HomeMy WebLinkAboutMP24-143 BR
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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.Qov
TRUSTEES BUILDING&FIRE INSPECTOR
Susan R. Epstein Steven E. Fews
Stephanie J. Fischer
David M. Heiser
Salvatore W. Morlino
CERTIFICATE OF COMPLIANCE
January 24,2025
Win Ridge Realty LLC
c/o Alena Hakanjin
24 Rye Ridge Plaza
Rye Brook,New York 10573
Re: 14B Rye Ridge Plaza,Rye Brook,New York 10573
Parcel ID#: 141.27-1-7
This document certifies that the work done under Mechanical Permit #24-143 issued on 11/6/2024 for the
installation of a new rooftop HVAC unit has been satisfactorily completed.
Sincerely,
a4
Steven E. Fews
Building&Fire Inspector
/to
QyE BR(�k•
'9a2 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' DATE:
PERMIT# M� Z'-�' �� ISSUED: SECT: 11J. 7 7 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 1 '�
❑ NATURAL GAS f
❑ L.P. GAS
❑ FUEL TANK
❑ FIRE SPRINKLER
❑ FINAL PLUMBING
❑ CROSS CONNECTION
�y. FINAL
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VIL OF RY OOK
938 KING ET RYE BR ,NY 1057 �� . �OZy
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. 0v VILLAGE OF RYE BROOK
BUILDING DEPARTMENT
APPLICATION FOR PERMIT TO INSTALL AND/OR REMOVE
HEATING, VENTILATION AND/OR AIR CONDITIONING EQUIPMENT
FOR OFFICE USE ONLY: PERMIT#:
Approval Date: �►���0 �- Permit Fee: $
Approval Signature: Other:
Disapproved:
(fees are non-refundable)
DO NOT START WORK or CONSTRUCTION UNTIL A PERMIT HAS BEEN ISSUED BY THE BUILDING
INSPECTOR. THE ADMINISTRATIVE FEE FOR WORK PROGRESSED OR COMPLETED WITHOUT A PERMIT IS
12% OF THE TOTAL COST OF CONSTRUCTION WITH A MINIMUM FEE OF 7$ 50 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#C105.2 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.
& Plumbing/Gas work requires a separate Plumbing Permit&Plumbing Inspection.
Application dated, -L Cn 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 confortgance with all applicable Local,County,State&Federal laws,
codes,rules and regulations. (��p.�,
1. Address: 1Ir �1 k�—b� I l�l G SBL: Zone:
2. Property gOwner: � �� t'fY� Address: ,. Myr— �J;Ws PLA��4
Phone#: I� '��'�'(� Cell#: email: AHA K& T2`�I @ Wig co
3. Contractor ��AS'Atrl,�Clf Ick,wlks 1(_ Address: D � y,ll 6 DelVc,SmIT JCT
Phone#: 243"163' 335Z. Cell#:Zo j " 53S3 _ email:NW E 6) Cc*} -'jt;(Ucg&)I )Lt Ces
4. Scope of Work:New Installation( ) Replacement( )•Removal( )•Other( ):
5. List Equipment:QC [T— $ CrAS
0AIM `R- 1�►rlaf�11N SI p
6. Location of Equipment: Cd►` l l T ' G-1 coc--
7. Method of Installation/Removal(list all equipment needed to perform job):
t
6/1/2024
STATE f OF NEW YORK,COUNTY OF WESTCHESTER ) as:
b1tV IA Jj6SJ-9P—Fjj5,- Lb ,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 Code,the Code of the Village of Rye Brook and all other applicable laws,ordinances and regulations.
