000 60,000 80,000 80,000 80,000 80,000 100,000 120,000 Natural Gas Output 32,000 48,000 48,000 48,000 64,000 64,000 64,000 64,000 80,000 96,000 LP Gas Output 32,000 48,000 48,000 48,000 64,000 64,000 64,000 64,000 80,000 96,000 AFUE' 80 80 80 80 80 80 80 80 80 80 Available AC @ 0.5"ESP 3 3 3 4 3 4 4 5 S 5 Temperature Rise Range("F) 25-5S 20-50 20-50 20-50 35-65 35-65 35-65 35-65 3S-65 40-70 CIRCULATOR BLOWER Size (D x W) 10"x 6" 10"x 6" 10"x 8" 10"x 8" 10"x 8" 10"x 8" 10"x 10" 10"x 10" 10"x 10" 10"x 10" Horsepower @1075 RPM 0.5 0.5 0.5 0.75 0.5 0.75 0.75 0.75 0.75 1 Speed 9 9 9 9 9 9 9 9 9 9 Vent Diameter Z 4" 4" 4" 4" 4" 4" 4" 4" 4" 4" No.of Burners 2 3 3 3 4 4 4 c 5 6 ELECTRICAL DATA Min.Circuit Ampacity 3 8.7 8.7 8.7 12.45 8.7 12.45 12.45 12.45 12.45 15.3 Max.Overcurrent Device(amps)° 15 15 15 15 15 15 15 15 15 20 SHIP WEIGHT(Ul 86 90 100 1 108 116 120 132 132 132 132 ' DOE AFUE based upon Isolated Combustion System(ICS) 2 Vent and combustion air diameters may vary depending upon vent length.Refer to the latest editions of the National Fuel Gas Code NFPA 54/ANSI Z223.1(in the USA)and the Canada National Standard of Canada,CAN/CSA B149.1 and CAN/CSA B142.2(in Canada). ' Minimum Circuit Ampacity=(1.25 x Circulator Blower Amps)+ID Blower amps.Wire size should be determined in accordance with National Electrical Codes.Extensive wire runs will require larger wire sizes. ° Maximum Overcurrent Protection Device refers to maximum recommended fuse or circuit breaker size. May use fuses or HACR-type circuit breakers of the same size as noted. NOTES • All furnaces are manufactured for use on 115 VAC,60 Hz,single-phase electrical supply. • Gas Service Connection''/:"FPT • Important:Size fuses and wires properly and make electrical connections in accordance with the National Electrical Code and/or all existing local codes. SS-AM9S80/AC9S80 www.amana-hac.com 3 AC9S80 PRODUCT SPECIFICATIONS HEATING CAPACITY Input 40,000 60,000 80,000 80,000 100,000 Natural Gas Output 32,000 48,000 64,000 64,000 80,000 LP Gas Output 32,000 48,000 64,000 64,000 80,000 AFUE' 80 80 80 80 80 Available AC @ 0.5"ESP 3 3 4 5 5 Temperature Rise Range("F) 25-55 30-60 35-65 35-65 40-70 CIRCULATOR BLOWER Size (D x W) 10"X 6" 10"X 6" 10"X 8" 10"X 10" 10"X 10" Horsepower @1075 RPM 1/2 1/2 3/4 1 1 Speed 9 9 9 9 9 Vent Diameter z 4" 4" 4" 4" 4" No.of Burners 2 3 4 4 5 ELECTRICAL DATA Min.Circuit Ampacity 3 8.7 8.7 12.45 15.3 15.3 Max.Overcurrent Device(amps)` 15 15 15 20 20 SHIP WEIGHT(Ill 90 94 107 115 115 DOE AFUE based upon Isolated Combustion System(ICS) ' Vent and combustion air diameters may vary depending upon vent length.Refer to the latest editions of the National Fuel Gas Code NFPA 54/ANSI Z223.1(in the USA)and the Canada National Standard of Canada,CAN/CSA B149.1 and CAN/CSA B142.2(in Canada). 3 Minimum Circuit Ampacity=(1.25 x Circulator Blower Amps)+ID Blower amps.Wire size should be determined in accor- dance with National Electrical Codes.Extensive wire runs will require larger wire sizes. ° Maximum Overcurrent Protection Device refers to maximum recommended fuse or circuit breaker size.May use fuses or HACR-type circuit breakers of the same size as noted. NOTES • All furnaces are manufactured for use on 115 VAC,60 Hz,single-phase electrical supply. • Gas Service Connection X"FPT • Important:Size fuses and wires properly and make electrical connections in accordance with the National Electrical Code and/or all existing local codes. 