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HomeMy WebLinkAboutMP24-162 BR(iv� Coo 4°�,Jj� tc VILLAGE OF RYE BROOK MAYOR 938 Bing 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 David M. Heiser Donald T.Krom,Jr. Salvatore W.Morlino CERTIFICATE OF COMPLIANCE June 30,2025 Askar Djabbarkhodjaev&Karina Babakulova 7 Winding Wood Road Rye Brook,New York 10573 Re: 7 Winding Wood Road,Rye Brook,New York 10573 Parcel ID#: 129.82-1-8 This document certifies that the work done under Mechanical Permit #24-162 issued on 12/6/2024 for the installation of a new condenser,coil and gas furnace has been satisfactorily completed. Sincerely, Steven E. Fews Building&Fire Inspector /to �QyE BR(��• O Zm cu � c7 1932 BUILDING DEPARTMENT 0 BUILDING INSPECTOR ZJ 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.oris - - - - - - - - - - - - - - - - - - - - INSPECTION REPORT - - - - - - - - - - - - - - - - - - - - ADDRESS : 7 lAA 1 k10Z) R Oc,(3 h) DATE: —Z 7^ 2 OZr PERMIT# 1"\p Z LI^ ��p� ISSUED: SECT: I Z-/. UL BLOCK:_ LOT:_ LOCATION: A Ir'0U-4 0 OCCUPANCY: ❑ VIOLATION NOTED THE WORK IS... ErACCEPTED ❑ REJECTED/ REINSPECTION ❑ SITE INSPECTION REQUIRED ❑ FOOTING ❑ FOOTING DRAINAGE ❑ FOUNDATION ❑ UNDERGROUND PLUMBING NOTES ON INSPECTION: ❑ ROUGH PLUMBING ❑ ROUGH FRAMING ❑ INSULATION ` ❑ NATURAL GAS , r✓� --r'G Cll/ 'J 0 1" Wew 6,19 ❑ L.P. GAS `&'yr' /C A C016 f .J ❑ FUEL TANK ❑ FIRE SPRINKLER ❑ FINAL PLUMBING ' ❑ CROSS CONNECTION FINAL [OTHER //, '4.C" E 4RG o �m cu � 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 : 7 ytl,i N b !Ali 1NOOtc� 'R 1, ' N DATE'_ �, � z / PERMIT# T1 2cl - 10(a ISSUED:12/b- SECT:IZ J• C32- BLOCK: LOT:$ LOCATION: N 'J I . OCCUPANCY: ❑ VIOLATION NOTED THE WORK IS... O ACCEPTED ❑ REJECTED/ REINSPECTION ❑ SITE INSPECTION REQUIRED ❑ FOOTING ❑ FOOTING DRAINAGE ❑ FOUNDATION ❑ UNDERGROUND PLUMBING NOTES ON INSPECTION: ❑ ROUGH PLUMBING ❑ ROUGH FRAMING ❑ INSULATION ,NATURAL GAS S NN ❑ L.P. GAS ❑ FUEL TANK N CA4 ❑ FIRE SPRINKLER FINAL PLUMBING ❑ CROSS CONNECTION ❑ FINAL ❑ OTHER N o " ILn 10 N N D „ v _ 0-4 OR z a vi a .b ■ a w O , � Z ' , © � z W g `� •Cam. p � " .c �' , � rT� � � ~ � � WF4f1 � V � 'n •bN '� C r-1 i w � � a Imo+ 00 Oc00 .� U, F O 5 1 N o o � a � '� cr Z en rO z 1-1 CN �-, WW. at mo 00 t� cn r� U O v x a"4i w ' a vovvo. w A F� ICI d z Z w cn O z cn x p a ' oov j U U � a F-, war P4 w o W O O Fy04 t • BUILD MEN`I' VIL OF R OOK DEC - 6 2024 938 KING ET RYE BR NY 10573 4 4 _0 -r . ov APPLICATION FOR PERMIT TO INSTALL AND/OR REMOVE HEATING, VENTILATION AND/OR AIR CONDITIONING EQUIPMENT //&FOR OFFICE USE ONLY: PERMIT#:/ A c Z/i Approval Date: Permit Fee: $ ,3 oo `)p 6 Approval Signature: Other: Disapproved: (fees are non-refundable) it�rirk*ik itit�kYr5r9r9r�tik*7r,tk�rYt9r�ir*ir�r9r,etri4**�49r**tr*�kie*ie*9eirir,r****:t:k*kk****:a it:F:t:t ie:F it:F kk:k:k*jt***iF************i:**�F at**iF**ie 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$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#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. Application dated, 'a / is hereby made to the Building Inspector of the Village of Rye Brook for a permit for the installation and or removal of the I-IVAC 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. c p 1. Address: -7- W i nd I no wl)od "Road No C11 SBL:��/i CI a '��� Zone: 2. Property Owner: ASk(Ar D\(AbbArkhDdiAfm Address: I Windialwond ROQd NDl'-tb Phone#: Cell#: ?H* - q 33 - 3*:*1- email: gst u r. d j Olh'd1ma i). r.0 h1 3. Contractor: 511 a 5k KY i U 5 LL G f ,45+n r-i o Address: 16 V00- "P60- 5iYfA+# Phone#: Cell#: email: OQ.CY A55)QSV060nWJ ,irl J. COW 4. Scope of Work:New Installation( )•Replacement Q0•Removal O•Other( ): 5. List Equipment:Emkffi ?Y1&,A api(A(.QYV1Lyl+ 11i k-jyi lz-NNOY• con dul5tr- (M I - Qqa-a3i coil ( U-NNOx cH35- 42 -aF) rind LJFNNQA RArna(L (ML1b0U"090vug13) 6. Location of Equipment: f3C45M9,11f- OVA ©u td our(Gor)&J nst r ) 7. Method of Installation/Removal(list all equipment needed to perform job): t 6n/2024 r STATE OF NEW YORK,COUNTY OF WESTCHESTER ) as: ,being duly swom,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 Df,(t M b�I' Sworn to before me this D e Y M vkl-t 1- day of 20 Qq day of 20_ IV 0 Signatur of Property Owner Signat kif licant / p6V)arkhod�u2� 511a Goal c.s LL.C - Prm me of Property Owner Pri7,7 e of Applicant y4v > ,4 otary Public Nfdtary Public �,mapda gucci Amatlda l3ucci [Notary Public-ConnecticutNotary Public-ConnecticutMy Comn}i�sion ExpiresFr�bruorv28,2025 My Commission ExpiresFPbrvarry28,2025- 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 10/30/2023 a � : s z � O O Ln �lo od ~ 14 - 0 ■ w w C w H , c96 ■ �W Dt �T Z B .i, _. ►.