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HomeMy WebLinkAboutMP19-1411 1 SECTIONr%A, C 1 (0 )9 /rqC) I lq EXP w A • rPERMIT * H 01:14 1 DATE%v. w 1-w� ll� , ci;q TYPE OF WORK I I �j (fc gen era (D Y� JOB LOCATION OWN EST. COBS; T' CO #�� EEE F TCO IF EEE DATE FOOTING FOUNDATION FRAMING RGH FRAMING INSULATION PLUMBING 11VSPECTIQN RECORQ DATE Q RGH PLUMBING (iAS 0 SPRINKLER ELECTRIC LOW VOLT ALARM AS BUILT FINAL William INSP sic 33p-o" I I 5mQq9(w1 OTHER APPROVALS ARC BOT PB Z8A OTHER C 4Ct� ✓ G VILLAGE OF RYE BROOK MAYOR 938 King Street, Rye Brook,N.Y. 10573 ADMINISTRATOR Jason A. Klein (914) 939-0668 Christopher J. Bradbury www.ryebrook.org TRUSTEES ACTING BUILDING& FIRE INSPECTOR Susan R. Epstein Steven E. Fews Stephanie J. Fischer David M. Heiser Salvatore W. Morlino CLARIFICATION OF RECORD April 18,2023 Michael Caso&Patricia Caso 5 Old Orchard Road Rye Brook,New York 10573 Re: 5 Old Orchard Road, Rye Brook,New York 10573 Parcel ID#: 135.34-1-29 Mechanical Permit#19-141 issued on 8/20/2019 to Install 22kw Natural Gas Fired Generator An inspection of the of the above referenced property on April 18,2023,reveals that although Mechanical Permit#19-141 dated 8/20/2019 was issued, the installation of a 22kw natural gas fired generator was never done,and this permit is rendered null and void. Sincerely, Steven E. Fews Acting Building& Fire Inspector /to BRCuk O �m w � BUILDING DEPARTMENT ❑BUILDING INSPECTOR VILLAGE OF RYE BROOK ❑ VILLAGE ENGINEER 938 KING STREET RYE BROOK,NY 10573 ❑ASSISTANT BUILDING INSPECTOR (914) 939-0668 FAx(914)939-5801 - - - - - - - - - - - - - - - - - - - - - INSPECTION REPORT - - - - - - - - - - - - - - - - - --- - ADDRESS: 1 C C` DATE: PERMIT# ` ISSUED: 1 11 SEcr: ` BU)Cm LOT: C I OCCUPANCY: LOCATION: ❑ VIOLATION NOTED THE WORK IS... ;El ACC D ❑ RE J ED/REINSPECTION Q� SITE INSPECTION _ REQUIRED ❑ FOOTING . i 0 FOOTING DRAINAGE 0 FOUNDATION ❑ UNDERGROUND PLUMBING NOTES ON INSPECTION: ❑ ROUGH PLUMBING 1 0 ROUGH FRAMING \ Ve t 1 "� ❑ INSULATION ❑ NATURAL GAS ❑ L.P. GAS ❑ FUEL TANK ,-`1 \�❑ FIRE SPRINKLER /� \ V� 1 \ Q l ❑ FINAL PLUMBING V p FINAL ❑ OTHER r f f •� N ' N e 01 O O N a 0�0 d m 0 96 C. �• •_; O CIA } Z O h-1 A • O rA o .00 as tn tn co 0%4 ��'�► z Q N A < > c m aid4 w tZ C U L, a°. ME BUILDING DEPARTMENT D E C E VILLAGE OF RYE BROOK AUG 19 2019 1 938 KING STREET RYE BROOK,NY 10573 1 .1D (914)939-0668 FAX(914)939-5801 VILLAGE OF RYE BROOK BUILDING DEPARTMENT ELECTRICAL PERMIT APPLICATION Westchester County Master Electricians License Required Q FOR OFFICE USE ONLY 1 - ` ' `�T I Ell' J� Approval Date: AUG 2 0 2019 Permit Fee: $__�I7L]� Approval Signature: Other: Disapproved: (fees are non-refundable) ***************** *** ***** ********************************************************************* 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/ r re ove 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 performed will be in conformance with all applicable/F,/ederal, State,County and Local Codes. 1.Address: 50 t "v- O rCk1 /�`(vim I ` 0 a C( SBL: ,13<.J"f � ' 2� Zone::, 2.Property O er: e CC S 0 Address: S J t� (7���CaL �Ck CA Phone#�: — Cell#: email: n 3.Master"1~e cl r t Y1 Qkddress: g 1 y\u Qf�_L 'ATV� f Lic.#: 7� Phone#: 9/y -'A I-?,�l. Cell#:�i(�(p (u U email: I n tiJ �-L Ae C`4-W In U. n e- Company Name: ZeA CO- C -S0!L\W*% O G cAMC Address: 4.Proposed Electrical Work/Fixture Co ********************************************************************************************************* p STATE OFW YORK,COUNTY OF WESTCHESTER ) as: {�PC)¢-l.6 CCCtiQ U -?being duly sworn,deposes and states that he/she is the applicant above named,and does further state that(s)he is the legal owner of the property to which this application pertains,or that(s)he is the 0r>"Tn/A'-To/z. for the legal owner and is duly authorized to make and file this application. 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,ordinan d regulations. S o befo e m 1 Sworn t e this day +_ 0 day 20 15'tgnature Pro er tur f A licant STE N � 1+1� 1A11D1i�M9 � t -RAT Pr1nt ame �0! 11110. 