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Home My WebLink AboutRP23-060PERMIT # `�� - 0 DATE: E(P: 61 �'7 SECTION /�� a S B�LOCK" LOT TYPE OF WORK cd JOB LOCATION OWNER ', COST �wicQFCT10N RECORD DATE FOOTING FOUNDATION FRAMING RGH FRAMING INSULATION PLUMBING M RGH PLUMBING GAS SPRINKLER Q ELECTRIC LOW -VOLT a ALARM AS BUILT 0 FINAL INSP 4/)937- 4M79 OTHER APPROVALS ARB BOT PB ZBA OTHER yE BR . 19 C Cep i ur t�•�1,vu`7 i 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 February 6,2024 James Arnett 43 Winding Wood Road Rye Brook,New York 10573 Re: 43 Winding Wood Road, Rye Brook,New York 10573 Parcel ID#: 135.25-1-3 Roof Permit#23-060 issued on 12/8/2023 to Re-Roof Existing Building This certifies that the new roof,installed under the above captioned permit has been satisfactorily completed. Sincerely, Steven E. Fews Building&Fire Inspector /to DLE C E V E R n For office we only: D ' BUII,DING`DEPARTMENT pr.R;<atT n - . JAN 2 9 2024 VILLAGE OF RYE 11k6OK ISSUED: 9 8 KING STREill'iRYE BROOK,Nm YORK 10573 DATE: VILLAGE OF RYE BROOK (914) 93%o0668 : r FEE: PAID BUILDING DEPARTMENT y'Nyyy.ryebroWor2 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 asatsaaat�iasaaiaataattaw<•a♦♦wrtliwiskaaiikiwi•t<w<s(l�)�afia�kaisal�kktla<kk+Yw Mk<iw Mstilwktaaiwk<i1Yal Mw«wtaa+i<akiraiilwsksi! Address: J ql L i i o W,)LDD `-ba— 2 I� Occupancy/Use: �-' LL Parcel ID 4: ( JJ, as- 1 — Zone: Owner: T6 V"e__5 �Yh e J 1 Address: q 3 v,),n Sin w��1�� (0 P.E./R.A. or Contraclor: ��^ I e J J / �/L C-- Address: �3 L'► /�' Person in responsible charge: �J k1 �` `��( � Address: '43q (.J r IC � , '— R0f}- C --e_1 Tom' 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: TAm f S ARMS%T i being duly swom,deposes and says that he/she resides at 13 y4l,4 5 .4 R4 At,'AX (Print Name of Applicant) (S'o.and Strcct) in Rye Rr-oa K in the County of WeS`fcb,,94r in the State of A_,that (Cihy)Towtr Village) he/she has supervised the work at the location indicated above,and that the actual total cast 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:S i d, \) w for the construction or alteration of: pb Y- Deponent further states that he/she has examined the approved plans of the structureiwork 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 herealler 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 10 Sworn to before me this �U (� day of J_J 1/J1/!�{/K , 20 d t day of _J_q M - , 20_4 MELANIA HRABOVSKY Signature of Property Owner NOTARY PUBLIC,STATE OF NEW YORK Sigjtature 'rApplicant Registration No.01 HR6324159 T�McS ARN+�7T Qualified in Westchester County �-�Lh ��✓� [lO\ Print Name or Properly O er Commission Expires 05104/27 Print Nante of Applicant Nuta Public ublic s i 2.2021 �yE BRC��. cu � �7 /'• 1982•� BUILDING DEPARTMENT ❑BUILDING INSPECTOR ❑ASSISTANT BUILDING INSPECTOR VILLAGE OF RYE BROOK ❑CODE ENFORCEMENT OFFICER 938 King Street . Rye Brook,NY 10573 (914) 939-0668 FAx (914) 939-5801 www ryebrook.org - - - - - - - - - - - - - - - - - - - - INSPECTION REPORT - - - - - - - - - - - - - - - - - - - - ADDRESS : 1 til 1 wJ lS YV � DATE: 2 — y L y PERMIT# '?, 1 2.3— OL L) ISSUED: /l-3-23SECT:, -ZS— BLOCK: LOT: —3 LOCATION: —z p OCCUPANCY: ❑ Violation Noted THE WORK IS... 0-- PASSED ❑ FAILED REINSPECTION ❑ SITE INSPECTION REQUIRED ❑ FOOTING ❑ FOOTING DRAINAGE ❑ FOUNDATION ❑ UNDERGROUND PLUMBING NOTES ON INSPECTION: ❑ ROUGH PLUMBING ❑ ROUGH FRAMING ❑ INSULATION ❑ Natural Gas Re - XI5 ❑ L.P. Gas ❑ FUEL TANK ❑ FIRE SPRINKLER ❑ FINAL PLUMBING ❑ CROSS CONNECTION &-FINAL ❑ OTHER O o C 6d r' O cq N 4c1 M 00oo o~c s Ln ca O �$ `rZ `4 CL �0 F A a v - `J M a. tj . c OI--{ pa pCI bi 4-4 'or ow 00 CN tonU z i K, 00 C1+ �] w CW7 '� '� v z ON ro: ti o o U 00 c U u _ ri O N .4 v lil m r ✓hF�� O 'Wy � �► � H � � � � � � 1--1 r-e z z V w C3 2 — a D V U Z V o �:f x Z w od : _ 0 q Q ] ,p v an = _ m BUIL MENTRV E OF RYE OK DEC - 5 2023 938 KING ET RYE BR € NY 10573 -0 VILLAGE OF RYE BROOK BUILDING DEPARTMENT FOR OFFICE USE ONLY: 11C Approval Date: �. y! 1023 mr : Application# Approval Signature: ARCHITECTURAL REVIEW BOARD: Disapproved: Date: BOT Approval Date: Case# : Chairman: PB Approval Date: Case# Secretary: ZBA Approval Date: Case# Other: ,,\\ Application Fee: Permit Fees: 'mw 6 -fhb 11 ROOF PERMIT APPLICATION Application dated: is hereby made to the Building Inspector of the Village of Rye Brook,NY,for the issuance of a Permit to Re-Roof an Existing Building,as per detailed statement described below. � J /� I. Job Address: ` 3 WIn 10q Wob +�k /V i SBL: �S' —3 Zorn�e/C— Property Owner: �Gt 1/yr� A d`n E'i __Address: mil'. i0 C yo J Phone#: I`1 "D�30 ' Offg Cell#: email:,T, .