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HomeMy WebLinkAboutBP24-113PERMIT#FJ�d 7 - J DAM, SECTION BLOCN� )d4q TYPE OF WORN 0 Q✓Y12 vCtJ,S JOB LOCATION GU /✓1Q QP O / OWNER /Q Q/ A4,8 Q1v QII CONTRACIUN / C f / L/S M iq O�cxks L - EST. COST FEED �O �//cO # cc FEE O - ,DATE TCO # FEE DATF 1• h�: DATE INSP FOOTING FOUNDATION FRAMING RGH FRAMING INSULATION PLUMBING RGH PLUMBING GAS SPPINKLER ELECTRIC LOW -VOLT O ALARM 0 AS BUILT 0 -eTT FINAL wtj �ASXC w 89 go OTHER APPROVALS ARB BOT Pa ZBA OTHER �yE 4R kC w��.i�,• �G C(tiC(C Jj�vi vl O� VILLAGE OF RYE BROOK MAYOR 938 King Street, Rye Brook,N.Y. 10573 ADMINISTRATOR Jason A. Klein (914) 939-0668 Christopher J.Bradbury www.tyebrookn TRUSTEES BUILDING&FIRE INSPECTOR Susan R. Epstein Steven E. Fews Stephanie J. Fischer David M. Heiser Salvatore W. Morlino CERTIFICATE OF COMPLIANCE June 24,2024 William Cally&Karen Calley 12 Wyman Street North Rye Brook,New York 10573 Re: 12 Wyman Street North, Rye Brook,New York 10573 Parcel ID#: 141.35-1-4.4 Building Permit#24-113 issued on 6/3/2024 for Replacement Windows This certifies that the six new windows,installed under the above captioned permit have been satisfactorily completed. Sincerely, Freddy DiVitto Assistant Building&Fire Inspector /to For office use only: �ss JUN 10 2024 1 i BUILDING DEPARTMENT PER`iIIT# -/l3 VILLAGE OF RYE BROOK ISSUED: —3—� VILLAGE OF RYE BROOK 38 KING STREET,RYE BROOK,NEw YORK 10573 DATE: /0 cry BUILDING DEPARTMENT (914)939-0668 FEE: PAID K www.ryebrook.orp. APPLICATION FOR CERTIFICATE OF OCCUPANCY, CERTIFICATE OF COMPLIANCE, AND CERTIFICATION OF FINAL COSTS TO BE SUBMITTED ONLY UPON COMPLETION OF ALL WORK, AND PRIOR TO THE FINAL INSPECTION ............................................................................................................................. Address: 12 Wyman St N,,,fA,B.,L-r;K NY 10573 - Unit 4 Occupancy/Use: Residential Parcel ID#: 141.35-1-4.4 Zone: kQ F Owner: William Cally Address: 421 West Avenue, Stamford CT 06902 P.E./R.A. or Contractor: Renewal by Andersen Address: Person in responsible charge: Franklin Barahona Address: Application is hereby made and submitted to the Building Inspector of the Village of Rye Brook for the issuance of a Certificate of Occupancy/Certificate of Compliance for the structure/construction/alteration herein mentioned in accordance with law: STATE OF NEW YORK,COUNTY OF WESTCHESTER as: William Cally being duly sworn,deposes and says that he/site resides at 12 Wyman St N,Port Chester NY 10573 • Unit 4 (Print Name of Applicant) (No.and Street) in Rye Brook in the County of Westchester in the State of New York that (citylrown/village) lie/she has supervised the work at tine location indicated above,and that the actual total cost of the work,including all site improvements, labor,materials,scaffolding,fixed equipments.professional fees,and including the monetary value of any materials and labor which may have been donated gratis was:$ /- P I o — for the construction or alteration of: Installation of(6 )replacement windows in to existing openings with no structural alterations Deponent further states that he/she has examined the approved plans of the structure/work herein referred to for which a Certificate of Occupancy/Compliance is sought,and that to the best of his/her knowledge and belief,the structure/work has been erected/completed in accordance with the approved plans and any amendments thereto except in so far as variations therefore have been legally authorized,and as erected/completed complies with the laws governing building construction.Deponent further understands that it shall be unlawful for all owner to use or permit the use of any building or premises or part thereof hereafter created,erected,changed,converted or enlarged,wholly or partly,in its use or structure until a Certificate of Occupancy or Certificate of Compliance shall have been duly issued by the Building Inspector as per§250-IO.A.of the Code of the Village of Rye Brook. Shorn to before me this ID 7 Sworn to before me this 10 d of VnIt, .20 2O day of StJAe , 20 Z� Si nature of Property Owncr Signature of pli William Cally Franklin Barahona Print Name of Properly Owner / Print Name ol'Applicant Notary Public Notary Public BRIAN MACDONALD BRIAN MACDONALD NOTARY PUOIJC NOTARY PUBMC State of Connecticut State of Connecticut MY COMMISSION EXPIRES Oct 31 202t MY COMMISSION EXPIRES Oct 31 2028 QyE BRC�j� 1932 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 : F IV11 I H DATE: L Z J Z `l PERMIT# r 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 p OTHER a w _ � O N CZ• vv � _ ■ � tin � � p„' � a' � +a y gu �C 0-4 a & F-4 ° 2 w W V . `' ° � � Q " Q W H z A o o i °' of E� T S e—+ a O1 v a c!1 CA z Tt oo g � � u Z •d- W v • a Z O W .