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HomeMy WebLinkAboutMP24-007 �QyE.DRy � t� ' 19 VILLAGE OF RYE BROOK MAYOR 938 King Street, Rye Brook,N.Y. 10573 ADMINISTRATOR Jason A. Klein (914) 939-0668 Christopher J. Bradbury www.iyebrookny.gov TRUSTEES BUILDING& FIRE INSPECTOR Susan R. Epstein Steven E. Fews David M. Heiser Donald T. Krom,Jr. Salvatore W. Morlino CERTIFICATE OF COMPLIANCE June 3,2025 Bryan Wexler&Nicole Wexler 134 Brush Hollow Crescent Rye Brook,New York 10573 Re: 134 Brush Hollow Crescent, Rye Brook,New York 10573 Parcel ID#: 129.76-1-126 This document certifies that the work done under Mechanical Permit #24-007 issued on 1/10/2024 for the installation of a new oil fired boiler has been satisfactorily completed. Sincerely, Steven E. Fews Building& Fire Inspector /to �yE BRC��. cu � 1982 BUILDING DEPARTMENT [I BUILDING INSPECTOR {a 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 : J Li l rIA d�O 1.LUV .` DATE: PERMIT# —2 ISSUED: SECT: BLOCK: i LOT:� v LOCATION: )J OCCUPANCY: ❑ VIOLATION NOTED THE WORK IS... ❑ ACCEPTED ❑ REJECTED/ REINSPECTION ❑ SITE INSPECTION REQUIRED ❑ FOOTING ❑ FOOTING DRAINAGE ❑ FOUNDATION ❑ UNDERGROUND PLUMBING NOTES ON INSPECTION: ❑ ROUGH PLUMBING ❑ ROUGH FRAMING ❑ INSULATION ❑ NATURAL GAS ❑ L.P. GAS ❑ FUEL TANK ❑ FIRE SPRINKLER ❑ FINAL PLUMBING ❑ CROSS CONNECTION FINAL ❑ OTHER QyE BRC�k cu � 1932 BUILDING DEPARTMENT ,a-$UILDING INSPECTOR ❑ASSISTANT BUILDING INSPECTOR VILLAGE OF RYE BROOK ❑CODE ENFORCEMENT OFFICER 938 KING STREET • RYE BROOK,NY 10573 (914) 939-0668 FAx (914) 939-5801 www.ryebrook.org - - - - - - - - - - - - - - - - - - - - INSPECTION REPORT - - - - - - - - - - - - - - - - - - - - ADDRESS : DATE: PERMIT# ISSUED: SECT: BLOCK: LOT: LOCATION: OCCUPANCY: ❑ VIOLATION NOTED THE WORK IS... ❑ ACCEPTED ❑ REJECTED/ REINSPECTION ❑ SITE INSPECTION REQUIRED ❑ FOOTING ❑ FOOTING DRAINAGE ❑ FOUNDATION ❑ UNDERGROUND PLUMBING NOTES ON INSPECTION: ❑ ROUGH PLUMBING ❑ ROUGH FRAMING ❑ INSULATION ❑ NATURAL GAS ❑ L.P. GAS ❑ FUEL TANK ❑ FIRE SPRINKLER ❑ FINAL PLUMBING ❑ CROSS CONNECTION ❑ FINAL ❑ OTHER a a _o o v � rn U m v o � 0 F� O ` ai O w s°3 0 v V� © H A _ W z �, ° � c . o b p a v o 0 • O L p ° Is, Ln a 1 in O W W Ocaw a, w Z �3 z z „ Q 00 clztWn c� o Ca pq oc a H O aW z W cn C d LE 0 5 -o rs, w O Cn r z z ro o V a O O0.4 ix [� a H �i Q ✓ U z 0 Q P..y v � s v o W . O O v a U , z 3 o co m oI p U o V a0, 1 § ; � U x . e w i o a �--� A W Z H ° d 5 0 ^O U U W � a� a v w 0 � � BUILDING ISEPA R�TMENT JAN 10 2024 D) VILt��ttCE OF RYE�`OOK 938 KIN STREET RYE BR00 NY 10573 I VILLAGE OF RYE BROOK (914)939-0668 FAX(914): 39-5801 l B111L171NG I�EPAR i MENT ww"v:rvebrook.org APPLICATION FOR PERMIT TO INSTALL AND/OR REMOVE HEATING, VENTILATION AND/OR AIR CONDITIONING EQUIPMENT FOR OFFICE USE ONLY: PERMIT#: Approval Date: 1 14—7.102. Permit Fee:$ Approval Signature: ,P.- Other: Disapproved: (fees are non-refundable) RE UIREMENTS FOR RELEASE OF PF,RMIT&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 ol'Rye Brook must tx:listed as certilic:ue holder)&Workers Compensation Insurance on a NYS Board form(Form#C 105.2 or Form#1J26.31 or NY State Workers Compensation Waiver) 4. Payment of Fees/Unit:RESIDENTIAL=$I00.00/unit•COMMERCIAL=$350.00/unit. 5. Inspection by the Building Department for removal and/or installation.(48 hour notice required 6. Electrical work requires a separate Electrical Permit&Electrical Inspection. 