01 E K absNti f'R�lio 1i1� r COS, Tfd�fq�nbkbn ixpk� a t1. !0 _ MY Commission Expires Oct / r 11. 20 3/21/19 f Westchester Rockland Electrical Inspection Services, Inc. Phone: 14-34�7-3 9 DO NOT WRITE HERE-FOR OFFICE USE ONLY 43 North Lawn Avenue L Fax: 914-347-3596 Elmsford, NY 10523 BUILDING PERMIT NC. TEMP# DAT17 E - ' ')Jill CITY O gILLAGE ZIP CAD TOWNSHIP COUNTY ' r0J �� 7 Ilk STRE D I f (� POLE NUMBER BETWEEN WHAT TWO CROSS STREETS IS PREMISES LOCATED? SECTI BLOCK LOT 1 5. OCCUPANT'S NAMF BUILDING OCCUP NCY _ OWNER'S NAME AND ADDRESS - K F FPI-1 I (1 CURRENT SUPPLIED BY FROM THEIR OFFICE WORK TELEPHONE NUMBER LIST BELOW ALL EQUIPMENT WHICH YOU INSTALLED NUMBER OF OUTLETS NO.OF FIXTURES& MOTORS HEATERS OFFICE USE LOCATION LAMP RECEPTACLES ONLY SIDEWALL SWITCH INCADE FLUORE NO. H.P.EACH NO, WATTS EACH INSPECTION OUTSIDE ASEMENT '?n to FL. 2 FL. VILLA E OF RE BROOK 3'D FL. - ARTME REMARKS:LIST OTHER ELECTRICAL DEVICES NOT SET FORT: OVE: I THIS APPLICATION IS INTENDED TO COVER THE ABOVE LISTED ITEMS TO BE INSPECTED.IF AT ANY TIME OF INSPECTION ADDITIONAL ITEMS RAVE BEEN INSTALLED,YOU ARE AUTHORIZED TO MAKE THE INSPECTION AND ADJUST THE FEE FOR THE ADDITIONAL ITEMS INSPECTED AS PROVIDED BY THE APPLICANT.THE APPLICANT DECLARES THAT THERE IS NO OPEN APPLICATIONS FOR THE ABOVE WITH ANY OTHER INSPECTION COMPANY.WREIS,INC.IS NOT LISTING,LABELING,UNDERWRITING OR CERTIFYING ANY EQUIPMENT, MATERIALS OR DEVICES WHICH ARE PERFORMED BY OTHER CERTIFIED TESTING AGENCIES OR INSPECTION COITIPANIES.THE APPLICANT,OWNER,OR AUTHORIZED AGENT AGREES TO ALL THE ABOVE TERMS AND CONDITIONS AS SET FORTH FOR THE APPLICATION. +^. SIZE OF SERVICE FEEDERS a � CHARACTER OF WORK NEW❑ ADIPONAL❑ EXPOSED❑ CONCEALED 0 MUST ENTER APPLICANTS r • 11 D N'MFICATION NUMBER SERVICE ENTERS BUILDING OVERHEAD El UNDERGROUND❑ AVOID DELAYS BY GIVING FULL AND ACCURATE INFORMATION.ALL SPACE MUST BE FILLED IN OR AP ICATIO BE RETURNED. NAME OF rOMPANY-� ;ATE OF APPLICATION E OF AP ICANT STREET Aoon�A ' ! �TELEPFIONE NO.� ��. � ��' _/� •• CRY OR POST rOFFICCEt v` ZIP CO LICENSE NO.WHEN APPLICABLE �� Mike Izzo From: Mike Izzo Sent: Wednesday,January 27, 2021 1:19 PM To: Michele Griffin Cc: 'Tara Gerardi'; Laura Petersen; Steven Fews Subject: RE: 5 Old Orchard Road. PERMIT 19-141 EXTENSION REQUEST Dear Ms. Griffin, Your request for a six (6) month extension to open permit #MP19-141 was forwarded to my attention for response by Tara. Upon review of the file I see that one six (6) month extension was previously granted such that the new expiration date is 2/20/21. Please note that Village Code allows for only two (2) such extensions thus making this your last possible permit extension. Please note that your request is hereby granted and that the new permit expiration date is August 20, 2021. Please arrange for all work to be completed and successfully inspected, and for all paperwork & fees to be remitted to the Village such to facilitate the issuance of the Certificate of Occupancy on or before that date. Thank you. 1#11G4aell(/, f/ZZO Building& Fire Inspector Village of Rye Brook, NY (914) 939-0668 From: Michele Griffin<michele@zaccapnino.net> Sent:Wednesday,January 27, 2021 10:39 AM To:Tara Gerardi <tRerardi@ryebrook.orR> Subject: FW: 5 Old Orchard Road. PERMIT 19-141 EXTENSION REQUEST HI Tara: This email is to request a final extension for an additional 6 months for 5 Old Orchard Road Generator permit. The plumber has finalized everything with Con ED and the homeowner is moving ahead with install. Thank you for your attention to this matter. Michele Griffin Office Manager ZACCAGNINO ELECTRIC 81 Maple Avenue Rye, NY 10580 914-921-3244 Fax: 914-921-1722 https://www.facebook.com/pp,/ZaccaeninoElectric/about/ From: Michele Griffin Sent:Tuesday, August 18, 2020 9:18 AM To: 'Mike Izzo' <Mlzzo@rvebrook.org> Subject: RE: 5 Old Orchard Road. PERMIT 19-141 EXTENSION REQUEST Thank you. Michele Griffin Off ce Manager ZACCAGNINO ELECTRIC 81 Maple Avenue Rye, NY 10580 914-921-3244 Fax: 914-921-1722 https://www.facebook.com/pg/ZaccagninoEIectric/about/ From: Mike Izzo<Mlzzo@ryebrook.org> Sent:Tuesday, August 