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HomeMy WebLinkAboutMP25-017 BRA � ,y 7. 19 VILLAGE OF RYE BROOK MAYOR 938 King Street, Rye Brook,N.Y. 10573 ADMINISTRATOR Jason A. Klein (914) 939-0668 Christopher J. Bradbury www.Eyebrookny.gov TRUSTEES BUILDING& FIRE INSPECTOR Susan R. Epstein Steven E. Fews Stephanie J. Fischer David M. Heiser Salvatore W. Morlino CERTIFICATE OF COMPLIANCE March 12,2025 Jason Lupow&Melissa Lupow 10 Mark Drive Rye Brook,New York 10573 Re: 10 Mark Drive, Rye Brook,New York 10573 Parcel ID#: 135.33-1-12 This document certifies that the work done under Mechanical Permit #25-017 issued on 2/13/2025 for the installation of a new gas fired furnace has been satisfactorily completed. Sincerely, Steven E. Fews Building&Fire Inspector /to L-QyC D 4 LGV'd�'a�v VILLAGE OF RYE BROOK MAYOR 938 King Street,Rye Brook,N.Y. 10573 ADMINISTRATOR Jason A. Klein (914)939-0668 Christopher J.Bradbury www.tyebrookn.gv TRUSTEES BUILDING & FIRE INSPECTOR Susan R.Epstein Steven E. Fews Stephanie J. Fischer David M.Heiser Salvatore W. Morlino CERTIFICATE OF COMPLIANCE March 12,2025 Jason Lupow&Melissa Lupow 10 Mark Drive Rye Brook,New York 10573 Re: 10 Mark Drive,Rye Brook,New York 10573 Parcel ID#: 135.33-1-12 This document certifies that the work done under Plumbing Permit #25-021 issued on 2/13/2025 for the installation of a new gas water heater has been satisfactorily completed. Sincerely, Steven E.Fews Building&Fire Inspector /to QyE BRC��, 1982 BUILDING DEPARTMENT 7❑B LDING 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 : 1 V I \ �2 � �� DATE: PERMIT# MP25 ISSUED:1'13-2: SECT: 13S•31 BLOCK: LOT: = LOCATION: c� rN—nlA OCCUPANCY: ❑ VIOLATION NOTED THE WORK IS... ❑ ACCEPTED ❑ REJECTED/ REINSPECTION ❑ SITE INSPECTION REQUIRED ❑ FOOTING ❑ FOOTING DRAINAGE ❑ FOUNDATION ❑ UNDERGROUND PLUMBING NOTES ON INSPECTION: ❑ ROUGH PLUMBING ❑ ROUGH FRAMING ❑ INSULATION ❑ NATURAL GAS ❑ L.P. GAS ❑ FUEL TANK ❑ FIRE SPRINKLER ❑ FINAL PLUMBING ❑ CROSS CONNECTION ❑ FINAL C +� ❑ OTHER j /� J,�tieBRCb�• `�082 BUILDING DEPARTMENT ❑yBUILDING INSPECTOR ,y��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 : I'LJ MiO(Lt- DATE: PERMIT# -p f Z's- () 2 k ISSUED: SECT: BLOCK: LOT: '/ LOCATION: f-z,.,aA" r+' JI OCCUPANCY: ❑ VIOLATION NOTED THE WORK IS... C1. ACCEPTED ❑ REJECTED/ REINSPECTION ❑ SITE INSPECTION REQUIRED ❑ FOOTING ❑ FOOTING DRAINAGE ❑ FOUNDATION ❑ UNDERGROUND PLUMBING NOTES ON INSPECTION: ❑ ROUGH PLUMBING ❑ ROUGH FRAMING ❑ INSULATION ❑ NATURAL GAS ❑ L.P. GAS _ ❑ FUEL TANK r �� ❑ FIRE SPRINKLER _❑ FINAL PLUMBING ❑ CROSS CONNECTION ❑ FINAL ❑ OTHER l� o � o N N a ' N OG + a O W ■ ca r/? v v N CA ICI .. C.r V 91. ww � voo0 ju M d Q c ti wlo o cd U iz- 20 U Z n � Q rOl O � o � ov d - 00 G1 cn coA �,M v F c� W , t F O z A zacav a 0 U .r o �ti x U wO 'sv � " v r1 o z p LO LO Ogw �? o z W � dL� q � r-I PG � 0.4 .4 w x � P � b BUILD I&AIRTMENT LMO VIL OF RYE OOK938 KING ET RYE I3x ,NY I0573 5ov 3ROOK MENT APPLICATION FOR PERMIT TO INSTALL ANDI HEATING,VENTILATION AND/OR AIR CONDITIONING IEQUIPMtt��EN—T7 FOR OFFICE USE ONLY: PERMIT#- 'C)� Q/ / Approval Date: FEB1 H0251n Permit Fee: $ Approval Signature: Other: Disapproved: (fees are non-refundable) DO NOT START WORK or CONSTRUCTION UNTIL A PERMIT HAS BEEN ISSUED BY THE BUILDING INSPECTOR.THE ADMINISTRATIVE FEE FOR WORK PROGRESSED OR COMPLETED WITHOUT A PERMIT IS 12% OF THE TOTAL COST OF CONSTRUCTION WITH A MINIMUM FEE OF$750.00 REQUIREMENTS FOR RELEASE OF PERMIT&CERTIFICATE OF COMPLIANCE*. 1. Properly completed&Signed Application. 2. Site/Staging Plan if Required by the Building Inspector. 3. Copy of Licensed Contractor's Liability Insurance.(Village of Rye Brook must be listed as certificate holder)&Workers Compensation Insurance on a NYS Board form(Form#C105.2 or Form#U26.3/or NY State Workers Compensation Waiver) 4. Payment of Fees/Unit: RESIDENTIAL=$I50.00/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 separatc Electrical Permit&Electrical inspection. 