-. [—b °a a 'a acn 'Q u CA o W w C, N a o 0CA � a W � w z a M A Qv a � � Z ` Q 7 O H p O v 110, = H O O wz4 v. � O A 0 pp ' 0 W � � u � v, 1•■� G1 r'� � Z W y+ cn [� a �' v 3 0 g ma i. y LN � O tz r�-E w H p z z r� U O ° " O V H $ w�° a •" y3 V o V z � � o - C: A w O O N Z rA H w6 . u as A aW. z b xvi � 5 �' •c _ Q BUILDING DEPARTMENT VILLAGE OF RYE BROOK MAY 3 0 2024 938 KING STREET RYE BROOK,NY 10573 (9I4)939-0668 VILLAGE OF RYE BROOK ",%,w.ryebrook.org BUILDING DEPARTMENT ADMINISTRATIVE EXTERIOR BUILDING PERMIT APPLICATION FOR EXTERIOR WORK WHICH DOES NUT REQUIRE VILLAGE ARCHITECTURAL REVIEW BOARD APPROVAL FOR OFFICE USE ONLY: APPROVAL DATE: ^RMIT#/-'/ �s APPLICATION FEE: ,& V "� APPROVAL SIGNATURE: PERMIT FEES: 9 b H.O.A.APPROVAL: . DATE: DISAPPROVED: OTHER: Application dated:May 21, 2024 is hereby made to the Building Inspectorof the Village of Rye Brook,NY,for the issuance ofa Permit for the construction of buildings.structures,additions.alterations or for a change in use,as per detailed statement described below. 1. Job Address: 12 Wyman St N,,(.yp,gyet DIY 10573 - Unit 4 2. ParcellD#: 141.35-1-4.4 Zone: co 3. Proposed Improvement(Describe in detail): Installation of(6 ) replacement windows in to existing openings with no structural alterations 4. Property Owner: William Cally Address: 12 Wyman St N,9W9,-VLKNY 10573 - Unit 4 Phone#(914) 844-8980 Cell#(914) 844-8980 e-mail wvcallyesq@verizon.net List All Other Properties Owned in Rye Brook: Applicant-.Franklin Barahona Address:421 West Avenue, Stamford CT 06902 Phone#203.406.0545 Cell# 203.249.1986 c-mail Permits@RBAWestchester.com Architect: Address: Phone# Cell# e-mail Engineer: Address: Phone# Cell# c-mail General Contractor: Fairchester Custom Windows dba Renewal by Andersen Westchester Address:421 West Avenue, Stamford CT 06902 Phone#203,406.0545 Cell# 201249.1986 c-mail Permits@RBAWestchester.com tll 6,112023 5. Occupancy;(I-Fam_,2-Fam.,Commercial.,etc...)Pre-Construetion: 1-FAM Post-construction: 1-FAM 6. Area of lot: Square feet: Acres: 7. Dimensions from proposed building or structure to lot lines: front yard: rear yard: right side yard: left side yard: other: 8. If building is located on a corner lot,which street does it front on: 9. Area of proposed building in square feet: Basement: 11 fl: 2'fl: 311 fl: 10. `total Square Footage of the proposed new construction: 11. For additions,total square footage added:Basement: 11 fl: 2'fl: 3'fl: 12. Total Square Footage of the proposed renovation to the existing structure: 13. N.Y.State Construction Classification: N.Y.State Use Classification: 14. Construction Type&Location:()Typical Western Lumber Frame;()Timber Frame[TC];O Wood Truss[TT]; ()Pre-engineered wood[PW];Located;O Floor Framing[F];O Roof Framing[R];()Floor&Roof Framing[FR];Other: 15. Number of stories:3 Overall Height: Median Height: 16. Basement to be full,or partial: finished or unfinished: 17. What material is the exterior finish: 18. Roof style:peaked,hip,mansard,shed,etc: Roofing material: 19. What system of heating: 20. If private sewage disposal is necessary,approval by the Westchester County Health Department must be submitted with this= application. 21. Will the proposed project require the installation of new,or an extensionlmodification to an existing atic fire= suppression system?(Fire Sprinkler,ANSL System,FM-200 System,Type I Hood,etc...)Yes:_--No: (if yes,applicant must submit a separate Automatic Fire Suppression System Permit application&2 sets of detaile engineered plans) 22. Will the proposed project disturb 400 sq.ft.or more of land,or create 400 sq.ft or m / impervious coverage requiring a= Stormwater Management Control Permit as per§217 of Village Code? Yes: No V Area: 23. Will the proposed�ct require a Site Plan Review by the Village Planning Board as per§209 of Village Code? Yes: No:Ly (tf yes,applicant must submit a Site Plan Application,&provide detailed drawin s) 24. Will the proposed project require a Steep Slopes Permit as per§213 of Village Code Yes: No: (if yes,you must submit a Site Plan Application,Bc provide a detailed topographical survey) 25. Is the lot located within 100 ft.of Wetland as per§245 of Village Code? Yes: No: (ifyes,the area ofwetland and the wetland buffer zone mast be properly depicted on the survey&site p an) ❑ 26. Is the lot or any portion thereof located in a Flood Plane as per the FIRM Map dated 9/28107? Yes: No: (if yes,the area and elevations of the flood plane must be properly depicted on the survey&sire plan) 27. Will the proposed project require a Tree Removal Permit as per§235 of Village Code?Yes: No:21 (if