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HomeMy WebLinkAboutMP23-177 BRAn� tt tNIiJJ V G 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 January 23,2024 Eric Schroeder&Sukanya Krishnan 37 Rock Ridge Drive Rye Brook,New York 10573 Re: 37 Rock Ridge Drive, Rye Brook,New York 10573 Parcel ID#: 135.35-1-26 This document certifies that the work done under Mechanical Permit#23-177 issued on 12/12/2023 for the installation of a new water heater has been satisfactorily completed. Sincerely, Steven E. Fews Building& Fire Inspector /to �yE BR k. cu � • �9a2 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: _ O(A �C 2 1 DATE: O 1 PERMIT# m(— 2 —3 7 :2 ISSUED: 1 Z SECT: BLOCK: LOT: 2 LOCATION: /�G SC'n P i✓ 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 IVA .S /j U'j 12 - 2 7 - 0 as ❑ FUEL GTANK •<� u;,/c�� c;; � /2/// � hf�•�c ,y/� ��. ��. ❑ FIRE SPRINKLER _ ❑ FINAL PLUMBING ❑ CROSS CONNECTION ❑-•FINAL ❑ OTHER N \ v a� r� 7� y F y 0-4 10 3 Q z o � x / tiQ WL O �T. O , � - con o w Q N �-� ' E " - � O rq (h E� oo Cn v o o V W ) O U F O O •o v v ' � w oo z U z D a � o A 04 V A z W - oo z Y E� CA - cxi5 cal) y" ? H � Q ~ W x A � � Q z � zz � v� •� � �, = w � CY � w r.r a 0-0 tj r� >4 Q z a vi a y o M Z w Qd . W a � 0 w 0 � � b BUI4D, MENT DEC -5 2023 VILOK 938 KING NY 10573VILLAGE OF RYE BROOD BUILDING DEPARTMENT APPLICATION FOR PERMIT TO INSTALL AND/OR REMOVE HEATING, VENTILATION AND/OR AIR CONDITIONING EQUIPMENT FOR OFFICE USE ONLY: PERMIT #: / /r`1�3 - 1 7 7 Approval Date: U EP r Permit Fee: $ /00 A Approval Signature: Other: Disapproved: (fees are non-refundable) DO NOT START WORK or CONSTRUCTION UNTIL A PERMIT HAS BEEN ISSUED Bl"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 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 R),e gook 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. 8. Plumbing/Gas work requires a separate Plumbing Permit&Plumbing Inspection. Application dated, 11129/23 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: 37 Rock Ridge Dr, Rye Brook, NY 10573, USA SBLI3S,36_4-4/o Zone: — /o 2. Property Owner: Eric Schroeder Address: 37 Rock Ridge Dr,Rye Brook,NY 10573,USA Phone#: 917 224 4053 cell#: email: smokeyl0573@gmail.com 3. Contractor. Dandelion Energy Inc Address: 333 North Bedford Rd Suite 220 Mt Kisco NY 10549 Phone#: 845-649-6073 Cell#: email: jdevore@dandelionenergy.com 4. Scope of Work:New Installation 0O•Replacement( )•Removal( )•Other( ): 5. List Equipment: Install electric water heater 6. Location of Equipment: Install electric water heater — l4s e M�j 7L 7. Method of Installation/Removal(list all equipment needed to perform job): Install electric water heater t 10/30/2023 STATE OF NEW YORK.COUNTY OF WESTCHESTER ) as: Jolm OeVore of dandelion Energy Inc ,being drily 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 maize 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 Sworn to before me this "' day of t ,20 �• day of '" ,20 rgnature of Property Owner Signature of Applicant Eric S roede Print f erty Owner Print l'Name �of Applicant r a Notary Public Notary Public .'�tr l4� SAN®I ralan t l/�ti n MICHAEL ESQUIVEL ,o MA Notary Public-state of New York r YrOolrf �u, NO.OIES6442359 ' or"' Quatified in Westchester County "6 My Commission Expires Oct 11,2026 'this application must be properly completed in its entirety and must include the notarized signature(s)of the legal owner(s)of the subject property,and the applicant of record in the spaces provided.Any application not properly completed in its entirety and/or not properly signed shall be deemed null and void and will be returned to the applicant. 