18, 2020 9:17 AM To: Michele Griffin <michele@zaccagnino.net> Cc:Tara Gerardi <tgerardi@ryebrook.org>; Laura Petersen <LPetersen@rvebrook.org>; Steven Fews <SteveFews@ryebrook.org> Subject: RE: 5 Old Orchard Road. PERMIT 19-141 EXTENSION REQUEST Dear Ms. Griffin, In light of this information your request for a six(6) month extension is hereby approved. Please note the new expiration date is February 20, 2021. Thank you. lffl and(l Izzo Building & Fire Inspector Village of Rye Brook, NY (914) 939-0668 From: Michele Griffin [mailto:michele@zaccagnino.net] Sent: Monday, August 17, 2020 4:07 PM To: Mike Izzo <Mlzzo@ryebrook.org> Subject: RE: 5 Old Orchard Road Hi Mike: The plumbers are still going back and forth with Con-Ed. Con-Ed has not given us a definite date yet, but we assume this job will be completed within the next 6 months. Michele Griffin Office Manager ZACCAGNINO ELECTRIC 81 Maple Avenue 2 Rye, NY 10580 914-921-3244 Fax: 914-921-1722 https://www.facebook.com/pg/ZaccagninoEIectric/about/ From: Mike Izzo<Mlzzo@ryebrook.org> Sent: Monday, August 17, 2020 1:32 PM To: Michele Griffin <michele@zaccagnino.net> Cc: Tara Gerardi<tgerardi@ryebrook.org>; Laura Petersen <LPetersen@ryebrook.org>; Steven Fews <SteveFews@ ryebrook.org> Subject: RE: 5 Old Orchard Road Dear Ms. Griffin, Your email was forwarded to my attention for response from our Planning Secretary Tara. Please provide a specific time frame for completion of the job and a specific time frame for the requested permit extension. Thank you. 1/ZZO Building & Fire Inspector Village of Rye Brook, NY (914) 939-0668 From:Tara Gerardi Sent: Monday, August 17, 2020 12:57 PM To: Mike Izzo <Mlzzo@ryebrook.org> Subject: FW: 5 Old Orchard Road TARA A. GERARDI SECRETARY - PLANNING BOARD, ZONING BOARD OF APPEALS & ARCHITECTURAL REVIEW BOARD VILLAGE OF RYE BROOK 938 KING STREET RYE BROOK, NEW YORK 10573 OFFICE (914) 939-0668 FAx (914) 939-5801 From: Michele Griffin [mailto:michele@zaccagnino.net] Sent: Monday, August 17, 2020 12:18 PM 3 • To:Tara Gerardi<tperardi@ryebrook.org> Subject:5 Old Orchard Road Tara: This email is to request an extension for Permit# 19-141 for 5 Old Orchard Road which expires on August 20`h 2020. We appreciate your assistance with this matter. Michele Griffin Office Manager ZACCAGNINO ELECTRIC 81 Maple Avenue Rye, NY 10580 914-921-3244 Fax: 914-921-1722 https://www.facebook.com/pe/ZaccagninoElectric/about/ 4 Building Permit Check List&Zoning Analysis Address: S cl JL'7� SBL Zone- I S5' Use: Z Const.Type: Other. Submittal Date: Z Revisions Submittal Dates: Applicant: G Nature of Work: l N S L t- Z Z 1ZI.y p 4:T-LXI A t- Reviews:ZBA:A11G 1 5 7019 PB: BOT: Other. NEED OK ( ( ) FEES:Filing•. 2� _BP: 6 0. C/O: Legalization: ( ) (4/APP: Dated Notarized: SBL Truss I.D. Cross Connection: H.O.A.: ( ) ( ) Scenic Roads: Steep Slopes: Wetlands: Storm Water Review: Street Opening. ( ) ( ) ENVIRO:Long. Short: Fees: N/A: ( ) ( ) SITE PLAN:Topo: ite Pr tection S/W Mgmc: Tree Plan Other. ( ) ( SURVEY:Dated i.Z 7_ O.s._ Current: Archival: --� Sealed " Unacceptable: ( ) ( ) PLANS:Date Stamped. Sealed Copies: Electronic Other. ( ) ( ) License Workers Comp: Liability Comp.Waiver. Other. ( ) ( ) CODE 753#: Dated N/A: ( ) (. HIGH-VOLTAGE ELECTRICAL:Plans: Permit: ✓ N/A: Other. ( ) ( ) LOW-VOLTAGE ELECTRICAL:Plans: Permit: N/A: Other. ( ) ( ) FIRE ALARM/SMOKE DETECTORS:Plans: Permit: H.W.I.C.:_Battery:_Other. (� ( ) PLUMBING Plans: Permit: Nat.Gas: LP Gas: N/A/: Other. ( ) ( ) FIRE SUPPRESSION:Plans: Permit: N/A Other. ( ) ( ) H.V.A.C.: Plans: Permit N/A: Other. ( ) ( ) FUEL TANK:Plans: Permit: Fuel Type: Other. ( ) ( ) 20I7 NY State ECCC: N/A: Other. ( ) ( ) Final Survey. Final Topo: RA/PE Sign-off Letter. As-Built Plans: Other. ( ) ( ) BP DENIAL LETTER: C/O DENIAL LETTER: Other. ( ) ( ) Other. ( )ARB mtg.date: approval: notes: ( )ZBA mtg.date: approval;- notes: ( )PB mrg.date: approval: notes: n REQUIRED EXISTING PROPOSED NOTES E3 m Area: f 018- Circle: Fla Front: Front: Sides: Rear. Main Cor. Accs.Cov: Ft.H Sb: Sd.H Sb: GFa Tot.jmR: Ft.I : Par ' Heigh IStories: notes: Aco I 05/17//2019 CERTIFICATE OF LIABILITY INSURANCE DATE(M Y) 019 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 David Barreras NAME: BNC Insurance Agency,Inc. a°Nr Ext (914)937-1230 FAX No): (914)937-1124 90 South Ridge Street E-MAIL dbarreras@bncagency.com ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC p Rye Brook NY 10573 INSURER A: Merchants Mutual Insurance Company 23329 INSURED INSURER B: Merchants Preferred Insurance Company 12901 Sterling Electrical Contracting Inc. INSURER C dba Zaccagnino Electric INSURER D 81 Maple Ave INSURER E Rye NY 10580-1583 INSURER F COVERAGES CERTIFICATE NUMBER: CL195390993 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 CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAYBE 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 ADDLSUBR TYPE OF INSURANCE POLICY EFF POLICY EXP LTR IN SD WVD POLICY NUMBER MMIDD/YYYY MMIDDIYYYY LIMITS X COMMERCIAL GENERAL LIABILITY 1.000,000 EACH OCCURRENCE 5 DAMAGETO RENTED CLAIMS-MADE X OCCUR PREMISES(Ea occurrence S 500,000 X Contractual Liability MED EXP(Any one person) 5 15,000 A Y BOP9095053 05/18/2019 05/18/2020 PERSONAL 8 ADV INJURY S GEN'L AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE $ 2,000,000 X PRO POLICY PRODUCTS-COMP/OP AGG $ ❑JECT ❑ Loc 2,000,000 OTHER: Employment Practices S 100.000 AUTOMOBILE LIABILITY C5©M91NE96"GEBtIMIT $ 1,000,000 Ea accident X ANYAUTO BODILY INJURY(Per person) S B OWNED SCHEDULED CAP8662546 05/18/2019 05/18/2020 BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE S AUTOS ONLY AUTOS ONLY Per accident Underinsured motorist S 300,000 �..�.. UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 2,000,000 A EXCESS LIAB CLAIMS-MADE CUP9139391 05/18/2019 05/18/2020 AGGREGATE 5 2,000,000 DED I X1 RETENTION$ 10,000 S WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY Y/N STATUTE I ER ANY PROPRIETOR/PARTNER/EXECUTIVE ❑ OFFICERWEMBER EXCLUDED? NIA E.L EACHACCIDENT 5 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE 5 If yes,Describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT 5 N/A 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 underwritten Contract or Agreement. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN Village of Rye Brook ACCORDANCE WITH THE POLICY PROVISIONS. 938 King Street AUTHORIZED REPRESENTATIVE Rye Brook NY 10573 ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD NEW Workers' ST�A E Compensation CERTIFICATE OF Board NYS WORKERS' COMPENSATION INSURANCE COVERAGE 1a. Legal Name and address of Insured(use street address only) 1b. Business Telephone Number of Insured STERLING ELECTRICAL CONTRACTING INC 1c. NYS Unemployment Insurance Employer 81 MAPLE AVE Registration Number of Insured RYE NY 10580 1d. Federal Employer Identification Number of Insured or Work Location of Insured (Only required if coverage is specifically Social Security Number limited to certain locations in New York State, i.e. a Wrap-Up Policy) 27-2148891 2. Name and Address of the Entity Requesting Proof of 3a. Name of Insurance Carrier Coverage(Entity Being Listed as the Certificate Holder) The Sentinel Insurance Company VILLAGE OF RYE BROOK 11000 938 KING ST 3b. Policy Number of Entity Listed in Box"1a": RYE BROOK NY 10573-1226 76 WEG Z04525 3c. Policy effective period: 05/08/2019 to 05/08/2020 3d. The Proprietor, Partners or Executive Officers are ❑ 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 "1a" for workers' compensation under the New York State Workers' Compensation Law. (To use this form, New York (NY) must be listed under Item 3A on the INFORMATION PAGE of the workers' compensation insurance policy). The Insurance Carrier or its licensed agent will send this Certificate of Insurance to the entity listed above as the certificate holder in box "2". The insurance carrier must notify the above certificate holder and the Workers' Compensation Board within 10 days IF a policy is canceled due to nonpayment of premiums or within 30 days IF there are reasons other than nonpayment of premiums that cancel the policy or eliminate the insured from the