yes,applicant must submit a Tree Removal Permit Application) 2& Does the proposed project involve a Home-Occupation as per§250-38 of Village Code? Yes: No:0 Indicate:TIER 1: TIER 11: TIER III: (if yes,a Home Occupation Permit Application is required) 29. What is the total estimated cost of construction: $ 18,090 Note:estimated cost shall include all site improvements,labor,material,scaffolding,fixed equipment,professional fees,including any material and labor which may be donated gratis.!f the final cost exceeds the estimated cost,an additional fee will be required prior to issuance of the C/O. 30. Estimated date of completion: TBD (2) &1=3 D ECE �WE BUILDING DEPARTMENT VILLAGE OF RYE BROOK MAY 3 0 2Q24 938 KING STREET RYE BROOK,NY 10573 (914)939-0668 VILLAGE OF RYE BROOK www.rvebrook.org BUILDING DEPARTMENT ****a**aaa***a**********#***********#************A*aa**a****aaa*faaa*******aaa*a**********************! AFFIDAVIT OF COMPLIANCE VILLAGE CODE 5216 - 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 ) as: I, William Cally , residing at. 12 Wyman St N, U�StCC)rW 10573 - Unit 4 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; 12 Wyman St N,Xye g-�_rk NY 10573 - Unit 4 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 cross-connections concerning either the storm sewer or sanitary sewer,and further that there are no roof drains,sump pumps, or other prohibited stormwater 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. V, r�ienr William Cally 11'rint ,_ Sworn to before me this day of may _ 20 Z�1 BRIAN MACD0r4,,L1J NOTARY PUBLIC Suite ojConneLUclit MY COMMISSION EXPIRES Oct 31 20:'� 1±) 6/1/2023 This application must be properly completed in its entirety by a N.Y. State Registered Architect or N.Y. State Licensed Professional Engineer& signed by those professionals where indicated. It must also 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. Please note that application fees are non-refundable. STATE OF NEW YORK,COUNTY OF WESTCHESTER ) as: Franklin Harahona , being duly sworn,deposes and states that he/she is the applicant above named, (prang name ollndnvtdual 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 archilect,contractor,agent,attorney,etc) That all statements contained herein are true to the best of his/her knowledge and belief, and that any work performed, or use conducted at the above captioned property will be in conformance with the details as set forth and contained in this application and in any accompanying approved plans and specifications,as well as in accordance with the New York State Uniform Fire Prevention& Building Code,the Code of the Village of Rye Brook and all other applicable laws,ordinances and regulations. By signing this application, the property owner further declares that he/she has inspected the subject property,and that to the best of his/her knowledge there are no roof drains, sump pumps or other prohibited stonmvater or groundwater connections or sources of infiltration into the sanitary sewer system on or from the subject property. 3 Sworn to before2 rc�i} me this 3 Sworn to before me this re-4- day of �'/ar . 20 day of ACA 20 Signature of Property Owner Signature 0 el I-t William G` Ily Franklin Barahona Print Name of Property Owner Print Name or Applicant Notary Public Notary Public BRIAN MACDONF.L!] NOTARYPUBUC BRIAN MACDONALD State of CoMecticut NOTARY MBUC MY COWISSIOM EXPIRES Del.312026 State of Connecticut FAY COi1inSSIOM EXPIRES OM!t 21M (4) 6/1/2023 (- VEW Agreement Document and Payment Terms DBA:RENEWAL BY ANDERSEN OF WESTCHESTER AND FAIRFIELD COUNTY William Cully Legal Name:Fairchester Custom Windows LLC 12 Wyman St INR E N A L CT HIC#.0667292,WC-35743-1-122.Putnam#51220 Ryebrook,NY 10573 brANDERSEN 421 West Ave,Building 11 Stamford,CT 06902 C:(914)844-8980 ,uam m.imw�an Phone:203-406-0545 1 Fax:203-406-0828 1 sales@rbawestchester.com William Cally 04/13/24 BUYERS)NAME CONTRACT DATE 12 Wyman St N, Ryebrook,NY 10573 (914)844-8980 BUYERS)STREET ADDRESS PRIMARY NUMBER SECONDARY NUMBER wvcallyesq@verizon.net PRIMARY EMAIL SECONDARY EMAIL NOTES: Buyer(s)hereby jointly and severally agrees to purchase the products and/or services of Fairchester Custom Windows LLC d/b/a Renewal By Andersen of Westchester and Fairfield County("Contractor"),in accordance with the terms and conditions described in this Agreement Document and Payment Terms, any documents listed in the Table of Contents,and any other document attached to this Agreement Document,the terms of which are all agreed to by the parties and incorporated herein by reference(collectively,this "Agreement"). Buyer(s)hereby agrees to sign a completion certificate after Contractor has completed all