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HomeMy WebLinkAboutPP24-085 LU C cCt.,°u o`w L VILLAGE OF RYE BROOK MAYOR 938 King Street, Rye Brook,N.Y. 10573 ADMINISTRATOR Jason A. Klein (914)939-0668 Christopher J.Bradbury www.iyebrookny.gov TRUSTEES BUILDING&FIRE INSPECTOR Susan R.Epstein Steven E. Fews Stephanie J. Fischer David M.Heiser Salvatore W.Morlino CERTIFICATE OF COMPLIANCE September 16,2024 Richard Greenberg&Elizabeth Pena Greenberg 1 Milestone Road Rye Brook,New York 10573 Re: 1 Milestone Road, Rye Brook,New York 10573 Parcel ID#: 124.65-1-60 This document certifies that the work done under Plumbing Permit #24-085 issued on 6/12/2024 for the installation of a new gas water heater has been satisfactorily completed. Sincerely, Steven E. Fews Building&Fire Inspector /to BR o tim 1982 BUILDING DEPARTMENT ❑BUILDING INSPECTOR 12'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 : ' 1 ► 1 LQ-!S ) DATE: PERMIT# fi'7 - Q ISSUED: SECT:/,?$/- kr BLOCK: LOT: LOCATION: 9AD(ASe M Q 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 0 OTHER WAI h P� Ln O rq N W e � N z W va a W h 00 z w x a 0 a - O o w �, w � w � ° 00 °o F z 00 d aU Oo o N z uz cn CN a ' A o IX M Co w w w H H O V z zZ o F - o ° w z zs � o O a o 4 V o ,_ tF 13RC� `I Ilr��j4}ll Lam! r !� I� 161, � j BULLYING DE MENT � VIL E OF RYE OK `'j UN 10 2024 938 KIN ET RYE B ,NY 10573 VILLAGE OF RYE BROOK BUILDING DEPARTMENT w .or ���^^ PLUMBING PERMIT APPLICATION FOR OFFICE USE ONLY BP #: PP#: �" / ` V O Approval Date: Permit Fee: $ 006 Approval Signature: o.?0A 4�' CG— DO NOT START WORK or CONSTRUCT R N UNTIL A PERM I F HAS BEEN ISSUED BY THE BUILDING INSPECTOR.THE ADMINISTRATIVE FEE FOR WORK PRO(;RESSED OR COMPLETED WITHOUT A PERMIT IS 12% OF THE TOTAL COST OF CONSTRUCTION WITH A MINIMUM FEE OF$750.00 Application dated, May 28, 2024 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. (.Address: 1 Milestone Rd, Rye Brook, NY 10573 SBL: 124.65-1-60 Zone: P.U.D. 2.Proposed work: Replacement of 75-gallon gas water heater; retrofit to existing gas line, water lines and venting. Same location. 3.Property Owner: Richard Greenberg Address: 1 Milestone Rd, Rye Brook, NY 10573 Phone#: (917)576-6207 Cell#: email: RBGreenbergl@optonline.net 4.Master Plumber: Thomas Webber Jr. Address: 3365 Route 9, Cold Spring, NY 10516 Lic.#: 1489 Phone#: (845)265-1400 Cell#: (845)666-0258 email: Permits@TWebber.com Company Name: T. Webber Address: 3365 Route 9, Cold Spring, NY 10516 INDICATE FIXTURES&LINES TO BE INSTALLED AS PER THE FOLLOWING SCHEDULE: Location Water Urinals Drinking Sinks Showers Bath Laundry Domestic Fire Sanitary NaturaU Other* Total Closets Fountains Tubs Tubs Service Service Sewer LP Gas Basement 1 1 1 st Floor 2nd Floor 31 Floor 41h Floor 5'Floor Exterior 5.* List Other Equipment/Provide Details: Bradford White RG2PV75H6N: 75-gallon power vented gas water heater. (Notarized Signatures Required Next 2 Pages) 313l2023 STAIF,OF NEW IY�O,RK,,COUNTY OF WESTCHESTER ) as: _—too ()lt'll'S 1�a4r, ,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 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 Sworn t before me this day of ;P- ,20Z day of ,20 r � Signature of Hoperty Owner t ature of Applican Richard Greenberg John O'Hare for T. Webber Print Name of Property Owner Print Name of Applic t