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HomeMy WebLinkAboutMP24-083 QyE DR C�4CV'u V o` Co 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 10,2024 Brian Balanoff&Jamie Balanoff 1 Maplewood Lane Rye Brook,New York 10573 Re: 1 Maplewood Lane,Rye Brook,New York 10573 Parcel ID#: 136.22-1-16 This document certifies that the work done under Mechanical Permit #24-083 issued on 6/25/2024 for the installation of a new heat pump, furnace and coil has been satisfactorily completed. Sincerely, Steven E. Fews Building&Fire Inspector /to QyE BRC�k - w � 1982 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 : ' r%P (o l poo C DATE: PERMIT# 2 ISSUED: -ZS-z SECT: BLOCK: LOT: / v LOCATION: i`o ASP '--P'-A +- k� + � r cal 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 II I ❑ NATURAL GAS ❑ L.P. GAS ❑ FUEL TANK { // I �' 1 ❑ FIRE SPRINKLER i Z o(k rA�of }� C9U t Sl l4p- -f T ❑ FINAL PLUMBING ❑ CROSS CONNECTION FINAL ❑ OTHER QyE BRC�k. w � 1982 BUILDING DEPARTMENT ❑BUILDING INSPECTOR E]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 : I m ( L 14') .) �- rl 1 DATE: ,J -i g 20 Z 1 ct PERMIT# Z 13 1 ISSUED:T SECT: BLOCK: LOT: LOCATION: V oe'V J 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 N c' ❑ L.P. GAS ❑ FUEL TANK ❑ FIRE SPRINKLER .0 FINAL PLUMBING ❑ CROSS CONNECTION ❑ FINAL ❑ OTHER - ` x � � • « .� • / imp y � : MTM , 2665 , 38661 700ft-4X . • � - Ao � • �« - 2- . � y • : : . . \ - � qf! 9 Jill ` ill I r Ot lot I • z 4 S 1 � Y ^. L r _ J *r► d 91 S = _ - o N N N �i N F a rO� N u O0, y a av A o �aacowa N > � I..� © to- So �--� w _ o vo � � v1 ■ Q m o o av , E Uo o vC04 z Z v W O �1 CA w w t -5 v fa e W v w c7 b a o� A O V� oN V A V GQ OEOOu � L pq a oo w � w U O PC � y° �v3o ' Vl \ O Q v 0v oG Wwz u 0 O z j \ ° L a w A z _ w ° ° - h—i H � � C/� z z O � P_ = O � M � O O O = Fig a w O api v v (� ■ z w o HS �° � •� .� _ o cu : r� A w ►�i H� f� C m PLO � 44 F+i CA P C -0 a BUILD ENT C IE N IE WIL :ET OF RY OOK JUN 2 4 2024 938 KING RYE BR© NY 10573 4 _� 6AC7VILLAGE OF RYE BROOK ig�. ov BUILDING DEPARTMENT APPLICATION FOR PERMIT TO INSTALL AND/OR REMOVE HEATING, VENTILATION AND/OR AIR CONDITION�IN/G EQUIPMENT FOR OFFICE USE ONLY: PERMIT#: /""/�c�21- 0 8 Approval Date: 2 Permit Fee: $ 3(D© P�s Approval Signature: Other: Disapproved: (fees are non-refundable) x•xx�•x,�**����*:��;���***•��**��****:a**���*�*****��,�*�•�**�*�*,��*,t***,�**,r*****r�*�r**,�,r***,t,�*,r,r**r.�sr****,t,t**+,� DO NOT START WORK or CONSTRUCTION UNTIL A PERMIT HAS BEEN ISSUED Bl'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#C 105.2 or Form#U26.3/or NY State Workers Compensation Waiver) 4. Payment of Fees/Unit: RESIDENTIAL- $150.00/unit-COMMERCIAL=S450.00/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, c!7 is hereby made to the Building Inspector of the Village of Rye Brook for a permit for the installation and or removal of the HVAC equipment as listed below.The applicant and property owner,by signing this document agrees that said equipment will be installed and/or removed in conformance with all applicable Local,County,State&Federal laws, codes,rules and regulations. l. Address-, �P_11.Y lt(1 . SBL: Zone: 2. Property Owner: _? c'�CA-) >y F Address: LwQja c c7C+ 1-Yl Phone#: 59 S- b6b2 Cell#: email: 'bOCtlU M(TIIP V_fiXlO(V 3. Contractor: Address: -Ib Q MeknCk l4U(J