7. Plumbing/Gas work requires a separate Plumbing Permit&Plumbing Inspection. Application dated, 1110/2024 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: 134 Brush Hollow Crescent SBL: 129.76-1-126 zone: Pub 2. Property Owner: Bryan Wexler Address: same Phone#: 516-528-8245 Cell#: email: Robison Oil One Gateway Plaza, Floor 3. Contractor: Address: Port Chester, NY 10573 Phone#: 914-847-0295 Cell#: email: iweir@robisonoil.com 4. Applicant: Same as above Address: Phone#: Cell#: email: 5. Scope of Work:New Installation( )•Replacement(X)•Removal( )•Other( ): 6. List Equipment: Replacement of oil boiler, 7. Location of Equipment: Outdoor Utility Shed. 8. Method of Installation/Removal(list oil equipment needed to perform job): Removal of existing boiler and install new Energy Kinetics EK-1 oil fired boiler. t 6/1/1 B STA FF 01:NEW YORK,COUNTY 01 WESTC1 LESTER ) as: Jean weir being duly sworn,deposes and states that he/she is the applicant above named, Orvlt name of tndrvidual 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 Contractor for the legal owner and is duly authorized to make and file this application. (indicate architect,contraetnr,�,enl,attornty,etc) That all statements contained herein arc 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 Ryc firook and all other applicable laws,ordinances and regulations. r �r Sworn to before me this- Sworn to bcfo e me this r/ day of jl.n `` 20 �I day of �I 20 /Si natu vfPropelny1vOs[vner /_ f_� S'mature LoffApplicant U� 1�� �✓�k��� / Jean Weir Print yme of Property Owns Prii-n-1 anlc- fAp I- t Nolan Public arnanda K olm. -1)ry Pu hi CAROL ANN PRIORS NOTARY PUBLIC,STATE UP NIiW YUR Notary Public Registration No.01OL6417632 Connecticut Qualified in WFSTCIIFSTF.R C my My ComRnttlon Expires May 31,2025 Commission t'xplr21 OVR 025 This application must be properly completed in its entirety and must include the notarized sionature(s)of the legal o%vner(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 Yaill fx returned to the applicant. 2 Wills ■ M • 0 \ �T� • s N N 00 hL�l • N N N a u 1�1—' ■ H C N O p GWG M u i° ►� o Lo x ow 4 z o O W fq N w ° W • 010 H � O L24i � A4 s 00 N z w Wa , Z x � � ; �i Wks O a � W w r- 200 z �a (� w H O w 0 j (A Z u z° C 0 ' W Z M 0.0 a W K, z o " � z = _ �+ x - O A � Z V W N ~ o H N W G DC N ►:� V a w w 3 z ;D W �� 3 a x f� ►n U H 8 a� o w zz � x M z w A 0c ° �I a a z w z � BUIL MENT 3D VIL '�E vF RYA OK FEB 2 3 2 224 938 KIN TYa✓B I NY 10573 VILLAGE OF RYE BROOK rg BUILDING DEPARTMENT ELECTRICAL PERMIT APPLICATION Westchester County Master Electricians License Required �] FOR OFFICE USE ONLY � ►j—C C-7 EP#: D� Approval Date: A��- Pi�) Permit Fee: S Approval Signature: Other: Application dated, 2/19/24 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: 134 Brush Hollow Crescent, Rye Brook NY 10573 SBL: 129.76-1-126 Zone:"jab 2.Property Owner: Bryan Wexler Address: Same Phone#: 9148470295 Cell#: email: 3.Master Electrician: Angelo Zaccagnino Address: R 1 Maple Ave_, Byer NY 105RO Lic.