Notary Public Notary Public CHRI J.BRADBURY Mkkft P4•am" Notary Public,State of New York PAk state of New ft* No.01 BR6159985 p� �W Oualtfied in Westchester County��7 CaawrMMan Express 2M This app�earin mt�i slle properly o mpreted in its entirety and must include the notarized signature(s) of the legal owner(s) of the subject property, and the applicant of record in the spaces provided. Applications not properly completed in its entirety and/or not properly signed shall be deemed null and void and will be returned to the applicant. -2- 1oi3012023 B7G � MENT Q VIOL oiF Rii OOKJ U N 10 20?938 K ��E v�•r RYE NY 10573(914)939-0 VILLAGE OF RYE BROOK ,v BUILDING DEPARTMENT **a4*************t**##k***k*�:***R9r:FYe**ah***yY*fir*******'k t4lk+k ak�:****:k***4:F**kk**Yr ik:F�r*k�F of is*al•#******k*****A'k'k*t it AFFIDAVIT OF COMPLIANCE VILLAGE CODE 4216 • STORM SEWERS AND SANITARY SEWERS `PHIS 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: 3J. Richard Greenberg ,residing at, 1 Milestone Road, Rye Brook, UY 10573 (Print name) I Address 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; 1 Milestone Road, Rye Brook, NY 10573 , Rye Brook,NY. (_lub Addresa) 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. (Signature of Property Owner(sll Richard Greenberg (Print Name of Propert} Owner(s)) �a Sworn to before me this 3 _ day of 0� � (Notaiy Pubiic) CHRISTORH A J. ADBURY NUtary Public a of New York No.01 3RSi 59985 Qualified in Westchester County Commission Expires January 29,20 -;- 8/1 212 02 1 BRADFORD HNITES W A T E R H E A T E R S Residential Power Vent Gas Water Heater The TTW®Models Feature: ■ Powerful Blower Motor-Exclusively featuring the AquaVENT MAX"from Fasco-is the quietest blower motor in the industry. This new blower is a lower profile than previous versions and features a more robust electrical connection. -10 Foot(3m)Power Cord-Included(120 VAC). ■ Horizontal and Vertical Venting-Designed for installations where atmospheric units cannot be used.Exhaust gases are vented under positive pressure directly out of the building through the roof or the wall with PVC,ABS or CPVC(Maximum equivalent vent length on reverse side). ■ High Attitude Ready-Water Heaters designed and certified for installations up to 10,100 feet _ (3078m)out of the box. No conversion kit required. ■ Bradford White ICON System®-Intelligent gas control with spark to pilot ignition system eliminates the constant burning pilot.This results in savings of pilot gas during standby periods(120 VAC). -Enhanced Performance-Proprietary algorithms provide enhanced First Hour Rating and tighter temperature differential. -Advanced Temperature Control System-Microprocessor constantly monitors and controls burner operation to maintain consistent and accurate water temperature levels. -Intelligent Diagnostics-An exclusive green LED light prompts the installer during start-up and provides ten different diagnostic codes to assist in troubleshooting. -Pilot On Indication-Flashing green LED provides positive indication that pilot is on. -Separate Immersed Thermowell-High-strength advanced polymer composite thermowell provides isolation between electric temperature sensor and surrounding water. No need to drain the tank when removing gas valve. ■ Advanced Screenl_olc Technology Flame Arrestor