8. Plumbing/Gas work requires a separate Plumbing Permit&Plumbing Inspection. Application dated, CD—) is hereby made to the Building Inspector of the Village of Rye Brook for a permit for the installation and or removal of the HVAC equipment as listed below.The applicant and property owner,by signing this document agrees that said equipment will be installed and/or removed in conformance with all applicable Local,County,State&Federal laws, codes,rules and regulations. / 1. Address: /Q A10R/C j"C SBL: /3S, 33 �'I/Zone: — 2. Property Owner: jo S o.v Address: (6 1,tf 2 K Q2 Phone#: i l� � a -� S Cell#: email: 3. Contractor: !L c"I C— /)2A v4 /C Address: 466. Phone#: �//`f �3y X3 d f Cell#: email: 4. Scope of Work:New Installation( )•ReplacementQ�-Removal( )•Other 5. List Equipment: I'w R N/J i0 ���.•, 6. Location of Equipment: Ar 7. Method of Installation/Removal(list all equipinent heeded to perfortnjob): I(ti x N^CA i 6/I/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 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 Sworn to before me this day of —ft b 6 a ,20 Z Sr enatur—eofr I CLIP _,20 ) E gnau ofPropertyOwner pplicant���'�►-' Vim''r`" S �����l 5 / rint Name of Property Owner t ame of Applicant SHARI MELILLO Notary Public Notary Public,State of New York No Public No.OIME6160063 Quallfiad In Westchester county . commlWon Expires JeinUary 29,20 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 6nno2a i' a, � M = O N N LJ a N w O N N M cz i F- W Lf) , a W , v _ W N T-4 y O a v G a W a M z0-4 � M f H W _ w o -- 0D to c ,r•, ,' In � GL, z 3 x A 00 a M V A w v a z 11ocW z a ✓ w/ c - CY w v w CA o � N 0 0a �I a. z w x � s BUILpjD ING DEP R,T,MENT VIL�c.,�,�E OF RYE�)�QOK 938 KINaET RvE BIt�O ; NY 10573 FEB 13 2025 �9�Of4�j` wwtiv; o.okny.g� VILLAGE OF RYE BROOK ELECTRICAL PERMIT APPLICATIO BUILDING DEPARTMENT Westchester County Master Electricians License Required FOR OFFICE USE ONLY _�P#s/% ��`� 0 7 EP#: o) — OS 7 Approval Date: FEB 14 2 Permit Fee: $ / S iQ`-' Approval Signature: 4L 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, 3-� is hereby made to the Building Inspector of the Village of Rye Brook NY,for the issuance of a Permit to install and/or remove electrical equipment,wiring, fixtures,or to perform other high or low voltage electrical work as per the detailed statement described below. 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: l �i`t/ �C �r��•c� SBL: ��3J�i 33 -�-� a Zone: IJ 2.Property Owner: 'S�SD� ("��� Address: 16 M kik Phone#: �� - 33 56 Cell#: email: /"YL C) 3-�7 5'il..00. a0.wt 3.Master Electrician/Licensed Installer:� -Address: .Sp✓o' P- 3 Lic.#: �16 Phone#:y1 L/-C ?,y-,(I16 Cell#:4?1 Lt'3 S 6 -_3_2-?-/email: �bV c..' c" G ®CLO' •Co✓h Company Name: Y(Og¢!t"J /►'tL"'uyer-u►I✓ Address:q� o-C Sfl�� Q-t�tti. IL 5�, np I.,oS}Gv 4.Proposed Electrical Work/Fixture Count: CU 5.3`d Party Electrical Inspection Agency: STATE OF NEW YORK,COUNTY OF WESTCHESTER ) as: G-e,T ,� rG ~c `-1 ,being duly sworn,deposes and states that he/she is the applicant above named,and does further (print name of individual s Wing as the applic t) state that(s)he is the �`� e r-C""`< C, 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. SwornIf re is Sworn to before me this day t 20� day of Fe 6 If20 Si ature f Property Owner .map rye Of Applicant ame of Property caner Prin am of Applicant C N Noti*A1 a of New York SW9 of NewYo* No.01ME6160063 � .OIWHS394M 6/t/2024 Qualified In Westchester County n Quelfied In We$b&d*t r COU* Commtsslon Expires January 29,20 G (,0 " 011 Exl*n July 6,2W STATE WIDE INSPECTION SERVICES, INC.' 0•0 • • SWIS JOB APPLICATION0. • Office Use Elect. Permit# �� 3 Date Scl Ft Plumbing Permit# Final Certificate# City/Village rye book Zip 10573 Building Dept. ryebrook County Address 10 mark drive Cross Street Section Block Lot Owner Name/Address(If different than above) Contact Number ❑✓ Basement ❑1st FI. ❑2nd FI. ❑3rd FI. ❑More Than 3 Fl. ❑Garage ❑Attic ❑Outside ❑Residential ❑Commercial Receptacles Special Recept GFCI AFCI Switches Dimmers Smoke Alarms C/0 Detector Hood Trash Compact Amt Amps Range(s) Cooktop(s) Oven(s) Dishwashers Refrigerator Disposal Microwave Luminaires Generator Transfer Switch SERVICE Amperage #Panels iP 3P # Meters # Disconnect 1❑Underground ❑ New ❑ Reconnect ❑ Repair ❑Overhead ❑ upgrade ❑ Disconnect Utility ID# ❑Con Ed ❑NYSEG ❑Central Hudson ❑Orange/ Rockland PHOTOVOLTAIC SYSTEM PV Modules Inverters AC Disconnect Junction Box Combiner Box Load Center PV Monitor Energy Storage System DC Disconnect ❑Legalization ❑ Safety Inspection ❑Consultation Scope of Work wiring for replacement of furnace ® DD V i FEB 13 2025 VILLAGE OF RYE BROOK 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 any time 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 gbranca6@aol.com Name gene br nca License# e716 Date 2/11/25 Signature Address 78 south regent City/State portchester ny zip Code 10573 Company rei property managment Phone# 914-356-3224 (� LL, State Wide Inspection Services MAR - 4 2025 1080 Main Street 4 ` Fishkill, NY 12524 845 202-7224 Phone VILLAGE OF RYE BROOK 914-219-1062 Fax STATE WIDE INSPEC710NSERVICES BUILDING DEPARTMENT Email: officegswisny.