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HomeMy WebLinkAboutMP25-070 BR1 t� 7. 19t1 J•�� VILLAGE OF RYE BROOK MAYOR 938 King Street, Rye Brook,N.Y. 10573 ADMINISTRATOR Jason A. Klein (914) 939-0668 Christopher J.Bradbury www.ryebrookny.gov TRUSTEES BUILDING& FIRE INSPECTOR Susan R.Epstein Steven E. Fews David M. Heiser Donald T.Krom,Jr. Salvatore W. Morlino CERTIFICATE OF COMPLIANCE June 23,2025 Robert Wilk&Haley Wilk 16 Birch Lane Rye Brook,New York 10573 Re: 16 Birch Lane, Rye Brook,New York 10573 Parcel ID#: 135.43-1-5.28 This document certifies that the work done under Mechanical Permit#25-070 issued on 5/19/2025 for the installation of a new condenser and a new air handler has been satisfactorily completed. Sincerely, Steven E. Fews Building&Fire Inspector /to QyE 4RO o`` tim 1932 BUILDING DEPARTMENT ❑BUILDING INSPECTOR �KMSISTANT 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.ors; - - - - - - - - - - - - - - - - - - - - INSPECTION REPORT - - - - - - - - - - - - - - - - - - - - ADDRESS : / 43/Qc a v i� DATE: (/ " 2D - Z02,V PERMIT# M Z.T -O 7D ISSUED:S:- -L�SECT:Jtr BLOCK:/LOT: L. LOCATION: 3 P S E M Div el Cs-" OCCUPANCY: ❑ VIOLATION NOTED THE WORK IS... R ACCEPTED ❑ REJECTED/ REINSPECTION ❑ SITE INSPECTION REQUIRED ❑ FOOTING ❑ FOOTING DRAINAGE ❑ FOUNDATION ❑ UNDERGROUND PLUMBING NOTES ON INSPECTION: ❑ ROUGH PLUMBING ❑ ROUGH FRAMING ❑ INSULATION❑ NATURAL GAS _ _�y f+���/L �7 Qwd &A 'y� Zoeg/wC�tlr ❑ L.P. GAS Au� DU 7 coo Z e!20Aja1 a Sevt ❑ FUEL TANK ❑ FIRE SPRINKLER ❑ FINAL PLUMBING ❑ CROSS CONNECTION FINAL [�OTHER ■ i i ■ N v N N N m n.72 : e n LO s 00 ■ '�' "" v t to w Lei cr. v ICI T z Q v M M O z a00 s 100 1 M N � A � a ( � 00 �` v v z W U Q .�... U F" o � zp N ienW o ba v s Q § f� 000 Ono y 1-1 . 3 o p Sr x a O zQou ■ lu e� W x v � u � v A O i • BUILDrie.DEPARTMENT VILE O>F RYE BROOK MAY 15 2025 938 KING t `i ET RYE BROOK,NY 10573 (014)939-0668 VILLAGE OF RYE BROOK BUILDING DEPARTMENT �y�yw.r4`8t)ruoknti.zov ...-- APPLICATION FOR PERMIT TO INSTALL AND/OR REMOVE HEATING,VENTILATION AND/OR AIR CONDITIONING EQUIPMENT FOR OFFICE USE ONLY: PERMIT#: �LJLts /O Approval Date: MAY 2 0 Permit Fee: $ ��scx) '^?PL Approval Signature: Other: Disapproved: ' (fees are non-refundable) xxxxxxxxxxxxxxxxx,t**,r***xxx****xxxxxxxxx**xxxxxxx*xxx*x**#xxt**�r**xr**xx*x***xx***xxx**xx*x,rtx**,t**x*** DO NOT START WORK or CONSTRUCTION UNTIL A PERMIT HAS BEEN ISSUED BV THE BUILDING INSPECTOR.THE AD'SIINISTRATIVE 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: l. 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#C 105.2 or Form#U26.3/or NY State Workers Compensation Waiver) 4. Payment ofFees/Unit: RESIDENTIAL= S150.00/unit •COMMERCIAL = S450.00/unit. 5. Complete specifications for each unit being installed. 6. Inspection by the Building Department for removal and/or installation. (48 hour notice required) 7. Electrical work requires a separate Electrical Permit& Electrical Inspection. 