Design-Flame arrestor is designed to prevent ignition of flammable vapor outside of the water heater(excluding RG1 PV55H6N& RG2PV75H6N). ■ Flammable Vapor Sensor-Electronic sensor prevents burner operation if flammable vapors are detected.The sensor will also prevent operation if there is ongoing flammable vapors ' G®' burning inside the combustion chamber(excluding RG1 PV55H6N&RG2PV75H6N). ■ Maintenance-Free-No regular cleaning of air inlet openings or flame arrestor is required under normal conditions(excluding RG1PV55H6N&RG2PV75H6N). ■ Sight Window-Offers a view into the combustion chamber to observe the operation of the pilot and burner. ■ Vitmglas'Lining with Microban'-An exclusively engineered enamel formula that provides superior tank protection from the corrosive effects of water;and with Microban'antimicrobial product protection to help prevent the growth of bacteria,mold and mildew on the surface of the tank lining. Photo is of ■ Factory-Installed Hydrojet®Total Performance System-Sediment reducing device that RG1 PV506N also increases first hour rating of hot water while minimizing temperature build-up in tank. ■ Insulation System-Non-CFC foam covers the sides and top of the tank, reducing heat loss. This results in less energy consumption,improved efficiencies,and jacket rigidity. FEATURING: ■ Water Connections-3r4"(19mm)NPT factory-installed true dielectric fittings extend water heater life and simplify water line connections. I� N ■ 3/4"(19mm)NPT Side Connections-(RG2PV50H6N, RG1 PV55H6N,and RG2PV75H6N "-*++ System• only). ■ Factory-Installed Heat Traps-Design incorporates a flexible disk that reduces heat loss in piping and eliminates the potential for noise generation. ZAP ..... °'""'"' ■ Protective Anode Rod-(RG1 PV55H6N has 2). MICROBnnt1 ■ T&P Relief Valve-Installed. ■ Thermostatic Mixing Valve(ASSE Approved)-Included(RG1 PV55H6N only). ■ Low Restrictive Brass Drain Valve-Durable tamper proof design. ■ NOx Emissions-Less than 40 ng/J. 6 or 10-Year Limited Tank Warranties/6 or 10-Year Limited Warranty on Component Parts. For more information on warranty,please visit www.bradfordwhite.com For products installed in USA,Canada,and Puerto Rico.Some states do not allow limitations on warranties.See complete ® copy of the warranty included with the heater. ' Microban antimicrobial product protection helps prevent the growth of bacteria mold and mildew that may affect the product.The built-in antimicrobial properties do not protect users or others from disease-causing organisms.Microban®is a registered trademark of e Microban Products Company. MANUFACTURED IRi 8 ONE OR MIORE OF TIE FOLLOWNG US PATERS:5,682,666:7,634,976;5,660,166;5,954,492;6,056,542;6,935.280;5,372,185;5.485,879;5,574,822;7,971,560;7,992,526;6,684,821;7.334,419;7,866,168; 7,270,087;7,007.748;5,596,952;6,142,216;7,699,026;5,341,770:7.337,517:7.665,211;7,665,210;7,063,132;7,063,133;7,559293:7,900,589;5,943.984;8.082,888;5,998.117:7,621,238;7,650,859;5.761,379 7,409,925;5,277,171; 8,146,772;7,458,341:2,262,174.OTHER U.S.AND FOREIGN PATENT APPLICATIONS PENDING.CURRENT CAfNADWI PATENTS:2,314,845;2,5D4,824;2.108,186;2,143,031;2,409,271;2.548,958;2.112,515;2.476.685:2,239,007;2,092,105; 2,107,012.Defender Safeq Bye",SoroonW,TIW",Vhr&W and IgboW we ngWt red trademarks of Bradford WhW C rporatlan.MNraabrn`is a repialeed trademark of Mioreban Products Carpsry. 