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: Gene Branca Electrical Contractor Lupow Residence Gene Branca 10 Mark Drive 78 South Regent Street Rye Brook, NY 10573 Port Chester, NY 10573 Located at: 10 Mark Drive, Rye Brook, NY 10573 Section: Block: Lot: Electrical Permit Number: EP25-037 135.33 1 12 Certificate Number: 2025-1307 Building Permit Number: MP25-017 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: 10 Mark Drive, Rye Brook, NY 10573 The Basement Utility/Lundry Room 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 41h Day of March 2025. Name Quantity Rating Circuit Type Boiler 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. Ur s ' ' \ M N N r 44 4 0 = Z W a 14 CA fs. w • QZ G W yC a 0 � c C ; A . _ Q ... O � v �, , H -I- A "CO l \ z UZ (hk � 04 k0 - r Iz z a W V H za c: z w U w C ••' o Z o cn ' �4�„ � �+''' Q z U OW. to Ti..� • ° f� .. .. W J U yE_[1R _ LS 0 VED BUILPII DEPA!;yTMENT D VILi E OF RYES bOK FEB 2025 938 KIN d ET RYE B NY 1057 \\ ' Iq VILLAGE OF RYE BROOK vvygony.gov BUILDING DEPARTMENT PLUMBING PERMIT APPLICATION FOR OFFICE USE ONLY ,. p-v �c��� 'CJ PP#: Approval Date: FEB 1 4 2025Permit Fee: $ / 5&Dc�- 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 IS 12% OF THE TOTAL COST OF CONSTRUCTION WITH A MINIMUM FEE OF$750.00 Application dated, c�)—//—c�_'S_ is hereby made to the Building Inspector of the Village of Rye Brook NY, for the issuance of a Permit to install and/or remove Plumbing as per detailed statement described below.The applicant&property owner,by signing this document agree that said plumbing work will be in conformance with all applicable Federal,State,County and Local Codes. 1.Address: /V ��1��� 1) i✓ /��Kn,. - d SBL: Zone 2.Proposed Work: y 1"' a 3.Property Owner: S 0 N .'�9 c .'� Address: Phone#: Cell#: I/? ?J `/3 35& email: 4.Master Plumber: Address: Lic.#:1 Y(S_1 Phone#: Cell#: email: a,4,- j c- 4L �,t Company Name: 40 c 1 lc- "A G4sq-1 t Address: d /v /1'U44"S !� 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 1 st Floor 2nd Floor 31 Floor 41'Floor 5t°Floor Exterior �u A /V.?+ * 5. List Other Equipment/Provide Details: (Notarized Signatures Required Next 2 Pages) -1- 611/2024 1 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 Sworn to before me this day of ,20 S day o Si atu of Property Owner Signature of Applicant Print Name of Property Owner Print Name of Applicant Aa, N0fiirT0JWWELJLL0 otary Publi"y WLM Pdotary Public,State of New York Nifty Pubft State of New Yok No.09.ME6160063 No.01 WH6394580 Qualified In Westchester County OustM W In Westchester Co Commission Expires JanUary 29,20D July 8. 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. 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- 6/1/2024 - BUILD[NC, D P.ARTMENT D ECENE VILLA0E OF RYir' ROOK 938 KING$fiI EET RYE BRcj0"k,NY 10573 FEB 11 2025 4). -Ob68 VILLAGE OF RYE BROOK wwrriYe kni :;:ov BUILDING DEPARTMENT AFFIDAVIT OF COMPLIANCE VLLLAGE 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: M ��'�^> �✓ �/ , residing at, (Prim name) (Address where you liecl 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; , 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. (Si. nanne oftProperty O r(s)) _ASj�'S� V "r (Print Name of Property Owner(s)) Sworn to before me this da ( 20 � (Notary Public) SHAR1 MEULLO Notary Public,State of New York No.OWEU60063 Qualified In Westchester County 3 Commission Expires JanUWY 29.207 6/1/2024 COMMERCIAL-GRADE Ore ® RESIDENTIAL GAS WATER HEATERS PROLINE° HIGH CAPACITY ATMOSPHERIC VENT COMMERCIAL-GRADE RESIDENTIAL HIGHEST RECOVERIES ENHANCED-FLOW BRASS DRAIN • Capacity/input combinations up to 98 VALVE gallons/75,100 BTU's produce recoveries • Our residential water heaters have a up to 81 gallons per hour solid brass,tamper resistant,enhanced- �s+nttrt FULLY AUTOMATIC CONTROLS WITH flow,ball type,drain valve. SAFETY SHUTOFF • Uses a standard female hose fitting • Accurate,dependable