� w �1 00 O 00 A C w = CPR vrgON vt PNI M O _ s - _ ■ 00 0.4 • �T . A �i �..� (� W �, -- o� V m _ c/n M A CIS 0 Z w ►� zON � 00 - !1�1 F� � � � OC1 � G � _ w� !� ■ a (3� Z V p w O .� oA a : : : : : _ : a a a : : : : : s s ■ a : m a fi a a t t� i t' p CC ENE *OFRYE;OK BULLENT JAN 15 2025VIL938 KINoNY 10573 VILLAGE OF RYE BROOK BUILDING DEPARTMENT ELECTRICAL PERMIT APPLICATION Westchester County Master Electricians License Required FOR OFFICE USE ONLY ; -$1�!. /"/ /�J�"— / (Io � EP#: �O Approval Date: I `' Permit Fee: $ Approval Signature: Other: ************************************************************************************************** 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$750.00 Application dated,_/—/S 4K- 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. By signing this document, the applicant & property owner agree that all electrical work performed will be in conformance with all applicable Federal,State,County and Local Codes. / 1.Address: o0 j P�>11 SBL: c3 /� ' dvr-4" Zone: 'l 2.Property Owner: A-C d tAkldress: 7 W I nj In e rd Aj Phone#: Cell#: email: 3.Master Electrician/Licensed Installer: -P u u„ C I-e-o Address: 30 2 Lic.#: Phone#: __ Cell#I� 3� Z �14-51 email: er tC�r�G GL ooycoi-� Company Name: �r kj-f'is t-L C Address: 4.Proposed Electrical Work/Fixture Count: w 1 C_'C�1 j! 4 5.3rd Party Electrical Inspection Agency: 15 U-U'l S STATE OF NEW YORK,COUNTY OF WESTCHESTER ) as: being duly sworn,deposes and states that he/she is the applicant above named,and does further (print name of individual signing as the applicant) state that(s)he is the for the legal owner and is duly authorized to make and file this application. (Master Electrician/Licensed Installer) The undersigned further states that all statements contained herein are true to the best of his/her knowledge and belief,and that any work performed,or use conducted at the above captioned property will be in conformance with the details as set forth and contained in this application and in any accompanying approved plans and specifications,as well as in accordance with the New York State Uniform Fire Prevention&Building Code,the Code of the Village of Rye Brook and all other applicable laws,ordinances,and regulations. Sworn to before me this Sworn to before me this J day of ,20 day of >vnJ_,20 9-�;- Signature of Property Owner Signature of Applicant Print Name of Property Owner P n e of Applicant Notary Public N6ta6ft6flbMELIL 0 Cublic,State of New York 01G1E6160063 6/1/2024 in Westchester County plres J:vrt r y 29,20,�?-7 STATE WIDE INSPECTION SERVICES, INC. Service With Integri4, 0•0 • • 4119WIS JOB APPLICATION tel 845.202.7224 1 fax 914.219.1062 1 SWISNY.coml SWISTRAINING.COM Office Use Elect. Permit# Date Bldg Permit# Sq Ft Plumbing Permit# Final Certificate# City/Village Zip Building Dept. County Address Cross Street Section Block Lot Owner Name/Address(If different than above) Contact Number ❑Basement ❑ 1st Fl. ❑2nd Fl. ❑3rd Fl. ❑More Than 3 Fl. ❑Garage ❑Attic ❑Outside ❑Residential ❑Commercial Receptacles Special Recept GFCI AFCI Switches Dimmers Smoke Alarms C/O Detector Hood Trash Compact Amt Amps Range(s) Cooktop(s) Oven(s) Dishwashers Refrigerator Disposal Microwave Luminaires Generator Transfer Switch SERVICE Amperage #Panels 1P 3P # Meters # Disconnect ❑Underground rEl NewReconnect ❑ 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 3D JAN 15 2025 VILLAGE OF RYE BROOK 9 BUILDING DEPARTMENT This application is valid for one(1)year from the date received by SWIS.This application is intended to cover the above listed items to be inspected,if at anytime of inspection additional items have been installed,you are authorized to make the inspection and adjust the fee for the additional items inspected.The applicant declares that there is no open applications for the above address with any other inspection company.The applicant, owner or authorized agent agrees to all the above terms and conditions as set forth for the application. Email Address Name License# Date Signature Address City/State Zip Code Company Phone# � N ppN p p V Cl) a " w � NM Z G Lt: eA � N �' a v O z ocz a �\ M .. w > n (14 � W � A d a z z O00co polo Cl) W p z a w Z V ^ ri M OF � cc � Z � A A o � w � ♦ W i M I-� c� O aQ N H ] cz1 CA ~ U w � ozOlt � a 0-4 x 0 L iL g H o P-o IL I- U W 0 _ �I as a � � I•� x � E aRc� • - BUIL � 15Ep . MENT ELI �- DEC 16 2024 VIL OF RYE OK s_.