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HomeMy WebLinkAboutMP24-157 �yE.DR VILLAGE OF RYE BROOK MAYOR 938 King Street,Rye Brook,N.Y. 10573 ADMINISTRATOR Jason A. Klein (914) 939-0668 Christopher J.Bradbury www.ryebrooknygov TRUSTEES BUILDING & FIRE INSPECTOR Susan R.Epstein Steven E.Fews Stephanie J. Fischer David M.Heiser Salvatore W.Morlino CERTIFICATE OF COMPLIANCE December 23,2024 David Schaefer&Roberta Schaefer 1 Doral Greens Drive West Rye Brook,New York 10573 Re: 1 Doral Greens Drive West,Rye Brook,New York 10573 Parcel ID#: 129.34-1-33 This document certifies that the work done under Mechanical Permit#24-157 issued on 11/25/2024 for the installation of a heat pump and wall unit has been satisfactorily completed. Sincerely, Steven E. Fews Building&Fire Inspector /to �yE BRCuk. Q�i� ��O•c • 1982 BUILDING DEPARTMENT ❑BUILDING INSPECTOR Q-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 C`L ;� aq Y 'j t.LA DATE: L J Z y PERMIT# P Z Lj — I 5 ISSUED: SECT:OF. 3`/ BLOCK: LOT: 3 LOCATION: 1 K �_ 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 h ❑ NATURAL GAS / V' e_ ❑ L.P. GAS Co U ►�1 ❑ FUEL TANK ❑ FIRE SPRINKLER /r ❑ FINAL PLUMBING ❑ CROSS CONNECTION ❑ FINAL ❑ OTHER �� =1 _ ^� 0 h _ L N N W ai ^N.. o" a.a Ln h+� N �+ v 0 e N y CA i n �.q M W B &0.4 , I�1 M to1.4 a 3 H N W ° a o W 0 _ M �i Shy W In a' in � =j " W � F-a w °% O��J tom'• .iyd � r a 9. w , 2a OW00rj en V E-� a o - i `J cn y 11-1 o � V w A. W W W S CIOC. cn cn gel N � u _ W W z 0 44 c t/1 n O O O H °" .� H z� x z o ° p 80 . ! A y v 0 A 0 ' C A W z O � H o b a .. 0 V1 w a w s p E '7- D BUILq,ET 'MENT VILOFA OOK NOV 2 2 2024 938 KINGRoolt,NY 10573 �4:-10668_i. VILLAGE OF RYE BRCOK tr ov BUILDING n17Rf1,RTV'rN1T APPLICATION FOR PERMIT TO INSTALL AND/OR REMOVE HEATING, VENTILATION AND/OR AIR CONDITIONING EQUIPMENT FOR OFFICE USE ONLY: PERM IT#: Approval Date: 1 Permit Fee: $ Approval Signature: Other: Disapproved: (fees are noes-refundable) *******,r,�,t,�t*,r***,t***,���,t,t*********,t***�.,t,t**,t********,�*�.�,�,�**,►*******�*�*****t**,tom*t*,t****,tt,�***,t,t***,t,t DO NOT START WORD 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$750.00 REOUIREMENTS 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 =$450.00/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. *'�•*�[•*•k'k•A•'A••k*•�'r*7k 1�C'It lk 1�'AY•k***•��**�********•��•*'�"k•�[!1'�'k!t'�1Y'1['�'lY'1F�`'A'ft`�'lf 1f�''A.**•I['A"A"�l'X'�f]F'I!f�'k it't�fk]f*SY]F 1F 11f�t 11t�f 57[11f i[]i[lY ft 9F'if Y fF cif Y Application dated, - is hereby made to the Building Inspector of the Village of Rye Brook for a permit for the installation and or removal of the AC 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. n p 2�/ 1. Address: �- 1b"fGl V=KeA@rfb lei We- l�� SBL: /3/,3 -r-33 Zone: ` 2. Property Owner: %R Ou NG o3cme_�ei Address: A - xo1 QC e en5 Phone#: Glil4 -3Db-1q 10 Cell#: email: (r? f Q C-5cbLtG _ 1'fT6( 3. Contractor: ��`�. Gt71( , Address:_2f� V�P �Clt Phone#: (A qq 1-Ci I C) Cell#: email: 4. Scope of Work:New Installation(V�_Replacement( )•Removal( )•Other( ): 5. List Equipment:�� {,t� } .