control system that allows for fast and easy draining requires no electric connections.Fixed during maintenance. automatic gas shutoff device for added • Designed for easy operation,this valve safety. includes an integral screwdriver slot GREEN CHOICE®GAS BURNER that features a 1/4 turn(open/close) radius,which not only permits full • Patented eco friendly burner design straight-through water flow but also a reduces NOx emissions by up to 33% quick and positive shut off and complies with Low-NOx emission requirements of 40 ng/1. CODE COMPLIANCE DYNACLEANTm DIFFUSER DIP TUBE • Meets UBC,CEC and ICC National • Reduces lime and sediment buildup and Codes. maximizes hot water output.Made from • Meets the thermal efficiency and long-lasting PEX cross-linked polymer. standby loss requirements of the COREGARDT"ANODE ROD U.S.Department of Energy and current edition of ASHRAE/IES 90.1. • Our anode rods have a stainless steel core that extends the life of the anode CSA CERTIFIED AND ASME RATED rod allowing superior tank protection far T&P RELIEF VALVE longer than standard anode rods. MAXIMUM HYDROSTATIC WORKING PUSH-BUTTON PIEZO IGNITOR PRESSURE 150 PSI • Makes lighting the pilot fast and easy DESIGN-LISTED BY CSA with one-hand push-button spark INTERNATIONAL ignition. • Certified at 300 psi test pressure and 150 psi working pressure. NIPPLES • Listed according to ANSI Z21.10.3 CSA • Factory-installed for faster installation. 4.3 standards governing storage tank- BLUE DIAMOND®GLASS COATING type gas water heaters. • Provides superior corrosion resistance 6-YEAR LIMITED TANK AND PARTS compared to industry standard glass WARRANTY lining. • For complete information,consult written warranty or go to hotwater.com C$P GAS-FIRED Green Choice, LISTED ©July 2017 A.0.Smith corporation.All rights reserved. Page 1 of 2 www.hotwater.com 1800-527-1953 Toll-Free USA I A.0.Smith Corporation 1 500 Tennessee Waltz Parkway I Ashland City,TN 37015 AOSRG47002 hth M Ice ® RESIDENTIAL GAS WATER HEATERS COMMERCIAL-GRADE Rated First BTU Recovery @ Dimensions in Inches Approx. Model Nominal Storage UEF Hour Input 90'F Rise Draft Shipping Number Capacity Volume Rating Natural Gallon A B C D E F G H Hood Weight Gallons Gas Per Hour FCG-75' 74 71 0.60 125 75,100 81 61 58-1/2 26-1/2 15-3/16 16 50-1/4 15-1/2 50-1/4 4 1 21u FCG-100 98 95 0.58 170 75,100 81 68-1/2 66-1/2 27-3/4 15-3/16 16 1 57-3/8 1 N/A I N/A 4 340 Water connections-1"on FCG-75 and 1-114'on FCG-100 For 10-year tank and 10-year parts limited warranty,change"F"to"P"in model number(example:PCG-75). 'For optional side-mounted recirculating taps,add"L"to the suffix of the model number(example:FCG-75L). All models are certified from sea level to 7,700 ft.elevation. Dimensions and specifications subject to change without notice in accordance with our policy of continuous product improvement. HOTWATER TOP VIEW INLET COLD WATER INLET - E10 T&P TEMPERATURE AND PRESSURE RELIEF VALVE DRAIN +� VALVE +--- C HOT \ `J COLD F B 4 H A DRAIN VALVE ® GAS INLET T_ G-T D G FRONT VIEW For Technical Information,call :11product r prior July 2017 A.0.Smith Corporation.All Rights Reserved Page 2 of 2 www.hotwater.com 1 800-527-1953 Toll-Free USA I A.0.Smith Corporation 1 500 Tennessee Waltz Parkway I Ashland City,TN 37015 AOSRG47002 r A0ktk., Product Data Upflow/ Horizontal Left/Right, Downflow Two Stage Condensing Gas Fired Furnace Upflow, Convertible to Downflow Only Horizontal Right or S9V2B040D3PSBB Horizontal Left S9V2B060D3PSBB S9V2B040U3PSBB S9V2B080D4PSBB S9V2B060U3PSBB S9V2C100D4PSBB S9V2B060U4PSBB S9V2C100D5PSBB S9V2B080U4PSBB S9V2D120D5PSBB �o S9V2C080U5PS8B ®- S9V2C10004PSBB Iri S9V2C10005PSBB . o S9V2D120U5PSBB o Note:Graphics in this document are for representation only.Actual model may differ in appearance. COIL REQUIREMENTI Failure to folow MI9 Caution Could result In prop"damage or personal injury.4OXC'and 4MXC'calk installed on upf ow furnaces In vertical,horl rantal left,a horizontal right aderdaaone without a factory Ir1aldMd metal drain pan ah1eld meet use a MAY'FERCOLKITAA lea.Calk imWled on upllow tumew mwt have drain pars Net we suitable for 400'F Izos•CI a have a metal dran pen ehleld.Dnwngrrw fumagba eo not require a metal drain pen —1,1 nr Nn M,n1 IM AY'FERMn kit KITAA Sir.Irtataanr's f.