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Home My WebLink AboutMP24-103 �yE DR ��4�4'Do JJi ,n t� (�f,4 Vuyj VILLAGE OF RYE BROOK MAYOR 938 King Street, Rye Brook,N.Y. 10573 ADMINISTRATOR Jason A. Klein (914)939-0668 Christopher J. Bradbury www.tyebrookny.gov TRUSTEES BUILDING & FIRE INSPECTOR Susan R. Epstein Steven E. Fews Stephanie J. Fischer David M. Heiser Salvatore W.Morlino CERTIFICATE OF COMPLIANCE October 7,2024 Win Ridge Realty LLC c/o Alena Hakanjin 24 Rye Ridge Plaza Rye Brook,New York 10573 Re: 138B South Ridge Street,Rye Brook,New York 10573 Parcel ID#: 141.27-1-6 This document certifies that the work done under Mechanical Permit #24-103 issued on 8/6/2024 for the installation of a new rooftop HVAC unit has been satisfactorily completed. Sincerely, Steven E. Fews Building&Fire Inspector /to QyE BRC��, cu � o 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 : �� ti i-� C ) �. �1 DATE: ./Q PERMIT# MR 2 1 0 3 ISSUED: v -L V SECT: 77 BLOCK:_LOT: LOCATION: I 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 / �/ F ❑ L.P. GAS ❑ FUEL TANK ❑ FIRE SPRINKLER ❑ FINAL PLUMBING ❑ CROSS CONNECTION G}- FINAL 0 OTHER �/ V. A. W v h — 0 00 oo a _ LL V a� a+ w 0.' /Nye/ � w (Jr _ _ z oU }' z � H W y� �Z U � w° a _ 04 ©b W & y 6 44 O O � ~ Cl O � o �j ,�, G•� °o O 6 O. O .a' H VJ N � 2 c� 1-1 ° t�O, W pq � gyp/ � I� � W O A V o � C C� U W Fri �i ~ 1 W W vv, dQ a � _ s � � cA = o = 00 W a �t o ca r � � U V A A o � v � ° = W o a V ° 0 �U: ov F dd j� V tz zopa � � Ua�' w O a� v z en � � A ° � � -41 a CP- = M : ME VILLAGE: OF R)'E. BROOKftlll (jNG DEPh,RTl, MENT 938 KINGS'i`Fi'�.1-T i'>FIit�i)K,Nl' 10573(914)939=UG6$.ti i�cr' `cbrookul.ant APPLICATION FOR PERMIT TO INSTALL, MODIFYWOURK REMOVE MECIIANICAL EQUIPMENT OFFICE lJSE ONP ) Permit 9: �/ Building Inspector: Application Fee: Date of Approval: Permit Fee: Bldg/Usc Class: Res. ( );Comm. ( ); DO NOT STAR 1'1 0121ti 11r A I'F;R\ql"I 11:15 BEEN ISSUED F31''fills BUILDING FrE FOR WORK PROGRESSED 014 COMPLETED 111111(}1i'I'A PERMIT AS tz"'n OF T11F:TOTAL COST OF CONSTRUCTION 1YIT11 A 11'l1NINIUM FEF. OF:b7�l1.1111 REQUIREMENTS FOR Rfil_L'.ASL OF PERMIT: (A CLIMFICATF.or•CnMVUANCr is REQUIRED To Cost:Our In ns PrHMrr) I. Properly Completed&Signed Application. 2. Payment of Appiication Fee: Rcsiduntial -S I00.00; Conuncrcial=0-50.00(fees 3. Site/Staging Plan as required by the Building Inspector. 4. Scaled Construction/Installation Documents&Specifications as required by the Building Inspector. 5. Copy of Licensed Contractor's Liability II1surance.(Village oft'%Ic Brook nwst be listed as certificate huldet)& Workers Compensation Insurance on a NYS Board form (Nina it C 1 U5.2 m 17ortn 11 U2(,.', 'ur NY Male Wmkerc Counpensatinn Waiver) 6. Payment of Permit Fee: Residential_,S 19.00/1000.00 o1 (.Ol)5LrUuLiOniM.tLCI'Iit15 Cost Witll a minimum ICC ol'SI50.00. Commercial -_$25.00/1000.00 of(a ins IrtiaioniMaterials(',O5L tailh FI Inlntlnnnl Ica;ol'S275.00. 7.Inspection by Building Department for removal and/or installation. (48 hatu nndc•e req,d,ed) 8. Any electrical work requires a separate Electrical Permit and Electrical Inspection. 