work under this Agreement. TOTAL JOB AMOUNT: $18,661 By signing this Agreement,you acknowledge that the Balance Due,and the Amount Financed must be made by personal check,bank check,credit card,or cash. DEPOSIT RECEIVED: $0 BALANCE DUE: $18,661 We schedule Installations based on the date of the signed contract and secondarily on the date in which we complete the technical measurements.The installation date that we are providing at AMOUNT FINANCED: $18,661 this time is only an estimate.We will communicate an official date and time at a later date. Rain and extreme weather are the most common causes for delay. METHOD OF PAYMENT: Financing NOTES: Buyer(s)agrees and understands that this Agreement constitutes the entire understandings between the parties and that there are no verbal understandings changing or modifying any of the terms of this Agreement. No alterations to or deviations from this Agreement will be valid without the signed,written consent of both the Buyer(s)and Contractor.Buyer(s)hereby acknowledges that Buyer(s)1)has read this Agreement,understands the terms of this Agreement,and has received a completed,signed,and dated copy of this Agreement,including the two attached Notices of Cancellation,on the date first written above and 2)was orally informed of Buyer's right to cancel this Agreement. NOTICE TO BUYER:Do not sign this contract if blank.You are entitled to a copy of the contract at the time you sign. YOU,THE BUYER,MAY CANCEL THIS TRANSACTION AT ANY TIME NOT LATER THAN MIDNIGHT OF 04/17/2024 OR THE THIRD BUSINESS DAY AFTER THE DATE OF THIS TRANSACTION,WHICHEVER DATE IS LATER. SEE THE ATTACHED NOTICE OF CANCELLATION FORM FOR AN EXPLANATION OF THIS RIGHT. SIGNATURE OF SALES PERSON SIGNATURE SIGNATURE Charles Reichl William Cally PRINT NAME OF SALES PERSON PRINT NAME PRINT NAME 04/13/24 Page 2/ 30 Order Summary dba:RENEWAL BY ANDERSEN OF WESTCHESTER AND FAIRFIELD William Cally COUNTY 12 Wyman St N RENEWAL Legal Name:Fahchester Custom Windows LLC I License#CT HICa.0667292, Ryebrook,NY 10573 byANDERSEN WC-35743-1-122,Putnam a51220 C:(914)844-8980 421 West Ave,building 1 1 Stamford,CT 06902 Phone:203.406.0545 1 Fax:203-406-0828 1 techOrbawestchester.com D• ROOM SIZE DETAILS JOB 104 Kitchen 33" 34" Window: Acclaim"' Double Honp (DG). 1:1. Fat Sill. Insert Frame, Traditiona' Checkrad. Exterior White, Interior While Performance Calculator: PG Rating: 40 1 DP Rating: + 40; 40 Glass: All Sash: 1-1 gh Performance SmartSun with Heati_ork ,lase ?J0 Patten; Hardware: White, Standard Color Recessed Hiroo Lilt Screen: Fiberglass-. Full Screen Grille Style: No Grille Misc: None Construction: None. Material: None Window: Acclaim''' Double-Hun,IDGI._1:1, F at Si11. Insert Fame. 105 Bedroom 33" 46" � Tradoiorla Checkra '. Exterior White. Interior While Performance Calculator: PG Rating: 40 1 DP Rating: + 40 ,' 4n Glass: All Sash: High Performance SmurtSun with Hcatl-ock Glass No Pnrew Hardware: Whitc. Standard Color Recessed Hand Lift Screen: Fibcrv,, r,,;. Full Scre•r Grille Style: Grille c: None Construction: `one Material: None 106 Bedroorn 33" 46" Window: Acclaim`' Double Hung (DGI. I:I, Fla; Sill, Insert Frame, Tr:rfitiona; Checkrail. Exterior White. Interior White Performance Calculator: PG Rating: 40 ! DP "wing, + 40 ; - d0 Glass: Ail S,ish: High Performance Smar',Sur with HealLock Glass. No Pattern Hardware: While. Standard Color Recessed Hand hit Screen: Fiherglass, Full Screen Grille Style: No Grille Misc: None Construction: None Material: None 107 Bathroom 22" 34" Window: Acclt�im"' Double-Hurl!(DG). I:t, Fl,,t Sill, Insert Frame. Traditional Checkrail Exterior While. Interior While Performance Calculator: PG Rating: r10 ; DP Rating• +- 10 40 Glass: All S.-,s11: High Performance Smar,Sur', with Hcati-ock Glass. No Pattern, Tampered Glass Hardware: White, Standard Color Recessed Hand Lit, Screen. Fiberglass. Full Screen Grille Style: ,iu GrlCe Misc: None Construction: None Material: 'Joni 05/29/24 Page 2 / 14 Order Summary ., dba:RENEWAL BYANDEKSEN Of WFS'1'Clil•S'ffiKRND Iv\IKhIELD William Cally COUNTY 12 Wyman St N RENEWAL Legal Name:Fairchester Custom Windows LLC I License#CT HIC# 0667292. Ryebrook.NY 10573 brANDERSEN WC-35743-1-122,Putnam#51220 C (914)844.8980 421 West Ave,Building 1 I Stamford,CT 06902 Phone:203-406.0545 1 Fax:203.406.0828 1 tech®rbawestchesteccom ROOM SIZE DETAILS 0" Misr: 11, 1 1 fees. Town of Ric Brook Estima:cd Perm.l Fces. P .' . :. h} Ai cdersF:n svl;l facilila;e ;he application of tl,e III a IN: Tor:-1 of Rve Brook. Ho»eov:ner is responsible for any G r�l�•-iin-.i 1:1 pf`tr1•.t ;lp)Il:.a lrr its of rode Vrolil:tons lh it meat preCenl Rrine�:al 1r; ;;^ffersr•n Iron, nrocurinh permit. Renewal by Andersen is not tot 1,,, It <.toric,o or t,rr,hitectural reviev: applications and thnt W,I> hr: n;i{uirr;d a', an, requisite for it building permit. Construction. 