—.Inr morn inlnrmalinn. August 2019 22-1921 -1 F-EN CI—)Ingersoll Rand MANE General Features NATURAL GAS MODELS Central Heating furnace designs are certified by the American Gas Association for both natural and L.P.gas. Limit setting and rating data were established and approved under standard rating conditions using American National Standards Institute standards. SAFE OPERATION The Integrated System Control is a solid state device which continuously monitors for presence of flame when the system is in the heating mode of operation. Dual solenoid combination gas valve and regulator provide additional safety. QUICK HEATING Durable,cycle tested,heavy gauge tubular stainless steel primary heat exchanger quickly transfers heat to provide warm conditioned air to the structure. Low energy power vent blower,to increase efficiency and provide a positive discharge of gas fumes to the outside. BURNERS Multiport Inshot burners will give years of quiet and efficient service.All models can be converted to L.P. gas with LP conversion kit. INTEGRATED SYSTEM CONTROL Exclusively designed operational program provides total control of furnace limit sensors, blowers,gas valve,flame control and includes self diagnostics for ease of service.Also contains dry contacts for EAC and HUM. ENERGY EFFICIENT OPERATION Furnace is certified by the manufacturer to leak 1%or less of nominal air conditioning CFM delivered when pressurized to.5"water column with all inlets,outlets,and drains sealed. AIR DELIVERY The variable speed blower motor has sufficient airflow for most heating and cooling requirements and wilt switch from heating to cooling speeds on demand from room thermostat. SECONDARY HEAT EXCHANGER The S-Series furnace has a special type 29-4CTI stainless steel secondary heat exchanger to reclaim heat from flue gases which would normally be lost. STYLING Heavy gauge steel and "wrap-around"cabinet construction is used in the cabinet with baked- on enamel finish for strength and beauty. Every orientation has at least two venting options. There are no knockouts on cabinet. FEATURES AND GENERAL OPERATION The S-Series furnace utilizes a Silicon Nitride Hot Surface Ignition system,which eliminates the waste of a constant burning pilot.The integrated system control lights the main burners upon a demand for heat from the room thermostat. Complete front service access. a. Low energy power venter b.Vent proving pressure switches. 2 22-1921-1 F-EN TRINE` Features and Benefits 96.0%AFUE ACROSS ALL MODELS Meets utility rebates Lowers utility bills ELECTRICALLY EFFICIENT Efficient airflow design reduces electrical energy use 34 INCH TALL Lighter,easier to move and fit into tight spaces like short basements or tight closets Works great with larger, high-efficiency coils No knockouts 3—WAY MULTI-POISE/DEDICATED DOWNFLOW 8 SKU's — Upflow/Horizontal Left/Horizontal Right 6 SKU's — Downflow Added application flexibility and reduction in specification errors AIRFLOW At least 400 CFM/ton at 0.5 in.H2O external static pressure; setup airflow options down to 290 CFM/ton REGULATORY All models are air tight; 1%or less air leakage as per ASHRAE 193 Open vestibule design provides a full 34" high open vestibule DIMENSIONS Widths are industry standard: 17.5",21",and 24.5" Depth remains approximately 28" Cabinet will be compatible with industry standard coils,as well as,other accessories INTEGRATED FURNACE CONTROL Setup/Status/Diagnostics/Digital Display No dip switches Last six errors stored Dry contact EAC and HUM connections All Molex connections;no spade terminals Low voltage labeled above and below Rain shield over IFC keeps condensate off the control TUBULAR STAINLESS STEEL PRIMARY HEAT EXCHANGER 29-4C STAINLESS STEEL SECONDARY HEAT EXCHANGER Stainless steel is a more durable,corrosive-resistant material than aluminumized steel Integrated rail system for easy access if required Reduces or eliminates need for baffles VORTICA II BLOWER, DESIGNED EXCLUSIVELY FOR THE S-SERIES FURNACE Improved airflow efficiency Durable,easy to clean,two piece housing Single piece belly band/motor arm assembly Blower deck has full-length rails for easy removal and replacement, regardless of poise 22-1921-1 F-EN 3 0 MAKE' Features and Benefits THREE—WAY MULTI-POISE (UPFLOW, HORIZONTAL LEFT AND RIGHT) PLUS DEDICATED DOWNFLOW Easier to specify Shipped ready to install (no kits required) Every model has at least two venting options When in