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HomeMy WebLinkAboutPP24-033 4R '(Z. ,^ tt V 1�N4 Vu`L+ 9J,�yyW4 �O'C VILLAGE OF RYE BROOK MAYOR 938 King Street,Rye Brook,N.Y. 10573 ADMINISTRATOR Jason A. Klein (914)939-0668 Christopher J.Bradbury www.ryebrookny.gov TRUSTEES BUILDING&FIRE INSPECTOR Susan R. Epstein Steven E. Fews Stephanie J. Fischer David M.Heiser Salvatore W.Morlino CERTIFICATE OF COMPLIANCE September 26,2024 Jeffrey Feist&Lauren Feist 18 Rocking Horse Trail Rye Brook,New York 10573 Re: 18 Rocking Horse Trail,Rye Brook,New York 10573 Parcel ID#: 129.75-1-3 This document certifies that the work done under Plumbing Permit #24-033 issued on 3/7/2024 for the installation of a new indirect water heater has been satisfactorily completed. Sincerely, Steven E. Fews Building&Fire Inspector /to a a ■ x ■ i N \ a d a O fI1 s s v O (U v J = M A4 PI rI °Gl C S%J PL4@ a = O W z O A A W m O O H a w � s H a � � � � � W w � � � � o ■ o w W W o r! I] �' z ° 00 ~ w v °n Q O u " n w 1--1 � F � A U 0-1 x ON � ICI M z U CW U c!� z _ � 00 � MM M ■ h� z w w a0-4 w N O o c W o z z c�l� V 9 /a O fwJ C a O V O '.4 l� 4yE_bRC1uh. BUILDING 1EPA,RTMENT VILLAGE OF RYE BROOK MAR - 6 2024 ID 938 KING STREET RYE BROOK,NY 10573 \T E OF RYE BROOK *' uo BUILDING DEPARTMENT l�l;�k.org PLUMBING PERMIT APPLICATION '}� FOR OFFICE USE ONI,I 111' #: PP#: MA Approval Date: r 7 —`— Permit Fee: $ Approval Signature: Disapproved: (Tees are non-refundable) DO NOI :-�1 AR 1 N1 ORK or CONSTRUCTION L,N I IL A i'LRNiFI HAS BEEN iSSLLD B1 'I HE: BLILDING INSPECTOR. THE .XI)IMINISTRATIVE FEE FOR WORK PROGRESSED OR COMPLETED WITHOUT A PERMIT/I_S 12"4, ( F THE TOTAL COST OF CONSTRUCTION WITH A MINIMLI,N1 FEE- OF S7511.00 Application dated, 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 Plumbing as per detailed statement described below.The applicant&property owner,by signing this document agree that said plumbing work will be in conformance with all applicable Federal,State,County and Local Codes. l.Address: 1W L R 16 !! ` ' �l SBL: � p,7�r/-3 /Zone: 2.Proposed Work: Rao COCA. 1vZ;a,., y> C qcc., w/ 8v G,Qee, 3.Property Owner: �� �t ty �c t s Address: IXL- Phone#: `J/5� f 9 Cell#: 2 d) 9 3A 6`/3 email: —/fie eAd.vtr."O 4.Master Plumber: M i LKA- R kit ni No Address: 4IV FrANkli�► 51, �orEel��ku� N4, 1oS'►3(Won Lic.#: 1 1b Phone#: CWLI-3US-4oea Cell#: C1 14-4cio-N3'IS email: M(k 1or'r,rio11Q Pal,CoIv% Company Name:QC..\1t rrimn Q�U„hb�N„�He��;,y 7t•� Address: 4I8 ��P�lltli► 5 � 1 st}c.hjA'L_ N`.f- 105't 5 INDICATE FIXTURES&LINES TO BE INSTALLED AS PER THE FOLLOWING SCHEDULE: Location Water Urinals Drinking Sinks Showers Bath Laundry Domestic Fire Sanitary Natural/ Other* Total Closets Fountains Tubs Tubs Service Service Sewer LP Gas Basement Ist Floor 2nd Floor 3rd Floor 41'Floor 5`s Floor Exterior 5.*List Other Equipment/Provide Details: ae�S t '~' d n t..4 (Notarized Signatures Required Next 2 Pages) -1- 3/3/2023 ST E OF NEW YORK,COUNTY OF WESTCHESTER ) as: f ,being duly sworn,deposes and states that he/she is the applicant above named, (print name of indi dual signing as the applicant) and further states that(s)he is the Master Plumber for the legal owner and is duly authorized to make and file this application. That all statements contained herein are true to the best of his/her knowledge and belief,and that any work performed,or