Sworn to before me this +11 Sworn to before me this
day of Nay t:/Vt_O-, 20 74" day of ,20
F�"�—' -06�c
Signature df Property Ovwter-46w—) Signature of Applicant
We E0J&WS tom, Ip
"Mainef op rty r& Print Name of Applicant
r
otary Public TIMary Public
ALEMA NAKAM.lIM ALENA HAKAN9IN
NOTARY pUgM'STATE OF NEW YORK NOTARY PtBLIC,STATE OF NEW YORK
psatsgqlllstration No.OIHAO013645 Registration No.01HAOO13645
Quaintkly d in Wn tchester county Qualified in Westchester County
My Commission Expirea 911912027
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
6/1/2024
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KDEC31 2024
�l. 1��'• ,t , V0
ILLAGE OF RYE BROOK
BIJILI����G �DI';PAR 1VdE BUILDtNG DEPARTMENT
VIL Al l :OI, Iioolc
93 B ICIN�•\ST�tE6T RYE BIjOOIC,NY 10573
(914)93$..9W'.FAx(9
tv 4)939-5801
Mv .itq-clihdok.org
ELECTRICAL PERMIT APPLICATION
Westchester County Master Electricians License Regnired
FOR OFFICE;USE: ONLY �i3P f�! — Ep ik
Approval Date: V— 1 L� Z-5( Permit Fee:5
Approval Signature: Other:
Disapproved:
fccsarenan refundable)
�t>..,.,,•+:;t:>:>.t>:;:::f:{::i;:{ ::,1 a v4i:i: r}i�:;::;Sa+{:ist::h,`.i.':::>:k:i:i:� i:S<: : 't,}i}.k:::::Li f::�i:Sw�:;t.s:::':t^i-�:::
Application dated, /-)-3/ 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
perforated will be br conformance with all applicable Federal,State,County and Local Codes. l
1.Address: �� t!/�(2) P Ia 20 A A r1 SBL: / /�i a J— Zone:
2.Property Owner: \fit Q1 _ ,✓ l`�� �i`U UL Address: 24 t2�e I�,dge �Iq G
Phone#: qt- ci( Cell#: email ah(aKnn tt n L w,r1 Y . G c m
3.Master Electrician: A,'"N-\--honq CnO Iitn LL)t) Address: (vane �Ireo_E Irt �n(.Lallr
Lic.#: 33-1 Phone#:Alcl 2. 1133 Cell#: email:n%(jsrlc'(-J y-icciISe-vv,c-c "oLl6 .to
Company Name:_N t GY<S `r`pr ry tt nI 5ey vi(_e.NICE Address: U� (ryb nd S{i ce r N(,y�oryeWe N-( I n So ,
4.Proposed Elech•ical Work/Fixture Count: MP A:�- 2`t" IL 5
VC
:}:i is�:::{:{:{t 1':f i}{t 1t{f:::}:::t::::{:{:::1,t�{,__.: =:::::i.i..............�....i....1•:t i.:.•...).....Y.�.......i..i.....i...�.t..,...i..t.......4i..t....,:,}{t.},.....i.......Y....i i.1.i.1 i.:[:t
1 STATE OF NEW YORK,COUNTY OF WESTCHESTER ) as:
n�ho\\'t C(-,a-C��\V iko being duly sworn,deposes and states that he/she is the applicant above named,and does further
(print name of inc ividual signing ai tc applicant)
state that(s)hc is the legal owner of the property to}vhich this application pertains,or that(s)he is the
for the legal owner and is duly authorized to make and file this application. (indicate architect,contractor,agent,ationrcy,etc.)
The undersigned further states that all statements contained herein are true to the U-st of his/her knowledge and belief,and that any work
performed,or use conducted at the above captioned properly 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 Urtifornt 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 I S� Sworn before me this jI s+
day of t�<'c Pm br✓ _ ,20 1 I day f -, 1 20 L�
.vr�
Signature of Property O+' /rt,FWl t I,i alu•e fA c
A i,r✓Nt') k ltY1 i_��J h
Prh1t Name of Property OwmT- 11 G Print Name f Applicant ki
rl-Ac It r/� (h M��.fl l�R SrcLi u
Notary Public Notary Public
E
TIN M MCCONAGHY KRISTIN Nl MCCONAGHY
UBLIC STATE OF NEW YORK NOTARY PUBLIC STATE OF NEW YORK
Bronx County Bronx County 7n/17
iC. #01 MC6348554 Lic. #01 MC6348554
. P
y Comm. Exp. 6 C{tib�
STATE WIDE INSPECTION SERVICES, INC.