horizontal,trap extends only about 2" Barbed fitting on trap at hose connection and on cabinet transition for hose has barbed fitting and clamps at both ends for leak resistance. Vent table improvements including longer vent lengths;2" pipe can be used up to 100K 4 22-1921-1 F-EN 0 TAME' Accessories Table 1. Accessories Model Number Description Use with BAYHANG Horizontal Hanging Kit All Upflow Furnaces BAYVENT200B Sidewall Vent Termination Kit All Furnaces BAYVENTCN200B Sidewall Vent Termination Kit(Canada— All Furnaces CPVC) BAYAIR30AVENTA Concentric Vent Kit All Furnaces BAYAIR30CNVENT Concentric Vent Kit(Canada—CPVC) All Furnaces BAYREDUCE Reducing Coupling(CPVC) All Furnaces BAYLIFTB Dua4 Return Kit(B size extension) B Cabinet Upflow Furnaces BAYLIFTC Dual Return Kit(C size extension) C Cabinet Upflow Furnaces BAYLIFTD Dual Return Kit(D size extension) D Cabinet Upflow Furnaces BAYBASE205 Downflow Subbase All Downflow Furnaces BAYFLTR206 Filter Access Door Kit(Downflow only) All Downflow Furnaces BAYSF1165AA W 1"SlimFit Box with MERV 4 Filter All Upflow Furnaces BAYFLTR203 Horizontal Filter Kit B Cabinet Furnaces in Downflow/Horizontal BAYFLTR204 Horizontal Filter Kit C Cabinet Furnaces in Downflow/Horizontal BAYFLTR205 Horizontal Filter Kit D Cabinet Furnaces In Downflow/Horizontal BAYLPSS400B Propane Conversion Kit with Stainless Steel All Furnaces Burners BAYMFGH2O0B Manufactured/Mobile Housing Kit All Furnaces BAYCNDTRAP2A Inline Condensate Trap Kit used with Special All Furnaces Venting on 2"Vent Pipe BAYCNDTRAP3A Inline Condensate Trap Kit used with Special All Furnaces Venting on 3"Vent Pipe (a) Airflow greater than 1600 CFM requires dual returns 22-1921-1 F-EN 5 MAW Product Specification MODEL S9V2B04OU3PSBBlaI S9V2BO6OU3PSBBlaI S9V2BO6OU4PSBB(a) S9V2BOBOU4PSBBIai TYPE Upflow/Horizontal Upflow/Horizontal Upflow/Horizontal Upflow/Horizontal RATINGS(b) 1st Stage Input BTUH(ICS) 26,000 39,000 39,000 52,000 1st Stage Capacity BTUH 25,220 37,830 37,830 50,440 2nd Stage Input BTUH 40,000 60,000 60,000 80,000 2nd Stage Capacity BTUH(ICS)'c- 38,800 58,200 58,200 77,600 1st Stage Temp.Rise(Min.-Max.) 25-55 25-55 25-5S 30-60 2nd Stage Temp.Rise(Min.-Max.) 30-60 35-65 35-65 35-65 AFUE(%) 96.0 96.0 96.0 96.0 BLOWER DRIVE DIRECT DIRECT DIRECT DIRECT Diameter—Width(In.) 11 X 8 11 X 8 11 X 8 11 X 8 No.Used 1 1 1 1 Speeds(No.) Variable Variable Variable Variable CFM vs.in,w.g. See Fan Performance See Fan Performance See Fan Performance See Fan Performance Table Table Table Table Motor HP 1/2 1/2 3/4 3/4 RPM Variable Variable Variable Variable Volts/Ph/Hz 120/1/60 120/1/60 120/1/60 120/1/60 FLA 5.7 5.7 8.0 8.0 COMBUSTION FAN—Type Centrifugal Centrifugal Centrifugal Centrifugal Drive—No.Speeds Direct-2 Direct-2 Direct-2 Direct-2 Motor HP—RPM 3300/2600 3300/2600 3300/2600 3300/2600 Volts/Ph/Hz 120/1/60 120/1/60 120/1/60 120/1/60 FLA 0.66 0.66 0.66 0.66 FILTER—Furnished? No No No No Type recommended High Velocity High Velocity High Velocity High Velocity Hi Vel.(No.-Size-Thk.) 1—16x25—1 in. 1—16x25—1 in. 1—16x25—1 in. 1—16x25—1 in. VENT PIPE DIAMETER—Min(in.) 2 Round 2 Round 2 Round 2 Round re; F HEATEXCHANGER Type—Fired 409 Stainless Steel 409 Stainless Steel 409 Stainless Steel 409 Stainless Steel —Unfired 29-4C Stainless Steel 29-4C Stainless Steel 29-4C Stainless Steel 29-4C Stainless Steel Gauge(Fired) 20 20 20 20 ORIFICES—Main Nat.Gas Qty.—Drill Size 2-45 3-45 3-45 4-45 LP Gas Qty.—Drill Size 2-S6 3-s6 3-56 4-56 GAS VALVE Redundant-Two Stage Redundant-Two Stage Redundant-Two Stage Redundant-Two Stage PILOT SAFETY DEVICE Type 120 V SiNi Igniter 120 V SiNi Igniter 120 V SiNi Igniter 120 V SiNi Igniter BURNERS—Type Multiport Inshot Multiport Inshot Multipart Inshot Multiport Inshot Number 2 3 3 4 POWER CONN.—V/Ph/Hz - 120/1/60 120/1/60 120/1/60 120/1/60 Ampacity(In Amps) 7.9 7.9 10.8 10.8 6 22-1921-1 F-EN ® 7f0A11/i Product Specification MODEL S9V2BO4OU3PSBB(a) S9V2B060U3PS8B(a) S9V2B060U4PSBB(a) S9V260801,14PS613(a) Max.Overcurrent Protection(Amps) 15 15 15 15 PIPE CONN.SIZE(in.) 1/2 1/2 1/2 1/2 DIMENSIONS HXWxD HxWxD HxWxD HxWxD Uncrated(In.) 34 x 17-1/2 x 28-3/4 34 x 17-1/2 x 28-3/4 34 x 17-1/2 x 28-3/4 34 x 17-1/2 x 28-3/4 Crated(In.) 35-1/2 x 19-1/2 x 30-7/8 35-1/2 x 19-1/2 x 30-7/8 35-1/2 x 19-1/2 x 30-7/8 35-1/2 x 19-1/2 x 30-7/8 WEIGHT Shipping(Lbs.)