use conducted at the above captioned property will be in conformance with the details as set forth and contained in this application and in any accompanying approved plans and specifications,as well as in accordance with the New York State Uniform Fire Prevention&Building Code,the Code of the Village of Rye Brook and all other applicable laws,ordinances and regulations. Sworn to before nle this tt/ Sworn to before me this day oAR 20 L 7 day of ,20 tg e of Property Owner Signature of Applicant Print Name ofProperty Owner Print Name of Applicant otary Public UNA AL&I Notary Public Notary Public,State of New York No.01 WH6394580 Qualified in Westchester County Commission Expires July 8,2027 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. Applications not properly completed in its entirety and/or not properly signed shall be deemed null and void and will be returned to the applicant. -2- 10/30/2023 BUILDING DEPARTMENT D VILLAGE OF RYE BROOK 938 KING STREET RVE BROOK,NY 10573 MAR — 6 2024 (914)939-0668 VILLAGE OF RYE BROOK ww .r altrc► k.or BUILDING DEPARTMENT AFFIDAVIT OF COMPLIANCE VILLAGE CODE §216 • STORM SEWERS AND SANITARY SEWERS THIS AFFIDAVIT MUST BEAR THE NOTARIZED SIGNATURE OF THE LEGAL PROPERTY OWNER AND BE SUBMITTED ALONG WITH ANY BUILDING OR PLUMBING PERMIT APPLICATION. ANY BUILDING OR PLUMBING PERMIT APPLICATION SUBMITTED WITHOUT THIS COMPLETED AND NOTARIZED FORM WILL BE RETURNED TO THE APPLICANT . STATE OF NEW YORK, COUNTY OF WESTCHESTER l )QQ as: 3l, k �R� �ej 5 i ,residing at, / U �o c/.k;ti�ijol �2 L (Print name) (Addres>\% •cw soii Inc) being duly sworn, deposes and states that (s)he is the applicant above named, and further states that(s)he is the legal owner of the property to which this Affidavit of Compliance pertains at; Rye Brook,NY. Further that all statements contained herein are true,and that to the best of his/her knowledge and belief, that there are no known illegal crass-connections concerning either the storm sewer or sanitary sewer, and fiulher that there are no roof drains, sump pumps, or other prohibited storrnwater or groundwater connections or sources of inflow or infiltration of any kind into the sanitary sewer from the subject property in accordance with all State, County and Village Codes. — tIV-11� "'oA to I - 'Perry Owner(s)) Ili mi. N,iimc of Property Owner(s)) Sworn to before me this , : day of , 20I'Cha f� tan I'mhl��1 LINA WHALEN Notary Public,State of New York No.Ot WH6394580 ©ualified in Westchester County Commission Expires July 8,2027 _3_ 8/12/2021 �yE BR(�vk. cu � 1982 BUILDING DEPARTMENT V ILDING INSPECTOR SISTANT 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 : ' S \\�Cr\\ 1 1J C.. �Adr Se :l fZc,. +. L DATE: - Z LI Z d PERMIT# ISSUEDA 2 Y SECT: 0 !• 7 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 s HTP • 272 Duchaine Blvd, New Bedford, MA 02745 •www.htproducts.com SuperStor Ultra Indirect Fired Water Heater Submittal and Specification Job Name: Location_ Engineer: [Wholesaler: Mechanical Contractor: Notes: Model Number: Specifications: Indirect Fired Water Heater Models • Available in 20 through 119 gallon capacities • Example Model Number:SSU-30N Construction • 316L stainless steel tank tolerates high temperatures and offers superior corrosion resistance • Super-insulated with approximately 2"of environmentally safe,CFC free,water-blown,extra