Service With litlegritJ
•:0 • •
SWIS JOB APPLICATION •. •
Office Use Elect. Permit# G j J Date
81dg Permit-#- HP Z/— / 3 Scl Ft
Plumbing Permit#
Final Certificate#
City/Village 9Y6 0
K Zip 1OS1 Building Dept. O� County
Address ILA�1 E> Q g e ZA Cross Street Section Block Lot
1 �
Owner Name/Address(If different thalkat ve>ra� J, \� RPa 1 LL Contact Numberq(� _ 1- Ll C�
❑Basement ❑1st FI. ❑2nd Fl. ❑3rd FI. ❑More Than 3 Fl. ❑Garage ❑Attic ❑Outside ❑Residential [A Commercial
Receptacles Special Recept GFCI AFCI Switches Dimmers Smoke Alarms C/0 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
hl y (\CA -�u Y -�'�., �1-Z� cj e o,+r a e N 1 ,} S y S m S c>C� l (-'O-
D ECENE
DEC 31 2024
t,yl OR-R'Y� I ROOK
BUit i31N 'T ;ENT
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 any time.of ins#eytlon 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 w'lfh 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 \LN(S 1 a\ rV\La OL&ikoOK• C Name n6
License# Date Signature
Address LA� G S City/State w O '4e Zip Code lQ
Company �1�5 CcLk(03 '--eVV kLt N1 UL Phone# , - 1Z 3 11 3 3
R
State Wide Inspection Services
9cxk--:) 1080 Main Street
JAN 10 2025 Fishkill, NY 12524
V
U
845 202-7224 Phone
VILLAGE OF RYE BROOK 914-219-1062 Fax
STATE WIDE INSPECTION SERVICES BUILDING DEPARTMENT Email: office(d)swisny.com
-- ------ - 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 14B Rye Ridge Plaza
48 Grand Street Rye Brook, NY 10573
New Rochelle, NY 10801
Located at: 14B Rye Ridge Plaza, Rye Brook, NY 10573
Section: Block: Lot: Electrical Permit Number: EP24-245
141.27 11 1 6
Certificate Number:2025-0220 Building Permit Number: MP24-143
A visual inspection of the electrical system was conducted at the Commercial occupancy described
below.The electrical system consisting of electrical devices and wiring is located in/on the premises
at: 14B Rye Ridge Plaza, Rye Brook, NY 10573
The Exterior/Rooftop 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 10`h day of January 2025.
Name Quantity Rating Circuit Type
Condensers 02
Ito
Officer: Frank 1. 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.
FORM NO.X33-1605
EndeavorTm Line Classic® Series RA13NZ iM Air Conditioner
Cooling Efficiency: 15.2 SEER2/12 EER2
Nominal Sizes: 1 .5 to 5 Ton [5.0 to 16.3 kM
JOB NAME LOCATION
CONTRACTOR ORDER NO.
ENGINEER UNIT MODEL NO.
SUBMITTED FOR D APPROVAL ❑ RECORD COIL MODEL NO.
DATE AIR HANDLER MODEL NO.