/Net(Lbs.) 122/114 127/119 130/122 135/127 W Meets Energy Star (c) For U.S.applications,above input ratings(BTUH)are up to 2,000 feet,derate 4%per 1,000 feet for elevations above 2,000 feet above sea level.For Canadian applications,above Input ratings(BTUH)are up to 4,500 feet,derate 4%per 1,000 feet for elevations above 4,500 feet above sea level. W Central Furnace heating designs are certified to ANSI Z21.47 I CSA 2.3—latest edition. (a) Based on U.S,government standard tests. (e) Refer to the Vent Length Table in the Installer's Guide. (f) All 59V2 furnace models have a vent outlet diameter that equals 2 in. M The above wiring specifications are in accordance with National Electrical Code;however,installations must comply with local codes. MODEL S9V2C080USPSBB(3) S9V2C10004PSBB(a) S9V2C1000SPSBB(a) S9V2D120USPSBB(a) TYPE Upflow/Horizontal Upflow/Horizontal Upflow/Horizontal Upflow/Horizontal RATINGS(e) 1st Stage Input BTUH(ICS) 52,000 65,000 65,000 78,000 1st Stage Capacity BTUH 50,440 63,050 63,050 75,660 2nd Stage Input BTUH 80,000 100,000 100,000 120,000 2nd Stage Capacity BTUH(ICS)(c)(d) 77,600 97,000 97,000 116,400 1st Stage Temp.Rise(Min.-Max.) 30-60 25-55 25-55 35-65 2nd Stage Temp.Rise(Min.-Max.) 35-65 35-65 30-60 40-70 AFUE(%)(d) 96.0 96.0 96.0 96.0 BLOWER DRIVE DIRECT DIRECT DIRECT DIRECT Diameter—Width(In.) 11 X 10 11 X 10 11 X 10 11 X 10 No.Used 1 1 1 1 Speeds(No.) Variable Variable Variable Variable CFM vs.in.w.g. See Fan Performance See Fan Performance See Fan Performance See Fan Performance Table Table Table Table Motor HP 1 3/4 1 1 RPM Variable Variable Variable Variable Volts/Ph/Hz 120/1/60 120/1/60 120/1/60 120/1/60 FLA 10.5 8.0 10.5 10.5 COMBUSTION FAN—Type Centrifugal Centrifugal Centrifugal Centrifugal Drive—No.Speeds Direct-2 Direct-2 Direct-2 Direct-2 Motor HP—RPM 3300/2600 3300/2600 3300/2600 3300/2600 Volts/Ph/Hz 120/1/60 120/1/60 120/1/60 120/1/60 FLA 0.66 0.66 0.66 0.66 FILTER—Furnished? No No No No Type recommended High Velocity High Velocity High Velocity High Velocity Hi Vel.(No.-Size-Thk.) 1—20x25—1 in. 1—20x25—I in. 1—20x25—1 in. 1—24x25—1 in. VENT PIPE DIAMETER—Min(in.)(e)(f) 2 Round 2 Round 2 Round 3 Round HEATEXCHANGER Type—Fired 409 Stainless Steel 409 Stainless Steel 409 Stainless Steel 409 Stainless Steel —Unfired 29-4C Stainless Steel 29-4C Stainless Steel 29-4C Stainless Steel 29-4C Stainless Steel 22-1921-1 F-E N 7 ® 7EME Product Specification MODEL S9V2C080U5PSBB(a) S9V2C10004PSBB(a) S9V2CIOOU5PSBB(a) S9V2D120U5PSBB(a) Gauge(Fired) 20 20 20 20 ORIFICES—Main Nat.Gas Qty.—Drill Size 4-45 5-45 5-45 6-45 LP Gas Qty.—Drill Size 4-56 5-56 5-56 6-56 GAS VALVE Redundant-Two Stage Redundant-Two Stage Redundant-Two Stage Redundant-Two Stage PILOT SAFETY DEVICE Type 120 V SiNi Igniter 120 V SiNi Igniter 120 V SINI Igniter 120 V SINI Igniter BURNERS—Type Multiport Inshot Multiport Inshot Multiport Inshot Multiport Inshot Number 4 5 5 6 POWER CONN.—V/Ph/Hz(9) 12011160 120/1/60 120111 60 120/1/50 Ampacity(In Amps) 13.9 10.8 13.9 13.9 Max.Overcurrent Protection(Amps) 15 15 15 15 PIPE CONN.SIZE(in.) 1/2 1/2 1/2 1/2 DIMENSIONS HxWxD HxWxD HxWxD HxWxD Uncrated(In.) 34 x 21 x 28-3/4 34 x 21 x 28-3/4 34 x 21 x 28-3/4 34 x 24-1/2 x 28-3/4 Crated(In.) 35-1/2 x 23 x 30-7/8 35-1/2 x 23 x 30-7/8 35-1/2 x 23 x 30-7/8 35-1/2 x 26-1/2 x 30-7/8 WEIGHT Shipping(Lbs.)/Net(Lbs.) 149/139 154/144 155/145 167/156 (a) Meets Energy Star (b) For U.S.applications,above Input ratings(BTUH)are up to 2,000 feet,derate 40%per 1,000 feet for elevations above 2,000 feet above sea level.For Canadian applications,above Input ratings(BTUH)are up to 4,500 feet,derate 4%per 1,000 feet for elevations above 4,500 feet above sea level. (0 Central Furnace heating designs are certified to ANSI Z21.47/CSA 2.3—latest edition. (d) Based on U.S.government standard tests. (e) Refer to the Vent Length Table in the Installer's Guide. M All S9V2 furnace models have a vent outlet diameter that equals 2 in. M The above wiring specifications are in accordance with National Electrical Code;however,installations must comply with local codes. MODEL S9V2B040D3PSBB(a) S9V2B060D3PSBB(a) S9V2B080D4PSBB(a) TYPE Downflow Downflow Downflow RATINGS(b) 1st Stage Input BTUH(ICS) 26,000 39,000 52,000 1st Stage Capacity BTUH 25,220 37,830 50,440 2nd Stage Input BTUH 40,000 60,000 80,000 2nd Stage Capacity BTUH(ICS)(C)(d) 38,800 58,200 77,600 1st Stage Temp.Rise(Min.