2 10/30/2023 M c c w z W , � M O E• A (v(�s�� O �„� v ON : a 0" W � N �. � A W o4 ►+I M ►"`r O LO 7 z Ln 00 � � 5 ✓ � w A �n j� � � < . � A H w W z > wU z W ►-� �, M O a w � � W � � O uz > o W ' Onow M...� ao CA pA a N S� r A w Cz� • 1�1 � V � V U � v � W • w a ? z F. V zw o O o Cl) 0 3 a d an V O z w A I 01:1 �I w a z w � � _ BUILDING)EPARTMENT DEC -5 2M VH.LAf.E OF RYE$ROOD w 938 KfNo Smm'RYE BROOK,NY 10573 VILLAGE OF RYE BROOK (91' ) 9=0669 BUILDING DEPARTMENT ELECTRICAL PERMIT APPLICATION Westchester County Master Electricians License Required FOR OFFICE USE ONLY OP-#- /" o) 3-- EP#: - Approval Date: DEC Permit Fee:$ Approval Signature: Other: iii!!tt W,R ##t!##!!!!#Hitt!ltiitltli#iiit!#!tt#tti#!#!!t DO NOT START WORK or CONST A PERM AS BEEN ISSUED BY THE HIM-DIN 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 Application dated,/�--5 o')3 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:37 Rock Ridge Dr, Rye Brook, NY 10573, USA SBL: 135.35-1-26 -/p Zone: 2.Property Owner:Eric Schroeder Address: 37 Rock Ridge Dr, Rye Brook,NY 10573,USA Phone#:+1 (917)224-4053 Cell#: email: smokey10573@gM2ii.COM 3.Master Electrician/Licensed Installer:Joe COVais of Dandelion Energy Address: Lic.#:1768 Phone#:845-649-6073 Cell#: email:ldevore@dandelionenergy.com Company Name:Dandelion Energy Inc Address: 333 North Bedford Rd Suite 220 W Kisco NY 10549 4.Proposed Electrical Work/Fixture Count: Install circuits for electric water heater 5.31 Party Electrical Inspection Agency: SWIS t•**:*w**w**::**,r•*,r.*�.*:.,►.,►«..;,�t.rt�:*t+,.......f,.*.*....,�3.,e:....«...t.**.*#•*..t..*•«:.,.max*:.#.*.t... STATE OF NEW YORK,COUNTY OF WESTCHEST'ER ) as: John DeVore of Dandelion Energy irxmmg duly sworn,deposes and states that he/she is the applicant above named,and does further pnin?;:nn.,d u:.lr.•.lu:,l,irnin. ;r-the appllcmi;� state that(s)he is the Joe coveis Of n E1ew for the legal owner and is duly authorized to make and file this application. 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 Firc 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 — day of 20 -3-'b day of 120 Signature of Property Owner Signature of Applicant Eric SeXcIeder John DeVore of Dandelion Energy Inc Print a Prop Owner Print Name of Applicant o Public I Notary Public ]0/302023 MICHAEL ESQUIVEL 41� „°•' 61"1°""°„ Notary Public-State of New York NO.01ES6442359 (n n x1 ei Qualffied in Westchester County `'••�'��• "'ssOMF"°`: rh l ATs My Commission Expires Oct 11,2026 STATE WIDE INSPECTION SERVICES, INC. Service With Integrity I ;0 • • SWIS JOB APPLICATION0. • Office Use Elect. Permit# � Date Bldg Permit# - %A�3 —/ 7 Sq Ft Plumbing Permit# Final Certificate# City/Village �'� Atl(v K Zip Building Dept. (i� ��/Ua County Address ? �` /Cf r Cross Street Section �3�js Block Lot a-t� Owner Name/Address(If different\ man above) Contact Number VG5- ❑Basement ❑ 1st Fl. ❑ 2nd Fl. ❑3rd Fl. ❑More Than 3 Fl. ❑Garage ❑Attic ❑Outside ❑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 ❑ Safety Inspection ❑Consultation 07 1-2 RD EP DEC 12 2 223 3D VILLAGE OF RYE BROOK BUILDING DEPARTMENT This application is valid for one(t)year from the date received by SWIS.This application is intended to cover the above listed items to be inspected,if at anytime 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 the 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 A-1 ( p L 61' r�J y - G�\\ NameP ('G'�` License# ( 7 6 Date 1 r -k lG)i Signature Address I S Pt&v'cl4 f ( City/State fill 4 K I <( Zip Code/ Company d n ( il,`. e e V Phone# State Wide Inspection Services 1080 Main Street JAN 2 2 2024 Fishkill, NY 12524 845 202-7224 Phone 914-219-1062 Fax STATE WIDE INSPECTION SERVICES Email: office(d)swisny.com Service With Integrity Website: www.swisny.com BY THIS CERTIFICATE OF COMPLIANCE STATE WIDE INSPECTION SERVICES CERTIFIES THAT: Upon the application of: Upon Premises Owned by: Dandelion Energy Sukanya Krishnan Joe Covais Eric Schroeder 1 Corporate Drive 37 Rock Ridge Drive Peekskill, NY 10566 Rye Brook, NY 10573 Located at: 37 Rock Ridge Drive, Rye Brook, NY 10573 Section: Block: Lot: Electrical Permit Number: EP23-253 135.35 1 26 Certificate Number:2023-9081 Building Permit Number: MP23-0177 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: 37 Rock Ridge Drive, Rye Brook, NY 10573 The Basement 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 18th day of December 2023. Name Quantity Rating Circuit Type Electric Water Heater/ Pump 01 80 Gallon 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%vork performed on the date of inspection only. r BR"FORD WHITE Featurin BRADFORD WHITE 9 COnn¢Ct��1 W A T E R H E A T E R S AeroTherm® Series Heat Pump Water Heater AeroThermO Heat Pump Model Features: ENERGY STAR®Qualified-Meet or exceed requirements for ENERGY STAR®per the latest ENERGY STAR"criteria revision,as well as most utility rebate programs. Bradford White Connect'"-Turns a Bradford White Water Heater into a smart,connected appliance that can be conveniently controlled from a smart phone or device via an app. a The AeroTherm®Series Control Panel-Provides detailed diagnostic information including water heater fault codes,tank codes,need-to-assess codes,and heat pump codes. Additional functions allow you to monitor the status of temperature sensing thermistors and heating components. -User-Friendly,Easy to Read Display. - LED's Clearly Indicate the Current Operating Mode. - Display Communicates Current Status, Mode and Set Point,and Displays Error Messages When Applicable. Operating Modes Offer Flexibility. - Heat Pump(Only)Mode-Maximizes consumer savings.The most energy-efficient mode as it only utilizes the heat pump. - Hybrid Standard Mode-Saves while experiencing fast recovery.Hybrid mode is the factory setting combining heat pump efficiency and savings with recovery rates of standard electric when needed. - Hybrid Plus Mode-Utilizes bottom heating element as needed. - Electric(Only)Mode-Operates like a standard electric water heater,and eliminates the air flow and sound from the heat pump system when preferred(fastest recovery time,but least energy efficient). -Vacation Mode-Adjusts the temperature set point down to 50OF(10°C)for extended periods of time. T a 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. Can Be Laid Down for Easier Transportation-Easy-to-open,protective packaging. a Easily Accessible Top Mounted Washable Air Finer-User is automatically alerted when the air filter needs to be cleaned. a Operating air temperature range of 35-120°F(2-49°C)for the Heat Pump-(Unit operates in Standard/Electric Mode outside of this range). Photo is of a Backup Electric Heating Elements. RE2H50S10 a Direct Heat Transfer with Immersed Elements-Transfers heat directly and efficiently to the water. Screw-in style. FEATURING: a Insulation System-2"(51mm)Non-CFC foam insulation covers the sides and