coverage indicated on this Certificate. (These notices may be sent by regular mail.) Otherwise, this Certificate is valid for one year after this form is approved by the insurance carrier or its licensed agent, or until the policy expiration date listed in box "3c", whichever is earlier. This certificate is issued as a matter of information only and confers no rights upon the certificate holder. This certificate does not amend, extend or alter the coverage afforded by the policy listed, nor does it confer any rights or responsibilities beyond those contained in the referenced policy. This certificate may be used as evidence of a Worker's 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: Danielle Clausen (print name of authorized representative or licensed agent of insurance carrier) Approved by: ,��,�u,.StC` G,-,,_,,�c,• 05/10/2019 (Signature) (Date) Title: Operations Manager Telephone Number of authorized representative or licensed agent of insurance carrier: (877) 287-1312 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) Form WC 88 31 21 F Printed in U.S.A. www.wcb.ny.gov Page 1 of 2 GENERAC16/2 9,i2l: ® GUARDIAN® SERIES _ u , Residential Standby Generators Air-Cooled Gas Engine INCLUDES: Standby Power Rating • True Power'" Electrical Technology Models G007036-0,G007037-0(Aluminum-Bisque)-16 kW 60 Hz • Two Line LCD Multilingual Digital Model G007035-0(Aluminum-Bisque)-16 kW 60 Hz Evolution'" Controller (English/Spanish/ French/Portuguese) Models G007039-0,G007038-0(Aluminum-Bisque)-20 kW 60 Hz Models G007043-1,G007042-1 (Aluminum-Bisque)-22 kW 60 Hz • Two Transfer Switch Options Available: 100 Amp, 16 Circuit Switch or 200 Amp Service Rated Smart Switch. 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One reason for this PROTOTYPE TESTED NEMA MG1-22 EVALUATION confidence is that the GENERAC product line includes its own transfer SYSTEM TORSIONAL TESTED MOTOR STARTING ABILITY systems and controls for total system compatibility. w GENERAC ryaT3ss ,��~� ©� LM PROMISE Link Stp"pG h4RR AH, GENERACA 16/20/22 kW features and benefits Engines • Generac G-Force design Maximizes engine"breathing"for increased fuel efficiency.Plateau honed cylinder walls and plasma moly rings helps the engine run cooler,reducing oil consumption resulting in longer engine life. • "Spiny-lok"cast iron cylinder walls Rigid construction and added durability provide long engine life. • Electronic ignition/spark advance These features combine to assure smooth,quick starting every time. • Full pressure lubrication system Pressurized lubrication to all vital bearings means better performance,less maintenance and longer engine life.Now featur- ing up to a 2 year/200 hour oil change interval. • Low oil pressure shutdown system Shutdown protection prevents catastrophic engine damage due to low oil. • High temperature shutdown Prevents damage due to overheating. Generator • Revolving field Allows for a smaller,light weight unit that operates 25%more efficiently than a revolving armature generator. • Skewed stator Produces a smooth output waveform for compatibility with electronic equipment. • Displaced phase excitation Maximizes motor starting capability. • Automatic voltage regulation Regulates the output voltage to t 1%prevents damaging voltage spikes. • UL 2200 listed For your safety. Tranvi�r svvitcy (it applicable) • Fully automatic Transfers your vital electrical loads to the energized source of power. • NEMA 3R Can be installed inside or outside for maximum flexibility. • Remote mounting Mounts near your existing distribution panel for simple,low-cost installation. Evo;ui;on' wont ols • Auto/Manual/Off illuminated buttons Selects the operating mode and provides easy,at-a-glance status indication in any condition. • Two-line LCD multilingual display Provides homeowners easily visible logs of history,maintenance and events up to 50 occurrences. • Sealed,raised buttons Smooth,weather-resistant user interface for programming and operations. • Utility voltage sensing Constantly monitors utility voltage,setpoints 65%dropout,80%pick-up,of