Phone#: g11A - kf�Q-\o0b Cell#: email: 4. Scope of Work: New Installation(Replacement( )•Removal( )•Other{ ): 5. List Equipment: -c a1 1C1��� 11X( C � . �1 1 � j_(al b t ` ► d G%m-ztj 04?SA_ 0.Acd vc�� 6. Location of Equipment: i­oTccecx<A co(1`,' 1�n Yl c � od '>%CA L r)14 �i c)►r� Side ham. r IC:C a p►w i�1 1E'a t�l'1 IIJ 7. Method of Installation/Removal(list all equipment needed to perform job): t 611/2024 STATE OF NEW YORK,COUNTY OF WESTC14ESTER ) as: —bn R;l� (1 ,being duly sworn,deposes and states that he/she is the applicant above named, (print name of individual signing as the applicant) and further states 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 Cade,the Code of the Village of Rye Brook and all other applicable laws,ordinances and regulations. 5� Swom to before me this 21 Sworn to before me this r�15� day of �.>r`� ,20 day of 3—```K- ,20 2 4 Signature of Property Own/e'rr Si Lure o pplicant Print Name of Property Owner Print Name of Applicant " Notary P Notary Public JENNIFER RIVERA w York NotaryJENNIFER RIVERA Notary Public-state of Ne Public`State of New y No 01 R16398056 M0.O7R16388056 York Qualified in Bronx County Quaified in Br ires Feb 25,2027 MY Cor^mission Ex °nx County µy Connmission Expires Aires 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. 2 6/t/2024 Bosch 96% AFUE Gas Furnace �BGH96 Model BOSCHDimensions and Connections Comb.st-1 Air Inlet Cur-wrstiw�ar Inlet A t3r7i755mn,� Gas Pipe EnO Gas Pi En Vcvri Outlet Ekcl.aI Entry 0 �— Ccnderutete Drain 10 Electncal En (7 /Cdndensale Drain 331,a'1657mm1 •TherT:nstat wiring CD Taermoatat IYmng 1a'('3Emrrmml I LEFT SIDE RETURN AIR 1 I RIGHT SIDE RETURN AIR ' L _ _ �• 22-111615K-rn:; 263at't730rm! (Left) (Front) (Right) D 2�'(61Cvnmi 0• Combustion Aa Inlet Vanl Ou11' I' (Top) (Bottom with panel removed) ModelFurnace "A"CabMet Width T"Supply-Air Width "E" Return-Air Width Shipping Weight BGH96MO6OB3B 17.5(445) 16(406) 15-27/32(402) 1 162.5(73.7) BGH96MO8OB3B 17.5(445) 16(406) 15-27/32(402) 168.5(76.4) BGH96M08OC4B 21 (533) 19.5(495) 19-13/32(493) 184.6(83.7) BGH96M100C5B 21 (533) 19.5(495) 19-13/32(493) 194.6(88.3) BGH96M100D5B 24.5(622) 23(584) 22-27/32(580) 205.1 (93.0) BGH96M120D5B 24.5(622) 23(584) 22-27/32(580) 209.5(95.0) Bosch Thermotechnology Corp. 4 of 22 Londonderry,NH Watertown,MA• Ft.Lauderdale,FL Bosch Themwtechnology Corp.reserves the right to make changes without notice due to Tel: 1-866-642-3198 Fax:1-603-965-7581 www.bosch-homecomfort.us continuing engineering and technological advances I BTC 770508101 J 103.2024 Bosch 96% AFUE Gas Furnace BG H96 Model O BOSCH Technical Specifications Model BGH96M06083B BGH96M0SOB38 BGH96MOSOC46 BGH96MIOOCSB BGH96MIOOD5B BGH96M120058 Basic Product Bosch Part Number 7738007227 7738007228 7738007229 1/36007230 7/3800/231 7738007232 Information Fuel Type Natural Gas/ Natural Gas/ Natural Gas/ Natural Gas/ Natural Gas/ Natural Gas/ Propane Gas' Propane Gas' Propane Gas' Propane Gas* Propane Gas• Propane Gas• ENERGY STAR ENERGY STAR Certified Y/N Y Y Y Y 1 Y Y AFUE % 96 96 96 96 T__ 96 96 Input Natural Gas/Propane Btu/h 60000 80000 80000 I 100000 100000 120000 (High fire) Gas(LP) Input Natural Gas/Propane(Low tire) Gas(LP) BtWh 39000 52000 52000 65000 65000 78000 Gas Heating Output Natural Gas/Propane Rt,,Ai 57000 76000 76000 95000 95000 115000 Performance (High fire) Gas(LP) Output Natural Gas/Propane Btwt1 37000 49M 490M 62000 62000 75000 (Low fire) Gas(LP) Air Temperature Rise -F 30-60 35.65 35-65 35-65 ! 