top of the tank, reducing heat loss.This results in less energy consumption,improved efficiencies,and jacket rigidity. a Water Connections-3r4"(19mm)NPT factory-installed true dielectric fittings extend water heater MICROBmn\A life and simplify water line connections. a Factory-Installed Heat Traps-Design incorporates a flexible disk that reduces heat loss in piping BRADFORD WHITE and eliminates the potential for noise generation. connect. a Protective Anode Rod-Provides added protection against corrosion for long-term,trouble-free service. a T&P Relief Valve-Installed. a Low Restrictive Brass Drain Valve-Durable tamper proof design. ---�` a Meets Requirements for Tier 4 of Advanced Water Heating Specification(AWNS)-Demand .�► response ready with built-in CTA-2045 port. Optional Ducting Kit-Maximum duct length of 75 feet(23m)combined between inlet and exhaust. All models ship with Bradford White Connect-kit from the factory.No need to purchase separate kit. 6 or 10-Year Limited Tank Warranties/6 or 10-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. M C OUS w° ® See complete copy of the warranty included with the heater. �f Microban®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. MANUFACTURED UNDER ONE OR MORE OF THE FOLLOWING U.S.PATENTS:5,682,666:7.634,976,5.660.165:5,954,492.6,056,542.6,935,280;5,372.185,5,485,879;5.574.822:7.971,560;7.992.526.6.684,821;7,334,419; 7,866,168;7,270,087;7,007,748;5,596,952;6,142.216;7,699,026;5,341.770;7,337,517;7,665,211;7,665,210;7,063,132;7,063,133;7,559,293;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 CANADUIN PATENTS:2,314,845;2,50AIA24;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.Vftrayas•Is a mos0erod trademark of Bradford WNlsa Corporation.Mkxaban•Is a raostsrod trademark of Microban Products Company. 1901-G-1222 13RADFORD WHITE Heat Pump Water Heater Featuring conn¢ct1 AeroTherm® Model C.E.C.Listed model Rated DOE Rnt Ihilorm Recovery at 9117 Rise A B C D E F G Approx. Number Nominal Rated Hour Energy Roor Jacket Roor CIL of Boor Roor Water SNppirp VolumeStonge RalYg Favor US 6PN Imp GPH to Top Dies to Water to to Conn. Weight VoMme of Water Conn. T&P Condensate Stze III Imp. Campre>mr Can*—Compraaa Compressor Heater Conn. Can. Can. NPT Gal. Gal. GaL Gal. Only +Bement Only +9emerd In. kI. III. In. In. IIh In. lbs. *RE21,150S10-CON 50 42 45 65 3.44 6 24 5 20 593he 213/4 603/4 8 387/a 4613h6 3/4 195 *RUH65T10-130N 65 54 65 79 3.64 6 24 5 20 6311, 25 651h 8 427/8 513h 3/1 236 *REMOT10-CON 80 67 75 88 3.59 6 24 5 20 7017he 25 731h 8 50% 5811/11 3/4 259 Nmodel er REM DO H � Hnd Lk*Ofm Reomry at 501C RIes• A B C D E F 6 ApproL Nominal obaro Store y Roes Jacket B a Floor Boor C/L of Re Water Shlppkng ge Raft Favor lhemftw to Top Dla to Water to to Conn. Weight Volume of Water Can. T&P Condensate Sire CNW-W cmwmsor Heater Conn. Conn. Conn. NPT Were When When +Bomerd o m mm ram am ram. an. ma k8. *REM010-0011 189 170 246 3.44 23 91 1503 552 1543 203 987 1189 19 Be *RE2H65T10-CON 246 246 299 3.64 23 91 1619 635 1664 203 1216 1305 19 107 *RE211016-CON 303 284 333 3.59 23 91 1799 635 1867 203 1280 1491 19 117 Based on Hybrid Standard Mode with 67.5°F ambient temperature and 50%relative humidity(RH). For 6 year models,change suffix from 10"to"6"; G 6 year models may not qualify for some local rebates. B i 6 year models qualify for AWHS Tier 1. D Uniform Energy Factor and First Hour Rating is based on the latest AHRI directory listings. *=ENERGY STAR*Qualified. PARTSINCLLDED IT C A