__.... ...__.._..._.._._ __ 938 KIN ET RYE B ,NY 10573 VILLAGE OF RYc BROOK BUIL1?ING DEPART MENT ov PLUMBING PERMIT APPLICATION FOR OFFICE USE ONLY /`��� / "-�&,� PP#:c--:)- Approval Date: ��e��\ Permit Fee: $ �� Q Approval Signature: 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 I//S 12%OF THE TOTAL COST OF CONSTRUCTION WITH A MINIMUM FEE OF$750.00 Application dated, /.-)—/ is hereby made to the Building Inspector of the Village of Rye Brook NY,for the issuance of a Permit to install and/or remove Plumbing as per detailed statement described below.The applicant&property owner,by signing this document agree that said plumbing work will ben in conformance with all applicable Federal,State,County and Local Codes. 1.Address::- j�K]CI I Kj G Wood Road N Q r 11-1 SBL:f c4 9i o C) �—d Zone: 2.Proposed Work: as c{7t j Ech6yi s +0 CL{ rn a U, 3.Property Owner: ASIXtr W 1 to b6a r k hod a Qtl Address: I wi nd j'nr, Wood RC.o6 �JoM Phone#: Cell#: email: 7 4.Master Plumber: 5Rj2 VU►/'j L AV(A jtflt Address: 40 f6a Pbi of S-fm_ (,4/k �(,Yp 9 rj! Lic.#: g Phone#: cD03—o)S3 D710ICe11#: email: L1jYm/�X QA �j/ Company Name:_4c;i1a %rul(� SE(A c y Address: 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 1st Floor 2nd Floor 31 Floor 41 Floor 5m Floor Exterior 5.*List Other Equipment/Provide Details: (Notarized Signatures Required Next 2 Pages) -1- 6/1/2024 STATE OF NEW YORK,COUNTY OF WESTCHESTER ) as: ,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 I Sworn t efore me this day of day of �. 20 2`1 /9 15 rk - Signature of Propetxwner Signatur of Applicant La 0 l-e �k Print Name of Property Owner Prin of Applicant -- ---- NotaryLob �—�_Tina Lopetpr na-LopezNotar P lic-Connectrc utY utilic-Con mission ExpiresMyCommfission e 30, 202$ June 30,\2o? This application muy completed in its entirety and must include the notarized signatures o the legal ovvnc-,r(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/2024 'v BUILDI; TMENT VILE E OF RYV BROOK DEC 16 2024 _DJ 938 KING"ET RYE BR6(IW,NY 10573 \� 4 -0 VILLAGE OF RYE BROOK w wfye o �gov BUILDING DEPARTMENT �z7t3'r 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: T, A 5 to v D I a bar>Lht)d 'A P residing at, (Print name) J (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; W I rld I riq W On QOGI d N0 r-fli , 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. qdR� (SignaftWee oflPr9feny Owner(s)) w (Print Name of Property Owner(s)) Sworn to before me this � day of D�J`ny_ / , 20 2—\ r (Notary Public) ------------------- Tina Lopez 3_ Notary PubliC-Connecticut MY Commission Expires June 30,, 2029 _ ..._._ 6/1/2024 State Wide Inspection Services 1080 Main Street JAN 2 2 2025 Fishkill, NY 12524 TO �] 845 202-7224 Phone VILLAGE OF RYE BROOK 914-219-1062 Fax STATE WIDE INSPECTION SERVICES BUILDING DEPARTMENT Email: officeCd)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: Ammer Electric LLC Skar Djabbarkhodjaev& Karina Babakulova Kevin McLeod 7 Winding Wood Road North 3302 Gunther Avenue Rye Brook, NY 10573 Bronx, NY 10469 Located at: 7 Winding Wood Road North, Rye Brook, NY 10573 Section: Block: Lot: Electrical Permit Number: EP 25-009 192.82 1 g Certificate Number:2025-0428 Building Permit Number: MP 24-162 A visual inspection of the electrical system was conducted at the Residential occupancy described below.The electrical system consisting of electrical devices and wiring is located in/on the premises at:7 Winding Wood Road North, Rye Brook, NY 10573 The Exterior was inspected in accordance with the NYS and NFPA 70-2017 and the detail of the installation, as set forth below,was found to be in compliance on the 20th Day of January 2025. Name Quantity Rating Circuit Type HVAC System 01 Officer: Frank J. Farina This certificate may not be altered in any way and is validated only by the presence of a seal at the location indicated.This certificate is valid for work performed on the date of inspection only. L ENNOX INSTALLATION ©2022 Lennox Industries Inc. INSTRUCTIONS Dallas,Texas,USA Merit° Series ML17XC1 Units -- - AIR CONDITIONER 508254-01 4/2022 A WARNING Improper installation, adjustment, alteration, service or maintenance can cause property damage, THIS MANUAL MUST BE LEFT WITH THE injur or loss of life. Installation HOMEOWNER FOR FUTURE REFERENCEperformed by licensed professional installer or equivalent, or ..