Loading...
HomeMy WebLinkAboutMP24-063 Qy D Q� '« U' y b 4+tt d � tad C Ctt v . Q VILLAGE OF RYE BROOK MAYOR 938 King Street,Rye Brook,N.Y. 10573 ADMINISTRATOR Jason A. Klein (914)939-0668 Christopher J.Bradbury www.ryebrookM.gov TRUSTEES BUILDING & FIRE INSPECTOR Susan R. Epstein Steven E. Fews Stephanie J. Fischer David M. Heiser Salvatore W.Morlino CERTIFICATE OF COMPLIANCE June 18,2024 David Ruzow&Berdine Ruzow 3 Arrowwood Circle Rye Brook,New York 10573 Re: 3 Arrowwood Circle, Rye Brook,New York 10573 Parcel ID#: 129.26-1-32.2 This document certifies that the work done under Mechanical Permit#24-063 issued on 5/14/2024 for the installation of a new condenser, furnace and coil has been satisfactorily completed. Sincerely, Freddy DiVitto Assistant Building&Fire Inspector /to �E DRcb O� 2m 1982 BUILDING DEPARTMENT ❑BVILDING 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 :�J A i!LckZ c���� ��; � DATE: PERMIT# 1' `� ZLA-0(.3 ISSUED: )/ - Z-11 SECT: ,4, BLOCK: LOT: jpf LOCATION: ` ' rS Y f 1 '"t �.�C(_. OCCUPANCY: ❑ VIOLATION NOTED THE WORK IS... ❑f 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 0 FINAL OTHER �•(I/9 C e s = x M o _ W v \ n H N � � o04 v� n 2 y a W taA w n o0oo A =� w O oI � 0 to I..r o i--i A p = Fil O R] N Ad v 10, a o4 D Q C'O �• WI �r rrl 'j C Q O W 3 W s�/ ° V cn p Q N U Q U a ' ~ 0 py Z ." O �* w o 0o p u Z V m � � EM -0 u w a �7 w zo o U 00 CN �104 O ate " ° Iu _ V av) n 4, V 0 n O-�i Y�1 � F" O Z w o5 U w O zoaa � c� A v U � - 5 a _ L4 � OG w O .80 v y O z z w c o5 N V Q V O N � 6; b �, Z i o8 t'' 7 o M z x d o � °w � � b oE-F w y, . u Q;I m a c a w xcAF b x DR BUILD MENT --" VIL E OF RY OOK 3 MAY 938 KING ET RYE BR NY 10573 ___^ 4 -0 VILLAGE OF RYE BROOK r'31yi.nING DEPARTMENT APPLICATION FOR PERMIT TO INSTALL AND/OR REMOVE HEATING, VENTILATION AND/OR AIR CONDITIONING EQUIPME INT #: FOR OFFICE USE ONLY: `L� PERMIT d — C)(' 3 Approval Date: Permit Fee: $ ,.—)oo Approval Signature: Other: Disapproved: (fees are non-refundable) �,t*********,�,r,�**********�r**�*****,r****�****,r**,twvr,t,r*****��r**,r,r*,r**�r*****�****r********,�**,r*,��,�******,t,►rt DO NOT START WORK or CONSTRUCTION UNTIL A PERMIT HAS BEEN ISSUED BY THE BUILDING INSPECTOR.THE ADMINISTRATIVE FEE FOR WORK PROGRESSED OR COMPLETED WITHOUT A PERMIT IS 12% OF 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 Rye Brook must be listed as certificate holder) &Workers Compensation Insurance on a NYS Board form(Form 0 C105.2 or Form#U26.3/or NY State Workers Compensation Waiver) 4. Payment of Fees/Unit: RESIDENTIAL $100.00/unit •COMMERCIAL=S350.00/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, a —c} is hereby made to the Building Inspector of the Village of Rye Brook for a pennit 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 reguulationns." l I. Address: +1 I Ct(CW �" fuL SBL:/a9i c)ta 30'.ozone:AUb 2. Property Owner: (�3 L'C1tP � .�? Address: Phone#: CiI� '4 'ZG-+I Cell#: email: de2oCe.CZ1 aJ�C1(Y1�1 `C 1^1 3. Contractor: CI�X MC-C�GC�1�S Address: 22.6 \1 C,ezkeid R\J 1�, Phone#: C04-bqc) - IC00 __ ___ Cell#: email:Wecuxn . 4. Scope of Work: New Installation( )•Replacement(JS•Removal( )•Other( ): 5. List Equipment: 2"A!L NQ{�N otC -1Fx ffm,I CC\ IDtyBCi t-,) Qom. 0AQF A422 _ , 0*146C AQ-10 6. Location of Equipment: V Ct1 _ a- t 1n CAC in ockk &P \*30:�e- 7. Method of Installation/Removal(list all equipment needed to perform job): t 10/30/2023 STATE OF NEW YORK,COUNTY OF WESTCHESTER ) as: ,being duly sworn,deposes and states that he/she is the applicant above named, (print name of individual signing,as the applicant) and further slates that(s)he is the Heating,Ventilation and/or Air Conditioning Contractor for the legal