-Max.) 25-55 25-55 30-60 2nd Stage Temp.Rise(Min.-Max.) 30-60 35-65 35-65 AFUE(%)(d) 96.0 96.0 96.0 BLOWER DRIVE DIRECT DIRECT DIRECT Diameter—Width(In.) 11 X 8 11 X 8 11 X 8 No.Used 1 1 1 Speeds(No.) Variable Variable Variable CFM vs.in.w.g. See Fan Performance See Fan Performance See Fan Performance Table Table Table Motor HP 1/2 1/2 3/4 RPM Variable Variable Variable Volts/Ph/Hz 120/1/60 120/1/60 120/1/60 FLA 5.7 5.7 8.0 COMBUSTION FAN—Type Centrifugal Centrifugal Centrifugal 8 22-1921-1 F-EN AC ON DATE IMM/DD/YYYYI k CERTIFICATE OF LIABILITY INSURANCE F12/14/2024 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 pollcy(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 CUNIACI NAME: CLIENT CONTACT CENTER FEDERATED MUTUAL INSURANCE COMPANY PHONE FAX C Npi,�Q7 44G�BBO HOME OFFICE: P.O.BOX 328 IA/C,No,Ew:888-333A949 OWATONNA, MN 55060 ADDRESS:CLIENTCONTACTCENTER®FEDINS.COM INSURERS AFFORDING COVERAGE NAIL a INSURER A:FEDERATED MUTUAL INSURANCE COMPANY 13935 INSURED INSURER w:FEDERATED RESERVE INSURANCE COMPANY 16024 ARCTIC MECHANICAL INCORPORATED INSURERC: 460 N MAIN ST -- — PORT CHESTER,NY 10573-3310 INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:90 REVISION NUMBER 0 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 i POLICY EFF POLICY EXP LIMITS TR INSR WVD MM/DD/v YYV MMIDD/YY X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $1,DOO,000 J CLAIMS-MADE !X I OCCUR EAMAOaE TOO RENTED PREMISES $100 000 __... MED EXP(Am ona Person) EXCLUDED A N N 1887W 01/18/2025 01/18/2026 PERSONAL&ADV INJURY $1000000 GENL AOOREOATE LIMIT APPLIES PER. GENERAL AGGREGATE $2 000 WO X POLICY 'CT L J LOC PRODUCTS&COMPIOP ACC $2,000,000 OTHER. LLL�JJI���� JJJ AUTORWW-t LWILITY COMBINED SINGLE LIMIT $1 000 000 '(Es accident) _ X ANY AUTO BODILY INJURY(Per Person) A OWNED AUTOS ONLY AUTEDULEU N N 1887386 01/18/2025 01/18/2026 BODILY INJURY(Per Axoden0 HIRED AU DAMAGE AUTOS ONLY NON-OWNED PROPERTY AUTOS ONLY Per AcddenS - —- -- _ X UMBRELLA LIAR X OCCUR EACH OCCURRENCE S5.000,000 A EXCESS LAB CLAIMS-MADE N N 9907994 01/18/2025 01/18/2026 AGGREGATE S5,000,000 OED X RETENTION f10,D00 WORKERS COMPENSATION AND EMPLOYERS'LIABILITY YIN X I PER STATUTE THER ANY PROPRIETOR/PARTNERI EXECUTIVE B OFFICERIMEMBER EXCLUDED M '' N/A N 9298530 01/18/2025 011182026 E.L EACH ACCIDENT $1,DD0,000 (Meetory In NHI E.L DISEASE fA EMPLOYEE S1,000,000 11 yes,describe order DESCRIPTION OF OPERATIONS below E.L DISEASE POLICY LIMIT $1,000,000 DE SCRIPTION OF OPERATIONS I LOCATIONS r VEHICLES IACORD 101,AOWbonal Remarks Schedle may be alhched 0 mope space is required) CERTIFICATE HOLDER CANCELLATION VILLAGE OF RYE BROOK 90 0 ST 938 KING ST SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED RYE BROOK,NY 10573-1226 BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AU'HOR.ZED REPRESENTATI.1 9 1988-2015 ACORD CORPORATION All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD 1 YOR Workers' CERTIFICATE OF STATE I Compensation Board NYS WORKERS' COMPENSATION INSURANCE COVERAGE 1 a. Legal Name&Address of Insured(use street address only) 1b.Business Telephone Number of Insured (914)934-8301 Arctic Mechanical Incorporated 286468-4 460 N Main St Port Chester NY 10573-3310 1c NYS Unemployment Irsurance Employer Registration Number of Insured Work Location of Insured(Only required it 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 06-1596446 2. Name and Address of Entity Requesting Proof of Coverage 3a. Name of Insurance Carrier (Entity Being Listed as the Certificate Holder) Federated Reserve Insurance Company Village Rye Brook 938 Kingg St 3b. Policy Number of Entity Listed in Box"I a"Rye Brook,NY 10573-1226 9298530 3c. Policy effective period 01/18/2025 to 01/18/2026 3d.The Proprietor,Partners or Executive Officers are ❑X included.(Only rheck box it all partners/officers rncluded,i all excluded or certain partners/officers excluded. This certifies that the insurance carrier indicated above in box'T'insures the business referenced above in box"I 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: Melissa Kopperud (Print name of iaauthorveo representative cr I�censec agent of insurance carrier) Approved by �Q� S61 12/14/2024 (Signatu*)V (Date, Title: Authorized Representative Telephone Number of authorized representative or licensed agent of insurance carrier. 888-333-4949 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