35-65 40-70 Design Max.Outlet Air Temperature - °F 160 165 165 165 165 170 Static I Certified EXT Heating in.WC 0.12 0.15 0.15 0.2 j 0.2 0.2 Pressure static pressure coofing in.WC 0.5 0.5 0.5 0.5 0.5 0.5 it Material - Metal Type ECM Circulating Blower: Diameter Inch 12 3/8 12 6/8 j blower wheel Height Inch 8 111/4 blower wheel i Tons AC @ 0.5"ESP tons 1.5/2/2.5/3 1.5/2/2.5/3 2.5/3/3.5/4 3 5/4/4.5/5 3.5/4/4.5/5 ( 3.5/4/4.5/5 Circuating Motor Horsepower HP 3/4 1 Fan Motor Air Flow(O.S ESP in.WC) High CFM 1280 1271 1312 2031 2095 2127 Circulating Blower Air Flow(0.5 Mid-High CFM 1100 1071 1092 1836 I loge 1907 Data I ESP in.WC) Air Flow(QS Mid ESP in.WC) CFM 910 886 894 1573 1609 1620 Air Flow(0.5 Mid-Low ESP in.WC) CFM 690 649 625 1241 ( 1241 1265 Air Flow(0.5 Low CFM 500 539 455 820 i 802 814 ESP in.WC) R speeds 5- or Speeds settings High/Mid-High/Mid/Mid-Low/Low r/min 1050(rated) inducer Pnwer Input (High) 'N 63-10% Motor Power Input I (Low) W 3700% 42tl0%. ♦ Power supply V/Hz/PH 115V/60HZ/1 PH Electrical Max Overcunem Protection(MOP•'°) Amps 15 I 20 Data Blower motor full load(FLA) - Amps 8 8 7.8 11.5 10.5 10.5 ' With factory supplied Natural Gas to LP Conversion Kit '•5 selectable speeds via wiring,unit operates in two speeds in concert with HVLOW fire operation MOP refers to the maximum recommended fuse or breaker size. Bosch Thermotechnology Corp. 5 of22 Londonderry,NH Watertown,MA' Ft.Lauderdale,FL Bosch Thermotechnology Corp.reserves the right to make changes without notice due to Tel: 1-866.642-3198 Fax:1-603-965-7581 www.bosch-homecomfort.us continuing engineering and technological advances I BTC 770508101 J 103.2024 Bosch 96% AFUE Gas Furnace BGH96 Model ® BOSCH Technical Specifications Continued Model 8GH96M0S0830 BGH98M060638 06H96MOSOC4B 1 B6H96M100C58 BGH96MIOOD5B ! 111161496M1201D511111 Natural Gas in.WC 10.5 Max.Inlet Gas Press Propane Gas(LP) in WC ;� 13 Natural Gas in.WC 4.5 Min.Inlet Gas Press Propane Gas 1 in.WC 11 (LP) Natural Gas Manifold Pressure(High in WC 3.5 fire) Natural Gas Manifold Pressure(Low in.WC 1.5 fire) Propane Gas Mae!olo Pressure in.WC 10 (High fire) Combustion Propane Gas Mangold Pressure in WC f 4 System (Low fire) Specifications Natural Gas Factory Orifice (0-2000 feet) ° 45 Propane Gas(LP)Factory Orifice I(0.2000 feet)' n 55 Gas Connection Size in.NPT 1/2 Igndon Device Hot surface Number of Burners e 3 i 4 4 5 5 6 • Prmary Heat Exchanger Diameter Inch 1 6/8 Primary Heat Exchanger a tubes 3 4 4 5 5 6 I I Secondary Heat Exchanger Diameter Inch 3/8 Secondary Heat Exchanger ! 0 tubes 33 33 39 39 1 48 46 Flue Vent Diameter Inch 2`/3' 2"/3" 2.13. 2`0 _ _ 2"/3 3' Hearing Blower Control(Heating Adjustable:90,120,150,180 seconds Off-Delay)Dip ff 1 Cooing Blower Control(Cool Off- f Switches I - I Adjustable:60,90.120.150 seconds Delay) Upstage WI to W2 Delay - Adjustable.OFF,10 minutes,AUTO,20 minutes Cabinet Type j B B C C D D i Cabinet Size Cabinet Size Width Inch 17.5 17 5 21 21 24 5 245 i Cabinet Size(DxH) (DxH) Inch (28.3/4)'(33-3/4) i (28-3/4)'(33.3/4) (28.3/4)'(33.3/4) (28-3/4)'(33-3/4) (28 3/4)(33.3/4) (28.3/4)'(33-3/4) ___ Parking D iensrt'i (without pallet) (WxDxH) Inch (20)'(31)'(35-1/2) (20)'(31)'(35-1/2) (23-1/2)'(31Y(35.1/2) (23-1/2)'(31)135-1/2) (27)(31)'(35-1/2) (27)-(31)'(35-1/2) '. I Packing Dimension Shipping I (with pallet) (WxDxH) Inch (20)'(31)*(40) (20)'(31)'(40) (23.1/2)'(31r(40) (23.5)'(31)'(40) (27)-(31)'(40) (27)'(31)-1 Dab Net Weight(unit only) '.. Ibs 135 ! 