(`y (�( T) +V_inn }1� 'Q�IyI 24�JuJV I ��IV1Z� W�� 6. Location of Equipment: (^)(\Q. CX (7 '1.0- 40%- , C�'�� ``n iA- t 0 7. Method of Installation/Removal(list all equipment needed to perform job): t 6/I/2fl24 STATE,OF NEW YORK,COUNTY OF WESTCHESTER ) as: 1O $3\ ,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 %—a Sworn to before me this 2-.Qn(3 day of N0\1(M11 ,20 2q day of W Signature of P perty Owner lgnature of Applicant 11'► � �C h �i � � .�1✓r V �/ ' Print Name of Property Owner Print Name of Applicant i,�L Notary Pub c Notary Pub JENNIFER RIVEERA JENWFER RIVERA Notary Public-State Of New York Notary Public-State of New York N0,01R16188056 NO.01R16388056 Qualified In Bronx County y Commission Expires fob 25, 2027 Qualified in Bronx County My Commission Expires Feb 25, 2027 M 7 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/tr2024 rDAIKAFN Submittal Data Sheet Daikin ATMOSPHERA 2.0-Ton Wall Mounted Heat Pump System FTXM24WVJU9RXM24WVJU9 FEATURES BENEFITS Daikin Swing Compressor • 12 Year limited parts and compressor warranty • Quiet Operation • Included WiFi and Handheld controller • Simplified Maintenance-Easy Drain Pan removal • Precharged to 49' • Built In WiFi for easy control • R-32 Refrigerant for low GWP and lower Carbon impact • Intelligent Eye • Hybrid Cooling-dehumidifies even in low cooling loads • Enhanced Cooling and Heating Capacity-100%heating Capacity at 5F;100%Coding at 115F • Facilities cooling mode for Cooling to-4F(See Install Manual) INDOOR UNIT OUTDOOR UNIT �r = Daikin North America LLC,19001 Kermier Rd.Wager,TX 77484 Daikin City Generated Submittal Data www.aaiWnac mm wvw.aaienwmrMoom (Daikkn's products are subject to continuous Improvements.Daikin reserves 0*right to modify product design,specifications and information in this data sheet without notice and without incurring any obligations) Submittal Date:11/222024 7:15:56 AM Page 1 of 5 rDAIKIN Submittal Data Sheet Daikin ATMOSPHERA 2.0-Ton Wall Mounted Heat Pump System FTXM24WVJU9RXM24WVJU9 SYSTEM PERFORMANCE Indoor Unit Model No. FTXM24WVJU9 Indoor Unit Name: Daikin ATMOSPHERA 2.0-Ton,Heat Pump,Wall Mounted IDU Outdoor Unit Model No. RXM24WVJU9 Outdoor Unit Name: Daikin ATMOSPHERA 2.0-Ton,Heat Pump,Ductless ODU Rated Cooling Capacity(Btu/hr): 21,600 Rated Cooling Conditions: Indoor(°F DB/WB):80 167 Ambient(°F DS/WB):95/75 Sensible Capacity(Btu/hr): Rated Piping Length(ft): 25 Max/Min Cooling Capacity(Btu/hr): 26,000/9,000 Rated Height Difference(ft): 0.00 Cooling Input Power(kW): 1.800 Heating Input Power(kW): 1.99 SEER2(Non-Ducted/Ducted): 22.00/ HSPF2(Non-Ducted/Ducted): 10.0/ EER2(Non-Ducted/Ducted): 12.00/ Heating COP(Non-Ducted/Ducted): 3.5/ Rated Heating Capacity(Btu/hr): 24,000 Rated Heating Conditions: Indoor("F DB/WB):70/60 Ambient(°F DB/WB):47/43 Max/Min Heating Capacity(Btu/hr): 32,000 19,000 SYSTEM DETAILS Refrigerant Type: R-32 Cooling Operation Range(°F