9.Any gas/plumbing work requires a separate Plumbing Permit and Plumbing Inspection. Application dated, 7 ✓1 is hereby made to the Building Inspector of the Village of Rye Brook,NY,for a permit for the installation,modification.n,and/or removal of the specific Mechanical 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 the approved plans,and with all applicable Local,County,State&Federal laws,codes,rules and regulations. I.Address:- 121 22.L,1�6 SBL: Zone. 2.Property Owner: W R� bml— )101C Address:2. ' Phone#: OK Cc11#: email: 4 IN !.�i 1111Ud[I t I�E�.rG4�Iy 3.Contractor: (__ Ll1/LC4-{-{ [ ram_Address: Phone ll: Celt#: 20afq, ?j —:5- email:DAV�G+ C.Olor -rv1irG(-ilprin LwN. 4.Scope of Work:New Installation •Replacement( )•Removal( }•Other( ) 5.Type of Cquipmen(: a-kA- 1ACAV 6 lO MN) l��.Pj�• OWL 3[r— Ij 1 k:i tVytA� i� - 1 I -M" 6V1'bf-fd rLtG 6. Location of Equipment: 7.Cost of Equipment including Installation Cost:S ��7� Tom• > r NUNN STATE OF NEW YO-RRK.COUNTY OF WESTCHESTER ) as: , /Q BEi-fG 42f)6� ,being duly sworn,deposes and slates that he/she is the applicant above named, (prim naine of individual signing as the applicants and further states that(s)hc is the Mechanical Equipment 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. sr s� Sworn to before me this.3 q Sworn to before me Otis day of V� 20 G day of 120 i re of Pioperty twwei- Signature of Applicant Prin ee off Pr p gwtter f; Print Na a of AppIi ant UJW iv, Notary Public Notary blic �~ LWTARALENA NANANdfN E::: Y MM.STATE OF NEW PORK vistrstion No.01NAO013645 Notary Pnecticut lbod In W 1tchestor Couotmr, E" m�11 roperly Completed in its entirety and rnu *jincde le nTt, 4R f the legal owner(s) of the subject property, attd tlic applicant of record in the spaces provided. Any app icatlon 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 6/1/2024 Commercial Air � CAD/BIM All Categories>Packaged Gas/Electric>RGED,7.5-12.5 ton>Item#RGEDZT120A Item # RGEDZT120A, RGEDZT Commercial Prestige® Series REQUEST INFORMATION Printable_Page Email This Pa • Factory charged with R-410A ItFC:refrigerant VIEW CAD DRAWING • Scroll compressors with internal line break overoad arid high pressure protection • Mode'RGFDZR has a single-stage compressor Models RGEDZS and RGEDZT have two-stage compressor • Convertible ai!tlow-vertical down float or horRontal s!de flow of • Forkabie base rails for easy handling and lifting 3D • Cooling operation up to 12SF ambient -- • Two-stage gas heat input with direct spark ignition system,solid state furnace controls,and optimized induced draft more o 0. Cooling Capacity 118000 6twhr System Performance EER 11 2D Left__S_i_de View__ System Performance IEER 14.6 Nominal CFM 4000 ft>Jmin AHRI Rated CFM 3480 ft'Jmin 2D Right Side View AHRI Net Cooling Capacity 114000 Bturhr Q° Net Sensible Cooling Capacity 79600 Btu:hr Net Latent Cooling Capacity 34400 Btu/hr 2..D_Top.View. Net System Power 9.83 kW Outdoor Sound Rating 88 dB Refrigerant Charge 136 oz 21D Bottgm View Weight 896 lb Shipping Weight 935 lb 2D Back View 0 Revit Model DOWNLOADS B Revit Family Download welcome to the rebirth of cc ,,, , The Rheem' Commercial Renaissance" HVAC Line w .,_ Q g , . e , 1 .. ,� � e 3-12.5 Ton Package Air Conditioners (RACCZR,RACCZT, RACDZT,RACDZS,RACDZR) '' � `' 3-12.5 Ton Package Gas Electric Units (RGECZR,RGECZT,RGEDZT,RGEDZS, RGEDZR) 3-10 Ton Package Heat Pumps (RHPCZR,RHPCZT,RHPDZT,RHPDZS) ....................................... 