141 152 162 169.6 114 Gross Weight(shipping weight with Ibs 162.5 168.5 184.6 194.6 1 205.1 209.5 pallet&packaging) I 'All Bosch 96%AFUE Gas Furnaces come standard with Natural Gas to LP Conversion Kits.These kits are only applicable for units installed at elevations between 0 and 2.000 feet. 4 For LP applications above 2000 h elevation,the manifold and inlet gas pressure requirements remain the same as stated to this manual,the only change is to the orifices used.Refer Tables 14&15 in Section 9.2 of the Installation,Operation,and Maintenance Manual to determine which orifice to use based on your applica- tion. Bosch Thermotechnology Corp. 6 of 22 Londonderry,NH Watertown,MA• Ft.Lauderdale,FL Bosch Thermotechnology Corp.reserves the right to make changes without notice due to Tel: 1-866-642-3198 Fax:1-603-965-7581 www.bosch-homecornfort.us continuing engineering and technological advances I BTC 770508101 J 103.2024 Product Specifications BOSCH 8 Dimensions NOTE:APPEARANCE OF UNIT MAY VARY AIR DISCHARGE:ALLOW 60" MINIMUM CLEARANCE `fir R`W� 000000000000 00��0 ALLOW A MINIMUM OF 12" 000 9 o00 00o CLEARANCE ON ONE SIDE OF �0 00 ACCESS PANEL TO A WALL 000 0 H oo� (f'�I OOO ODO AND A MINIMUM OF 24"ON ooO�000oU000 THE ADJACENT SIDE OF �O� 000 00� ACCESS PANEL 000000000000 000000 0000000 0 0000000000 00000000 000 �0 000 0 000000000000 �0 000 00 AIR INLET LOUVERED PANELS: ALLOW 12"MINIMUM CLEARANCE Figure 3 Model Size Dinensions(Inches) BOVB20-36 24-15/16[633] 29-1/8[740] 29-1/8[740] BOVB20-60 33-3/16�843] 29-1/8[740] 29-1/8[740] Table 18 22 Bosch IDS L• C 0 5 plit System Heat Pump BTC 761701318i(02.2023) Product Specifications BOSCH s 3 Product Specifications Nominal Cooling(BTU/h) 34,600 54,500 Nominal Heating(BTU/h) 34,200 56,000 _- -- - ... ...................... _ . _ ............ Decibels([dB(A)] Max@ 100%load 77 79 Min @ min load 56 60 RLA 19 29 CandMuerFen lMoler Horsepower(HP) 1/3 1/3 FLA 2.5 2.5 Refrigeration System ........... Refrigerant Line Size' Liquid Line Size(OD) 3/8" 3/8" Suction Line Size(00) 3/4" 7/8" Refrigerant Connection Size Liquid Valve Size(OD) 3/8' 3/8" Suction Valve Size(OD) 314" 7/8" Refrigerant Charge(R410-A.oz) 7 Ibs.9 oz 11 lbs.5 oz. Expansion Device EEV EEV Maximum Line Length 150 FT 150 FT Maximum Elevation Difference 50 FT 50 FT operating Range --- ----- - Cooling 15-125°F Heating -4-86'F Electrical Data Voltage-Phase-Hz 208/230-1-60 208/2304.60 Minimum Circuit Ampacity' 26.3 38.8 Max.Overcurrent Protection' 45 60 Max Fuse Size 45 60 M)n/Max Volts 172V/270V weight Net Weight(without packaging) 151 221 Gross Weight(including packaging)' 181 254 dimensions Unit L x W x H(in.) 29-1/8 x 29-1/8 x 24-15/16 29-1/8x29-1/8x33-3/16 outdoor Cog Net face area-sq.ft.Outer Coil 13.6 18.4 Tube diameter-in. 9/32"(7mm) 9/32"(7mm) No.of rows 2 2.8 Fins per inch 17 19 Table 1 'Tested and rated in accordance with AHRI Standard 210/240. 'Wire size should be determined in accordance with National Electrical Codes; Always check the rating plate for electrical data on the unit being extensive wire runs will require larger wire sizes. • installed. 