thick foam insulation • Allows less than 1/2 degree Fahrenheit per hour heat loss • Outerjacket constructed of silver finished durable plastic for rust and impact resistance • Stainless steel inlet and outlet connections for all models-side tappings • Internal bent hot water outlet tube extracts 5-7%more hot water from the top of the tank dome • Temperature and pressure relief valve port(not available on all models) • Stainless steel control well for accurate temperature measurement inside vessel High Efficiency Super Flex Heat Exchanger • High output finned 90/10 cupronickel heat exchanger provides maximum corrosion resistance and energy transfer to domestic water • Gasketless heat exchanger design • Low pressure drop through the heat exchanger • 1"NPT heat exchanger inlet/outlet size-all models • Live Steam Applications are allowed ONLY on 80 and 119 gallon SSU / SSU-C models. Pressure of steam in the indirect heat exchanger MUST NOT EXCEED 10 PSI. Additional Features • Standard Limited Residential Use Warranty - Ten (10) years coverage against inner tank leakage from the date of installation • Extended Limited Residential Use Warranty if registered online -Lifetime coverage against inner tank leakage from the date of YJ installation • Standard Limited Commercial Use Warranty- Seven (7) years coverage against inner tank leakagefrom the date of installation • One(1)year warranty coverage on component parts O Included Components • ASME rated Temperature and Pressure Relief Valve(not included with all models) O • Brass Piping Adapters • Control Well Certifications and Ratings Efficiency • ETL Design Certified to meet UL 174 Water Heater Construction Standard O • Lead Free compliant per the Safe Drinking Water Act, Section O O O 1417 • Tested below the maximum allowable standby loss levels of current ASHRAE standards according to ANSI test procedures • Exceeds energy efficiency codes of all states,including California AT M-I , Energy Commission(CEC) • NSF 5 Listed CCOTUS NOTE:HTP reserves the right to make product changes or updates without notice and will not be held liable for typographical errors in literature. 1p-787 Rev.9.23.21 LP-786-A 09/24/21 SUPERSTOR ULTRA MODEL A B C D E CAPACITY DOMESTIC SHIPPING U.S.GAL. CONNECTION WEIGHT SSU-20N 22" 27" 20 GAL. 51 LBS 19-114" p SSU-30N 34" 39-1/2" 62 LBS C 30 GAL. O SSU-30LBN 5-1/4" 9-3/4" 22" 28-1/2" 23-1/4" 3/4"NPT 71 LBS SSU-45N 19-1/4" 45 GAL. 72 LBS 46" 52-1/7' SSU-60N 60 GAL. 109 LBS SSU-80N 6" j 29" 64-3/4" 72" 23-1/4" 80 GAL. 143 LBS 1-1/2"NPT O SSU-1 19N 7-1/4" 30-1/4" 66 74" 1 27" 119 GAL. 212 LBS B O A SUPERSTOR ULTRA COMMERCIAL MODEL A B C D E F G SSU-60CN 5-1/4" 9-3/4" 14" 18.75" 46" 52-1/2" SSU-80CN 6" N/A N/A 29" 64-3/4" 72" 23-1/4" F SSU-119CN 7-1/4" N/A N/A 30-1/4" 66" 74" 27' E O F E O MODEL CAPACITY DOMESTIC SHIPPING U.S.GAL. CONNECTION WEIGHT SSU-60CN 60 GAL. 1"NPT 126 LBS C SSU-80CN 80 GAL. 1 1/2"NPT 175 LBS D D SSU-1 19CN 119 GAL. 242 LBS B �F- 7-71 - i A G I � �G� 45/60 GAL. 80/119 GAL Figure 1-Specifications,Dimensions,and Performance-'AHRI TEST METHOD BASED ON 77"F TEMPERATURE RISE,58"F/135"F W/BOILER WATER AT 180°F 1p-787 Rev.9.23.21 • SUPERSTOR ULTRA 180'BOILER 200'BOILER WATER FIRST WATER FIRST MODEL HEAT EXCHANGER PRESSURE TEST WORKING HOUR RATINGS HOUR RATINGS BOILER BOILER RECOMMENDED SURFACE/VOLUME DROP (FT.) PRESSURE PRESSURE (GAL) (GAL) BTU/SIZE BTU/SIZE FLOW RATE 140'F 1 15'F 140'F 1 15'F SSU-20N 121 168 136 185 84,000 187,000 SSU-30N 15 SO.FT./1.,5 GAL. 6.0 154 212 172 234 102,000 117,000 8 SSU-30LBN 169 234 189 1 257 114,000 131,000 SSU-45N 300 PSI 150 PSI 212 292 237 322 141,000 161,000 20 SQ.FT./2.0 GAL. 7.9 10 SSU-60N 266 370 298 405 174,000 198,000 SSU-80N 9.1 330 440 370 503 212,000 241,000 12 34 SQ. FT./3.0 GAL. SSU-119N 11.3 423 1 564 474 645 269,000 301,000 14 SUPERSTOR ULTRA COMMERCIAL 180'BOILER 200'BOILER WATER FIRST WATER FIRST 180'F 200'F MODEL HEAT EXCHANGER PRESSURE TEST WORKING HOUR RATINGS HOUR RATINGS BOILER BOILER RECOMMENDED SURFACE/VOLUME DROP (FT.) PRESSURE PRESSURE (GAL) (GAL) BTU/SIZE BTU/SIZE FLOW RATE 140'F 1 15'F 140'F 1 15'F SSU-45CN 6.8 314 414 351 477 215,000 246,000 20 40 SQ.FT./4.0 GAL. SSU-60CN 9.2 354 467 396 539 245,000 270,000 22 300 PSI 150 PSI SSU-80CN 68 SQ.FT./6.0 GAL. 10.0 490 647 548 745 331,000 374,000 24 SSU-119CN 12,7 637 i 841 713 970 425,000 490,000 28 'DOE TEST METHOD BASED ON 90'F TEMPERATURE RISE,50'/140'W/BOILER WATER AT 180'F LP-730-A NOTE:TANK RECOVERY FROM COLD START WILL BE BETWEEN 10-13 MINUTES WHEN SIZED WITH CORRECT FLOW RATE,BOILER SIZE AND 9/24/21 PRESSURE DROP RATINGS FROM LIST IN ABOVE CHART. Table 1-Specifications Continuous Flow Performance Calculation First Hour Rating-(.75 X Tank Capacity)=Continuous Flow Example:SSU-45CN=314-(.75 X 45)=280.25 Typical Specifications The indirect fired water heater shall be an HTP model# with a gallon storage capacity,with a recommended boiler input of BTU/hr and a 180OF(82.2°C)boiler input first hour rating of Gallons at 140OF(600C). The tank shall be constructed of 316L stainless steel,and have a working pressure of 150 PSI (1,034 kPA)and test pressure of 300 PSI.The water heater shall be design certified by ETL to meet the UL 174 Water Heater Construction Standard,and meet or exceed the standby loss requirements of ASHRAE. Water heaters shall be supplied with "NPT stainless steel side inlet and outlet connections.The outlet connection features a bent tube to draw the hottest water from the top of the tank. The water heater shall be equipped with a stainless steel control well.Some water heaters will be shipped with an ASME Rated temperature and pressure relief valve. Models with a"C"Suffix are equipped with dual heat exchangers for indirect hot water heating from multiple sources. Models with an W Suffix ship with an installed anode rod. Residential use water heaters shall be covered by a standard ten(10)year limited warranty against inner tank leakage,or an extended lifetime limited warranty when registered online with HTP. Commercial use water heaters shall be covered by a standard seven (7) year limited warranty against inner tank leakage.See product warranty for specific coverage details. The surfaces of these products contacted by consumable water contain less than 0.25%lead by weight,as required by the Safe Drinking Water Act,Section 1417. Water heaters shall be listed to meet the requirements of NSF Standard 5. Maximum unit dimensions shall be length inches,width inches and height inches.Maximum unit weight shall be pounds. 