RE2H50S10 CON ® F D�AdapW olmal D,n"erne' E Q 4 ® ® (6) (8) ® • G InM Du Hld e'lame comps(2 Optional Ducting Kit: B Part No.415-52820-00 D Kit installation also requires-8' (203mm)insulated flexible ducting, ducting support hangers and exterior wall vents for inlet 8 outlet. — (� Additional clearances required for ducting,refer to ducting kit instructions. C A BADF RORD WHITE RE2H65T10-00N E F conn¢ct1 RUH8010-CON Scan OR code to learn more about Bradford White aConnect" General Meets NAECA Requirements.All models are UL listed.These heaters are wired inter-locking(Non-Simultaneous,Single Phase)240V with 4000W upper element and 4000W lower element. All water connections are 3/4'(19mm)NPT and electrical connections are 1/2'(13mm)NPT.All models certified at 300 PSI test pressure(2068 kPa)and 150 PSI working pressure(1034 kPa.)Dimensions and specifications subject to change without notice in accordance with our policy of continuous product improvement.Suitable for Water(Potable)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. —13RADFORD WHITE IS— AMERICAN Sales:800-523-2931 a Fax 215-641-1612 STRONG. 2417 Technical Support-800-334-3393•Email techserv@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 1901-G-1222 ©2022,Bradford White Corporation,USA.All rights reserved. Printed in U.S.A. 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O iq 0 ct IlL t N• I - It y l• �r1 1y 7 \tN �cAs r//I1 ' • _f 1 z � O y o O LL Y J M n' 00 t t N o CU k �,, : �? • . • . _ \7 T / ; y1j11�14l1. .. 11�11+11IIi �sa9 rT;;rlrl,Il!yiRis�3 i 7 11 !!.•1 a �t.. .. . . .. \:. ♦ 1••1./ 11111� g} }.3 q(1�,11111/111tA f µt�ll�lf+! + ♦• $Tw �iE. \:1 �ItitS9•41 1>IIII 1111111 ISI 111 j `11, 11� sh (0)> C A !� v���n �� �",�: w�! .. 1'i4 ���'f7.'1 11, *<�r►y '�. ' ? ll. A d r » 1 rl' .� iit� `!f � t I ♦♦ 1 A /1�1�1 i:. .:. v1id' •t+r7�Fv+�r . 'W�O�Aiti p�pt � Q �.,,tr�./����,t�, O '`� +, ti ` Q :�(1�r A ,'dy ii �j„j �� x� � ✓y,�vt r\:''^�q v�t �..'"{Si+U�'' x V lv. /{�� V4�� "Kt �• �y� i DANDENE-01 RMANDEL ACORO CERTIFICATE OF LIABILITY INSURANCE DATE( YYYY) 918/20212023 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 C NTACT York International PHONE 500 Mamaroneck Ave (A/C,No,Ezt):(914)376-2200 (AJC No):(914)376 2891 Suite 220 EA-p RIL .info yorkintl.com Harrison, NY 10528 INSURERS AFFORDING COVERAGE NAIC N __ INSURER A:Hamilton Insurance Designated Activity Company INSURED INSURER 8, Dandelion Energy,Inc. INSURERC: 333 N Bedford Rd,Suite 220 INSURER D: Mount Kisco,NY 10549 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE ANDL SUBR POLICY NUMBER O ICY EFF POLICY EXP LIMITS A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE FX—]OCCUR ENVPKGH1803226-01 9/8/2023 9/8/2024 DAMAGE TO RENTED 50,000 MED EXP(Any oneperson) 5,000 PERSONAL&ADV INJURY 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE 2,000,000 POLICY�X JECT LOC PRODUCTS-COMP/OP AGG 2,000,rd 000 OTHER. $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Ea accident) $ ANY AUTO BODILY INJURY Per on $ OWNED SCHEDULED AUTOS ONLY AUTOS SSyyNEp BODILY INJURY Per accident $ AUTOS ONLY AUONo ONLY PPe�acGdent AMAGE $ a A X UMBRELLA LU1B M OCCUR EACH OCCURRENCE $ 1,000,000 EXCESS LIAB CLAIMS-MADE ENVXSH1207528-01 9/8/2023 9/8/2024 AGGREGATE 11000,000 DED X RETENTION$ 10,000 WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY Y/N ANY PROPR IET gO ER/PARTNER/EXECUTIVE (Mend t/%In NHj EXCLUDED? El N/A E.L.EACH ACCIDENT $ E.L.DISEASE-EA EMPLOYE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,AddKlonal Remarks Schedule,may be attached If more space Is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Village of Rye Brook THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN g y ACCORDANCE WITH THE POLICY PROVISIONS. 