'Jon( Material' Nnn;: 111 Dinlnq 93" d5" Window: Acclaimr" Midmp Triple• 1:I:1. Base Fi awe. E�.ierior While. Interrr)r White Performance Calculator: PG Rating: 30 � DP Rating: + 30 J - 30 Glass: All Sash: Wi,,I) ?c•rformijnce SniartSun with Heati-ock Glass, No Pattern Hardware: While Screen: Finciglass. ;-u!I Screen Grille Style: No Grille Mlsc: Nsnv Construction: None Material: None 112 Primary 68 46" Window: Acctainll••' Gliding Triple 1:1:1, Base Frame. Exterior White. Bedroom Interior While Performance Calculator: PG Rating: 40 1 DP Rating: + 40/ - 40 Glass: Ali S.as.h: High Performance SlnartSLan with HeatLock Glass, No Pal:ern Hardware: 1Vnitr. Screen: Fiberglass, Full Scrr:,:n Grille Style: No Grille Misc: Noer- Construction: None Material: None PRODUCTS: 7 WINDOWS: 6 PATIO DOORS: 0 ENTRY DOORS: 0 SPECIALTY: 0 MISC: 1 Updated 5129124 Estimated Duration: 05/29/24 Page 3 / 14 VAV4"PNN/ i RENEWAL Technical Data bYANDERSEN FULL•SERVI(E WINDOW 8 DOOR REPLACEMENT SPECIFICATION AND TECHNICAL MANUAL 4 .Oft ' Aw �. r. to k Fairchester Custom Windows is not using an Engineer / Architect due to installation ; of replacement windows and doors into EXISTING openings with NO structural alterations . =� low RENEWAL BY ANDERSEN SPECIFICATION& TECHNICAL MANUAL TECHNICAL INFORMATION PERFORMANCE RATINGS AND TEST DATA NFRC Total Unit Performance Renewalby �1:ltwu7xierinal= Solar Heat Gain Coefficient(SHGC)1 Andersen Product Clear WfthoutGdlfes 0.42 0.41 0.51 0.51 .82 Full Divided Light Grilles 0.43 0.41 0.46 0.46 Without Grilles 0.31 0.28 0.28 0.27 .72 Low-E4' Full Divided Light Grilles 0.32 0.29 0.25 0.25 Without Grilles 0.32 0.29 0.17 0.17 .40 Low-E4'Sun Full Divided Ught Grilles 0.33 0,30 0.16 0.15 Low-E4"SmartSud" Without Grilles 0.31 0.28 0.19 0.18 .65 Full Divided Light Grilles 0.32 0.29 0.17 0.17 LOW-E40SmartSun Without Grilles 0.26 0.24 0.18 0.18 .63 with Heatlock' Full Divided Light Grilles 0.26 0.24 0.17 0.16 EnhancedTnplePane Without Grilles n/a 0.20 n/a 0.25 .42 Enhanced Triple pane with Without Grilles n/a 0.19 n/a 0.17 .37 SmartSun' Clear Without Grilles 0.43 0.41 0.51 0.51 .82 Full Divided Light Grilles 0.43 0.41 0.46 0.46 Low•E4`° Without Grilles 0.31 0.28 0.28 0.27 .72 Full Divided Light Grilles 0.32 0.29 0.25 0.25 Low•EQ'Sun Without Grilles 0.32 0.29 0.17 0.17 .40 Full Divided Light Grilles 0.33 0.30 0.16 0.15 Low•E4`SmartSun' Without Grilles 0.31 0.28 0.19 0.18 .65 Full Divided Light Grilles 0.32 0.29 0.17 0.17 Low•E4''SmartSun Without Grilles 0.27 0.25 0.18 0.18 .63 with HeatLock" Full Divided Light Grilles 0.27 0.25 0.17 0.16 Enhanced Triple Pane Without Grilles n/a 0.20 n/a 0.25 .42 Enhanced Triple pane with Without Grilles n/a 0.20 n/a 0.17 .37 SmartSun' Without Grilles 0.46 0.58 - .82 Clear Full Divided Light Grilles 0.46 - 0.52 - Without Grilles 0.33 0.30 0.31 .72 Low-E4' Full Divided Light Grilles 0.34 0.31 0.28 0.28 Low-E4`r Sun Without Grilles 0.33 0.30 0.20 0.19 .40 Full Divided Light Grilles 0.35 0.31 0.18 0.17 DG Double-Hung Without Grilles 0.32 0.29 0.21 0.21 .65 (All Frames) Low-E4®SmartSun'" Full Divided Light Grilles 0.34 0.30 0.19 0.19 Low-E4"SmartSun Without Grilles 0.27 0.25 0.20 0.20 .63 with HeatLock' Full Divided Light Grilles 0.30 0.27 0.18 0.18 Enhanced Triple Pane Without Grilles n/a 0.20 n/a 0.29 .47 Enhanced Triple pane Without Grilles n/a 0.20 n/a 0.19 .43 with SmartSunt° law mart n ow- Ow ®Sun'and Hemlock*are Andersen bademarks for'Low E'glass. I)u•Eadta defines the amount of neat loss through the total un,t,n elu/h/1t2.OF.Pie lower the value,the less heat is lost wrought the entire product.W,ndow values represent norotempdred glass.use of teraDMed glass can increase U-Facto, ratings,see anonrsenwindova.com/of'C for spec fic mfofmance values. 21 Solar Heal Gain coefficient(SHGC)defires the fraction of Sour radiation admitted through the glass both directly transmitted and absafbed and subsequently released inward.The lower the value.the less heal Is transmitted through the product. 