- General A CAUTION This ML17XC1 outdoor air conditioner with all-aluminum coil is designed for use with HFC-410A refrigerant only. ith equipment, ' sharp This unit must be installed with an approved indoor air han- sheet metal edges" personal dler or coil. For AHRI Certified system match-ups and ex- care while handling this equipment - • wear gloves an• panded ratings, visit www.LennoxPros.com. protective cl• • These instructions are intended as a general guide and do IMPORTANT: Special procedures are required for clean- not supersede local codes in any way. Consult authorities ing the all-aluminum coil in this unit. See page 15 in this having jurisdiction before installation. instruction for information. NOTICE! Charging information is given on the charging procedure sticker on the unit access panel.For more in- depth information, consult the Installation and Service Procedures manual on LennoxPros.com or through the Technical Support department at 800-453-6669. STEP 1 — SETTING THE UNIT — Clearances See NOTES NOTES- Service clearance of 30 in.(762 mm)must be maintained on one of the sides adjacent to the control box. Clearance to one of the other three sides must be 36 in. (914 mm). See O See NOTES NOTES Clearance to one of the remaining two sides may be 12 in. (305 mm)and the final side may be 6 in.(152 mm). A clearance of 24 in. must be maintained between two units. CONTROL 48 in. (1219 mm)clearance required on top of unit. See NOTES BOX NOTICE: Specific applications may require adjustment of the listed installation clearances to provide protection for the unit from physical damage or to avoid conditions which limit operating efficiency. (Example: Clearances may have to be increased to prevent snow or ice from falling on the top of the unit. Additional clearances may also be required to prevent air recirculation when the unit is installed under a deck or in another tight space.) FIGURE 1 N y •, 508254-01 Pagel DIMENSIONSUNIT 1 IMPORTANT • This unit must be matched with an indoor coil as -— specified with AHRI. For AHRI Certified system match- __ —= ups and expanded ratings, visit www.LennoxPros.com Coils previously charged with HCFC-22 must be flushed. A IMPORTANT Exhaust vents from dryers, water heaters and furnaces should be directed away from the outdoor unit.Prolonged exposure to exhaust gases and the chemicals contained SIDE VIEW within them may cause condensation to form on the steel cabinet and other metal components of the outdoor unit. This will diminish unit performance and longevity. PLACEMENT Model .- FROMWINDOWS ML •• • 2 0• • •• 0• 3 •• 0• - 90'ELBOWS INSTALLED IN LINE SET • �• �.. WILL REDUCE • - • MOUNTINGSLAB Install unit level or,if on a slope,maintain slope tolerance •egrees(or 2 inches per - UIL IN 1 • building structure. Before attempting to perform any service or maintenance, t DISCHARGE turn the electrical power to unit OFF at disconnect switch. 1 To prevent personal injury, as well as damage to panels, _ unit or structure, observe the following: While installing or servicing this unit, carefully stow all MOUNTING removed panels so that the panels will not cause injury to personnel, objects or nearby structures. Also, take care to store panels where they will not be subject to 1,. GROUND LEVEL damage (e.g., being bent or scratched). While handling or stowing the panels, consider any weather conditions (especially wind) that may cause panels to be blown around and damaged. Roof • D. containsThis system both refrigerantRefrigerant can be harmful if it is inhaled. Refrigerant rubber • roofing material may absorb oil, causing the must be used and recovered responsibly. damagerubb to degrade.result in Failure.. Failure to follow this warning may result in personal injury or death. INSTALLATION L ENNOX INSTRUCTIONS ©2024 Lennox Industries Inc. M L 180 U H V Dallas,Texas USA °`31°" MERITS SERIES GAS FURNACE HORIZONTAL AIR DISCHARGE 41 507945-02 04/2024 Supersedes 08/2023 THIS MANUAL MUST BE LEFT WITH THE HOMEOWNER FOR FUTURE REFERENCE ►� ' j('�► � I 1 A This is a safety alert symbol and should never be ignored. When you see this symbol on labels or in man- ` x+� uals, be alert to the potential for personal injury or death. g A IMPORTANT DO NOT oY to lift, drag or pull the furnace to its installation location. Doing so will loosen the bracket causing noise . or unsafe operation. Bracket A WARNING improper installation, adjustment, c - ; "alteration, , . . W,installer (or equivalent), service agency or the . . Contents Unit Dimensions- inches (mm........................................2 Gas