DB): 50-115 Holding Refrigerant Charge(lbs): 2.98 Heating Operation Range(`F WB): -13-64 Additional Charge(oz/ft): 0.22 Max.Pipe Length(Vertical)(ft): 82 Pre-charge Piping(Length)(ft): 49 Cooling Range w/Baffle(°F DB): -4-115 Max.Pipe Length(Total)(ft): 99 Max Height Separation(Ind to Ind ft): 0 Daikin North America LLC,19001 Karin*Rd,Waller,TX 77484 Dalkin City Generated Submittal Data —aailorwa.carn—oaanconrtwx. (Daikin s Products are subject to continuous improvement&Daikin reserves the right to modily product design,specifications and information in this data sheet without notice and without irwring any obligations) Submittal Dale:11/22/2024 7:15:56 AM Page 2 of 5 r' nA MiN Submittal Data Sheet Daikin ATMOSPHERA 2.0-Ton Wall Mounted Heat Pump System FTXM24WVJU9RXM24WVJ U9 INDOOR UNIT DETAILS Power Supply(V/Hz/Ph): 208/230/60/1 Airflow Rate(H/M/USL)(CFM): 844/653/498/452 Power Supply Connections: See Outdoor Unit for Electrical Specs Moisture Removal(Gal/hr): Min.Circuit Amps MCA(A): Gas Pipe Connection(inch): 5/8 Max Overcurrent Protection(MOP)(A): Liquid Pipe Connection(inch): 1/4 Dimensions(HxWxD)(in): 11-3/4 x 43-5/16 x 10-13/16 Condensate Connection(inch): 518 Net Weight(lb): 33 Sound Pressure(H/M/LJSL)(dBA): 51/44137/34 Ext.Static Pressure(Rated/Max) / Sound Power Level(dBA): (inWg): DIMENSIONAL DRAWING - INDOOR UNIT FTXM24WVJU9 THE wmc —)SHOWS PIpwG DIRECTION REQUIRED SPACE F OR SERVICE ANU VENTILATION I7-S 16 r 1100mm` b BOGOR AIWLOW REAR REAR} j NOTE LEFT ZT PICLUDNO INSTALLATION PLATE I to 7 ) .....RJLLF FIXING SCREWS RC.0N=TA0LKA0E NAME PTTED �AN OUTLET �R I NSiDEI TERMINAL BLOCK WITH1-15'16150 mmi MIN 1-�IS/II!{lDmmI MIN EARTHIGROUND SPACE FOR MAINTENAN�.S TSPACE IOR-iCANTE a riT TERMtlKL(NSIDE; TEMPERATURE AND TV SENSOR PIPE QIT I INTELLIGENT ) EYE SENSOR LXNO PIPE 1+a(Oer.L)aT ANDWINDECTION DPANHM BLE RANGE I(CON01111107911101 PART) BOTTOM BOTTOM` - --- , INDOOR UNIT TIMER LAAP OD.♦"r♦lerw) BOUT IC1'B{<IO_ FLAPS ON.OFT SWITCH 6 OPERATION LAMP � CLEAN LAMP ',�_BOUT 16-1: f 41Dmn; NTELUDEW EYE LAMP '�ADOIfT (4]5 WIRELESS LAN CONNECTION ADAPTER LAMP RI 1IYF 1NEi1 F an PPE MAIN NOSE SIGNAL RECEIVER — _ --- LIQUID PPE R1GNT;LEFT(AUTOMATIC) MODEL NAME PLATE EE A[Ip1T 14.7.1 i]TSmmI /I f mm E ABOUT I4-711065mm, -..-. INSTALLATION PLATE T/t ABOUT Il-1T'1e L450mm) --..__ OUTER DPEIISIONS i SIGNAL TRANSMrrTER 1\�. i16(1I00mm) OF THE UNIT UP:DOWN UUTOMATTC 1 77-16'1{(B67 mm: 4i�1I 11eArw) ❑ COOLN4DRY HEATING FAN My r�� 1 10' _ _ ^ •. '>,: ) :'15 �. IP HOLE FOR EMBEDDED PPNG - -- APCMeA71 IS ]s 651/ 55 fS �. - O]I:a O80-el HOLE FOR EMBEDDED YYIIIELESS REMOTE CONTROLLER '^^. 