1261-H-1223 Residential Power Vent Gas Water Heater TTW® Power Vent Models 1119 Series" NATURAL GAS AND LIQUID PROPANE GAS Model Rated DOE First Uniform Recovery at Model Rated DOE First Undorm i Recovery at Number Nominal Rated Hour Energy 90°F Rise* Number Nominal Rated Hour Energy 50°C R1W Volume Storage Lp Rating Factor LP LP Volume Storage Lp Rating Factor Lp US. Imp. Volume BTWHr. BTU/Hr. US. Imp. US. Imp. Volume kW kW Liters/ Litew Gal. Gal. Gal. Input Input Gal. GPH GPH GPH GPH Liters Liters input Input Liters Hour Hour RG1PV4OS6N 40 33 38 40,000 38,000 75 0.68 43 36 41 34 RG1PV40S6N 151 144 11.7 11.1 284 0.68 163 155 RG1PV5OS6N 50 42 48 40000 38OD0 78 0.69 44 37 42 35 RG1PV50S6N 189 182 11.7 11.1 295 0.69 167 159 RM4OS6N 40 33 38 1 40000 38000 75 0.72 44 36 41 35 RG2PV4OS6N 151 144 11.7 11.1 284 0.72 165 157 RG2PV5OS6N 50 42 48 40000 38000 78 0.72 44 37 44 37 RG2PV5OS6N 189 182 11.7 11.1 295 0.72 167 167 RG2PV4OT6N 40 33 38 40,000 40,000 78 0.72 43 35 40 34 RG2PV40T6N 151 144 11.7 11.7 295 0.72 161 153 RG2PV5OT6N 50 42 48 40,000 40,000 75 0.72 44 36 44 36 RG2PI50T6N 189 182 11.7 11.7 284 0.72 165 165 RG2PV5OH6N 48 42 46 65,000 58,000 116 0.68 70 58 62 52 RG2PV5OH6N 182 174 19.1 17.0 440 0.68 265 235 RG1PV55H6N 1 55 46 55 78,000 76,000 116 0.68 84 70 82 68 RGIPV55H6N 208 208 22.9 22.3 440 0.68 318 309 R62W/5NNM 1 75 62 72 76000 750 1 121 0.69 1 82 68 81 67 FWPV75M 204 1 235 22.3 22.1 459 0.8E 310 30T Modd A B C D E F G H J K L M R S Approx. Number Floor to Jacket Vend Floor to Floor to Floor to Floor to Depth CIL Floor to Floor to water Space Gas ShIppklg Top of Dia. Size T&P Gas Top of water of water Space Heating Space Heating Can. Heating Conn. weight Blower Conn. Conn. Heater Conn. Conn. Inlet OtMet NPT Conn.Size Size in. in. In. In. In. in. in. In. In. In. In. in. In. in. lbs. RG1PV40S6N 557/n 20 2or3 40 111/2 461/2 49 2515/,6 8 WA WA 3/4 N/A h 140 RG1PV50S6N 56316 22 2or3 40Ne 111/2 483h6 501/2 273/16 8 N/A WA '/4 N/A /, 166 RG2PV40S6N 557he 22 1 2or3 40 lie 111/2 473Ae 49 273/16 8 WA I WA 3/4 N/A 'h 142 RG2PV5OS6N 567/16 24 1 2or3 40 3h 1 111h 483h6 501/2 281/e 1 8 WA WA 3h NIA h 168 RG2PV4OT6N 65 20 2 or 3 49"h6 11112 563/4 58 261/6 8 WA WA Ih N/A 'h 146 RG2PV50T6N 6513h6 22 2or3 509hE 111/2 57IN 58 273/16 8 WA WA 3h N/A 'h 173 RG2PV5M 647/16 22 3or4 49116 111h 563/4 573/4 2615/16 11 13% 497/6 3/4 114 Ih 187 RG1PV55H6N 621/2 22 3or4 47151,6 111h 5431, 56 273I16 7314 133/8 47i/16 3/1 3h 12 219 FOM5H6N 67711, 26 3or4 51i61e 13% 5911/s 60114 301'/* 11 16"M 5116/16 3h 3h 'h 20 Model A B C D E F G H J K L M R S ApproL Number Floor to Jacket Vent Poor to Floor to Poor to Floor to Depth CA Floor to Floor to Water Space Get Stippling Top of Dia. Size T&P Gas Top of Water of Water Space Heating Space Heating Conn. Heating Can Weight Blower Conn. Conn. Heater Conn. Conn. Inlet outlet NPT Conn.Size Size mm. mm. mm. mm. mm. mm. mm. mm. mm. mm. mm. mm. mm. mm. kg. RGIPV4DS6N 1408 508 51or76 1016 292 1181 1245 659 203 WA WA 19 N/A 13 64 RGIPV5DS&N 1432 559 51or76 1D32 292 1224 1283 691 203 WA WA 19 WA 13 75 RG2PV4OS6N 1408 559 51or76 1019 292 1199 1245 691 203 WA WA 19 WA 13 64 RG2PV5OS6N 1408 610 1 51or76 1032 292 1244 1 1283 733 1 203 1 WA WA 19 1 WA 13 1 76 RG2PV4OT6N 1651 508 51or76 1262 