standard voltage. • Generator voltage sensing Constantly monitors generator voltage to ensure the cleanest power delivered to the home. • Utility interrupt delay Prevents nuisance start-ups of the engine,adjustable 2-1500 seconds from the factory default setting of 5 seconds by a qualified dealer. • Engine warm-up Ensures engine is ready to assume the load,setpoint approximately 5 seconds. • Engine cool-down Allows engine to cool prior to shutdown,setpoint approximately 1 minute. • Programmable exercise Operates engine to prevent oil seal drying and damage between power outages by running the generator for 5 minutes every other week.Also offers a selectable setting for weekly or monthly operation providing flexibility and potentially lower fuel costs to the owner. • Smart battery charger Delivers charge to the battery only when needed at varying rates depending on outdoor air temperature. Compatible with lead acid and AGM-style batteries. • Main line circuit breaker Protects generator from overload. • Electronic governor Maintains constant 60 Hz frequency. Unit • SAE weather protective enclosure Sound attenuated enclosures ensure quiet operation and protection against mother nature,withstanding winds up to 150 mph.Hinged key locking roof panel for security.Litt-out front for easy access to all routine maintenance items.Electrostat- ically applied textured epoxy paint for added durability. • Enclosed critical grade muffler Quiet,critical grade muffler is mounted inside the unit to prevent injuries. • Small,compact,attractive Makes for an easy,eye appealing installation,as close as 181,away from a building. Installation System • 1 It(305 mm)flexible fuel line connector Absorbs any generator vibration when connected to rigid pipe. • Direct-to-dirt composite mounting pad Complex lattice design prevents settling or sinking of the generator system. • Integral sediment trap Prevents particles and moisture from entering the fuel regulator and engine,prolonging engine life. GENERAC 16/20/22 kW specifications .ae—:srator G007035-0,G007036-0. 13007038-0,G007039-0 G00704j22,GrOi 7043-1 Model G007037-0(16 kW) (20 ll 16.000 Watts` 20,000 Watts' 22,000 Rated Maximum Continuous Power Capacity(LP) 16,000 Watts' 18,000 Watts' 19,500 Rated Maximum Continuous Power Capacity(NG) 240 240 P40 Rated Voltage 66.6/66.6 83.3/75 91.6/81.3 Rated Maximum Continuous Load Current—240 Volts(LP/NG) Less than 5% Less than 5% Less than 5% r Total Harmonic Distortion 70 Am 100 Amp 100 Amp Main Line Circuit Breaker p 1 t 1 Phase 2 2 2 Number of Rotor Poles 60 Hz 60 Hz 60Hz Rated AC Frequency 1.0 1.0 10 Power Factor Battery Requirement(not included) 12 Volts,Group 26R 540 CCA Minimum or Group 35AGM 650 CCA Minimum 406/186 448/203 466/211 Unit Weight(InAg) 48 x 25 x 29/1218 x 638 x 732 Dimensions(L x W x H)in/mm 66 B6 67 Souno output in dB(A)at 23 ft(7 m)with generator operating at normal load" 58 58 58 Sound output in dB(A)at 23 ft(7 m)with generator in Quiet-Test—low-speed exercise mode" 58 min 5 min 5 min Exercise duration Engine GENERAC G-Force 1000 Series Type of Engine 2 2 2 Number of Cylinders 999 cc 999 cc 999 cc Displacement Aluminum w/Cast Iron Sleeve Cylinder Block Overhead Valve Overhead Valve Valve Arrangement Overhead Valve Ignition System Solid-state w/Magneto Solid-stale w/Magneto Solid-stale w/Magneto Electronic Electronic Electronic Governor System 9.511 9.5:1 9.5:1 Compression Ratio 12 Vdc 12 Vdc 12 Vdc Starter Approx.1.9 1 8 L Approx.1.9 gt/1.8 L Oil Capacity Including Filter Approx.,60 gU1.8 L App qV . 3.600 3.600 3.600 Operating rpm Fuel Consumption fta/hr(ma/hr) Natural Gas 218(6.17) 204(5.78) 228(6.46) FulllLoad Load 309(8.75) 301(8.52) 327(9.26) uI Liquid Propane 03/hr(gaVhr)[Vhr1 1/2 Load 91.6(2.52)[9.531 86(2.37)18.991 92(2.53)[9.571 Full Load 106.8(2.94)[11.111 129.6(3.56)[13.491 142(3.90)[14.771 Nole.Fuel pipe must be sized for lull load.Required fuel pressure to generator fuel inlet at all load ranges-3.5-7"water column(7-13 mm mercury)for natural gas,10-12"water column(19-22 mm mercury) for LP gas.For Btu content,multiply ON x 2500(LP)or ft3/hr x 1000(NG).For Megajoule content,multiply ma/hr x 93.15(LP)or ma/hr x 31.26(NG) ^oy2rols Simple user interface for ease of operation. 