1-I1rle(eemm) PPNG 0]-IA(080 ) STANDARD LOCATION OF NOIES IN THE WALL Daikin North Amenca LLC,19001 Kenn-Rd.Waller,TX 77484 Daikin City Generated Submittal Data Hww.oaiklrM^wrn--kinrorman.can (Daikin's products are subject to continuous improvements.Daikin reserves the right to modify product design,specifications and information in this data sheet without notice and without ilcumng any obligations) Submittal Dale:11t22/2024 7:15:56 AM Page 3 of 5 rDAFKFN Submittal Data Sheet Daikin ATMOSPH ERA 2.0-Ton Wall Mounted Heat Pump System FTXM24WVJU9RXM24WVJU9 OUTDOOR UNIT DETAILS Power Supply(V/Hz/Ph): 208-230/60/1 Compressor Stage: Inverter Power Supply Connections: L1,L2,L3 Ground Capacity Control Range Min.Circuit Amps MCA(A): 19.8 Airflow Rate(H/L)(CFM): 2179/1,833 Max Overcurrent Protection(MOP) 20 Gas Pipe Connection(inch): 518 (A): Max Starting Current MSC(A): Liquid Pipe Connection(inch): 114 Rated Load Amps RLA(A): 19.25 Sound Pressure(H)(dBA): 55 Dimensions(HxWxD)(in): 28-15/16 x 34-1/4 x 12-5/8 Sound Power Level(dBA): Net Weight(lb): 132 DIMENSIONAL DRAWING - OUTDOOR UNIT RXM24WVJU9 SlII"t. )!-VUtICI 7-L/lit) VftTl •t-S/RIYYII rY/YI1:. �� E.r[nll(nwr Ir►qXITHY 010 r41f7 STr1 —_ 11 i I Y/t; + i 1-10tfS fyl i°AIATIRI itrs 1/11(If-S) MID) ]-J-l—/(HCI 1-'SJrSIttSI !Y•S/It YCfI 7/tf 111) ! (f9S'IaAllol ItY I. n1 1{TrH S ° 14 MOO) �' ° •1=• FILL ttflW 04 AIR DMLET SIDE 2-tl9r/f lfotr_u — Y:IIaA;Y SPACE FOR Al R PASSA4E -LESS TFAA 41-1/4(ino) �[ Stirs V uyr � ) us cFArl NTIL STOP IAt YT 11•DffA1.14.1)ICSE raP o _ Q snna - - t>✓'rfS11 r , )-IS/If(S/1 1•!S/1itS/) f•)1/tfltt)I 11 co D RRIYfilr a ST1'I'SS rJftl 16 !)tIpIW Sitil ttNl Daikin North America LLG,19001 Kermier Rd,Wager,TX 77484 Daikin City Generated Submittal Data rww.°agwact°m www.°aianwml°ncon (Daikin's products are subl-I to continuous improvements.Dalkin reserves the right to modify product desgn,specifications and information in this data sheet without notice and without i cumng any obligations) Submittal Date:11/22/2024 7:15:56 AM Page 4 of 5 DA I KAFN Submittal Data Sheet Daikin ATMOSPHERA 2.0-Ton Wall Mounted Heat Pump System FTXM24WVJU9RXM24WVJU9 INDOOR ACCESSORIES PART DESCRIPTION INCLUDED NUMBER AZA16WSPDKC DKN Plus Interface No BRC944132-A08 Wired Remote Controller kit No BRCW901A03 BRC944132 CONTROL CABLE,10FT No BRCW901A08 Wired Remote Controller Cord-8m/26ft No DACA-C P 1-1 Mini Aqua Condensate Pump No DACA-CP4-1 MINI WHITE PUMP KIT 100-250V No DTST-LTE-LA-A Daikfn One Lite(with Translation Adaptor for S21 only) No DTST-ONE-ADA-A Daikin One+Smart Thermostat for VRV,SkyAir,Single-and Multi-Zone System No KAF970A46 Titanium apatite photocatelytic air-purifying filter WITHOUT frame No KER087A41 S21 conversion connector No KKF910A4 Loss Prevention Chain for Wireless Controller/Holder NO KRP928BB2S RA Interface Adaptor for DIII-Net- No OUTDOOR ACCESSORIES PART DESCRIPTION INCLUDED NUMBER DACA-WB-3 Powder-Coated Wall-Mounted Bracket No KEH063A4EA Bml LRg Drain Pan Heater Rev A No KKG063A42 Back protection wire net No KKP937A4 Drain Plug for OD Unit No KPS063A41 Snow hood(intake side plate)(15,18&24) No KPS063A44 Snow hood(intake rear plate)(15,18&24) No KPS063A47 Snow hood(outlet)(15,18&24) No Daikin North America LLC,19001 Kermier Rd,Waller,TX 77484 Dalkin City Generated Submittal Data www.aalxlnac.wm. yaiklnwewt un'r (Daikin's products are subject to continuous improvements.Dalkin reserves the right to modify product design,specinealions and information in this data sheet without notice and without incurring any obligations) Submittal Date:11/22/2024 7:15:56 AM Page 5 of 5 O O O co 04 G. N 73 o cc ca (tom10 � �,�\� � R►\a�'w""i►/!,y/��ii/,� � "%�//�z��' �co)> � lz •a eO Q- rci, cn V O a0.. C/� �• : W l U N N 0LO � ' G� r•, Q w o a .