'Must use time-delay fuses or HACR-type circuit breakers of the same size as •Unit is factory charged with refrigerant for 15'of%"liquid line. noted. System charge must be adjusted per Installation Instructions Final 'Weight values are estimated. Charge Procedure. TXV is required at indoor unit to match our outdoor unit. 61 Bosch IDS:e t !Split System Heat Pump7617013 !(02.202 = r r , r , �r.l N N ■ 0 o CZ ■ � N W • N � � ■ o W ' a H R„ r44 ' Z 0-4a o u Cn 0 � yv ti w x a W ao ■ N (� C v H r r 00 c O LO w o can , w = Q x 0 o x z a m o V O °° o Au o z H o a z o z w N z uz cn W z _ W z M � o W4t � 0 z _ W v O o _ Q B N ] W A A z o H o � y O ¢ F U os OIL Z O N o O O8 _ z W CA x a °PLO � _ H a _ �) as a ►..a � w x p ECENE yE BRnv�, BUIL E MENT JUL - 1 2024 VIL E OF RYE OK 938 KIN ET RYE B ,NY 10573 VILLAGE OF RYE BROOK BUILDING DEPARTMENT ov PLUMBING PERMIT APPLICATION ,/ > FOR OFFICE USE ONLY ' -/per�'"-y's PP#: Approval Date: Permit Fee: $ QCO .approval Signature: Disapproved: (fees are non-refundable) ******************************** * ************************************************************** DO NOT START WORK or CONSTRUCTION UNTIL A PERMIT HAS BEEN ISSUED BV 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 Application dated, 4—a 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. 1.Address: WAWkei •n`— �U- - SBL�:13(Or d4 2.Proposed Work: 3.Property Owner: Address: Phone#: Cell#: email: 4.Master Plumber:_ t �'1-�1 � Address: Lic.#: \ Phone ����" Cell#: email: 1 Company Name: : \\`r; 1 `►�it� � Address: CeQ 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 1 st Floor 2nd Floor 3`d Floor 41 Floor 51 Floor Exterior 5.*List Other Equipment/Provide Details: (Notarized Signatures Required Next 2 Pages) 6/1/2024 STATE OF NEW,YORK,COUNTY OF WESTCBESTER ) as: � ` 4 �. W ,being duly sworn,deposes and states that he/she is the applicant above named, (print name of individual sigqJA 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 me this 21t�r Sworn to before me this 21 5� day of Q�LK. ,20 21- da 3-� I 202A Signature of Property Owner 'Signa44 of Afplicant 11 4/4 li/O 1`9 Print Name of Property Owner Print Name of Applicant Notary Public Notary Pub JENNIFER RIVERA Notary Public-State of New York Eth61ndM1h t4NIFER RIVERA NO.OI R16389056 bli,:•State of New York Qualified in Bronx County 0�R16388056 My Commission Expires Feb 25, 2027 ed in Bronx County This applica in its entirety and must incluP2�21�'i AI 7 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- 6/l i2024 BUILD NT D ID VIL E OF RYk OOK 938 KING ET RYE BR Y NY 10573 J U L - 1 2024 -0 an e _ ov VILLAGE OF RYE BROOK 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 ) as: 3, c�c. �\��`�' -� ,residing at, t M0 r_ (Print name) ddress where you live) 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; �c 7\t\.v G o \�- \' �,✓1-L Rye Brook, NY. (Job Address) 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. J (Signature orProperty Owner(s)) (Print Namc of Property Owner(s)) Sworn to before me this l� h JENNIFER RNERA Notary Public-State of New York day Of , 2� 4 NO.01RI6388056 Qualified in Bronx County My Commission Expires Feb 25, 2027 (Notary-Public) -3- 6/I/2024 `. r Iil NIIIIi s�1�`'i1011�r _ I Iih1i;r•, r1111111i;r - f s .rs3. �s3_..:,rl!.Irrr _tst.. s3.,. NIIr-:cis •',Nllli: -a ;3��► Ir ���Y Wllr,�-;y� o .. y .,= cq CCS O i > N 'd 0w O � O O cq S L - r i +�+ O b i{ V •� y cr cn • �' U o S w ULO �, 0 G� Q w O o io>`ection «o» U Q Q Z .:: U J O O Q O ` y W u. p �V X 4-4w to W c O O z o G� C� a 3 Q c° a c '4 d CL .:t o „ . co j ♦= X fa CO y O OD •`i' O O N 72' c U V N #: --- _. . . . .. . . . .,r r� I=;c rr�1111rrrt r : i.