3)visible bansmrttance into measures how much light comes through a p(oduct(glass and frame)The higher the value.from 0 to 1.the more daylight the product lets in over he product S total unn area Yrsible Lleh'.Transmntance is measured over the 38o to 760 nanometet portion of the Solar spectrum •NFRC ratings are based on modeling by a third parry agency as validated be an independent test tab in compliance wdh NI HC program and prbcMUfal requirements •Th s data is accurate as of soot 2021.Due to ongoing product changes.updaiea test results,of new industry standards Or requ cements.thb data may Change over time.Ratings are for sites spec fed by NFRC fortest9ag and certification.Rat figs may vary decena ng o,use o,tempered glass.ddferent gore options.glass wn^capillary breathef tubes for nigh arcades.etc'low-E4(i.'lo*-E415 SmarSun^"and'Low.E4+v sun' 09-9 COMPANY CONFIDENTIAL- REVISION AA-01 RENEWAL BY ANDERSEN SPECIFICATION&TECHNICAL MANUAL TECHNICAL INFORMATION PERFORMANCE RATINGS AND TEST DATA NFRC Total Unit Performance (continued) eain Coefficient r_ e Product GlassType Air At e Without Grilles 0.46 0.44 0.57 0.57 .82 Clear Full Divided Light Grilles 0.46 0.44 0.51 0.51 Without Grilles 0.33 0.30 0.31 0.31 .72 Low-E4' Full Divided Light Grilles 0.34 0.31 0.28 0.28 Without Grilles 0.33 0.30 0.19 0.19 .40 Low-E41 Sun Full Divided Light Grilles 0.35 0.31 0.18 0.17 DEI Double-Hung (Full Frame) Without Grilles 0.33 0.29 0.21 0.21 .65 Low-E4'°SmartSunTN1 Full Divided Light Grilles 0.34 0.30 0.19 0.19 Low-E4'SmartSun Without Grilles 0.28 0.25 0.20 0.20 .63 with HeatLock` Full Divided Light Grilles 0.28 0.25 0.18 0.18 Enhanced Triple Pane Without Grilles n/a n/a n/a n/a n/a Enhanced Triple pane with Without Grilles n/a n/a n/a n/a n/a SmartSun" Without Grilles 0.46 0.44 0.57 0.57 .82 Clear Full Divided Light Grilles 0.46 0.44 0.51 0.51 Without Grilles 0.33 0.30 0.31 0.31 .72 Low-E4" Full Divided Light Grilles 0.35 0.31 0.28 0.28 Without Grilles 0.34 0.30 0.20 0.19 .40 Low-E4'Sun Full Divided Light Grilles 0.35 0.31 0.18 0.18 s: sr Without Grilles 0.33 0.29 0.21 0.21 .65 Low-E4"SmartSun'" Full Divided Light Grilles 0.34 0.30 0.19 0.19 Low-E4°SmartSun Without Grilles 0.27 0.25 0.20 0.20 .63 with HeatLock° Full Divided Light Grilles 0.27 0.25 0.18 0.18 Enhanced Triple Pane WithoutGtilles n/a n/a n/a n/a n/a Enhanced Triple pane with Without Grilles n/a n/a n/a n/a n/a SmartSun' Without Grilles 0.47 0.45 0.59 0.59 .82 Clear Full Divided Light Grilles 0.47 0.45 0.53 0.53 Without Grilles 0.34 0.30 0.31 0.31 .72 Low-E4 Full Divided Light Grilles 0.35 0.32 0.29 0.28 Without Grilles 0.34 0.30 0.20 0.19 .40 Low-E410 Sun Full Divided Light Grilles 0.35 0.32 0.18 0.18 Without Grilles 0.33 0.29 0.21 0.21 .65 Low-E4T SmartSun' Full Divided Light Grilles 0.34 0.31 0.19 0.19 Low•E4'SmartSun _ Without Grilles _�n 0.27 0.25 0.20 0.20 .63 with HeatLock a Full Divided Light Grilles 0.27 0.27 0.18 0.18 Enhanced Tnple Pane Without Grilles n/a 0.20 n/a 0.28 .47 Enhanced Triplepanewith Without Grilles n/a 0.19 n/a 0.18 .43 SmartSun`" 'lole-E4d1)Snert$unnr,"Low E4dD,*tow E4 F7 Sun'and Head ocadD are Andersen trademarks for'Luw E'glass. g)U•Factor derives the amount or heat loss through the total un t in BTU/nr/It2.'F.The lower the value,the less neat is lost through the entne product.Window values represent non.:emperea pass.Use of lempe•ed pass can increase U•Factor ratings.see anaersenwindows.com/ehc for smofic performance values. 2)Saar Heat vain eoe":Ulnt(SIIGC)defines the traction of solar radiation admitted through the pass both ouaody tran wa•ylldted and absorbed and subsequently released h1ward.the Io the value.the less heat is transmitted through the product. 31 Vvnble Transmdtance(V1)measures how much light comes through a product(glass aid framof the higher the value.from 0:01.the more daylightthe product lets in omr the productstotal unit area.VryDIC Lgnl ifansmt:ance rs meawrcd over the 390 to 760 narwmeter portion of the Saar spectrum •NFRC ratings are based on modeling by a third party agency as validated by an independent test lab in compliance with NFRC program and procedural tequurments •Th s data is accurate as of April 2021.Due to ongdng product changes.uDdate:test results,or new industry standards or requ rements.this data may change over bme.Ratings are to-Sims specdred Cry NFRC Pot testing and certification,Rat ri may vary depene ng o1 use of tempered pus,d.nerent give ophons.passwon capillary breather tubes for high attitudes.etc,Ishi E4`Low•E410 Sin artsunr•-ana'Low-E4:1D sun' 09-1 0 COMPANY CONFIDENTIAL- REVISION AA-01 RENEWAL BY ANDERSEN SPECIFICATION 8 TECHNICAL MANUAL TECHNICAL INFORMATION PERFORMANCE RATINGS AND TEST DATA NFRC Total Unit Performance (continued) Renewal by Andersen' High Performance Glass Type U-Factor (BTU/(hrft2oF))' Product Without Grilles 0.44 0.42 0.61 0.61 .82 Clear Full Divided Light Grilles 0.45 0.43 0.55 0.55 Without Grilles 0.31 0.27 0.33 0.32 .72 Low-E4' Full Divided Light Grilles 0.32 0.28 0.29 0.29 Without Grilles 0.31 0.27 0.20 0.20 .40 Low-E4'Sun Full Divided Light Grilles 0.33 0.29 0.18 0.18 Picture (Full Frame) Low•E4'SmartSun' Without Grilles 0.30 0.26 0.22 0.22 .65 Full Divided Light Grilles 0.32 0.28 0.20 