(-YA4 Y"I 2. Applicant: C)DLdo k P j 55 66 C Address: q 3 W Jf� ' ��. ✓ G Phone#: `1 l V` 93 n I —q;l� ) a/; �j,� r EI _Cell#: email: � , � 1.•i bra-( „q!x*�/, 3. Roofing Contractor DU 1, l � Q J L Address: `13'l L-1�1 e�—,�Ay- CCA ��:^^�� rS Phone#: +I ��'13�'`f�� 1 Cell# email: 01.,kdej 4. Job Description,list all Methods&Material . VL 5. Estimated Cost of Job: $ I D , '70 0 (NOTE: The estimated cost shall include all site improvements,labor,material,scaffolding,fixed equipment,professional fees,and material and labor which may be donated gratis.) G. If corner property,indicate street frontage: 7. Construction Type: r NYS Construction Class: 8. Number of stories: I Height: 9. Is garage being re-roofed:No: ( •Yes: ( )Attached No:( )•Yes: ( )Number of Cars: 10. Is roof peaked,hip,mansard,flat,etc: Gq k I E1 11. Estimated date of completion: -1- 10130/2023 Please note that this application must include the notarized signature(s) of the legal owner(s) of the above-mentioned property, in the space provided below. Any application not bearing the legal property owner's notarized signature(s) shall be deemed null and void, and will be returned to the applicant. STATE OF NEW YORI COUNTY OF WESTCHESTER ) as: _ T�Gr, So r 4Q 1fo, , 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 legal owner of the property to which this application pertains, or that (s)he is the C_6174:CL6�r 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 f4 Sworn to before me this day of 20 -3 day of fyjt��'"' 20 73 Signature of Property Owner Signat6re of Applicant UVi ES AR,N�-:T7 - c,� O Sjf�11� Print Name of Property Owner Print Name of Applicant . f " L Nola` ublic I rNotary Public fv1ELANIA HRABOVSKY ,NOTARY PUBLIC,STATE OF NEW YORK Registration No. 01 HR6324159 Qualified in Westchester County Comrnission Expires 05/04127 -2- 1013012023 LICENSE NUMBER "THE ORIGINAL" Westchester WC3620OH23 pOUBLE Family Owned And Connecticut 0668826 Operated Since 1960 All Home Improvements - EST. 1960 439 Willett Ave. Port Chester, N.Y. 10573 Tel#(914)937-4279 Fax(914)937-4172 http://www.DoubleRwindows.com James Arnett Nov 27, 2023 43 Windingwood Rd N Rye Brook,NY 10573 Jamtt22@gmail.com 914-280-0898 Insurance: All work involved within the following proposal is covered by Workmen's compensation,Public Liability,and Completed Operations Insurance. Roof Contract Labor and material for the following • Double R to remove the existing shingled roof from the entire house down to the sheathing. • If any additional rotted plywood is found it will be an additional cost. Cost to be determined. • Prepare the edge of roof lines with 6 feet of ice/water shield including all valleys. (standard is 3 feet) • Install a GAF Pro Armor synthetic base sheet on the remainder of roof in place of tar paper. • Install all new F- 5 white aluminum drip edge around the entire perimeter edge of roof. • Install the new GAF Timberline shingled roofing system in the color of your choice • Supply and install copper flashing on the chimney. • Supply a container to cart away any job-related debris. Labor and materials $12,700 for entire house, includes copper for chimney. Terms: Painting,and windows cleaning to be done by others.Hidden rotten wood not included. Standard industry cash term,one half with the order,balance due upon completion. Terms may be modified to meet special conditions. Past due balances are subject to a monthly service charge of 1 