Loading...
HomeMy WebLinkAboutMP25-016 �yE BR(ivk ic4�4.°VJ�v GG C l�tttv��J 4 VILLAGE OF RYE BROOK MAYOR 938 King Street,Rye Brook,N.Y. 10573 ADMINISTRATOR Jason A.Klein (914)939-0668 Christopher J.Bradbury www.tyebrookny.gov TRUSTEES BUILDING & FIRE INSPECTOR Susan R. Epstein Steven E. Fews Stephanie J. Fischer David M.Heiser Salvatore W. Morlino CERTIFICATE OF COMPLIANCE March 17,2025 Win Ridge Realty LLC c/o Alena Hakanjin 24 Rye Ridge Plaza Rye Brook,New York 10573 Re: 10 & 14 Rye Ridge Plaza,Rye Brook,New York 10573 Parcel I D#: 141.27-1-7 This document certifies that the work done under Mechanical Permit #25-016 issued on 2/12/2025 for the installation of two new chillers have been satisfactorily completed. Sincerely, Steven E. Fews Building&Fire Inspector /to 4ye BRa?k. 0 Z� cu � Q�i� '982 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 : /O 7 K r e / C e- DATE:-3' /-3 - Z y t S- coF 4-0 PERMIT# In S - D to ISSUED:Z" t-ZS SECT: BLOCK: LOT: LOCATION: Poo � OCCUPANCY: ❑ VIOLATION NOTED THE WORK IS... ET-'ACCEPTED ❑ REJECTED/ REINSPECTION ❑ SITE INSPECTION REQUIRED ❑ FOOTING ❑ FOOTING DRAINAGE ❑ FOUNDATION ❑ UNDERGROUND PLUMBING NOTES ON INSPECTION: ❑ ROUGH PLUMBING ❑ ROUGH FRAMING ❑ INSULATION ❑ NATURAL GAS l'' " / , �✓`''�C J ❑ L.P. GAS ❑ FUEL TANK ❑ FIRE SPRINKLER ❑ FINAL PLUMBING ❑ CROSS CONNECTION ❑ FINAL ❑ OTHER v A N• �Y C_ a x a a x O u7 pJ y w En 4d 4 -0 (�] R w L" x o > O -p LO O cz 4 © O H N Qd '' f o Ln w N w F-4 a U Y v n 00 VA o orb 20� -0Q _ w � O z a w �, H � o •� '� � � L� UCR o a1-4 � •� v rn -i o p �, o Howes U p V n 0.4 H W d U C a W a— a � U (sa x 5ECENE t VILI, ;Cr ,bF�R ; BROOK JAN 14 2025 BUI N(; DEP 'MFNT 938 Kllvc. :T vE IC,NY I1I573 VILLAGE OF RYE BROOK (914)y14" , rookimeov BUILDING DEPARTMENT a APPLICATION FOR PERMIT TO INSTALL, MODIFY AND/OR REMOVE MECHANICAL, E. UI E OFFICE USE ONLY, Permit#: f �S —� V! Building Inspector: Application Fee: Date of Approval: FEB 1 2 2025 Permit Fee: 19 CXD�`7-40--b Bldg,/Use Class: Res.( );Comm. ( ); DO NOT START WORK or CONSTRUCTION UNTIL A PERMIT IIAS RFEN ISSIIF.1)HV'Flff BUILDING INSPECTOR.THE ADMINISTRATIVE FEE FOR WORK PROGRESSED OR COMPLETED WITHOUT A PFRM1T IS 12%OF THE TOTAL COST OF CONSTRUCTION WITH A MINIMUM FEE OF$750.00 MUIREMENTS FOR RLrLEASE OF PP.RMTT: (A CLRTIFICATL OP COMPLIANCE Is REQutRF:n'ro CInsv OUT THIS PERMIT) 1.Properly Completed&Signed Application, 2.Payment of Application Fee: Residential=$100.00; Commercial $250.00(fees are nun-refundable) 3. Site/Staging Plan as required by the Building Inspector, 4. Sealed Construction/Installation Documents&Specifications as required by the Building Inspector. 5. 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#CI 05.2 of Form 0 U26.3/or NY Sucre Workers Compenxation Waiver) 6. Payment of Permit Fee: Residential=$18.00/1000.00 of Construction/Materials Cost with a minimum fec of S 150.00. Commercial $25.00/1000.00 of Construction/Materials Cost with a minimum fee of$275.00. 