Piping....................................................................20 ML180UHV Gas Furnace...............................................3 Electrical.......................................................................22 Shipping and Packing List..............................................3 Integrated Control.........................................................25 Safety.............................................................................3 Unit Start-Up.................................................................29 Use of Furnace as a Construction Heater).....................4 Gas Pressure Measurement.........................................30 General...........................................................................4 Proper Combustion.......................................................30 Combustion, Dilution, Ventilation Air...............................5 High Altitude .................................................................30 Setting Equipment..........................................................8 Other Unit Adjustments.................................................32 Filters............................................................................11 Service..........................................................................32 DuctSystem.................................................................12 Blower Data..................................................................35 Venting .........................................................................13 Page 1 z 507945-02 Unit Dimensions -inches (mm) —►{ 3-1/8(79) 1 NOTE-60C size units that require air volumes over I 1800 cfm must have one of the following: M100, 1.Single side return air and Optional Return Air Base flflllflo with transition that must accommodate required D 20 x 25 x 1 inch(508 x 635 x 25 mm)air filter to maintain proper velocity. + 2.Bottom return air. SUPPLY AIR 3.Return air from both sides. / OPENING 4.Bottom and one side return air. FLUE OUTLET u a a u u See Blower Performance Tables for additional information. (Top) u a a o o u000a nflflflfl 2 Flue outlet may be horizontal but furnace must be u a a n u vented vertically u u a o u 3 Optional External Side Return Air Filter Kit is not for use with the optional Return Air Base. 3 ��I � -----------� OPTIONAL I� (6 3) — EXTERNAL (603) SIDE RETURN 25 AIR FILTER KIT (635) (Either Side) TOP VIEW 3/4(19) 27-3/4 Front Panel (705) A 3-1/4(83) i3 3(76)Right 19-7/16 9/16 9/16(14) 6-3/4(171)Left (494) (14) s FLUE OUTLET + (Either Side) 9-1/8(232)Right o®®®®e c e®®o®c 3 OPTIONAL 8-5/8(219)Left ELECTRICAL INLET c0000c0000cac b (Either Side) EXTERNAL ccenccocol1''''��ooc SIDE RETURN C C C C C C C C C d C C C AIR FILTER KIT c o c c c c o c o o c c c (Either Side) 5-3/8 137 Right GAS PIPING INLET c c c o c c e c c o e c c 33 ( ) 9 (838) 2-3/16(56)Left (Either Side) Cooc000c�.�oce ELECTRICAL/ 23 I 1 1/2 14-3/4 INLET(Either Side) �- (584) (38) CODD (375) Side Return 14 16 Air Opening (356) (406) (Either Side) II J --1-1s/16(49) C ►� 5/8 3/4 3/4 (16) 3-1/4 23-1/2 (19) (19) (83)� (597) Bottom Return Bottom Return Air Opening Air Opening FRONT VIEW SIDE VIEW ML180UHV A B C D Model in mm in mm in mm in mm 030V36A 045V36A 14-1/2 368 13-3/8 340 13 330 4-3/4 121 070V36A 070V36B 070V48B 17-1/2 446 16-3/8 416 16 406 6-1/4 159 090V486 11OV60C 21 533 19-7/8 504 19-1/2 495 8 203 Page 2 ����������„�r,n�„n�.�.�r��rw•r.w+►�s*��s"'.�'..a�w.wei..�wa�wrw.....w.wwt�a� 108.17 17.74 4 5 ::E 7 Winding Wood Rd N a 129.82-1-8 to 5 Wmdir N � Q s 12 A re � g Q � CL a z M 7 10000 16.46 fib,y i WOODMWERED := rkhod 'DJ'a bba aev J 7 Windingwood Road North, Rye Brook, NY OUTDOOR DESIGN CONDITIONS Weather station: White Plains, Westchester Co. AP Summer Outdoor F Summer Indoor F Design Grains ® Daily Range '` r Winter Outdoor F ® Winter Indoor F Cooling RH Elevation (Ft) LOAD CALCULATION TOTALS HVAC System: Direct swap Heated square footage "^ Heating BTUH Cooled square footage Cooling BTUH k" Heated volume (above grade CF) > CFM k Cooled volume (above grade CF) Sensible cooling Exposed wall area (SF) Latent cooling SHR Load Calculation Cooling Heating 0 25,000 50,000 75,000 100,000 125,000 BTUH APPROVED ACCA MJ8 CALCULATIONS Calculations are based on the ACCA Manual J 8th Edition and are approved by ACCA. All computed calculations are estimates on building use, weather data, and inputted values such a R-Values, window types, duct loss, etc. Equipment MANUAL J selections should meet both the latent and sensible gain as well as building heat loss. HEATING LOADS Section Area Heat Loss Heating Loads aboveGradeWalls 2,929.9 16,484 aboveGrade... ceilings 2,679.4 5,905 windows ceilings ducts 0 13,154 www 00 00 1 ducts floors 2,581.9 17,137 infiltration 0 14,406 infiltration floors skylights 0 0 windows 678 34,212 Totals 101,298 COOLING LOADS Section Area Sensible Latent Cooling Loads AEDExcursion 0 309 0 aboveGrade... 