4 www.amana-hac.com SS-AM9S80/AC9S80 AM9S80 DIMENSIONS Alternate Gas Inlet Alt.Flue Outlet—Horizontal Left A 11/a. B 33'/e' - Alt.Gas Inlet __T 20" ® 235/,6" �Alt.High Voltage High-Voltage Inlet 0 13'/++" Low-Voltage Inlet- Alt.Low Voltage 23„ 28"-mil MODEL • AM9S800403A* 14" 12YZ" AM9S800804B* 17Y2" 16" AM9S800603A* 14" 12%" AM9S800804C* 21" 19'%" AM9S800603B* 17Y2" 16" AM9S800805C* 21" 19Yz" AM9S800604B* 17'/=" 16" AM9S801005C* 21" 19Y2" AM9S800803B* 17Y2" 16" AM9S801205D* 24%" 23" NOTEs • Line voltage wiring can enter through the right or left side of furnace. Low-voltage wiring can enter through the right or left side of furnace. • Conversion kits for high-altitude(4500+ft)natural gas operation are available. Contact your Goodman distributor or dealer for details. • Installer must supply the following gas line fittings,according to which entrance is used: Left:One 909 street elbow;one 2A"pipe nipple;one 902 elbow;straight pipe;one ground joint union Right:Straight pipe to reach gas valve MINIMUM CLEARANCES TO COMBUSTIBLE MATERIALS SIDES REAR FRONT' .• 1" 0" 3" 6" 1" 1" 24"clearance for serviceability recommended. : Single Wall Vent(SW)to be used only as a connector.Refer to the latest editions of the National Fuel Gas Code NFPA 54/ANSI Z223.1(in the LJSA)and the Canada National Standard of Canada,CAN/CSA B149.1 and CAN/CSA B142.2(in Canada). Note:AMFS80 approved for line contact in the horizontal position. SS-AM9S80/AC9S80 www.amana-hac.com 5 Heating&Air Conditioning Air ASXH3 AMERICA'S BRAND FOR COMFORT' ENERGY-EFFICIENT SPLIT SYSTEM AIR CONDITIONER UP TO 14.5 SEER2 1'z TO 5 ToNs Con tents Nomenclature .......................................2 } Product Specifications ..........................3 Expanded Cooling Data ........................4 �"`► Performance Data...............................18 b - Wiring Diagram ...................................20 .,. Dimensions .........................................21 Accessories .........................................21 i i t Standard Features Cabinet Features • Energy-efficient scroll compressor • Removable grille-Style top design • High-density foam compressor compliant with UL 60335-2-40 sound blanket • Venturi for increased velocity of airflow, • Advanced Copeland®CoreSenser" • Attractive Architectural Gray powder-paint Technology finish with 500-hour salt-spray approval • Copper tube/enhanced aluminum • Wire fan discharge grille fin coil-5mm diameter • Steel louver coil guard • Single-speed PSC condenser fan motor . Top and side maintenance access • Factory-installed filter drier • Single-panel access to controls with space • Sweat connection service valves provided for field-installed accessories with easy access to gauge ports • Contactor with lug connection • Ground lug connection • AHRI Certified; ETL Listed eorywywnr corwwrwmr e otuurrawre. a*1lM err•DWs P s CtalffM•1'011Vi1 C op-m Marty YL MP .16D[tl01� ntertek •Complete warranty details available from your local dealer or at www.amana-hac.com.To receive the 10-Year Parts Limited Warranty,online