292 1441 1473 664 203 WA WA 19 WA 13 66 RG2PV5DT6N 1672 559 51or76 1284 292 1462 1473 691 203 WA WA 19 WA 13 78 RG2PV50H6N 1637 559 76or102 1267 292 1441 1467 684 279 340 1267 19 19 13 85 RG1PV55H6N 1588 559 76or102 1218 292 1391 1422 691 197 340 1218 19 19 13 99 FWPVMM 1713 660 76orl02 1319 354 1516 1543 719 279 424 1319 19 19 19 118 Propane models feature a Titanium Stainless Steel propane bumer. For Propane(LP)models change suffix"N"to "X".For 10 year models,change suffix from"6"to 10"(Not available on RG1 PV55H6N).'Based on manufacturer's rated recovery efficiency. 120 VAC Required for Power Venting/ 120 VAC, 60Hz., 3.1 Amperes. Uniform Energy Factor and First Hour Rating is based on the latest AHRI directory listings. O s H -I ij RG2PV4OS6N RGlPV50M RG2PV5OH6N ^� RG2PV5OS6N RG2PV4OT6N 2"(51mm) 3"(76mm) 4"(102mm) RG1PV55H6N 3"(78mm) 4'(102mm) M RG1PV4OS6N RG2PV5OT6N Vent Pipe Vent Pipe Vent Pipe RGM511gN Vern Pipe Vent Pipe Max.Equivalent Length t50 ft.tl5.2m tl20 fL t36.6m t200 ft t61.Om Max t75 fL t23.Om tl80 fL t55.Om Min.Equivalent Length 7 ft. 2.1 m 15 ft. 4.6m 15 ft. 4.6m Min.Equivalent Length 7 it 2.1m 15 fL 4.6m rc Number 1 45 ft. 13.7m 115 fL 35.Om 195 ft. 59.4m Number 1 70 ft 21.3m 175 ft. 53.3m Of 2 40 ft. 12.2m 1101t. 33.5m 1 190 ft. 58.Om of 2 65 ft. 20.Om 170 ft. 52.Om 90'Elbows 13 35 ft. 10.7m 105 ft. 32.Om bows 185 ft. 56.4m 90"El 3 60% 18.3 165% 50.3m Subtract 5ft.(1.5m)for each additional 90'elbow t For high altitude installations,consult the installation instructions. G General:Meets NAECA or EPACT Requirements,as applicable.All gas water heaters are certified at 300 PSI(2068 kPa)test A pressure and 150 PSI(1034 kPa)working pressure.All water connections are 3/4"(19mm)NPT,all gas connections are 12" F (13mm).All models design-certified by CSA Intemational(formerly AGA/CGA)to ANSI standard Z21.10.1. n Dimensions and specifications subject to change wffl wIt notice in accordance with our policy of continuous product Improvement Suitable for Water(Potable)Heating and Space Heating.Toxic chemicals,such as those used for boiler g treatment,shall NEVER be introduced into this system.This unit may NEVER be connected to any existing heating system or i component(s)previously used with a non-potable water heating appliance. T E e -BRADFORD WHITE IS- AM=RICAN Sales:800-523-2931 ■Fax 215-641-1612 STRONG- 2417 Technical Support:800-334-3393■Email techserv@bradfordwhite.com Products made by Bradford White are manufactured in the United States using the finest raw materials and components from around the world. Built to be the Best 1261-H-1223 02023,Bradford White Corporation,USA.All rights reserved. Printed in U.S.A. c E O X r• U CL .`i A� 1 z O O h+Mw}�� �i O Y _O �Q 0 >� O U � c N O a) a. U 4� 4 c M aJ � e- aJ L 4d _ • r„ Y iA , W C a, v1 Z C V1 .* C �. 7 V K i W L DATE(MMIDD/YYYY) ACORO' CERTIFICATE OF LIABILITY INSURANCE 11 1 1/28/2023 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 Higginbotham Insurance Agency, Inc. PHONE Jane Kinsella FAX 1700 Eastpoint Parkway tac.No,eg);502-244-1343 AJC,No) P.O. Box 23790 ADDRESS: JKinsella@higginbotham.net Louisville KY 40223 INSURERS AFFORDING COVERAGE NAIC0 Li :2081754 INSURERA:Safety National Casualty Corporation 15105 INSURED ESSESER-01 INSURERS:HomeSite Insurance Company Of Florida 11156 T Webber