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No matter the condition of your current units or type of business,the Renaissance-Line offers you the best replacement for commercial rooftop applications—delivering easy installability,masterful performance and smart serviceability—plus,industry-leading efficiencies and the world-renowned Rheem dependability you trust. Visit Rheemxom/Renaissance iouay, in keeping with its policy of continuous progress&program improvement. Rheem reserves the right to make changes without notice. Printed in the USA•7/20•QG•Form No.M11-1995 Rev 3 .1 N v t M .. IN 47 e Z LIFE r t �� s�.sy 6 w. Y. #v[e�•�.c . 26 ttge DetE Ce�bOne's 17 ' � `$ S iE? S lty oa Y s N� Ilk i 3} E$ t , = s' fi M M M L' _ ,I�V si N N p N a ,• L O, CN PG t vu i s �[ ,c _ a c L W r �;Lin o M w z C O � 77 � Z00 ell INO cell O a W a o A S< z a W g U .r ■ a a z `r w 0 ■ f O r O < e cf) N 2 F— _� z � ■ ! s e 414 4 4 = f4 ■ : 41 tog 4 41414 a e4 41 ■ 4 446 f ■ 4 4 414 44 44 44 a D ��L Ir ,� F7 13RC� BUIL y� E�� MENT ['SEP - 9 2024 VIL E OF RYE OK I I 938KIN ETRYEB ,NY 10573 VIL�P,C COK (914)9 939-5801 or ELECTRICAL PERMIT APPLICATION Westchester County Master Electricians License Required FOR OFFICE USE ONLY #: EP#: Approval Date: SEP I I Permit Fee: $ Approval Signature: Other: Disapproved: (fees are non-refundable) 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 electrical equipment,wiring, fixtures,or to perform other high or low voltage electrical work as per the detailed statement described below. The applicant & property owner, by signing this document agree that all electrical work performed will be in conformance with all applicable Federal, State,County and Local Codes. �7 1.Address: 13$L3 S, 1Z t e ex;t Z"K SBL: H// a /—11�__CO Zone:C� 2.Property Owner: \N t� �ra Z.O. LL(, Address: a4 �y it 1 CAR. P IQZ O. Phone#: q I y- -I d I' `1 Ub S Cell#: email: QhQ KG n 1 i✓1 Ca w n p 49 Co I"- 3.Master Electrician: �1 COSC V'1 ]Qclvto Address:LA j CryanJ SiI ree N C w Bock (6 A y I09d/ Lie.#: 33") Phone#: 9l-�- -1 2 �), It33 Cell#: email:/)1C1`%eler-jylcAjSPyv-a @oc,k{look•ca,% Company Name: Nk�- EIfC-` jceAI SeYv;&NyUCAddress: yk CyGytcl 4 -jyeR-4 ►N[w>zoe,k J'yio"I 4.Proposed Electrical Work/Fixture Count: sn>�C0.1\ new LoU f�C - � �� 0 isCoiltlP� " //�� STATE OF NEW YORK,COUNTY OF WESTCHESTER ) as: 1't \o" ,being duly sworn,deposes and states that he/she is the applicant above named,and does further (print name of i dividual signing as the applicant) rr state that(s)he is the legal owner of the property to which this application pertains,or that(s)he is the IMA 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 efore me this -1)V. Sworngto before me of 1 ,20 Zq' jeIl ,20 tore,off( roperty OYrrrqM I of t G0�% /Fny hdv.a, C'0sc_6;4C,n 0 Pr a e of P e erl Print Name of Applicant WV V'r\ V11LC01 otary Public ` ALENA HAKANJIN EM3 CONAGHY NOTARY PUK C,STATE OF NEW ram TE OF NEW YORK Registration No.O1HAO013645 ounty Qualified in Westchester County My Commission Expires 911912027 6348554 2 1 19 � �:7 STATE WIDE INSPECTION SERVICES, INC. Service Wilh Integrity 0:0 • • SWIS JOB APPLICATION0. Office Use Elect. Permit# Y ✓�< Date Bldg Permit# Scl Ft Plumbing Permit# Final Certificate# City/Village ) \ ✓ zip I d —13 Building Dept. 12 c ��o County Address L Cross Street Section Block Lot Owner Name/Address(If different than above) W ,ci o LC Contact Number q I H _ `7 U l L4 Oa l ❑Basement ❑ 1st FI. ❑ 2nd FI. ❑3rd Fl. ❑More Than 3 FI. ❑Garage ❑Attic ❑Outside ❑Residential ❑Commercial Receptacles Special Recept GFCI AFCI Switches Dimmers Smoke Alarms C/O Detector Hood Trash Compact Amt Amps Range(s) Cooktop(s) Oven(s) Dishwashers Refrigerator Disposal Microwave Luminaires Generator Transfer Switch SERVICE Amperage #Panels 1P 3P # Meters # Disconnect ❑Underground ❑ New ❑ Reconnect ❑ Repair ❑Overhead ❑ Upgrade ❑ Disconnect Utility ID# ❑Con Ed ❑ NYSEG ❑Central Hudson ❑ Orange/Rockland PHOTOVOLTAIC SYSTEM PV Modules Inverters AC Disconnect Junction Box Combiner Box Load Center PV Monitor Energy Storage System DC Disconnect ❑Legalization ❑ Safety Inspection ❑Consultation (0O )4-fyl p 3 L 1 Stc! AlkSccvlyxoct WRFSP - 9 2024 VILLAGE OF RYE BROOK BUILDING DEPARTMENT This application is valid for one(1)year from the date received by SWIS.This application is intended to cover the above listed items to be inspected,if at anytime of inspection additional items have been installed,you are authorized to make the inspection and adjust the fee for the additional items inspected.The applicant declares that there is no open applications for the above address with any other inspection company.The applicant, owner or authorized agent agrees to all the above terms and conditions asset forth for the application. Email Address 11,1 y 1 _C o— Name AAhqa, , GNLkilici4iiiiO License# Date i 2� Signature. Address L4 Cjyiq r et City/State JC w w If JN/\,I Zip code 6 � Company W&CS ( '(q S-VVwLM Ll Phone# ' Cl I _ MI I t State Wide Inspection Services CA� _ 1080 Main Street OCT 3 2024 Fishkill, NY 12524 S TO845 2 Phone 914-219-119-1062 Fax STATE WIDE INSPECTION SERVICES VILLAGE OF RYE BROOK Email: officeCc-oswisny.com BUILDING DEPART MENT 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: Nicks Electrical Service of NY, LLC Win Ridge Realty LLC Anthony Coschigano 138E South Ridge Street 48 Grand Street Rye Brook, NY 10573 New Rochelle, NY 10801 Located at: 138E South Ridge Street, Rye Brook, NY 10573 Section: Block: Lot: Electrical Permit Number: EP 24-183 141.27 1 6 Certificate Number: 2024-6957 Building Permit Number: A visual inspection of the electrical system was conducted at the Commercial Residential occupancy described below.The electrical system consisting of electrical devices and wiring is located in/on the premises at: 138E South Ridge Street, Rye Brook, NY 10573 The Exterior 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 3`d Day of October 2024. Name Quantity Rating Circuit Type Fused Disconnect 01 30 Amp 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. COASMEC-02 PSUZ-IQ A�OKO CERTIFICATE OF LIABILITY INSURANCE DATE(M1202VVV) 12/52023 _ 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 suchppendorsernent(s). PROD Ak NAMEACT Paul A.SuZloAssure -- -- 100 Beard New England,Inc. JAIL No.E■p (203)514-7863 ;nit.NoI(203)514-7863 100 Beard Saw Mill Road L Shelton,CT 06484 ADDRESS PaLEI.SuzioJr@AssuredPartners.com INSURER(S)AFFORDING COVERAGE NAIC e INSURER Cincinnati Insurance Co. 10677 INSURED INSURER B Coastal Mechanical Services.Inc. INSURER