- 3;• 1/11rr1 @ �} r1/1-r.j �j/1111rr` �)a `pftq��irrOW > ;I"WA0W •` i-� PHOEMEC-03 FH LZHAY r-- ACORO CERTIFICATE OF LIABILITY INSURANCE DAT D/VYYY) 3/25/225/2024 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 Luann Silano Acrisure Insurance Partners Services of NY, LLC (PHHCONN,Et):(914)937-1230 , No 90 S. Ridge Street Rye Brook, NY 10573 ED RL 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 y 1,000,000 CLAIMS-MADE ❑X OCCUR X MPGR3802-02 3/16/2024 3/16/2025 DAMAGE TO RENTED = 100,000 -PREMISES(Ea occurrence)MED EXP(Any one y 10,000 PERSONAL BADVINJURY 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY X JECT LOC PRODUCTS-COMP/OP AGG E 2,000,000 OTHER: E A AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT 1,000,000 (Ea accident) $ X ANY AUTO BAGR3802-02 3/16/2024 3/16/2025 BODILY INJURY Per n $ OWNED SCHEDULED AUTOS ONLY AUTOS BODILYBORDILY INJURY Per accident $ ATY UTOS ONLY AUTOS ONLY PPS PERd.tDAMAGE _ A X UMBRELLA LIAB X OCCUR EACH OCCURRENCE E 5,000,000 EXCESS LIAB CLAIMS-MADE XSGR3802-02 3/16/2024 3/16/2025 AGGREGATE $ 5,000,000 DED I X I RETENTIONS 10,000 _ _ y WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY Y/N ANY FICE R/MEMBER EXCLUDED? WECUTIVE ❑ N f A E.L.EACH ACCIDENT E (Mandatory in NH) E.L.DISEASE-EA EMPLOYE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT f 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 I ACORD 25(2016/03) 01988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD YORK Workers' CERTIFICATE OF STATE Compensation NYS WORKERS' COMPENSATION INSURANCE COVERAGE Board 1 a. Legal Name&Address of Insured(use street address only) 1 b. Business Telephone Number of Insured Phoenix Mechanical Corp 914-690-1000 26 Vreeland Ave 1 c. NYS Unemployment Insurance Employer Registration Number of Elmsford, NY 10523 Insured Work Location of Insured (Only required if coverage is specifically limited to 1 d. Federal Employer Identification Number of Insured or Social Security certain locations in New York State, i.e., a Wrap-Up Policy) Number FEIN-13-3934943 2. Name and Address of Entity Requesting Proof of Coverage 3a. Name of Insurance Carrier (Entity Being Listed as the Certificate Holder) Indemnity Insurance Company of North America Village of Rye Brook 3b.Policy Number of Entity Listed in Box"la" 938 King Street C57272879 Rye Brook, NY 10573 3c. Policy effective period 05/29/2024 to 09/29/2024 3d.The Proprietor,Partners or Executive Officers are Q included.(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"T' 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: Lynne Boone (Print name of authorized representative or licensed agent of insurance carrier) Approved by: 961B,f� 06/06/2024 (Signature) Date; Title: Assistant Program Manager Telephone Number of authorized representative or licensed agent of insurance carrier: 214-721-6248 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) www.wcb.ny.gov