registration must be completed within 60 days of installation.Online registration is not required in California or Quebec.The duration of warranty coverages in Tems differs in some cases. SS-ASXH3 www.amana-hac.com 06/23 Amara*is a registered trademark of Maytag Corporation or its related companies and is used under license.All rights reserved. Supersedes 11/22 PRODUCT SPECIFICATIONS 0• •0 1• 0• 1•' .0 r• COOLING CAPACITY Nominal Cooling(BTU/h) 18,000 24,000 30,000 I 36,000 42,000 48,000 60,000 Decibels(dBA) 68.0 68.0 72.0 70.0 69.0 73.0 73.0 COMPRESSOR RLA 9.0 11.5 12.8 I 14.1 17.7 18.5 25.6 LRA 47.5 59.5 67.8 I 87.4 110.2 124 150 Stage Single Single Single I Single Single Single Single type Scroll Scroll Scroll Scroll Scroll Scroll Scroll CONDENSER FAN MOTOR Motor Type PSC PSC PSC I PSC PSC PSC PSC Horsepower(RPM) 1/8 1/8 1/6 I 1/6 1/6 1/4 1/4 FLA 0.70 0.70 0.95 0.95 0.95 1.30 1.30 REFRIGERATION SYSTEM Refrigerant Line Size' Liquid Line Size("O.D.) %" ''/" /B" I '/e' W. Suction Line Size("O.D.) 3/4-1W. '/ I Y8' lYe' 1%" 1W Refrigerant Connection Size Liquid Valve Size("O.D.) W. %." W, I W. W. Ye' %' Suction Valve Size("O.D.):3 %" W. I 3/4 Valve Connection Type Sweat Sweat Sweat I Sweat Sweat Sweat Sweat Refrigerant Charge4 62 75 78 71 115 120 130 ELECTRICAL DATA Voltage-Phase 208/230-1 208/230-1 208/230-1 I 208/230-1 208/230-1 208/230-1 208/230-1 Minimum Circuit Ampacity 5 12.0 15.1 17.0 I 18.6 23.1 24.4 33.3 Max.Overcurrent Protection 6 20 25 25 I 30 40 40 50 Min/Max Volts 197/253 197/253 197/253 I 197/253 197/253 197/253 197/253 Electrical Conduit Size '/z"or'/" Y:"or'/," Y:"or'/." %"or '/"or%" Yz"or Y2 or'/." Equipment Weight(Ibs) 122 136 151 153 188 215 227 Ship Weight(Ibs) 135 149 166 168 203 235 247 Line sizes denoted for 25'line sets,tested and rated in accordance with AHRI Standard 210/240.For other line-set lengths or sizes, refer to the installation&Operating instructions and/or the long line-set guidelines. ' Wire size should be determined in accordance with National Electrical Codes;extensive wire runs will require larger wire sizes ' Must use time-delay fuses or HACR-type circuit breakers of the same size as noted. ` Installer will need to supply Y,"to Yi'adapters for suction line connections. ' Installer will need to supply%"to 1Y."adapters for suction line connections. ' Must use time-delay fuses or HACR-type circuit breakers of the same size as noted. NOTES • Always check the S&R plate for electrical data on the unit being Installed. SS-ASXH3 www.amana-hac.com 3 EHXSV-SS wor:)ey-euewe'mmm b ? o J V w m m O n � fw Ln S �'v .0 vVi o t�'iL o 0 N v o 3acp n � o = 3 p n � o x3 �cp n � o = 3 p n � o ? 3 C> ? 3 acp n � d CD z a z z s z � c P W A A ~ N p ippp 0o w J 0 m r A W ? A ~ NONPAN J WAO A rrONA O r N0 N w OV 0o W A O O 0 l! 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O W m V Ln " r O v W J to r r O v w to iD in w in Oo to A W W F+ Oo in to A w A N i.i A Ln O w A J ON V N ~ In lrn �A+ v W r to W N J r ~ W r v r r In Ln r v W �- lo tr m N S J V W Ln r S A to r to O S r tD In m N V S m J W r O S A Ln r In O S �- A m r N r r r A OL r N r r r A m i-' r O r r A m r r O r t+ A m r r 0 m r V tD N Ln r V O p to w r V r Ln m r m �1 to J W Ln F+ W V m M v+ r V J m �- O m m r S to 00 A r O C� m N O S A O m r r iD OO A r 00 iT m N in O G O O r F. p r O r r A r O r r A r O r F. p r O In m m r r m m r °1 " In m �' 01 m r m m r A 00 m m O A F+ 4m In r V J r O p Ln VO OD N t0 W oo t71 �J+ N V A FJ W A i-+ O A u' O A 000 A r r A r �, r A r ".mD N m r r O V m N m r O m m r m r O M V N O m V w In Ln V to J to In O O N tp O N O O O V a i p V r N p r r p�p�.