owner and is duly authorized to make and file this application. That all statements contained herein are true to the best of his/her knowledge and belief,and that any work performed,or use conducted at the above captioned property will be in conformance with the details as set forth and contained in this application and in any accompanying approved plans and specifications,as well as in accordance with the New York State Uniform Fire Prevention& Building Code,the Code of the Village of Rye Brook and all other applicable laws,ordinances and regulations. Sworn to before me this G Sworn to before me this (3-ffl. day of � ,20� day of 20 ignature of Property Ow ure of A can Fer-4 l 4,0 /2. 1pil 20 41-J J-1 Print N of Pro erty Owner Print Name of Applicant Notary P luftr Notary P Etc JEµµIFER RIVERA Notary Public-State of New York NO.01 R16388056 JENNIFER RIVEItA Qualified in Bronx county Notary Public•State of New York µy comm4ssion Expires Feb 25,2027 N0.OIR16388056 Qualified In Bronx County My Commission Expires Feb 25,2027 This application must be properly completed in its entirety and must include the notarized signature(s)of the legal 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. z 10/30/2023 IN A'V. w` L49lit CIL �•� • �*• '� � �;' �aAw � - Cis � `•I' -. Let j �`• � �~• �.. � � !r ,..ems. .. _. _ t�� . Jam.. AAW ti "DA/K/N Submittal Data Sheet Two-Stage,9-Speed ECM Gas Furnace up to 80%AFUE, 100k BTU/h, Upflow/Horizontal DM80TN1005CN STANDARD FEATURES • Heavy-duty stainless-steel dual-diameter,tubular heat exchanger • Two-stage gas valve provides quiet,economical heating • Durable Silicon Nitride igniter • Quiet two-speed draft inducer tttt�ttr • Self-diagnostic control board with constant memory fault history output to a 3-digit 7 segment LED display and push buttons • Multi-speed(9-speed tap)ECM blower motor • Multiple continuous fan speed options offer quiet air circulation • California Low NOx emissions-compliant models available • Can no longer be installed in Califomia&E 's South Coast Air Quality Management District(SCAQMD)on or after October 1,2019 • AHRI Certified • ETL Listed CABINET FEATURES • Designed for multi-position installation Upflow,horizontal left or right • Convenient left or right connection for gas and electrical service • Cabinet air leakage(QLeak)=2% • Heavy-gauge steel cabinet with durable finish ------ • Foil faced insulated heat exchanger < ®R, 1J - i JN)r(�J •r r .r r rrr:eaia7r/ ap. NOTES • Complete warranty details available from your local dealer or at www.daikincomfort.com.To receive the Lifetime Heat Exchanger Limited Warranty(good for as long as you own your home),the 6-Year Unit Replacement Limited Warranty and the 12-Year Parts Limited Warranty,online registration must be completed within 60 days of installation.Additional requirements for annual maintenance are required for the Unit Replacement Limited Warranty.Online registration and some of the additional requirements are not required in California or Quebec. Daikln North America U.C.IQW1 Kermier Rd,Waller,TX 77484 Daikin City Generated Submittal Data �• -- (Daikin'.s products am subject to continuous improvements.Datkin reserves the right to modify product design,specifications and information in this data sheet without notice and without incumng any obligations) Submittal Date 5/62024 222:18 PM Page 1 of 3 OVDAIKIN Submittal Data Sheet Two-Stage,9-Speed ECM Gas Fumace up to 80%AFUE,100k BTU/h,Upflow/Horizontal DM80TN1005CN PERFORMANCE Two-Stage,9-Speed ECM Gas Product Model No. DMBOTN1005CN Product Model Name: Furnace up to 80%AFUE,100k BTU/h,Upflow/Horizontal AFUE%Rating: 80% Rated Heating Capacity(Btu/hr): Temperature Rise