C 40 Hathaway Dr. INSURER D Stratford,CT 06615 ,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 ADDLISUBR POLICY EFF POLICY EXP TYPE OF INSURANCE POLICY NUMBER LTR_ _ MSD:WVD. iMMM.IVPfYYYY)_ (MMIDD/YYYYI LIMITS A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE S 1,000,000 CLAIMS MADE X I oc:CUR X EPP0701539 12/17/2023 12/1712024 DAMAGE A E TO RENTED 300,000 ME EXP(Any one person) 15,000 PERSONAL B ADV INJURt E 1,000,000 GENL AGGREGATE LIMIT APPLIES PER I GENERAL AGGREGATE 2,000,000 X POLICY JE LOC PRODUCTS-COMPIOP AG(, S 2,000,000 OTHER A AUTOMOBILE LIABILITY COMBINED SINGLE UMIT S 1000000 , , .tLa accident) ,S ANY AUTO _ x EPP0701539 12/17/2023 12/17/2024 BODILY INJURY(Per person) 5 AUTOS OWNED X SCHEDULED BODILY INJURY(Per acadent) S OWNS ONIV v AUTOS X AVTO$ONLY ^ AUU ONID IPerOacutle accident) S S A X*UMBRELLA LIAR X OCCUR — EACH OCCURRENCE S 2,000,000 EXCESS LIAR CLAIMS MADE X EPP0701539 12/17/2023 12/17/2024 AGGREGATE $ 2,000,000 _ DED RETENTION S S A WORKERS COMPENSATION � X PER QTH AND EMPLOYERS•LIABILITY YIN EPP0701539 12/1I2023 12/1I2024 STATUTE ER ANY PROPRIETORIPARTNERIE.XECUTIVE E L EACH ACCIDENT S 500.000 1(%:ICER/MflMggEER EXCLUDED' N I A ndatory in NNI L.L DISEASE EA EMPLOYEE S 500,000 11 yes describe under DESCRIPTION OF OPERATIONS below f L DISEASE-POLICY LIMIT S 500,000 DESCRIPTION Or OPERATIONS I LOCATIONS I VEHICLES(ACORD 101.Additional Remarks Schedule.may be attached if more space is required) Village of Rye Brook is additional insured. 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 938 King Street ACCORDANCE WITH THE POLICY PROVISIONS. Rye Brook,NY 10573 -- AUTHORIZE D REPRESENIA TIVE ACORD 25(2016/03) C)1988.2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD NEW Workers' YORK S ATE Compensation CERTIFICATE OF Board NYS WORKERS' COMPENSATION INSURANCE COVERAGE la.Legal Name 8 Address of Insured(use street address only) lb Business Telephone Number of Insured oastal Mechanical Services,Inc. (203)953-3732 0 Hathaway Dr. Iratford ,CT 06616 1c NYS Unemployment Insurance Employer Registration Number of Insured ork Location of Insured(Only required if coverage is specifically limited to 1d. Federal Employer Identification Number of Insured or Social Security certain locations in New York State.i e..a Wrap-Up Policy) Number 06-1450112 2.Name and Address of Entity Requesting Proof of 3a Name of Insurance Carrier Coverage(Entity Being Listed as the Certificate Holder) irlcinnati Insurance Co. Village of Rye Brook i 3b Policy Number of Entity Listed in Box"la" 938 King Street EWC 0701548 Port Chester. NY 10573 3c. Policy effective period 12/1/2023 to 12/1/2024 3d The Proprietor,Partners or Executive Officers are ®included.(Only check box if all pannersloffioers included) ❑all excluded or certain partners/officers excluded. This certifies that the insurance earner 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 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: Paul A Suzio fl��A��1lhonred represen[alive or licensed agent of insurance carnen Approved by: Pam(. S 16,r 3/13/2024 6[14C91fWrM(tJfC) (Date) Title: Account Executive Telephone Number of authorized representative or licensed agent of insurance carrier (203)514-7863 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.