2-Line Plain Text Multilingual LCO Display fa Automatic Start on Utility failure.7 day exerciser. Mode Bultons:Auto Start with starter control,unit slays on.II utility fails,transfer to load lakes place. Manual Stops unit.Power is removed.Control and charger still operate. Off Standard Ready to Run/Maintenance Messages Standard Engine Run Hours Indication Standard(programmable by dealer only) Programmable start delay between 2-1500 seconds From 140-171 V/190-216 V Utility Voltage Loss/Return to Utility Adjustable(Brownout Setting) Standard Future Set Capable Exerciser/Exercise Set Error Warning 50 Events Each RurVAlarm/Mainlenance Logs Engine Stan Sequence Cyclic cranking.16 sec on.7 rest(90 sec maximum duration). Starter cannot re-engage until 5 sec after engine has stopped. Starter Lock-out Standard Smart Battery Charger Standard Charger FaufUMissing AC Warning Standard Low Battery/Battery Problem Protection and Battery Condition Indication Standard Automatic Voltage Regulation with Over and Under Voltage Protection Standard Under-Frequency/Overload/Stepper Overcurrent Protection Standard Safety Fused/Fuse Problem Protection Standard Automatic Low Oil Pressure/High Oil Temperature Shutdown Standard Overcrank/Overspeed(@ 72 Hz)/rpm Sense Loss Shutdown Standard High Engine Temperature Shutdown Standard Internal Fault/Incorrect Wiring Protection Standard Common External Fault Capability Standard Field Upgradable Firmware ^Sound levels are taken from the front of the generator.Sound levels taken from other sides of me generator may be tughei depending m installation parameters.Rating definitions-Standby Applicable for supplying emergency power Inn the duration of the utility power outage.No overload capability is available for this rating.(All ratings in accordance with BS5514,IS03046 and DiN6271).."mum kikwoit amps and current are subject to and limited oy such factors as tuel Btu/megaloule content,ambient temperature,aNtude,engine power and condition.etc.Maximum power decreases about 3.5 percent for each 1.000 feet(304.8 meters)above sea level,and also will decrease about 1 percent for each 6`C(10`Fl above 16'C(60'Fl GENERAC 16/20/22 kW _ _ switch options Model G007036-0(16kW) � `"l14F 6Ef GGllls switch F"atures No.of Poles 2 • 16 space,24 circuit,breakers not included. Current Rating(Amps) 100 • Electrically operated,mechanically-held contacts for fast,positive Voltage Rating(VAC) 120/240,10 connections utility Voltage Monitor(Fixed)' 80% • Rated for all classes of load,100%equipment rated,both inductive and _o pour 65% reSIStIVe. Return to Utility` approx.15 sec r • 2-pole,250 VAC contactors. Exercises bi-weekly lot 5 minutes't Standard • 30 millisecond transfer time. ILL Listed Standard • Dual Coll design. Total Circuits Available 24 • Rated for both copper and aluminum conductors. Tandem Breaker capabilities 8 tandems • Main contacts are silver plated or silver alloy to resist welding and sticking. Circuit Breaker Protected • NEMA/UL 3R aluminum outdoor enclosure allows for indoor or outdoor Available RMS Symmetrical 10,000 Fault Current on 250 Volts mounting flexibility. • Multi listed for use with 1"standard,tandem,GFCI and AFCI breakers from ;Function of Evolution Controller Siemens,Murray,Eaton and Square D for the most flexible and cost effec- Exercise can be set to weekly or monthly five install. wl Dimensions Height �691�] Ht iT4i H1in 26.75 30.113.5 . mm 679.4 764.3 266.7 343.0 Wire Ranges — Conductor Lug Neutral Lug Ground Lug L oEvrH I--W2—� 1/0-#14 2/0-#14 2/0-#t4 —— --- - G007037-0(16 kW)/G007039-0(20 kW)/ emart Switch Fipf-jr-c Model G007043-0(22 kW) • Includes Digital Power Management Technology standard(DPM). No of Poles 2 • Intelligently manages up to four air conditioner loads with no additional Current Rating(Amps) 200 hardware. Voltage Rating(VAC) 120/240,10 • Up to four more large(240 VAC)loads can be managed when used in Upcitty P ltage