7.Inspection by Building Department for removal and/or installation. dos hou,.nonce required) 8. Any electrical work requires a separate Electrical Permit and Electrical Inspection, 9. Any gas/plumbing work requires a separate Plumbing Permit and Plumbing Inspection. �lr* Application dated, 10 i Z� is hereby made to the Building Inspector of the Village of Rye Brook,NY,for a permit fur the installation, mnr ification,and/or removal of the specific Mechanical Equipment as listed below.The applicant and property owner,by signing this document agrees that said equipment will be installed and/or removed in conformance with the approved plants,and with all applicable Local,County,State&Federal laws,codes,rules and regulations. W y� 1.Address:_ I4- luG F—th& VIA k _SBL: � Zone: �T 2.Property Owner: � �. i .�, (, L Address: 2+ Phone#: G - _' OUT Cell#: email: K�}1v�✓rVp;(�►�Ljd3K, �{,1+i 3.Contractor: COVIST#Nf- t/Vhl:itr4. &EMujL&;S. Address: 410 ft 19,11in, 3,1,_Cell#:3gj-_c g -563 email:DAwip t t c•dL 4.Scope of Work:New Installation Replacement( )•Removal( )•Other 5.Type of Equipment:.i?"Ltp!(41, C--) l — 6.Location of Equipment: MeLAW(ti c _ /ZOO AAS Qj—. 131 1 L-A)I 14 _ 7.Cost of Equipment including Installation Cost:$ 1 6/1/2024 STATE OF NEW YORK,COUNTY OF WESTCHESTER ) as: tM Z� _ ,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 Mechanical Equipment 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 G day of � Z_ 20 day of SM'tYW ,20 4veAof1 -perry Owrw Signature of Applicant ame of P y pt�rt((fi--� Print i�rtne of Applicant tJ i Not V1 N c � ,_ ps NE4ti•ORK Ichce,. �G�n; n nwsl )c 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. FALENIA HAKAI:,,;N ,STATEOF ' estchester Gouty od Espirat MUM 2 6/112024 _ _ _ o � N N N p� ' _ W \ N _ F V rri a CA y i a p � M, !�I GL7 ►.: O 0-4 N ac 00 C � 0-4 M w eo = r cn M V V ., z CA A x w W _ ap ,�,� V 0--1 CY Q•1 W W z Z r H U W. g �I 0 ° 0-4w w o z � x W C7 a, ui O 8 V w z V °' • _ _ D L� V � BUIL ' DEY'�� '�TMCNT FEB 1 3 2025 VIL t E OT RYP OK 938 KIN ETJl fc,B ,NY 10573 VILLAGE OF RYE BROOK � 4 - 3 BUILDING DEPARTMENT W S _1-do n v ELECTRICAL PERMIT APPLICATION Westchester Comity MasterElectricians License Required FOR OFFICE USE ONLY / / /"p� —O 1(U I,P#: Approval Date: FEB 14 202 - Permit Fee: S /C 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 WITHOU'r A PERMIT IS 12%OF THE TOTAL COST OF CONSTRUCTION WITH A MINIMUM FEE OFS750.00 Application dated, '2 2 is hereby tnadc to the Building Inspector of the Village of Rye Brook NY,for the issuance of a Pennit 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 perfornicd will be in confornhance with all(applicable Federal,State,County and Local Codes. W I k� 9% Y �"� Gp rve-Ctt\Luw- to,?L CvvT 1.Address: SBL: Zone: 2.Property Owner:%(,,, K%8!�e- R c.1.1,I LLC Address: 2-Lj .l e Q',Ace 1-31g 2 Phone#: C11N- -1O1- ttpc,S CelIM email: 4A 3.MasterElectrician/Licensedlnstaller: Ar,.vr.,,,,,I Address:_y$ Grar.a S1 Ne..,�tri,.IjFNltoopl Lie. Phone0: 9t4- 19 ?1•• li3 ell/{: emaiLrl�CYSPIr•L�ritc.ISc�rv,��C���.� IucK.tvti Catnpany Name: N u> . l..,r1y,E t SFov;c.e4OLLL Address: yr� rvr.�1 < aC 6e I►e ►[,ems-�_I_ 4.Proposed Electrical Work/Fixture Count: t P✓1 t Ch ?v S 5.3rd Party Electrical Inspection Agency: SW IS STATE OF NEW YORK,COUNTY OF WESTCHESTER ) as: 1n��nn� C. C 5 C Vl,4C01() ,being duty sworn,deposes and slates that he/she is the applicant above named,and does further (print(print namcofilildividual si ling as the applicant) state that(s)he is the 1 -cAm—A ('co rckro�for the legal owner and is duty 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 wodc perfonmed,or use conducted at the above captioned property will be