Range(°F) / Furnace Input Capacity(Btu/hr): 100,000 (Low/High): Rated External Static Pressure- Furnace Output Capacity(Btu/hr): 80,000 inWG: Blower Speed(RPM): Blower Motor Rating(HP): 1 Blower Input Power(kW): Blower Available AC Tonnage(L/H): / PRODUCT DETAILS Power Supply(V/Hz/Ph): 115/60/1 Airflow Rate(High/Low)(CFM): 2,073/1,498 Min.Circuit Amps MCA(A): 15.32 Motor Type: Multi Speed ECM Max Overcurrent Protection(MOP) 20 Gas Valve Type: Two Stage (A): Dimensions(HxWxD)(in): 33-3/8 x 21 x 28 Installation Configuration: Upflow/Horizontal Number of Burners: Blower Size Diameter(inch) 10 Heating Vent Diameter in.(Min/Max): / Blower Size Width(inch): 10 Condensate Connection(inch): Sound Pressure()(dBA): Net Weight(lb): 124 Gross Weight(lb): 131 Daikin North America LLC,19001 Kermier Rd.Waller.TX 77484 Daikin City Generated Submittal Data (Daikin's products are subject to continuous improvements.Daikin reserves the right to modify product design,specifications and inrormation In this data sheet iMth=notice and without tirwmng any obligations) Submittal Date-5/62024 222:18 PM Page 2 of 3 FDAIKIN Submittal Data Sheet Two-Stage.9-Speed ECM Gas Furnace up to 80%AFUE, 100k BTU/h, Upflow/Horizontal DM80TN1005CN DIMENSIONAL DRAWING Alternate Gas Inlet Alt.Flue Outlet—Horizontal Left 33%' Alt.Gas Inlet 27Ys" "High-Voltag7/ 11 23s/y. Alt.High Voltage 0 15" Low-Voltage Inlet Alt.Low Voltage 2 � 23" 8" — DIMENSIONS DM80TN0403A* 14" 12%2" 14 28 33% DM80TN0603B* 17%2" 16" 1736 28 333/s DM80TN0803B* 1Tf" 16" 17% 28 33%s DM80TN0805C* 21" 19'fl' 21 28 33s/a DM80TN1005C* 21" 19%" 24Y22 28 33%s DM80TN1205D* 24%" 23" 21 28 33a/s MINIMUM CLEARANCES TO COMBUSTIBLE MATERIALS 1 0 3 C 6 1 1 C=If placed on combustible floor,the floor MUST be wood ONLY NOTES • For servicing or cleaning,a 24"front clearance is recommended. • Unit connections(electrical,flue,and drain)may necessitate greater clearances than the minimum clearances listed above. • In all cases,accessibility clearance must take precedence over clearances from the enclosure where accessibility clearances are greater. • Refer to the appropriate USA and Canadian codes: • In the USA:the National Fuel Gas Code NFPA 54/ANSI Z223.1 • In Canada:the Canada National Standard of Canada,CAN/CSA B149.1 and CAN/CSA B142.2 Daikin Norlh Mrerica LLC,19001 Kermier Rd,Waller,TX 77484 Daikin City Generated Submittal Data _ uTemor.nc„r, (Daikin's products are subject to continuous improvements.Daikin reserves the right to modify product desgn,specifir tians and information in this data sheet without notice and without earring any ob8gations) Submittal Dates 5/612024 2:22:18 PM Page 3 of OVDAIKIN Submittal Data Sheet 14.3 SEER2 AC,3.5 ton DX4SEA4210 STANDARD FEATURES • High-efficiency Copeland®scroll compressor • Advanced Copeland®CoreSensea,O Technology • Copper tube/enhanced aluminum fin coil-5mm diameter on 1.5- 3.OT • High-density foam compressor sound blanket • Factory-installed bi-flow line filter drier r • High-and low-pressure switches • Service valves with sweat connections and easy access to gauge ports • Fully charged for 155ET of tubing length • AHRI Certified • ETL Listed CABINET FEATURES • Removal grille-style top design compliant with UL 60335-2-40 • Venturi for increased velocity of airflow • Custom Nickel Gray powder-paint finish • 500-hour salt-spray tested • Wire fan discharge grille • Steel louver coil guard • Rust-resistant coated screws • Top and side maintenance access • Single-panel access to controls with space pro-vided for field- installed accessories • When properly anchored,meets the 2020 Florida Building Code unit integrity requirements for hurri-cane-type winds(Anchor bracket kits