#: 755 Phone#: 914-921-3244 Cell#: email: Office@Zaccag_nino.net Company Name: Address: 4.Proposed Electrical Work/Fixture Count: Wiring of replacement oil-fired boiler 5.31 Party Electrical Inspection Agency: SWIS STATE OF NEW YOM COUNTY OF WESTCHESTER ) as: Angelo Zaccagnino ,being duly swom,deposes and states that he/she is the applicant above named,and does further (print name of individual signing as the applicant) state that(s)he is the legal owner of the property to which this application pertains,or that(s)he is the Electrician for the legal owner and is duly authorized to make and file this application. (indicate architect,contractor,agent,attorney,etc.) The undersigned further states that all statements contained herein are true to the best of his/her knowledge and belief,and that any work performed,or use conducted at the above captioned property will be in conformance with the details as set forth and contained in this application and in any accompanying approved plans and specifications,as well as in accordance with the New York State Uniform Fire Prevention&Building Code,the Code of the Village of Rye Brook and all other applicable laws,ordinances,and regulations. Sworn to lorg me this Sworn to be e ipe this , day of 20 day 0 yy Signature of Prope Owner / SignAure o pptc,4ci Bryan Angelo lnN Print wQfp> NEW YORK Print Na NEW YORK No. 6 0 GA 238 NotarYQb&lft n West hestEr county NO�[]r~in We lest;,,ir County My Comm sion Expires October 14, 2i � My commission Ex ester 14, 20j 6/23/2022 STATEWIDE • Service Willi litlegrilY 0:0 Main Street,Fishkill, NY 12524 1 email:. • SWIS • : APPLICATION0. . e Office Use Elect.Permit# �� /—0 3 7Date I3fdg'PeffraS.#-PA „ /— C(�—7 Utility ID# Final Certificate# City/Village Zip Township County Address Cross Street Section Block TLot Owner Name/Address(if different than above) Contact Number ❑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 Carbon Monox Hood Trash Compact Amt Amps Range(s) Cooktop(s) Oven(s) Dishwashers Refrigerator Disposal Microwave Warm Draw Incandescent Fluorescent SERVICE Amperage Voltage 1 P 3P #Meters #Disconnect ❑Underground ❑New ❑Reconnect ❑Overhead ❑Change <.4 ❑Visual Re Inspection ❑ Safety Re Inspection ❑ Re-Inspection Additional Information In �( � IE FDi FFEiB2 3 2024 VILLAGE OF RYE BROOK s BUILDING DEPARTMENT r This application is valid for one(1)year from We date received by SWIS.This application Is intended to cover the above listed items to be Inspected,If at any time of inspection ddditonal 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 a ress othe Inspection company.The applicant owner or autlwrized agent agrees to all the above terms and conditions as set forth for the application. WrInspector Date Finalized Ins or# Company Name Date Signature Address City/State Zip Code License# Phone# R[ DDState Wide Inspection Services cok--> 1080 Main Street MAR 2 7 2024 Fishkill, NY 12524 asw u s L 845 202-7224 Phone VILLAGE OF RYE BROOK 914-219-1062 Fax STATE WIDE INSPECTION SERVICES BUILDING r)FPARTA11ENT Email: officeCcbswisny.com - _........ Website: www.swisny.com Service With Integrity BY THIS CERTIFICATE OF COMPLIANCE STATE WIDE INSPECTION SERVICES CERTIFIES THAT: Upon the application of: Upon Premises Owned by: Zaccagnino Electric Bryan Wexler Angelo P. Zaccagnino 134 Brush Hollow Crescent 81 Maple Avenue Rye Brook, NY 10573 Rye, NY 10580 Located at: 134 Brush Hollow Crescent, Rye Brook Section: Block: Lot: Electrical Permit Number: EP24-037 129.76 1 126 Certificate Number:2024-1900 Building Permit Number: MP24-007 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: 134 Brush Hollow Crescent,Rye Brook The First Floor 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 27th day of March 2024. Name Quantity Rating Circuit Type Oil Fired Boiler 01 Officer: Frank J. Farina This certificate may not be altered in any way and is validated only by the presence of a seal at the location indicated.This certificate is valid for work performed on the date of inspection only. a `0 co > C00 N N 7 O O 2 m o � C O LL i a a� L ` N a C co 0 N O L w 0 Y U m L 0 N 0 r-� O U C O w L O L a L ca O O N -0 W o 'o m L O 0 Y U m co $� a'o. 3a (V CN'4 ay N o V LO 3 CN Nq :. V-- 41.14 9� P Brush Notlory Cres �- —__.. 