938 King Street Rye Brook, NY 10573 AUTHORIZED REPRESENTATIVE ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD I Workers' YORK STATk COMPellSat.0f) CERTIFICATE OF r.: Boatd 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 CO XXIII,Inc. 8334364255 5800 Windward Parkway Alpharetta,GA30005 1c.NYS Unemployment Insurance Employer uCrF Registration Number of Insured Dandelion Energy Inc 45-17531 7 333 N BEDFORD RD Mt Kisco.NY 105490000 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) 821328341 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. 3b.Policy Number of Entity Listed In Box"1 a" Village of Rye Brook WC 034302915 NY 938 King Street All worksite employees working for Dandelion Energy Inc Rye Brook,NY 10573 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 partnerstofficers excluded. This certifies that the insurance carrier indicated above in box"3"insures the business referenced above in box"1 a"for workers'compensation under the New York State Workers'Compensation Law.(To use this form,New York(NY)must be listed under Item 3A on the INFORMATION PAGE of the workers'compensation insurance policy).The Insurance Carrier or its licensed agent will send this Certificate of Insurance to the entity listed above as the certificate holder in box"2". The insurance carrier must notify the above certificate holder and the Workers'Compensation Board within 10 days IF a policy is canceled due to nonpayment of premiums or within 30 days IF there are reasons other than nonpayment of premiums that cancel the policy or eliminate the insured from the coverage indicated on this Certificate.(These notices may be sent by regular mail.)Otherwise,this Certificate is valid for one year after this form is approved by the insurance carrier or its licensed agent,or until the policy expiration date listed in box"3c",whichever is earlier. This certificate is issued as a matter of information only and confers no rights upon the certificate holder.This certificate does not amend,extend or alter the coverage afforded by the policy listed,nor does it confer any rights or responsibilities beyond those contained in the referenced policy. This certificate may be used as evidence of a Workers'Compensation contract of insurance only while the underlying policy is in effect. Please Note:Upon cancellation of the workers'compensation policy indicated on this form,if the business continues to be named on a permit,license or contract issued by a certificate holder,the business must provide that certificate holder with a new Certificate of Workers'Compensation Coverage or other authorized proof that the business is complying with the mandatory coverage requirements of the New York State Workers'Compensation Law. Under penalty of perjury,I certify that I am an authorized representative or licensed agent of the insurance carrier referenced above and that the named insured has the coverage as depicted on this form. Approved by Michael Price (Print name of d representative or licensed agent of insurance tamer) Approved by: p�i � = +� 20atrne-2023 (Signature) (Date) Title: CEO North America Telephone Number of authorized representative or licensed agent of insurance carrier: 8W-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: cow",.wcb.ny.gov