in confornhancc 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 Unitnmh Fire Prevention&Building Code,the Code of the Village of Rye Brook and all other applicable laws,ordinances,and regulations. Sworn tQ before nc this t D11) Swolo to ore i tl n a of ,20_ 5— day ,20 Z Si ►re of Pt perty Gwitet-�, Signa e o Appli nt IWID USIA C Pr' t N tc of Prop -��yT tt 7FrM` KRISTIN M MC I G 03 tENA 14AKANJIN NOTARY PUBLIC STAT ,• ; NOTARY Puelic,STATE OF NEW YORK Bronx County 611/2024 Registration No.OIHAO013645 LiC. #Ol MC6348554 Qualified In Westchester County Mp Commission Expires 911912027 Comm. Exp- 21 STATE WIDE INSPECTION SERVICES, INC. SWIS • B APPLICATION0, Office Use Elect.Permit# �� ci ycl Date 2/13/2025 Sq Ft Temp# Utility ID# Final Certificate# City/Village Rye Brook ZIP 10573 Township Rye Brook County Westchester Address 10 & 14 Rye Ridge Plaza Cross Street Section Block Lot Owner Name/AddresS(if different thanauove. Wirt Ridge Realty LLC Contact Number (914) 701-4005 [:]Basement ❑ l st FI ❑2nd FI ❑ rd I ❑More Than 3 FI ❑Garage ❑Attic ❑Outside ❑Residential ❑✓ Commercial Receptacles Special Recept GFCI I Switches Dimmers Smoke Alarms Carbon Mnnox Hood Trash Compact Amt Amps Range(s) Cooktop(s) Oven W Dishwashers Refrigerator Microwave ANanr,Draw Incandescent Fluorescent SERVICE Amperage Voltage I F 3P #Meters #Disconnect Underground ❑New ❑Reconnect ❑Overhead ❑Change ❑Visual Re-Inspection ❑ Safety Re-Inspection ❑ Re-Inspection Additional Information Wire 3 replacement chillers D �C E U MCS ID ' FEB 13 2025 VILLAGE OF RYE BROOK BUILDING DEPARTMENT Ths application is valid for one 0 i year from the date received by WAS 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 ke 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,osvner or authorized agent agrees to all the above terms and conditions as ut forth for the application Inspector Date Finalized Inspect r# 'I Contractor Nicks Electric Service of NY, LLC. Date 2/13/2.5 ,ign/treLz Address 48 Grand Street City/State New Rochelle, N 7lp Code 10801 License# 337 ID# Phone# (914) 723-1133 / • Project Name: Performance Report Rye Ridge Tag Narne: Submitted by:Marc Cosgrove 70T Thg Name:70T 30MPW Water Cooled Scroll Chiller Operating Rvaperalar Mamd Maio[teat Exrbatiger(RPHI;) Fluid Type Fresh Water Fluid Concentration % 00) Fluid Volume gal 8.90 Fouling Factor (hr-sytt-F)HTli ii.d01,111f0 1,eaving•remptvautre `r 41.00 Entering Tempent me r r4.00 Fluid Flow gpm 11E.6 Min.Fluid Flaw g)ni 99.00 lityaure OmP fr wg 14.4 Sat.Suc(fanTerri Circwi 1 •F 38A9 Non Contractual Plaurc Fluid Type m m Fluid C.ancerintion % Model Numim iOMPYKO6tF13 I_0115 Fuulift Factor (hr-AIt-ryB1*U Unit Quantity 2 l.1..nuer "I" 't>imp"anor 'F t,mmdelype -_ -- _ Water Cooled_ Fntmiug'Rmperamre -F t:omprxcsum Type _ _ Standard Stroll Fbdd Plow glen Communication 4 CCN p Pressure Dvlp tt wg Manufacturing Source Chadotte,_NCUSA +Sat_Uis ar-Tenp(C.I-,i,I) 'F ASHRAE 90.1 1 2007,2010"2013f2016.Z119 Re�igerantType R-32 _ InformationPerformance Indepen&Ti Refrigerant Circuits I Cooling rapacity Ttnx 7" Shipping Weigin lb I(K Pleating(:aparity MRH (peradng Weight IL --- - I806 Tntal CAmq)rrswr Power kW Aid Refrigerant Weight [h',-_-- _87 Tina]Unit Pcmwel(wlfionlpump� kw 49.1z Unit Dimensions(1.x W x H) in. 62 tt 3Z a 6(i Minimum Capacity % 40 Rawroil Dimensions(L x W) In' -- _55 x 32 Capacity Control Steps 3 Cooling E(hcieucy(F.FR) BTUi(W hr) 17Z2 Unit Features Gaoling Rfllrien y LW,Tou HN�hI Adjitrlmm Kit Heating Gfliciency fCC)PH) kW/kW Ma61111y Kil.