23.84 9 eo CO T.6 N N 4wm `t ,t° -- �` co CN CC CN ry a r 0 u ' z _ a s S 2 U CO co C'7 QD . ' a 00 • ' Whisper Quiet/ • I Chimney Venting! „ l l , . • ' ENERGY KINETICS' COMBINED HEAT AND HOT WATER SYSTEN:m u MW r ° rr -+rr. > �1 EK1 and EK2 Frontier EK1 and EK2 Stackable Approved for venting below the breech! NATURAL GAS, OIL or PROPANE Provides nearly endless hot water! a Proven 30 year boiler design With lifetime limited warranty ^w Proudly made in the USA! Pr Y o Whisper quiet operation Serviceable with _ �-� stock parts. 'asts and outperforms other boilers! Hard water?NEWT Our unique SEALIX'coaled plate heat exchanger „ is shielded from mineral build , up and corrosion! .. () Virtually unlimited hot waters I 1. less energy! Plus.I More hot water using .� .. Energy Kinetics' boiler design combines Our both heat and hot water into one unit. Energy Kinetics'hot water tanks use a high- performance plate heat exchanger that allows i the tanks to completely heat from the top down with the energy in the boiler. Our tanks finish hot and fully charged, and the boiler finishes cool with no wasted heat. r � Y YSTEM ❑ can this I code to access our additional ��� .a System 2000 S9' ' 1 ❑• J'i dale online. ___ WITH ENERGYRECOVERY ilt in stand keeps Z:::a Silent ope operation. is the ceramic door for easy System 2000off he cold floor. t�t� quiet chamber and 2"of thick insulation for servicing. more efficiency and quiet operation. . ,:-�•:��r��=-����'�"���� The Quiet Sound! / r_ System 2000 is Virtually silent. At 62 decibels, other boilers NOISE LEVELS OF OTHER BOILERS: �r� I � 1 make it hard to hear a TV in the next room. At just 47 decibels — the sound of a private conversation— System 2000 is virtually S tern FK Y, -- silent!To understand 2000' of how significant this decibel difference is, realize that . i a boiler that is just one decibel higher is 30 percent louder! FOOD BLENDER VACUUM CL EANER ROOM AIR CONDITIONER A1ICROWAVE OVEN A boiler that's just one decibel higher is 30 percent louder! r /-/OPO,�o C�3CO Y C 7+ low r� A 4 r, • YA b _ _ �a f e Y , 4 I/ r S r. t f 93� �� 4 ,' .r ��. a r � ,� _�� ._ ... . � `f , .. i:� .. ,� ., ���.� i T °�'� , �. _ .r d � � �, � ,r _ �'. '�. o r d „r -, �4 x � . z r , 1 - a 7Vyf1���, ��'+ � �l � � �� •� _, ...1� �� ",,, . _ _ _... 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'1j[{(A'3 ��•. • '�/ �q}•' p �j I♦ .�' Mtn �L"7 V' N nE 2; J:1.t� SA ♦s' ,,J1,'IArf 1 {� f■ ��1 f• .��(? �9Y: ..: �.fi.:ti tj:a a•,.lC3k ��£ .,'� � L ���j7;: �►' '_i9y+^„' �c I+�,li,j .•.. i L•J'., i �V��ram. :;U r. <J�1.. �� rc t,,!'"+,>`L%f V'llll°3A lli�r�;x '.��y '�F. `.'a •y i. +�h5h !'. - AM�• :t �'�£ {, ...I,�Y'�'�{;ark.. n _�.`•� i'.f�i�,�f 7 •n. hfi*r�.t.>��� k']'• \ r � f` �r�,,;, rY/� lns ly�osY.:" �rnr�b.rdr = , ` O' iQi�; '• :3�t: J. �`:., �+v},-ir1. �vy�fy�yt•/ ,y � tra rift�.I vI. v. r (rr •dth -- �+v;4�5 t.- -"%ciG.t{,yv�SV i�,� �S!vaS{h• � � S��rVF j'VIGY+•Y,q•'N �:tN .�rv,h��.�1.'+�,1�V G ney�(.51�.Y}.[i,4. �,r f. �.'.`,,.n['.•f•�J 1}..`(t) '.��a�Y(.1,.:`, •,M� •.��.� CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDD/YYYY) 12/27/2023 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 Matthew MOraskl,CISR Arthur J. Gallagher Risk Management Services, LLC PHDNE 18568663252 FAX 4000 Midlantic Drive A/c Ne:856-273-3663 .Suite 200 E-MAIL Mount Laurel NJ 08054 ADDRESS: matthew moraski@AJG.com INSURERS AFFORDING COVERAGE NAICN INSURER Ar New York Marine And General Insurance Company 16608 INSURED SINGHOL-02 INSURER B: Singer Holding Corporation 55 South Main Street,4th Floor INSURER C Port Chester NY 10573 INSURER D INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:2097147374 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. INSRT ADDL SUER LTR I TYPE OF INSURANCEIN.';nvvvnPOLICY NUMBER MMIDD/YYYY1 (MMIDDrYYYYJ LIMITS A X COMMERCIAL GENERAL LIABILITY PK202200020101 12/31/2023 12/31/2024 EACH OCCURRENCE $1,000,000 -(3-A—MAGE TO RENTED CLAIMS-MADE IJ OCCUR PREMISES Ea occurrence S 100,000 MED EXP(Any one person) $5.000 PERSONAL&ADV INJURY $1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $2,000,000 X POLICY D PRO- JECT LOC PRODUCTS-COMP/OP AGG $2,000,000 OTHER: S A AUTOMOBILE LIABILITY AU202200017525 12/31/2023 12/31/2024 COMBINED SINGLE LIMIT $1.000,000 Ea accident IX ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY(Per accident) S HIRED X NON-OWNED PROPERTY DAMAGE AUTOS ONLY AUTOS ONLY Per accident S $ A UMBRELLALIAB X OCCUR EX202200001405 12/31/2023 12/31/2024 EACH OCCURRENCE S5,000,000 X EXCESS LIAB CLAIMS-MADE AGGREGATE S5,000,000 DED I I RETENTIONS S WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY Y/N STATUTE ER ANYPROPRIETOR/PARTNER/EXECUTIVE E L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? ❑ NIA (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE S If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT S DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Village of Rye Brook Building Department is named as an additional insured with respect to the above General Liability Policy,if required by a written contract executed prior to services performed. 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 Building Department ACCORDANCE WITH THE POLICY PROVISIONS. 938 King Street AUTHORIZED REPRESENTATIVE Rye Brook NY 10573 ©1986-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD f� NEW YORitL3f){ f !.._.-� ST E Compensation Board 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 TotalSotrce FL XVII,Inc. 9143455700 5800 Windward Parkway Alpharetta,GA 30005 1c.NYS Unemployment Insurance Employer UCAF: Registration Number of Insured Singer Holding Corporation 45-04510 8 1 Gateway Plaza 4th Floor Port Chester,NY 10573 1d.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) 133121491 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 Building Department 3b.Policy Number of Entity Listed in Box"1 a" 938 King Street Rye Brook,NY 10573 WC 034298819 NY All worksite employees working for Singer Holding Corporation 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 Unat 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 dire 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 oruly 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 fire 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 aut prized representative or licensed agent of insurance carrier) Approved by: !!4"J,4- e. •:.x. 23-APR-2023 (Signature) (Date) Title: CEO North America Telephone Number of authorized representative or licensed agent of insurance carrier: 80067418130 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: wvw.wcb.ny.gov