1/2%(18%per annum). If the account becomes delinquent,we agree to pay any legal or collection fees expended by Double"R"arising from collection of the account.Permit&Application fees not included.Due to the Fluctuating prices in plywood,we reserve the right to adjust price. Double"R"is not responsible for reconnecting existing alarm systems on windows and doors. You the owner may cancel this transaction at any time prior to midnight of the third business day. After the date of this transaction,such Cancellation must be made in person,at the offices of community improvements,or in writing postmarked prior to the fourth business day.We accept VISA or Mastercard with a 3.5%convenience surcharge on total amount being charged. Acceptance: The above prices,specifications and conditions are satisfactory and are accepted. Double"R"is authorized to do the work as specified. Contractor Performance Warranty: Double"R"proposes to furnish and install labor and material in accordance with above specifications in order that the above qualifies for the Manufacturer's Long-Term Warranty. In addition,all labor provided by Double"R"is unconditionally warranted for a period of Two years from the date of installation. Approximate Start Date: Approximate Completion Date: Customer: $12,700.00 (Amount) Date: (sales Tax) Double "R": $12,700.00 (Total Amount) Date: $6,350.00 (Deposit) $6,350.00 (Balance Due Upon Completion) Return original contract to Double"R", retain a copy for your records. Visit Our Showroom Located At 439 Willett Avenue Port Chester, N.Y. 10573 Timberline HDZ® Specs •ABOUT •DOCS •VIDEOS SPECIFICATIONS (ALL DIMENSIONS ARE NOMINAL) AWARDS & RECOGNITION Good Housekeeping Rated 25-YEAR STAINGUARD PLUSTM ALGAE PROTECTION LIMITED StainGuard PIusTm Algae Protection Limited Warranty WARRANTY DURABILITY & TOUGHNESS Advanced Protection Shingle with GAF Dura Grip Adhesive EXPOSURE 5.625" (144 mm) EXTREME WEATHER IMPACT No RATED FIRE RATING Highest Rating -Class A MATERIAL Fiberglass Asphalt Construction WIND RATING Eligible for the WindProvenTm Limited Wind Warranty when installed with four required GAF accessory products SHINGLE STYLE Wood-Shake Look SHINGLE TYPE Architectural Shingles APPROX. NAILSISQ 256 CODES FBC State of Florida Approved ICC ESR-1475 SPECIFICATIONS (ALL DIMENSIONS ARE NOMINAL) ICC AC438 ESR-3267 MIAMI-DADE COUNTY Miami-Dade County Product Control Approved TDI Meets requirements of the Texas Department of Insurance TESTING METHODS & APPLICABLE STANDARDS TAS 100-95 Yes ENERGY RATING COOL ROOF RATINGS CRRC-rated (White only) COUNCIL (CRRC) MIAMI 21 (FLORIDA BUILDING CODE) Yes(White only) TITLE 24 (CALIFORNIA ENERGY Yes (two colors only) COMMISSION) SHIPPING AND PACKAGING APPROX. PIECES/SQ 04 APPROX. BUNDLES/SQ 3 5 22. 1:18 Phi Try WeatherWatchO Leak Barriers on Your Roof I GAF Roofing Specifications WeatherWatch° Ice & Water Leak Barrier Specs ABOUT SPECS DOCS VIDEOS (HTTPS://WWW.GAF.COM/EN- (HTTPS://WWW.GAF.COM/EN- (HTTPS://WWW.GAF.COM/EN- (HTTPS://WWW.GAF.COM/EN- US/PRODUCTS/WEATHERWATCH- US/PRODUCTS/WEATHERWATC H- US/PRODUCTS/WEATHERWATCH- US/PRODUCTS/WEATH ERWATCH- ICE-AND-WATER-LEAK-BARRIER) ICE-AND-WATER-LEAK- ICE-AND-WATER-LEAK- ICE-AND-WATER-LEAK- BARRIER/SPECIFICATIONS) BARRIER/DOCUMENTS) BARRIER/VIDEOS) SPECIFICATIONS (ALL DIMENSIONS ARE NOMINAL) COMPOUND Asphalt EXPOSURE Up to 60 days REINFORCEMENT Fiberglass mat SURFACING Mineral COMPOUND:Asphalt EXPOSURE:Up to 60 days REINFORCEMENT:Fiberglass mat SURFACING:Mineral CODES MIAMI-DADE COUNTY MiamkDade County Product Control Approved FBC State of Florida Approved ICC ESR-1322 MIAMI-DADE COUNTY: Miami-Dade County Product Control Approved FBC:State of Florida Approved ICC :ESR-1322 https://www.gaf.com/en-us/products/weatherwatch-ice-and-water-leak-barrier/specifications t/2 5:2:4. 