available.) Daikin North America LLC,19001 Kermler Rd,Waler,TX 77484 Daikin City Generated Submittal Data - ww.aa.KncoT':n.w, (Daikin's products are subject to continuous improvements Dakin reserves the right to modify product design,specifications and information in this data sheet without notice and without incurring any obligations) Submittal Dale:5&2024 2:23:16 PM Page 1 of 3 PFDAIKIN Submittal Data Sheet 14.3 SEER2 AC,3.5 ton DX4SEA4210 PERFORMANCE VALUES SHOWN ARE FOR AHRI RATED HIGH SALES VOLUME TESTED COMBINATION (HSVTC) Outdoor Unit Model No. DX4SEA4210 Outdoor Unit Name: 14.3 SEER2 AC,3.5 ton Rated Coding Conditions: Indoor ff DBIWB):80/67 Rated Heating Conditions: Indoor(°F DB/WB):/ Ambient ff DB/WB):195 Ambient( F DB/WB):/ EER: 'EER2: 11.70 SEER: 'SEER2: 14.30 Rated Cooling Capacity(Btu/hr): 40,000 OUTDOOR Power Supply(V/Hz/Ph): 208/230/60 I 1 Compressor Type: Single Stage Min.Circuit Amps MCA(A): Suction Valve Connection Size(Inch): Max Overcurrent Protection(MOP) 40 Liquid Valve Connection Size(inch): 3/8 (A): Rated Load Amps RLA(A): 17.7 Sound Power(High)(dBA): 72 Refrigerant Type: R-410A Cooling Operation Range ff DB): - Holding Refrigerant Charge(ozs): 177 Heating Operation Range ff DB): - Additional Charge(ounces/ft): Max.Pipe Length(Vertical)(it): Pre-charge Piping(Length)(it): 15 Min.Cooling Range w/Battle('F DB). Max.Pipe Length(Total)(ft): Min.Heating Range w/Baffle(°F DB): Net Weight(lb): 260 Gross Weight(lb): 276 Dimensions(HxWxD)(in): 36.5 x 35.5 x 35.5 Daikin North America LLC.19001 Kenner Rd.Waler,TX 77484 Daikin City Generated Submittal Data !nn , (Daikin a products are subject to continuous improvements.Daikin reserves Ore right to noddy,product design,specifications and information in this dots sheet without notice and without nwrnng any obligations) Submi tal Date:5B/2024 2:23:16 PM Page 2 of 3 FDAIKIN Submittal Data Sheet 14.3 SEER2 AC,3.5 ton DX4SEA4210 DIMENSIONAL DRAWING DIMENSIONS MODEL W. D" H" DX4SEA1810A' 26 26 27 DX4SEA2410A' 29 29 32 DX4SEA3010A' 35%: 35%: 39% W D DX4SEA3610A' 35Y, 35Y: 39%: \ DX4SEA4210A' 35Y, 35V, 36Y, DX4SEA4810A' 3 5 Y 35Y, 36%: DX4SEA6010A' 35Y, 35Y: 4IA H Daikin North America LLC.19001 Kartnier Rd,Waller,TX 77464 Daikin City Generated Submittal Data c ww.aa�k•n:o,rcn.cu, (Daikin's products are subject to continuous improvements.Daikin reserves the right to modify product design,specifirations and information in this oat.sheet without notice and without incurring any obligations) Submittal Data:5/6i2024 2,23:16 PM Page 3 of 3 v ♦♦ v v 4 1j°'.11�11' je£:-" q"t.:.1 (1►: i v 'r�i tll�/;l�l�l �: 3ssy .t�1�1�IVl.fir:,r -, Ti tx�tlll//ll�_. :f 1 1 .. 's�> :r,rll aFeAA5 Ul 4,4 C Q. .. C C) C C p \O . > Cd O uAz cn ., •�•���� V w O � W : = O W cM U v) r• _ LO •» �-,��`' Q w o Qtotiection �� G� Z Z E 70 C = O J .. I o X j N O 4a4i fey R +•r N W o LT. �edao ,t ►--i > h Cd 'xn : Ci' <(0)! ca )DI • .a to \� d U cn N N a� a> v_ U o d rn > r� tdc�/�cllr pd �Pcl/llht� �ppgg gg tt� �!tl►c1�Q4'� �)$0�{� 4e►►i0lilt' xt�) g� '►lil�lil►a1 �¢g�`�""'' ' - •• Ai! •1� 1i�ilAi�1 ` ��►) iTiAl*� ���� �1�}ilA��47f ��♦ r�)�•'7A�+•�q� PHOEMEC-03 FHOLZHAY CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DDIYYYY) 064� 3/25/2024 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 ,A ET CT Luann Silano Acrisure Insurance Partners Services of NY,LLC HCNr o,E>d):(914)937-1230 FAX,No 90 S.Ridge Street Rye Brook,NY 10573 E-M ' .lsilano@acrisure.com INSURERS AFFORDING COVERAGE NAIC# INSURER A:Stillwater Property&Casualty Insurance Compan 16578 INSURED INSURER B: Phoenix Mechanical Corp INSURERC: 26 Vreeland Avenue INSURER D: Elmsford,NY 10523 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 ADDL SUBR