Monitor(Fixed)' 80% 65% conjunction with Smart Management Modules(SMMs). -Dropout • Electrically operated,mechanically-held contacts for fast,clean connections. Return to Utility' approx.13 sec • Rated for all classes of load.100%equipment rated,both inductive and resis- Exercises bi-weekly for 5 minutes' standard tive. UL Listed Standard • 2-pole.250 VAC contactors. Enclosure Type NEMA/UL 3R • Service equipment rated,dual coil design. Circuit Breaker Protected 22,000 • Rated tot both aluminum and copper conductors. Lug Range 250 MCM-#6 • Main contacts are silver plated or silver alloy to resist welding and sticking. *Function of Evolution Controller • NEMA/UL 3R aluminum outdoor enclosure allows for indoor or outdoor mount- Exercise can be set to weekly or monthly ing flexibility. —wl Dimensions 200 Amps 120/240.10 Open Transition Service Rated Ht Height Width Depth H1 H2 W1 W2 in 26.75 30.1 10.5 13.5 6.91 mm 679.4 764.3 266.7 343.0 175.4 GENERAC 16/20/22 kW available accessories Model# Product Description _ The Wi-Fi enabled LP fuel level monitor provides constant monitoring of the connected LP fuel tank.Mon- G007005-0 Wi-Fi LP Fuel Level Monitor itoring the LP tank's fuel level is an important step in making sure your generator is ready to run during an unexpected power failure.Status alerts are available through a tree application to notify when your LP tank is in need of a refill. Generac's Mobile Link allows you to check the status of your generator from anywhere that you have ac- 5 of 5 G006463-4 Mobile Link" cess to an Internet connection from a PC or with any smart device.You will even be notified via e-mail or text message when a change in the generators status occurs.Available in the U.S.only. Every standby generator requires a battery to start the system.Generac offers the recommended 26R wet G005819 0 26R Wet Cell Battery cell battery for use with all air-cooled standby product(excluding PowerPact®). G007101-0 Battery Pad Warmer The pad warmer rests under the battery.Recommended for use if the temperature regularly falls below 0°F. (Not necessary for use with AGM-style batteries). Oil warmer slips directly over the oil filter.Recommended for use if the temperature regularly falls below G007102-0 Oil Warmer 0 F. Auxiliary Transfer Switch The auxiliary transfer switch contact kit allows the transfer switch to lock out a single large electrical load G005621-0 Contact Kit you may not need.Not compatible with 50 amp pre-wired switches. Fascia Base Wrap Kit The fascia base wrap snaps together around the bottom of the new air cooled generators.This offers a G007027-0-Bisque (Standard on 22 kW) sleek,contoured appearance as well as offering protection from rodents and insects by covering the lifting holes located in the base. If the generator enclosure is scratched or damaged,it is important to touch-up the paint to protect from G005703-0-Bisque Paint Kit future corrosion.The paint kit includes the necessary paint to properly maintain or touch-up a generator enclosure. G006485-0 Scheduled Maintenance Kit Generac's scheduled maintenance kits provide all the hardware necessary to perform complete routine maintenance on a Generac automatic standby generator. G006873-0 Smart Management Module Smart Management Modules are used in conjunction with the Automatic Transfer Switch to increase its (50 Amps) power management capabilities.It provides additional power management flexibility not found in any other power management system. dimensions & UPCs Dimensions shown are approximate.Refer to installation manual for exact dimensions.DO NOT USE THESE DIMENSIONS FOR INSTALLATION PURPOSES. Model UPC G007035-0 696471070354 — O- t - a G007036-0 696471070361 G007037-0 696471070378 n,mm = _ G007038-0 696471070385 (]e.6 m1 _ G007039-0 696471070392 G007042-0 696471070422 - - _ G007043-0 6964710704 39 LEFT,MVIEW VMW GENE-RAC' Generac Power Systems,Inc. • S45 W29290 HWY.59,Waukesha,WI 53189 • generac.com - ©2017 Generac Power Systems,Inc.All rights reserved.All specifications are subject to change without notice.Part No.10000000194-F 5/3/17