� p J r N r r r A V r N ppp�� J iD r r r 0��. p J r r r r r p V r N O bO m to A O N S 00 A LU A O W S in N A w p S w Omi A A O S 00 A N A O S in N O A 'DD p S i.- 0 r+ p J r N pr r r pA� V r N r r r A J r N r r r A v �' F, r W r 0A� J r r r A r A V r r p y . m A 0 0 0 0 Ln A A O r S W N A N S in "J T p O V S 0 Ln A A O V S V W - A ttoo O v_ r W 0 r NH rr J A l00 o m r t . W A J O Orp O p OpJ Irmp V r O OD2 J m Jm m wrLn m m iDW mLn iDrW m m LOAOJwJWAWOm 0 JAON Ln O LnApADw J w p tD w e 5' m 3 3 r A F-, r A L,,, r r A o V V V r f. O V m V r 0 V m V r O t D m rL, p m A tD A iD to OL N V Ja ip OL W In i i j F+ V W O J F' r r m 00 d33+,V9#8LSLt-4, VDI,VOLStNEHXSV— VIVO E)NnoOD a3aNVdx3 l DATE(MM/DD/YYYY) �acoRov CERTIFICATE OF LIABILITY INSURANCE 03/16/2023 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 CONTACT LuAnn Silano NAME: BNC Insurance Agency PH (914)937-1230 FAX (914)937-1124 A/C ONE No Ext: AIC,No 90 S Ridge St Ste UL-2 E-MAIL Isilano@bncagency.com ADDRESS: INSURER(S)AFFORDING COVERAGE NAIL 0 Rye Brook NY 10573-2836 INSURERA: 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. INSIR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER MM/DD/YYYY MWDD LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED CLAIMS-MADE �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 J'E LOC PRODUCTS-COMP/OPAGG $ 2,000,000 POLICY © OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000 Ea accident X ANY AUTO 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 PROPER cdTY DAMAGE $ AUTOS ONLY AUTOS ONLY Peradent BACEE $ X UMBRELLA UAB OCCUR EACH OCCURRENCE $ 5,000,000 A EXCESS LIAB CLAIMS-MADE XSGR3802-01 03/16/2023 03/16/2024 AGGREGATE $ 5,000,000 DEC) I X1 RETENTION$ 10,000 $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY YIN STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE ❑ E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? N I A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ if yes,describe under DESCRIPTION OF OPERATIONS below I E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS I 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 ^ 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 f"""NEW Workers' YM `....... STATE. CoilBoard CERTIFICATE OF 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 1 c.NYS Unemployment Insurance Employer L/C/F: Registration Number of Insured Phoenix Mechanical Corp. 4"5840 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 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 box"3"insures the business referenced above in box"I 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"30,whichever is earfier. 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 C� t- 1 —' 11/09/2023 (Signature) (Date) Title: CEO North America Telephone Number of authorized representative or licensed agent of insurance carrier: tloo 743E130 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