POLICY NUMBER POLICY EFF POLICY EXPLTR LIMITS A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE X OCCUR X MPGR3802-02 3/16/2024 3/16/2025 DAMAGE TO RENTED $ 100,000 MED EXP(Any oneperson) $ 10,000 PERSONAL&ADV INJURY 1,00000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY F PE LOG PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: $ A AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000 X ANY AUTO BAGR3802-02 3/16/2024 3/16/2025 BODILY INJURY Perperson) $ OWNED SCHEDULED AUTOS ONLY AUTOS SSyyry BODILY INJURY Per accident $ AUTOS ONLY AUUTOS ONLY Per acciden DAMAGE $ A X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 5,000,000 EXCESS LIAB CLAIMS-MADE XSGR3802-02 3/16/2024 3/16/2025 AGGREGATE $ 5,000,000 DED X RETENTION$ 10,000 $ WORKERS COMPENSATION PER I OTH- AND EMPLOYERS'LIABILITY Y/N ANY PROPRIETOR/PARTNER/EXECUTIVE [_1 E.L.EACH ACCIDENT $ WFICER/MEMBEER EXCLUDED? N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Village of Rye Brook is included as an additional insured when required under written Contract or Agreement; CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Village of Rye Brook THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 9 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 J��NEw Workers* ,............1, STATE. C.0111penSatiG � Board NYS OF NYS WORKERS' COMPENSATION INSURANCE COVERAGE 1 a. Legal Name&Address of Insured(use street address only) 1 b.Business Telephone Number of Insured ADP TotalSource DE IV,Inc. 9146901000 5800 Windward Parkway Alpharetta,GA 30005 1c.NYS Unemployment Insurance Employer L/c/F: Registration Number of Insured Phoenix Mechanical Corp. 46-05840 9 26 VREELAND AVE SUITE B Elmsford,NY 105230000 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) 133934943 2.Name and Address of Entity Requesting Proof of Coverage 3a. Name of Insurance Carrier (Entity Being Listed as the Certificate Holder) New Hampshire Insurance Co. Village of Rye Brook 3b. Policy Number of Entity Listed in Box"1 a" 938 King Street WC 034299107 NY Rye Brook,NY 10573 All worksite employees working for Phoenix Mechanical Corp. paid under ADP TOTALSOURCE,INC's payroll,are covered under the above stated policy. 3c. Policy effective period 07/01/2023 to 07/01/2024 3d.The Proprietor, Partners or Executive Officers are Eincluded.(Only check box if all partners/officers included) ❑ all excluded or certain partners/officers excluded. This certifies that the insurance carrier indicated above in box"3"insures the business referenced above in box"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"T'. The insurance carrier must notify the above certificate holder and the Workers'Compensation Board within 10 days IF a policy is canceled due to nonpayment of premiums or within 30 days IF there are reasons other than nonpayment of premiums that cancel the policy or eliminate the insured from the coverage indicated on this Certificate.(These notices may be sent by regular mail.)Otherwise,this Certificate is valid for one year after this form is approved by the insurance carrier or its licensed agent,or until the policy expiration date listed in box"30,whichever is 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: David McElroy (Print name of authorized representative or licensed agent of insurance carrier) Approved by: mac '�►' ' t�"_Z osrosnoza (Signature) (Date) Title: CEO North America Telephone Number of authorized representative or licensed agent of insurance carrier: 800-743-8130 Please Note:Only insurance carriers and their licensed agents are authorized to issue Form C-105.2.Insurance brokers are NOT authorized to issue it. C-105.2 (9-17) Certificate Number: www.wcb.ny.gov