(Wltedx)._ 1MV.IP anq hr) R ye_ --- ;V.lp k% Phu Water Manifold Pi�ing _Standard Scroll Cornprerwr Non-Fused Discmntect Unit Voltage 20W30-3-60 I Brazed Plate Heat Exclpngns(BP1P Electrical Connection Single Point Power-- 5[ngk 1"Power j Minimum Voltage V 187 _Shippinj,FhdeeBon-Sig_ Maximum voltage V 2S3 Norriirtal Vt,1i4ge V ___.,_ 220 MCA 6 236.1 MCorp 4 3S0.0 -- It A 901.0 'RecFtm Size A 300.0 • CERTIFIEDIvol Certified in accordance with the AHRI Water-Cooled Wa[ervChiOing and Heat Pump Water-Heating Padeages Certification Program,which it based on AIM Standard S50/590(I-P)and AHRI Standard SS1591(S1).Certified units may be found in the AKU Directory at www.ah directory.org. G eated on 4/19/2024 11:37:39 AM Package Chillets NAO v1.3.0.0 Page 1/2 Project Name: Performance Report Rye Ridge Tag Name: Submitted by:Marc Cosgrove 701' Integrated Part r Value(AHRI) tPLV.1P IiT111 wv) 25.67 1PLVIP kW/ton 0.4675 Unit Performance Percent Fuli Load Capacity % lilt) 7 St) 25 Percent Full IArod Kmtq % 100.0 51t.5 2J.9 t5 7 Cooling Capacity limn 10.411 52.06 35.24 17 62 I Ink Power Input kW 49.1) 23.7S 14,10 7 7 t Efhciency(Lrf?R) BTt N(W:hr) 17.27 22.Ilh 23.77 27.i!, Efficiency kW/Inn U.G9(il 0.:A38 I1.4191 0A38e EvaporworDalp Fluid Entringlbmptiatwe •F 54.00 5150 49.00 46.50 Fluid LravingTengnvature •F 44.01) 44.1.10 44M 44.0U Fluid now itau, gpts 168.6 Nr6b IfiBA, 180.G Fouling Factor (lit: it F il)_ "00100 OOOQ100 O.UiHi100 0A9)0100 Phud Entering Temperature •P Fluid Leaving Temperature `F Fluid How Rate gills Fouling Factor (hr-Sgfl-r-)fMl) valuesglum-1,Kq w.daM-d,l Ibmvmy mnda,ms Created on 4/19=4 11:37:39 AM Package Chillers NAO v1.3.0.0 Page 2/2 Dimensions (cont) � £ - � , 2 AIN ~ � § jK. • � - «� _ �� � _ ■ @ &� k£ - �� .! 2 a � • � - - - - - � - � ) . - � \ ® 10, } k � § , / o /§ � � � z . ■ / k \ \ . m tn | - - - - - - - -\22 - q � $ � . of 24 Dimensions (cont) Dimensions — 30MP Chiller Units Manifolded Together with Accessory Spacer Pipe (30MPW046 Shown) Style 0 59. 9 in. 6 In. 11.3a in. Connection 1 6 in.Victaulic o • • a a • • 0 1 Connection A Corner Post (Removed for clarity) Top View 68.82 in. (Unit Size 017-080) � I I i 'I I 1 o �•—•� A —70.63 in —_ Front View Side View NOTE:These figures show the sound erclosure panels,these are not currently available. 25 COASMEC-02 PSUZIO ACORO CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DDIYYYY) 1/22/2025 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(les)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 Ileu of such endomemen s. PRODUCER T Paul A.Suzio AssuredPartners New England, Inc. PHONE FAX 100 Beard Saw Mill Road iac,►taExQ:(203)514-7863 203)514-7863 Shelton,CT 06484 .Paul.SuzioJr@AssuredPartners.com INSURERS AFFORDING COVERAGE NAIC 0 iNsul:�R�;_Cincinnati Insurance Co. 10677 INSURED INSURERB:Cincinnati Indemnity Company 23280 Coastal Mechanical Services,Inc. INSLIRERC:` 40 Hathaway Drive INSURERD: Stratford,CT 06615 - —' INSURER E INSURER F; COVERAGES CERTFICATENUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED_BY PAID CLAIMS. INSR TYPE OF INSURANCE ADD L SUER POLICY NUMBER POLICY EFF POLICY EXP LIMITS LTR