Service Corporation T.Webber Plumbing, LLC INSURERC: 3365 Route 9 INSURERD: Cold Spring NY 10516 INSURERE: INSURER F COVERAGES CERTIFICATE NUMBER:1471627847 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 ADDL SUBR --- - - - - POLICY EFF POLICY EXP LTR TYPE OF INSURANCE POLICY NUMBER MM/DD M DD LIMBS A X COMMERCIAL GENERAL LIABILITY Y Y GL6676140 12/31/2023 12/31/2024 EACH OCCURRENCE $5,000,000 CLAIMS-MADE �OCCUR AGE TO RENT D PREMISES Ea occurrence $ 1,000,000 MED EXP(Any one person) $10,000 PERSONAL&ADV INJURY $5,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $10,000,000 POLICY EO-C LOC PRODUCTS-COMP/OPAGG $10,000,000 OTHER: $ A AUTOMOBILE LIABILITY Y Y CA 6676139 12/31/2023 12/31I2024 CO Ea accideMBINEDnt SINGLE LIMIT $5,000,000 X ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS X HIRED X NON-OWNED PROPERTYDAMAGE $ AUTOS ONLY AUTOS ONLY Per accident B X UMBRELLA LIAB X OCCUR Y Y CXP-001249-02 12/31/2023 12/31/2024 EACH OCCURRENCE $5,000,000 EXCESS LIAB CLAIMS-MADE AGGREGATE $ _ DED 1 X I RETENTION$gn nnn $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY Y/N STATUTE ER _ ANYPROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ OFF ICER/MEMBER EXCLUDED? ❑ N/A - (Mandatory in NH) E.L.DISEASE-EA EMPLOYE $ If yyes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT 1$ DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES (ACORD 101.Additional Remarks Schedule,may be attached if more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF. NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Village of Rye Brook 98 King Street Rye Brook NY 10573 AUTHORIZED REPRESENTATIVE ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD Workers' • RK IN A E Compensation CERTIFICATE OF Board NYS WORKERS' COMPENSATION INSURANCE COVERAGE la. Legal Name&address of Insured(use street address only) lb.Business Telephone Number of Insured T Webber Plumbing LLC 3365 US 9 Cold Spring, NY 10516 1 c.NYS Unemployment Insurance Employer Registration Number of Insured Work Location of Insured(Only required if coverage is specifically 1 d.Federal Employer Identification Number of Insured or Social Security limited to certain locations in New York State, i.e. a Wrap-Up Policy) Number 85-3910296 2.Name and Address of the Entity Requesting Proof of Coverage 3a. Name of Insurance Carrier (Entity Being Listed as the Certificate Holder) Safety National Casualty Corporation Village of Rye Brook 98 King Street Rye Brook, NY 10573 3b.Policy Number of entity listed in bo8x"la" LDS4066109 3c. Policy effective period 12/31/2023 to 12/31/2024 3d. The Proprietor,Partners or Executive Officers are x 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"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 the 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,1 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: Gus E. Aivaliotis (Print name of authorized representative or licensed agent of insurance carrier) Approved by: ", 12/21/2023 (Signature) (Date) Title: Chief Underwriting Officer Telephone Number of authorized representative or licensed agent of insurance carrier: 1-888-995-5300 Please Note: Only insurance carriers and their licensed agents are authorized to issue the C-105.2 form. Insurance brokers are NOT authorized to issue it. C-105.2(9-17) www.web.ny.gov