17` aboveGradeWalls 2,929.9 2,188 0 appliances 7 3", windows ceilings appliances 0 3,400 0 y ducts ceilings 2,679.4 4,582 0 1�,.G'; plants floors ducts 0 6,749 565 Ft'' occupants infikration floors 2,581.9 2,894 0 3I'' infiltration 0 1,531 2,602 occupants 0 1,380 1,200 plants 0 0 300 skylights 0 0 0 windows 678 19,083 0 Totals 42,115 4,667 FENESTRATION LOADS Warning (0): This application has glass areas that produced relatively large cooling loads for part of the day. Zoning may be required to overcome spikes in solar load for one or more rooms. A zoned system may be required, or some rooms may require zone control (provided by individual, motorized, thermostatically controlled dampers). Warning (1): The sensible load for this application peaks during late fall or early winter.This behavior is caused by glass that faces SouthEast, South or SouthWest. Some rooms may be noticeably cooler or warmer than the temperature set point if zoning is not provided. Simultaneous heating and cooling may be required. AED Graph(mid-summer) 30,000 20,000 2 m 10,000 0 8 9 10 11 12 13 14 15 16 17 18 19 — BTUH —Average Average 1.3 This graph represents hourly aggregrate fenestration loads in mid-summer. AED graph(fall) 30,000 2 20,000 ti m 10,000 0 8 9 10 11 12 13 14 15 16 17 18 19 —BTUH —Average Average'1.3 This graph represents hourly aggregrate fenestration loads in October. COMPONENT LOADS Above Grade Walls Map trace wall Construction nr. 1213-0b w Exposure: N Heating BTUH: 1,349 Frame Wall,Wood Area: 239.8 Cooling BTUH: 179 framing,R-11 cavity U Value: 0.097 insulation,Brick Veneer. Map trace wall Construction nr. 1213-0b w Exposure: N Heating BTUH: 1,296 Frame Wall,Wood Area: 230.3 Cooling BTUH: 172 framing,R-11 cavity U Value: 0.097 insulation,Brick Veneer. Map trace wall Construction nr. 126-0b w Exposure: E Heating BTUH: 2,112 Frame Wall,Wood Area: 375.4 Cooling BTUH: 280 framing,R-11 cavity U Value: 0.097 insulation,Brick Veneer. Above Grade Walls Map trace wall Construction nr. 12B-Ob w Exposure: S Heating BTUH: 2,565 Frame Wall,Wood Area: 455.9 Cooling BTUH: 341 framing,R-11 cavity U Value: 0.097 insulation,Brick Veneer. Map trace wall Construction nr. 12B-Ob w Exposure: SW Heating BTUH: 606 Frame Wall,Wood Area: 107.8 Cooling BTUH: 81 framing,R-11 cavity U Value: 0.097 insulation,Brick Veneer. Map trace wall Construction nr. 12B-Ob w Exposure: SW Heating BTUH: 1,250 Frame Wall,Wood Area: 222.2 Cooling BTUH: 166 framing,R-11 cavity U Value: 0.097 Insulation,Brick Veneer. Map trace wall Construction nr: 12B-Ob w Exposure: N Heating BTUH: 2,911 Frame Wall,Wood Area: 517.5 Cooling BTUH: 387 framing,R-11 cavity U Value: 0.097 insulation,Brick Veneer. Map trace wall Construction nr. 12B-Ob w Exposure: E Heating BTUH: 1,188 Frame Wall,Wood Area: 211.2 Cooling BTUH: 158 framing,R-11 cavity U Value: 0.097 insulation,Brick Veneer. Map trace wall Construction nr. 1213-0b w Exposure: S Heating BTUH: 2,292 Frame Wall,Wood Area: 407.4 Cooling BTUH: 304 framing,R-11 cavity U Value: 0.097 insulation,Brick Veneer. Map trace wall Construction nr: 12B-Ob w Exposure: Sw Heating BTUH: 914 Frame Wall,Wood Area: 162.4 Cooling BTUH: 121 framing,R-11 cavity U Value: 0.097 insulation,Brick Veneer. Below Grade Walls There are no components for this section. Ceilings Map trace Construction nr: 1613-25 ad Area: 305.4 Heating BTUH: 673 generated Cooling BTUH: 522 ceiling U value: 0.038 Ceiling under attic or attic knee wall, Asphalt shingles, Dark,R-25. Map trace Construction nr: 1613-25 ad Area: 837.1 Heating BTUH: 1,845 generated Cooling BTUH: 1,431 ceiling U value: 0.038 Ceiling under attic or attic knee wall, Asphalt shingles, Dark,R-25. Map trace Construction nr: 1613-25 ad Area: 1,536.9 Heating BTUH: 3,387 generated Cooling BTUH: 2,628 ceiling U value: 0.038 Ceiling under attic or attic knee wall, Asphalt shingles, Dark,R-25. Skylights There are no components for this section. Skylight cooling BTUHs shown here are daily average values. See AED graphs for details of fenestration loads during the day. Doors There are no components for this section. floors Map trace