A X COMMERCIAL GENERAL uABILrTY EACH OCCURRENCE 1,000,000 CLAIMS-MADE l ^I OCCUR X X EPP 0701539 12/17/2024 12/17/2025 ETORC-NTED 300,600 MEt]EXP[Any one pemonl 15,000 PERSONAL S ADV INJURY 6 1,000,000 AGGREGATE LIMIT APPLIES PER: G AGGRE TE 2,000,000 X Pt7LICY LOC PRODUCTS-C MP/ P A 2,000,000 �_Q t— HER A AUTOMOBILE LIABILITY COM13INED SINGLE LIMIT 1,000,000 -WAAMANY AUTO X X EPP 0701539 12/17/2024 121171202$ BODILY INJURY Perperson) OWNED Ix SCHEDULEDAAUUTOOS ONLY AUUpTNNOSBODILY INJURY Per accidentX AUTOS ONLY maw Peer a EaRidenl AMAGE S A X UMBRELLA Ll X OCCUR 5,000,000 EACH OCCURRENCE EXCESSLu►B CLAIMS-MADE X X EPP 0701539 12/17/2024 12/17/2025 AGGREGATE $ 5,000,000 DED I I RETENTION$ _ B WORKERS COMPENSATION X I PER OTH- AND EMPLOYERS'LIABILITY EWC 0701548 12/1/2024 12/1/202$ STATUTE I I ER 1,000,000 ANY PROPRIETOR/PARTNER/EXECUTIVE Y_ X E.L.EACH ACCIDENT _ PAindatery In N EXCLUOED7 N/A E.L.DISEASE-EA EMPLOYEE1,000,000 KM describe under 1,000,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached I/more space Is required) The Certificate Holders Win Ridge Shopping Center-DE LLC;Win Plaza-DE LLC;Win Ridge Shopping Center South-DE LLC;Win Ridge Realty LLC;Win Properties,Inc.c/o Win Properties,Inc.,Rye Ridge Park,LLC;&Athene USA,and Its subsidiaries Its Successors and/or Assigns c/o Athene Asset Management Attn:Athene Annuity and Life Company Loan#171000041 C/o Berkadia Commercial Mortgage LLC PO Box 557 Ambler,PA 19002-6687 are listed as additional insured under general liability as required for work performed by insured subject to terms and conditions of the policy. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Village of Rye Brook THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN g y ACCORDANCE WITH THE POLICY PROVISIONS. 938 King St Rye Brook,NY 10573 - AUTHORIZED REPRESENTATIVE ACORD 25(2016103) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD NEW Workers' sORK Compensation CERTIFICATE OF Board NYS WORKERS' COMPENSATION INSURANCE COVERAGE 1a.Legal Name&Address of Insured(use street address only) 1b. Business Telephone Number of Insured Coastal Mechanical Services,Inc. (203)953-3732 40 Hathaway Dr. 1c. NYS Unemployment Insurance Employer Registration Number of Insured Stratford ,CT 06616 Work Location of Insured(Only required if coverage is specifically limited to 1d. Federal Employer Identification Number of Insured or Social Security main locations in New York State,i.e.,a Wrap-Up Policy) Number 06-1450112 2.Name and Address of Entity Requesting Proof of 3a. Name of Insurance Carrier Coverage(Entity Being Listed as the Certificate Holder) Cincinnati Insurance Co. Village of Rye Brook 3b. Policy Number of Entity Listed in Box"1a" 938 King St EWC 0701548 Rye Brook,NY 10573 3c. Policy effective period 2/1/2024 to 12/1/2025 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 1"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: Paul A. Suzio p Dmus'"Mame of authorized representative or licensed agent of insurance carrier) Approved by: r sw)ihy 11/22/2024 NrIAQ (Signature) (Date) Title: Account Executive Telephone Number of authorized representative or licensed agent of insurance carrier: (203)514-7863 Please Note: Only insurance carriers and their licensed agents are authorized to issue Form C-105.2.Insurance brokers are Q authorized to issue it.