0.20 Low-E4°SmartSun Without Grilles 0.25 0.22 0.22 0.21 .63 with HeatLock' Full Divided Light Grilles 0.25 0.22 0.20 0.19 Enhanced Triple Pane Without Grilles n/a n/a n/a n/a n/a EnhancedTnple pane with SmartSun`" Without Grilles n/a n/a n/a n/a n/a Without Grilles 0.45 0.43 0.64 0.64 .82 Clear Full Divided Light Grilles 0.46 0.44 0.57 0.57 Without Grilles 0.31 0.27 0.34 0.34 .72 Low-E4' Full Divided Light Grilles 0.33 0.29 0.31 0.31 Without Grilles 0.31 0.28 0.21 0.2 .40 Lovi Sun Full Divided Light Grilles 0.33 0.29 0.19 0.19 Picture (Insert Frame) Low-E4"SmartSun' Without Grilles 0.30 0.27 0.23 0.23 .65 Full Divided Light Grilles 0.32' 0.28 0.21 0.21 Low-E4`SmartSun Without Grilles 0.25 0.22 0.22 0.22 .63 with HeatLock' Full Divided Light Grilles 0.25 0.22 0.20 0.20 Enhanced Triple Pane Without Grilles n/a n/a n/a n/a n/a Enhanced Triple pane with SmartSun'" Without Grilles n/a n/a n/a n/a n/a Without Grilles 0.44 0.42 0.61 0.61 0.82 Clear Full Divided Light Grilles 0.45 0.43 0.55 0.55 Without Grilles 0.31 0.27 0.33 0.32 0.72 Low-E4` Full Divided Light Grilles 0.32 0.28 0.29 0.29 Without Grilles 0.31 0.27 0.20 0.20 0.40 Low-E4''Sun Full Divided Light Grilles 0.33 0.29 0.18 0.18 Picture (Universal Frame) Without Grilles 0.30 0.26 0.22 0.22 0.65 Low-E4'SmartSun" Full Divided Light Grilles 0.32 0.28 0.20 0.20 LowiSmartSun Without Grilles 0.25 0.22 0.22 0.21 0.63 with Heattock Full Divided Light Grilles 0.25 0.22 0.20 0.19 Enhanced Triple Pane Without Grilles n/a 0.16 1 0.30 .50 Enhanced Triple pane with Without Grilles n/a 0.16 n/a 0.20 .45 SmartSun'" 'Low.E40&m%Sun-.'Low Ea®.'Low E4IS Sun'end Hcd!LockX ate Andersen trademarks to,*Low E'glass I I LI-f acts defetes the amount or heat loss through the total uu t in BlO/nr/f,2N.Iho tower the value,the leas"al's lost thrdugn poll-1-product.w wnw w4oms reprexnt r,o�;em)wrav pass.0u of tempNOd pass can nnease 0-factor ratings. See a^dersMw:ndtlssi.Com/nhc for specific pe,lormance values. 2)Solar Heat Gain Colic aent ISHGCI ddh^es the Ili of solar radiation admitted through the glass Dote three'Ibvansmrtted and absvded and suoseduendy released inward.The lower the value.tM less heat it transmitted through the product. 3)v,vble Transmittance(Yl)measures now much light comes through a product(glass and frame)the hgherihe value.from 0to 1.me mue daylight the product lets in thti the product'stctai unit area Vivble Lgnl Oansmrttancd ns moasurod ovenne 380 to 760 nanori portion of the sour spr4pum •his RC ratings arc based on modetmg by a third party agency as validated try an independent test Tao in compliance with NFRC program and plocedutal requirements •th s data is accurate as of April 2021.Due to ongoing product changes.updated test results.or new industry standards or requ,remit this data may change over time.Ratings are to,saes specified Cy NFRC for testing and certification.Ratings may nary dependirg on use of tempered glass.different gr Ile options glass w.ln capillary Weather tubes lot high alludes,etc.-Low-E4fV.'l ow{am Smwtsun"'and'Low Wt Sun' 09-11 COMPANY CONFIDENTIAL- REVISION AA-01 r•• Order Summary dba:RENEWAL BYANDERSEN OF WESTCHESTER AND FAIRFIELD William Cally COUNTY 12 Wyman St N R ENE WA L Legal Name:Fairchester Custorn Windows LLC I License#CT HIC#.0667292, Ryebrook,NY 10573 byANDERSEN WC-35743-H22,Putnam 451220 C:(914)844-8980 421 West Ave,Building 1 1 Stamford,CT 06902 Phone.203-406-0545 1 Fax.203.306.0828 1 tech grbawestch ester corn •• ••• UNIT NOTES Renewal by Andersen will facilitate the application of the building permit to the Town of Rye Brook. Homeowner is 104 u1 •• • FLOOR UNIT NOTES 105 SOG 107 112 •i PHOTOS Original: 04/16/24 1 Updaicd 0.;/I':,/24 1 .r, rr. Page 6 / 25 112 Primary Bedroom Acclaim"' Gliding-Triple-68.00W x 46.00H -CHANGE ORDER - M Primary Bedroom Acclaim'" Gliding-Triple-68.00W x 46.00H -CHANGE ORDER- LU Dining 8 Acclaim'" Gliding-Triple-93.00W x 45.00H -CHANGE ORDER - 911 Dining Acclaim'" Gliding-Triple- 93.00W x 45.00H -CHANGE ORDER - 107 Bathroom 107 Bathroom Acclaims-' Double-Hung (DG) - 22.00W x 34.00H Acclaims' Double-Hung (DG) - 22.00W x 34.00H - CHANGE ORDER - - CHANGE ORDER - EXTERIOR 3600 1 EXTERIOR Q6� INTE 107 Bathroom 107 Bathroom Acclaim' Double-Hung (DG) - 22.00A Acclaim'' Double-Hung (DG) - 22.00W x 34.00H - CHANGE ORDER - - CHANGE ORDER - EXTERIOR 360* IMTE EXTERIOR Q6� 1 104 Kitchen 104 Kitchen Acclaim" Double-Hung(DG)-33.00W x 34.00H Acclaim'u Double-Hung(DG)-33.00W x 34.00H CHANGE ORDER- CHANGE ORDER- 105-106 Bedroom 105-106 Bedroom Acclaim"' Double-Hung(DG)-33.00W x 46.00H Acclaim"" Double-Hung(DGI-33.00W x 46.00H -CHANGE ORDER- CHANGE ORDER- ..._ �! 1-14 i 4 �� __. tea-------•— __ - —_ 'L j wee, i I i i�� r� vk \Q2.tA.