Construction nr: 19A- Heating U Value: 0.295 Heating BTUH: 17,137 generated floor OCp Cooling BTUH: 2,894 Floor over enclosed Area: 2,581.9 Cooling U Value: 0.295 F Value: N/A unconditioned crawl space or basement, no floor insulation, Carpet or hardwood. Windows Default small Construction nr: 1G U Value: 0.87 Heating BTUH: 303 windows for wall Area: 6 sHGC: 0.67 Cooling BTUH: 97 id 9114750 Exposure: N Window,NFRC rated, Clear glass. Default medium Construction nr: 1G U Value: 0.87 Heating BTUH: 606 windows for wall Area: 12 sHGC: 0.67 Cooling BTUH: 195 id 9114750 Exposure: N Window,NFRC rated, Clear glass. Default large Construction nr: 1G U Value: 0.87 Heating BTUH: 1,817 windows for wall Area: 36 sHGC: 0.67 Cooling BTUH: 584 id 9114750 Exposure: N Window,NFRC rated, Clear glass. Default small Construction nr: 1G U Value: 0.87 Heating BTUH: 303 windows for wall Area: 6 sHGC: 0.67 Cooling BTUH: 97 id 9114752 Exposure: N Window,NFRC rated, Clear glass. Default medium Construction nr: 1G U Value: 0.87 Heating BTUH: 606 windows for wall Area: 12 sHGC: 0.67 Cooling BTUH: 195 id 9114752 Exposure: N Window,NFRC rated, Clear glass. Default large Construction nr: 1G U Value: 0.87 Heating BTUH: 1,817 windows for wall Area: 36 sHGC: 0.67 Cooling BTUH: 584 Windows id 9114752 Exposure: N Window,NFRC rated, Clear glass. Default small Construction nr: 1G U Value: 0.87 Heating BTUH: 606 windows for wall Area: 12 sHGC: 0.67 Cooling BTUH: 398 id 9114753 Exposure: E Window,NFRC rated, Clear glass. Default medium Construction nr: 1G U Value: 0.87 Heating BTUH: 1,817 windows for wall Area: 36 SHGC: 0.67 Cooling BTUH: 1,193 id 9114753 Exposure: E Window,NFRC rated, Clear glass. Default large Construction nr: 1G U Value: 0.87 Heating BTUH: 1,817 windows for wall Area: 36 sHGC: 0.67 Cooling BTUH: 1,193 id 9114753 Exposure: E Window,NFRC rated, Clear glass. Default small Construction nr: 1G U Value: 0.87 Heating BTUH: 303 windows for wall Area: 6 sHGC: 0.67 Cooling BTUH: 195 id 9114754 Exposure: S Window,NFRC rated, Clear glass. Default medium Construction nr: 1G U Value: 0.87 Heating BTUH: 1,211 windows for wall Area: 24 sHGC: 0.67 Cooling BTUH: 781 id 9114754 Exposure: S Window,NFRC rated, Clear glass. Default large Construction nr: 1G U Value: 0.87 Heating BTUH: 3,633 windows for wall Area: 72 sHGC: 0.67 Cooling BTUH: 2,344 id 9114754 Exposure: S Window,NFRC rated, Clear glass. Default small Construction nr: 1G U Value: 0.87 Heating BTUH: 303 windows for wall Area: 6 sHGC: 0.67 Cooling BTUH: 232 id 9114751 Exposure: SW Windows Window,NFRC rated, Clear glass. Default medium Construction nr: 1G U Value: 0.87 Heating BTUH: 1,211 windows for wall Area: 24 SHGC: 0.67 Cooling BTUH: 929 id 9114751 Exposure: SW Window,NFRC rated, Clear glass. Default small Construction nr: 1G U Value: 0.87 Heating BTUH: 303 windows for wall Area: 6 SHGC: 0.67 Cooling BTUH: 232 id 9114755 Exposure: SW Window,NFRC rated, Clear glass. Default medium Construction nr: 1G U Value: 0.87 Heating BTUH: 606 windows for wall Area: 12 SHGC: 0.67 Cooling BTUH: 465 id 9114755 Exposure: SW Window,NFRC rated, Clear glass. Default large Construction nr: 1G U Value: 0.87 Heating BTUH: 1,817 windows for wall Area: 36 SHGC: 0.67 Cooling BTUH: 1,394 id 9114755 Exposure: SW Window,NFRC rated, Clear glass. Default small Construction nr: 1G U Value: 0.87 Heating BTUH: 606 windows for wall Area: 12 SHGC: 0.67 Cooling BTUH: 195 id 9114756 Exposure: N Window,NFRC rated, Clear glass. Default medium Construction nr: 1G U Value: 0.87 Heating BTUH: 1,817 windows for wall Area: 36 SHGC: 0.67 Cooling BTUH: 584 id 9114756 Exposure: N Window,NFRC rated, Clear glass. Default large Construction nr: 1G U Value: 0.87 Heating BTUH: 3,633 windows for wall Area: 72 SHGC: 0.67 Cooling BTUH: 1,168 id 9114756 Exposure: N Window,NFRC rated, Windows Clear glass. Default small Construction nr: 1G U Value: 0.87 Heating BTUH: 606 windows for wall Area: 12 SHGC: 0.67 Cooling BTUH: 398 id 9114757 Exposure: E Window,NFRC rated, Clear glass. Default large Construction nr: 1G U Value: 0.87 Heating BTUH: 1,817 windows for wall Area: 36 SHGC: 0.67 Cooling BTUH: 1,193 id 9114757 Exposure: E Window,NFRC rated, Clear glass. Default small Construction nr: 1G U Value: 0.87 Heating BTUH: 606 windows for wall Area: 12 SHGC: 0.67 Cooling BTUH: 379 id 9114758 Exposure: S Window,NFRC rated, Clear glass. Default medium Construction nr: 1G U Value: 0.87 Heating BTUH: 606 windows for wall Area: 12 SHGC: 0.67 Cooling BTUH: 385 id 9114758 Exposure: S Window,NFRC rated, Clear glass. Default large Construction nr: 1G U Value: 0.87 Heating BTUH: 3,633 windows for wall Area: 72 SHGC: 0.67 Cooling BTUH: 2,320 id 9114758 Exposure: S Window,NFRC rated, Clear glass. Default small Construction nr: 1G U Value: 0.87 Heating BTUH: 606 windows for wall Area: 12 SHGC: 0.67 Cooling BTUH: 444 id 9114759 Exposure: SW Window,NFRC rated, Clear glass. Default medium Construction nr: 1G U Value: 0.87 Heating BTUH: 1,211 windows for wall Area: 24 SHGC: 0.67 Cooling BTUH: 909 id 9114759 Exposure: SW Window,NFRC rated, Clear glass. Window cooling 13TUHs shown here are daily average values.See AED graphs for details of fenestration loads during the day. Ventilation There are no components for this section. Hot water piping There are no components for this section. Ducts System generated ducts (above EHLF: 0.149 Heating BTUH: 13,154 conditioned space) ESGF: 0.193 Attic-Radial ELG: 565 Sensible BTUH: 6,749 Latent BTUH: 565 Infiltration Leakage Category: Average NCFM 229 Heating BTUH: 14,406 Heating: Sensible BTUH: 1,531 NCFM 117 Cooling: Latent BTUH: 2,602 Blower Motor There are no components for this section. Winter Humidification There are no components for this section. Occupants Nr.Occupants: 6 Sensible BTUH: 1,380 Latent BTUH: 1,200 Appliances Kitchen, utility room,additional fridge, Quantity: sensible BTUH: 3,400 lighting:3,400 BTUH Latent BTUH: Plants Plant Size: small Quantity: 5 Latent BTUH: 50 Plant Size: medium Quantity: 5 Latent BTUH: 100 Plant Size: large Quantity: 5 Latent BTUH: 150 ROOM DETAIL Room name:l Heated square footage Total Cooling BTUH em Cooled square footage Total Heating BTUH cm Heated volume (above grade CF) ® CFM Cooled volume (above grade CF) ® Exposed wall area (SF) Load Calculation Cooling Heating 0 20,000 40,000 60,000 80,000 BTUH AED Graph(mid-summer) 15,000 10,000 2 ro 5,000 0 8 9 10 11 12 13 14 15 16 17 18 19 — BTUH —Average Average*1.3 AED graph(fall) 20,000 10,000 m 0 8 9 10 11 12 13 14 15 16 17 18 19 —BTUH —Average Average*1.3 ROOM DETAIL Room name:2 Heated square footage Total Cooling BTUH Cooled square footage Total Heating BTUH Heated volume (above grade CF) CFM Ca Cooled volume (above grade CF) Exposed wall area (SF) Load Calculation Cooling Heating 0 10,000 20,000 30,000 40,000 BTUH AED Graph(mid-summer) 15,000 I 10,000 CO 5,000 0 8 9 10 11 12 13 14 15 16 17 18 19 — BTUH —Average Average* 1.3 AED graph(fall) 15,000 10,000 —-. j m 5,000 0 8 9 10 11 12 13 14 15 16 17 18 19 —BTUH —Average Average*1.3 j ,,,�,+.�w'!-. g ��-� 5°\� V:'k w� d�' �iy'�;�r7��� / �yl.Ce.;���;yit ..W%' j`(,.;a -@:""• Sc•} A ,f�. ��5//Ni �' ft �\/ �A�!''•'��ih4 y. 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Policy effective period 8/1b/1U14 to 8/26/2025 Rye Brook NY 10573-1226 3d.The Proprietor,Partners or Executive Officers are XI 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 1 a"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: Dylan Isadore (Print name of authorized representative or licensed agent of insurance carrier) Approved by: D,f„c�,( 8/26/2024 (Signature) (Date) Title: Senior Underwriter Telephone Number of authorized representative or licensed agent of insurance carrier: 646-227-6300 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 J`ORK ' Workers' CERTIFICATE OF —, SL E Compensation NYS WORKERS' COMPENSATION INSURANCE COVERAGE Board la.Legal Name 8 Address of Insured(use street address only) 1 b.Business Telephone Number of Insured 845-295-3887 Sila Services, LLC 1 c.NYS Unemployment Insurance Employer Registration Number of 55 Lafayette Ave. White Plains, NY 10603 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 85-1645781 2.Name and Address of Entity Requesting Proof of Coverage 3a.Name of Insurance Carrier (Entity Being Listed as the Certificate Holder) Starr Indemnity&Liability Company Village of Rye Brook 3b.Policy Number of Entity Listed in Box 1 a" 100 0005482 938 King St. 3c. Policy effective period Rye Brook 8/26/2024 to 8/26/2025 NY 10573-1226 3d.The Proprietor,Partners or Executive Officers are QX 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 1 a"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: Dylan Isadore (Print name of authorized representative or licensed agent of insurance carrier) Approved by: _bt,,�._,(,— —_ 8/26/2024 (Signature) (Date) Title: Senior Underwriter Telephone Number of authorized representative or licensed agent of insurance carrier: 646-227-6300 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