� o�ection ` � } U as a, � ✓� :� cn � V t• N O LL a� _a W J Cc GJ . 30' s bD O C N N \ / <( '� <( P. o v'. Q•'.!__, . PHOEMEC-03 _FHOLZHAY ACORO CERTIFICATE OF LIABILITY INSURANCE DAT 3 25I2/25/2 D2Y1 Y) 024 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 NAMTACT Luann Silano Acrisure Insurance Partners Services of NY,LLC PHONE FAX 90 S. Ridge Street (A/C,No,Ext):(914)937-1230 ac,No): Rye Brook, NY 10573 A-AIL .Isilano@acrisure.com INSURERS AFFORDING COVERAGE NAIC N INSURER A:Stillwater Property&Casualty Insurance Company 16578 INSURED INSURER B: Phoenix Mechanical Corp INSURERC: 26 Vreeland Avenue INSURERD: 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 POLII D EXP LIMITS LTRA X COMMERCIAL GENERAL LIABIUTY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE �X OCCUR X MPGR3802-02 3/16/2024 3/16/2025 DAMAGE TO RENTED $ 100,000 ence)MED EXP(Any oneperson) $ 10,000 PERSONAL&ADV INJURY 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY�X PEST LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: $ 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 BODILY INJURY Per accident $ AUTOS ONLY AO�JOOVVINED PF 2 PERd f DAMAGE $ A X UMBRELLA LIAB X OCCUR rTEACH OCCURRENCE $ 5,000,000 EXCESS LIAB CLAIMS-MADE XSGR3802-02 3/1612024 3/16/2025 AGGREGATE $ 5,000,000 DED J X I RETENTION$ 10,000 $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY Y/N ANY PROPRIETOR/PARTNER/EXECUTIVE F__1 E.L.EACH ACCIDENT $ i4FFICER/MEMBER EXCLUDED? NIA andatory In NH) E.L.DISEASE-EA EMPLOYE If Yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 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 ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD NEW Workers' YRI STATE Compensation Board CERTIFICATE OF NYS WORKERS' COMPENSATION INSURANCE COVERAGE 1a.Legal Name 8 Address of Insured(use street address only) 1 b. Business Telephone Number of Insured 914) 690-1000 Phoenix Mechanical Corp 6 Vreeland Avenue 1 c.NYS Unemployment Insurance Employer Registration Number of Elmsford, NY 10523 Insured 1d.Federal Employer Identification Number of Insured or Social Security Work Location of Insured(Only required if coverage is specifically limited to Number certain locations in New York State,i.e.,a wrap-Up Policy) 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"1 a" 38 King Street C72673621 Rye Brook, NY 10573 3c.Policy effective period 09/30/2024 to 09/30/2025 3d.The Proprietor,Partners or Executive Officers are M 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 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: ,Ly s ljbd9-4_ 10/09/9024 47 (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