�1�.\t�lliil. 1 . tir.fi'iA�J t'. i -J ` - .aao ,�N 1 i A 1�. 4 �� i e y� _ r i 1 � I i ' ur�cd I II im.. 1 � r� J� b:J }� )� 'r i�f"(/! �ii��.p� '�ij���p���- � � � .. .`�, 'a.�i '•�'.. !' .. � _� mot. .. � '� I, �+ � �;�, !(;:•. k ..�� ;,;� �' ''���' .� �r�V,� � ` .� �Y,�`,w�����y�' ;a -_ w ��; e � '' :. ,,x �.:�,, � .. ,�:. r��s� -� �1 � -� .. ._ � -- �. ' Z � .. _. ,. _---- --- ;�� , _ -s :. :1,!s :. � a�� �: d ,.ham y: ���; -� ':_� ., __ -f ', -. . �� — — is �t tr. �^a:[ �.� .'fit ��13 � _ _ � �. Y �, � ��� W AS. i4l tj COMID s r3 0 cv it & 04 0) CD 11: tO I tj ;Z7 LL LLJ 04 0 Lu o "z't:�� z ° section cr) o. co 0 CO I r-8 o LL LLJ 0 r-L LLJ e CO LL, > LL < Ire, 77 tj ca u C*4 C; ci 7 U') c) ML 0 4.1 a7 v , o % A%j tP —4. w 2v�- N, ff FAIRCUS-01 TBRAND ACORO CERTIFICATE OF LIABILITY INSURANCE DATE 1 DNY1�`' 9/29122912023 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(ios)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 ondorsoment. A statement on this certtficato does not confer rights to the certificate holder in lieu of such ondorsomont s. PRODUCER 5RUACT Theresa Brandon MBI Company Group LLC. Pk He Eat: 203 ac 288-3401 F 280 State Street Ne;(203)281-0414 North Haven,CT 06473 Robss.theresa.brandon@mbi-ins.com INSURERS AFFORDING COVERAGE NAIC 0 INSURER A:Selective Insurance Company of America 12572 INSURED INSURER B: Fairchestor Custom Windows LLC dba:Renewal by Andersen INSURER C: Falrchestor 2041 West Main Street INSURER 0: Stamford,CT 06902 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 AW SUBR WVDPOLICY NUMBER POLICY EFF POLICY EXP LIMM LTRA X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE [K OCCUR X S 2516791 8/12/2023 8I1212024 DAEMI E TO S(Ea RENTED 500,000 MFDEXP(Any oneperson) 15,000 PERSONAL&ADV INJURY 1,000,000 IOTHER L AGGRE ATE LIMIT APPLIES PER: EN RA AGGR GATE 3,000,000 POLICY�P �X LOC PROD CTS- MPIOPAGG 3,000,000 : $ COMBINED SINGLE LIMIT A AUTOMOBILE LueluTY a 1,000,000 ANY AUTO S 2516791 8/12/2023 8112/2024 BODILY INJURY Per $ OWNED SCHEDULED AUTOS ONLY X AUTOS BODILY BOODILY INJURY Per acdderd S X AUT0.S ONLY X AUTO ONLY PPa 8CCE dent AMAGE $ X Comp Ded$500 X Cdlision Ded$500 $ A X UMBRELLA LAB X OCCUR EACH OCCURRENCE S 4,000,000 EXCESS LIAB CLAIMS-MADE X 2516791 8/12/2023 8/12/2024 AGGREGATE $ 4,000,000 DED I X I RETENTIONS 0 $ A WORKERS COMPENSATION X PER I X OTH- AND EMPLOYERS LIABILITY STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE Y r N C 9099063 8112/2023 8112/2024 F.L.EACH ACCIDENT 500,000 QFFICERn�1gW EXCLU ❑N N r a 500,000 (M+nd:torl/In NH) F.L.01SFASF.-FA EMPLOYE It desarbe under 500,000 D ESCRIPTION OF OPERATIONS elaw E.L.DISEASE-POLICY LIMIT S DESCRIPTION OF OPERATIONS I LOCATIONS r VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached If more space Is raqutrod) Village of Rye Brook is Additlonal Insured as required by written contract per the endorsomonts Included with this certificate. 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. 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 r"oRK Workers' CERTIFICATE OF STATE Compensation Board NYS WORKERS' COMPENSATION INSURANCE COVERAGE 1a.Legal Name 8 Address of Insured(use street address only) 1b.Business Telephone Number of Insured Fairchester Custom Windows LLC. 203406-0545 dba:Renewal by Andersen Fairchester 1c.NYS Unemployment Insurance Employer Registration Number of 2041 West Main Street Stamford,CT 06902 Insured Work Location of Insured(Only required If coverage Is specifically llmfted to 1d.Federal Employer Identification Number of Insured or Social Security certain locations In New York State,i.e.,a Wrap-Up Policy) Number 88-2855660 2.Name and Address of Entity Requesting Proof of Coverage 3a.Name of insurance Carrier (Entity Being Listed as the Certificate Holder) Selective Insurance Company village of Rye Brook 938 King Street 3b.Policy Number of Entity lasted in Box"1 a' Rye Brook,NY 10573 WC9099063 3c.Policy effective period 08/12/2023 to 08/12/2024 3d.The Proprietor,Partners or Executive Officers are �X 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 7'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 38 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 Now 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: Theresa Brandon (Print name of authorized representative or licensed agent of insurance carrier) Approved by: �� � 09/29/2023 (Signature) (Date) Title:Agent Telephone Number of authorized representative or licensed agent of insurance carrier. 203-288-3401 Please Note:Only Insurance carriers and their licensed agents are authorized to issue Form C-105.2.Insurance brokers are N-Q-T authorized to Issue it. C-105.2(9-17) www,wcb.ny.gov