UNIT DATA FEATURES
COOLING PERFORMANCE • 7 mm Condenser Copper Coil': Requires less refrigerant allowing for a
EFFICIENCY.................................. SEER smaller and lighter footprint while enhancing reliability
TOTAL CAPACITY'................... MBH[kW] e PlusOne®Expanded Value Space:3 in.-4 in.-5 in.service valve
SENSIBLE CAPACITY`.............. MBH[kW] space—provides a minimum working area of 27-square inches for easier
OUTDOOR DESIGN TEMP......... -F[°C]DB access
TEMP.OF AIR ENTERING • PlusOne®Triple Service Access: 15 in.wide, industry leading corner
EVAPORATOR COIL.............. °F[°C]DB service access,two fastener, removeable corner and individual louver
°F[-C]WB panels-makes repairs easier and faster
POWER INPUT REQUIREMENT.......... kW
Cuses blower motor heat) ACCESSORIES/OPTIONS
HEATING PERFORMANCE Compressor Crankcase Heater.............................................................❑
EFFICIENCY.................................. HSPF Low Ambient Control(Model No. RXAD-A08).........................................❑
TOTAL CAPACITY'................... MBH[kW]
Compressor Sound Cover....................................................................❑
OUTDOOR DESIGN TEMP......... °F['C]DB
Compressor Hard Start Kit...................................................................❑
TEMP.OF AIR ENTERING
EVAPORATOR COIL.............. °F[°C]DB Classic Top Cap w/label(91-101123-21)...............................................❑
SUPPLYAIR BLOWER PERFORMANCE Compressor Time Delay.......................................................................❑
TOTAL AIR SUPPLY................... CFM[Vs]
Low Pressure Control..........................................................................❑
TOTAL RESISTANCE EXTERNAL High Pressure Control..........................................................................❑
TOUNIT....................................... IWG
BLOWER SPEED............................. RPM
POWER OUTPUT REQUIREMENT..... BHP
MOTOR RATING........................... HP[W]
POWER INPUT REQUIREMENT.......... kW
ELECTRICAL DATA
POWER SUPPLY.......................... Hz
TOTAL UNIT AMPACITY................. AMPS
MINIMUM WIRE SIZE...................... AWG
MAXIMUM OVERCURRENT DEVICE
FUSES/HACK BREAKER............ AMPS
Not available on 5 ton model
ACCESS SIDE 12"[604.8 mm] ISO O
AIR INLETS 12"[304.8 mm] , C o US ,
ABOVE UNIT 60" [1524 mm] 9001:2015 LISTED
'Proper sizing and installation of equipment is critical to achieve optimal performance.Split system air conditioners and heat pumps must be matched with
appropriate coil components to meet ENERGY STAR criteria.Ask your Contractor for details or visit www.enengystargov."
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RA13NZ
ALLOW 60"[1524 mm]
OF CLEARANCE
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SERVICE PANELS/
INLET CONNECTIONS/HIGH&LOW
VOLTAGE ACCESS
ALLOW 24"[610 mm]OF CLEARANCE
AIR INLET LOUVERS ALLOW
6"[152 mm]MIN.OF CLEARANCE ALL SIDES
12"[305 mm]RECOMMENDED
ST-A1226-02-00
Unit Dimensions
OPERATING SHIPPING
MODEL H(Height) L(Length) W(Width) H(Height) L(Length) W(Width)
NO.
INCHES mm INCHES mm INCHES mm INCHES mm INCHES mm INCHES mm
RA13NZ18 25.00 635 29.75 756 29.75 756 26.50 673 32.38 822 32.38 822
RA13NZ24 25.00 635 33.75 857 33.75 857 26.50 673 36.38 924 36.38 924
RA13NZ30 25.00 635 33.75 857 33.75 857 26.50 673 36.38 924 36.38 924
RA13NZ36 35.00 889 33.75 857 33.75 857 36.50 927 36.38 924 36.38 924
RA13NZ42 27.00 686 33.75 857 33.75 857 28.50 724 36.38 924 36.38 924
RA13NZ48 39.00 991 35.75 908 35.75 908 40.50 1029 38.38 975 38.38 975
RA13NZ60 1 45.00 1 1143 1 35.75 1 908 1 35.75 1 908 1 46.50 1 1181 1 38.38 1 975 1 38.38 1 975
[ ]Designates Metric Conversions
Before proceeding with installation,refer
to installation instructions packaged
with each model,as well as complying
with all Federal,State,Provincial,and Rheem Sales Company,Inc.
Local codes,regulations,and practices. 5600 Old Greenwood Road
Fort Smith,Arkansas 72908
"in keeping with its policy of continuous progress and product improvement, Rheem reserves the right to make changes without notice."