1p-787 Rev.9.23.21 CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DDIYYYY)03/06/2024 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 Meagan Wamer Quinton Insurance PHOAC.NENo,Et,. (800)454-1970 (FAX No): (585)388-9531 2700 Elmwood Ave E-MAIL ADDRESS: service@quintoninsurance.com uintoninsurance.com INSURERS AFFORDING COVERAGE NAIC# Rochester NY 14618 INSURER A: ERIE INSURANCE CO 26263 INSURED INSURER B: HARTFORD CASUALTY INSURANCE COMPANY 29424 Pellegrino Plumbing&Heating, Inc INSURER c: SHELTERPOINT 81434 418 FRANKLIN ST INSURER D: INSURER E: PORT CHESTER NY 10573-3521 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. ILTR TYPE OF INSURANCE ADOL SUBR POLICPOLICY NUMBER MM/DDY EFF POLICYMM/DD EXP LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED CLAIMS-MADE �OCCUR PREMISES Ea occurrence) $ 1,000,000 X Primary&Non-Contributory MED EXP(Any one person) $ 5,000 A Q28-5420126 04/04/2023 04/04/2024 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY CET LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: $ AUTOMOBILE LIABILITY COEa accidentMBINED SINGLE LIMIT $ 1,000,000 ANY AUTO BODILY INJURY(Per person) $ A OWNED X SCHEDULED Q04-8030229 04/30/2023 04/30/2024 BODILY INJURY(Per accident) $ AUTOS ONLY /� AUTOS XHIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY X AUTOS ONLY Per accident $ UMBRELLA UAB OCCUR EACH OCCURRENCE $ EXCESS LIAR HCLAIMS-MADE AGGREGATE $ DED I I RETENTION$ $ WORKERS COMPENSATION X STATUTE ERH AND EMPLOYERS'LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE Y/N E.L.EACH ACCIDENT $ 1,000,000 D B OFFICER/MEMBER EXCLUDE ❑Y N/A 01 WECAC9W24 04/04/2023 04/04/2024 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,000 NYS Disability and Paid Family C Leave D254550 06/07/2023 06/07/2024 Statutory DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be 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 Village of Rye Brook ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE 938 King Street Rye Brook NY 10573 91988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD hEw c Workers' CERTIFICATE OF �S9TATE Compensation Board NYS WORKERS" COMPENSATION INSURANCE COVERAGE 1a.Legal Name&Address of Insured(use street address only) 1b.Business Telephone Number of Insured Pellegrino Plumbing & Heating Inc. 914-305-4002 418 Franklin St. 1c.NYS Unemployment Insurance Employer Registration Number of Port Chester, NY 10573 Insured Work Location of Insured (OrNy required if coverage is specitfca#y limited to 1d.Federal Employer Identification Number of Insured or Social Security certain locations it New York State.i.e.,a Wrap-Up Policy) Number 54-2107173 2.Name and Address of Entity Requesting Proof of Coverage 3a.Name of Insurance Carrier (Entity Being Listed as the Certificate Holder) Hartford Fire & Casualty Group Village of Rye Brook 3b.Policy Number of Entity Listed in Box«1a« 938 King Street 01 WECAC9W24 Rye Brook NY 10573 3c.Policy effective period 04/04/2023 to 04/04/2024 3d. The Proprietor,Partners or Executive Officers are ❑ included.(Only check box if at partnerslofficers 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"1a"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: Aimee Nuara (Print name of authorized representative or licensed agent of insurance carrier) w� f l��c.t�/Approved by: C����-�_ 03/06/2024 (5 nature) (Date) Title: Chief Operating Officer Telephone Number of authorized representative or licensed agent of insurance carrier: 585-244-9004 x 118 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 (5-17) www.wcb.ny.gov