1 18 PM Try WeatherWatchO Leak Barriers on Your Roof I GAF Roofing Specifications Get automatic Lifetime Protection on your entire GAF roofing system When you install any GAF Lifetime Shingle and at least 3 qualifying GAF accessories,you'll automatically get a Lifetime LIFETIME LIMITED limited warranty on your shingles and all qualifying GAF WARRANTY TERM accessories' hftps://www.gaf.com/en-us/products/weatherwatch-ice-and-water-leak-barrier/specifications 2/2 \ �J � v O LO iT L > w p N \ y ._ N L U CU ca •:. h � .. y a+ u U G o i I- O 1^ •"'1 W LO U V� J CD LIJ } O co of s tOl8Gt1011 � °' Q F� 4 r J o o M x e O c .� 8Q ; oO i/ ( � o Q � '•Y / A ° � \ a 0 M "; W _ a� N Cl •C U C CNO v >U L 2 d � 14 Pwfiwq DATE(MM/DD/YYYY) . 66. R CERTIFICATE OF LIABILITY INSURANCE 1 17,2023 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 NAME: Betty Reyes The Willett Insurance Agency A/CO,NNo Eat: 914 481-5599 (A/c No): 888 371-9783 338 Willer Ave ADDRESS, bettyreyes,,^athewillettinsurance.us INSURER(S)AFFORDING COVERAGE NAIC# Port Chester NY 10573 INSURER A: Westchester Insurance Company INSURED INSURER B Double R PBJ,LLC INSURER C 439 Willett Ave INSURER D INSURER E Port Chester NY 10573-3179 1 INSURER F COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYri) LIMITS COMMERCIAL GENERAL LIABILITY FJ1CH OCCURRENCE $ 1,000,000 CLAIMS-MADE Ex-J OCCUR PREMISES Ea occurrence $ 100,000 MED EXP(Any one person) $ 5,000 A BP4904585Q2022 12/13/2022 12/13/2023 PERSONAL&ACV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY ❑PRO- ❑ JECT LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: $ AUTOMOBILE LIABILITY cam Ea accident $ ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY Per accident UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB HCLAIMS-MADE AGGREGATE $ DED I I RETENTION$ $ WORKERS COMPENSATION - ND EMPLOYERS'LIABILITY Y/N STATUTE I ER ANY PROPRIETOR/PARTNER/EXECUTIVE❑ N/A E.L.EACH ACCIDENT $ FFICERWEMBER EXCLUDED? Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ f yes,describe under ESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,maybe attached if more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN The 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(2016103) The ACORD name and logo are registered marks of ACORD NEW Workers' sOaTe Compensation CERTIFICATE OF Board NYS WORKERS' COMPENSATION INSURANCE COVERAGE 1a.Legal Name 8 Address of Insured(use street address only) 1b.Business Telephone Number of Insured Double R PBJ,LLC 914 937-2237 439 Willett Ave Port Chester.NY 10573 lc.NYS Unemployment Insurance Employer Registration Number of Insured Work Location of Insured(Only required if coverage is specifically limited to 1d.Federal Employer Identification Number of Insured or Social Security certain locations in New York State,i.e.,a Wrap-Up Policy) Number 92-1106938 2.Name and Address of Entity Requesting Proof of Coverage 3a.Name of Insurance Carrier (Entity Being Listed as the Certificate Holder) NYSIF The Village of Rye Brook 938 King Street 3b.Policy Number of Entity Listed in Box"I a" Rye Brook,NY 10573 8910587 3c.Policy effective period ivnwvrov to i?ngt?ms 3d.The Proprietor,Partners or Executive Officers are ❑ included.(Only check box if all partners/officers included) Z 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"l a"for workers' compensation under the New York State Workers'Compensation Law.(To use this form,New York(NY)must be listed under ItgnJ3 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". Will the carrier notify the certificate holder within 10 days of a policy being cancelled for non-payment of premium or within 30 days if cancelled for any other reason or if the insured is otherwise eliminated from the coverage indicated on this certificate prior to the end of the policy effective period? EYES ONO 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 1 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: Betty Reyes (Pnnt na uthorized representative or licensed agent of insurance carrier) Approved by: m (Sign ure) (Date) Title. Insurance representative Telephone Number of authorized representative or licensed agent of insurance carrier: 914 481-5599 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(9-15) www.wcb,ny,gov