PRINTED IN U.S.A. 8-22 QG FORM NO.X33-1605
COASMLC 02 PSUZIO
A141 I /� CERTIFICATE OF LIABILITY INSURANCE 1215/2023
THIS CERTIFICATE 15 ISSUFU AS A MAI It N of INf(jkMATi'.)N ()NJ I AND I.ONI LHS NU RIUHIS UPON THE CERTIFICATE HOLDER THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVI I Y AMLNU t Ali NO oR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW THIS CERIOW.ATF OF INSURANCE DOES NO] I.ONSIIIUII A I.ONTRACT BFIWEEN THE ISSUINGINSURERISI AUTHORIZED
REPRESENTATIVE OR PRODUCER.AND 1HE.CI.RIIf ICATI 1401 DI R
IMPORTANT 11 the ceddlcate holler man ADDITIONAI IN%URFD.the p1)h1.ylw%1 must have ADDITIONAL INSURI O pfuvismim ur tm endorsed
It SUBROGATION 15 WAIVED. sullied to the lermN and r ondldons of the pulay certain policies may require an endorsement A statement on
thm cegdtcate does not confer rights In the r erldm ale holder,In lieu of%m.h endursementlsl
Paul A.Suzlo
Assuredfiannem New England.hlc I w
100 Beard Saw Mill Road 'I 1203)614-7963 :A.' N„1(203)514.7863
Shelton 177 06484 '.; :{ PauLSuzioJr(WAssuredPariners com
IN 3UI1t RI S 1 AF I IIRINN(:C OW RAI A NA.,
Cincinnati Insurance Co 10677
Coastal Mechanical Services.hu. 111•
40 Hathaway Or
Slralfoid CT 06615
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Vdplge Id Rye Btnnk o adddurllal mAoied
CERTIFICATE HOLDER CANCELEATION
SIMLI)ANV Or THE ABOVE DFSCRIBEO POt JCIt S ol,CAItCLLLLD BEFORE
Village of Rye Brook tld 111PIRATION 01111 THEREOF. NOTICt "it 01 Ot(NEREO IN
938 King SIreN ACCORDANCE WITH THE POLICY 1•R0VISIONS
Rye Brook NY 10673
164. •.
ACORD 25120161031 .. 1988-2016 ACORD CORPORATION All rights reserved
Tito ACORD name and luyu are registered mrrks of ACORD
NEW Workers'
s'1QlTAt[ Compensation CERTIFICATE OF
Board NYS WORKERS' COMPENSATION INSURANCE COVERAGE
la tegal Narrx ry Ado,,•.•,ul ul.un d,ut.r .Orel a,1uu•Ss a„I, I. •,„u„,, Ie ephui k•NwnlNm ul IMuad
(Coastal Mechanical Services.Inc. 4203)953.3732
140 Hathaway or N1'�Unrenployrnerri Insurance Lrnployer Rutlisiraliun Nu ibex(it Insured
IStratlord.CT 06615
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06-1450112
2 Name and Address of I ably limlueslug I4uul ul r N,une ul Insuralrcr l:auirr
Coverailr it nldy Ilexx{I hied as ffw(.ettif"Ir iloluer I
C1116-11111ati Insurance Co.
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(•]xxJuded A-ir chmi,bu.if am Pdnlw sL^Imis 1nduuva
0 i-xcluli.•d or ued:Nn p:ntix!t sloflNrrs exrleNtea
This certifies that the insurance tamer ind"Ied above if box ensures Die business referenced above in box '1 a for workers
compensation under the New York State Workers Compensation taw (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 atxwe as the r.ethh,.,ile•he der In bo• 2'-
The insurance carrier must notify the above ceilificate holder and the Workers'Compensation Board within 10 days IF a policy is
canceled due to nonpayment of premiums or within 30 days IF Ilime are reasons other than nonpayment of premiums that Cancel the
policy or eliminate the insured from The coveiagr enillc.lted on Itut,Certdi-ite (These notices may be sent by regular mail)Otherwise.
this Certificate is valid for one year after this form Is approved by the n11clan(,e earner 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 cunlers nu ughts upon the cendicale holder This certificate does not amend
extend or alter the coverage afforded by the pokey listed INn duos It r onfel 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
now 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 porlury•I certify that I am an authonzed 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 So.,-
''Ail�rillbi:w�r,`, . I"r.wnnL�,vr•ru kon�wJ uyorn Ia nwlwlr o ra..,..,
Approved by PAW �ilv�IP 11' 311312024
Tide: Accoont I xeculivr-
Telephone Nuniner of authorired representative of 1,cowwo agent of w.o,ani.r e.Iunm (20 31 514 7863
Please Note:Only insurance carriers and their licensed agents are authorized to issue Form C-106.2 Insurance brokers are NOT
authorized to issue it