8. Plumbing/Gas work requires a separate Plumbing Permit&Plumbing Inspection. x*x,�xxx#*xx*x*x***,�*****x**xx*xxxx*,�**xxxx*xx**x,�x*****,�**,�+****,�**xx**•��****�*****x*�*x��****�** Application dated, e4Sis 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. pp 1. Address: & &AC,4kA NQ SBL: 3J`► ^�YS� one: � 2. Property Owner: Ala) Get+L/ Address: I p OCR 4,i^-,e- Phone#: Cell#: '7/J ?,zJf33? email: 9A 4J/LK0 `//I&c_ 3. Contractor: AA c r�c- WA 4,m cJ Address: 7(o0 /t/.14e- +"N -,J Phone#: 9 d q>y 1301 Cell#: email: J ft t lP ARC i - /lI CA-4 I 4. Scope of Work:New Installation( )•Replacement*K•Removal O.Other( ): 5. List Equipment: C n/ tw S t/L /7f -5 gyp ode Qr 6. Location of Equipment: i3m So.,A%w 7. Method of Installation/Removal(list all equipment needed to perform job): t 6/i/2024 STATE OF NEW YORK,COUNTY OF WESTCHESTER ) as: being duly swom,deposes and states that he/she is the applicant above named, (print name of individual signing as the applicant) and further states that(s)he is the Heating,Ventilation and/or Air Conditioning Contractor for the legal owner and is duly authorized to make and file this application. That all statements contained herein are true to the best of his/her knowledge and belief,and that any work performed,or use conducted at the above captioned property will be in conformance with the details as set forth and contained in this application and in any accompanying approved plans and specifications,as well as in accordance with the New York State Uniform Fire Prevention&Building Code,the Code of the Village of Rye Brook and all other applicable laws,ordinances and regulations. Sworn to before me this 5 Sworn to before me this \� day of ,20 day of 20 r4 C" S'gnature of Property Owner n of A plicant w Name of Property Owner FNName of Applicant Notary Public 1 Notary p,,h� SHpRI MEULLO 'SFf�I MEOLLO Notary public,State©f New York Notary Public.State of New York No.01ME6160063 No.01ME6160063 Qualified In westchester County Z Qualified In Westchester Count:ryyy Commission Expires January 29,202—, Commission Expires lantlary 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. z b/I/2024 ■ ■ M rl N N � ■ N N N L W \ \ N � � • M W 6vi r r F Cl W M C "" x W a ^ Gr Cn W X ` W �-1 ►� CNTr M �-. .r OC y %� W ■ Q M F _ O O O , Q d $ F O z Q CZ 0-4a _ � Q ■ eq M a w O co con • O (� w � � � � � w T z � , z w Zo o M o = Noe%* c A 0 C, -r" z Z M M J W o = OEM( 1�1 V �1 a C� iz W �-, �. w w a ° r► w Q = W F s H Zo U ° < M t BUILDING DEPARTMENT RF.. 1EC � 0 Y[F DVILLAGE OF RYE BROOK938 KING STREET RYE BROOK,NY 10573 15 2025 (914)939-0668 www.ryebrookny.gov VILLAGE OF RYE BROOK BUILDING DEPARTMENT ELECTRICAL PERMIT APPLICATION Westchester County Master Electricians License Required FOR OFFICE USE ONLY _�P- /- �S� �� EP#: C�1!5--13/ Approval Date: MAY Z Permit Fee: $ Approval Signature: Other: DO NOT START WORK or CONSTRUCTION UNTIL A PERMIT HAS BEEN ISSUED BY THE BUILDING INSPECTOR. THE ADMINISTRATIVE FEE FOR WORK PROGRESSED OR COMPLETED WITHOUT A PERMIT IS 12%OF THE TOTAL COST OF CONSTRUCTION WITH A MINIMUM FEE OF$750.00 Application dated, 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. // p �7 1.Address:1(/ 'QI �rG� r.`_�'� SBL:/ ,3,5t 7 3 —.�1 �O Zone: /2-1 J 2.Property Owner:�"f`'`�1 w<< k Address: ( Phone#: Cell#: email: 3.Master Electrician/Licensed Installer: ( �t Address: Lic.# w Phone#: L?ftf ?2q- I 1t9 Cell#: q(N-3SG" V 7-4 email:U brG`t/�4 Cc vI Co�M Company Name: 1 Address: —1PT )CbrF CI-e66 4.Proposed Electrical WorkFtxture Count: 5.31 Party Electrical Inspection Agency: (5 LA,1 STATE OF NEW YORK,COUNTY OF WESTCHESTER ) as: being duly swom,deposes and states that he/she is the applicant above named,and does further (print name of individual signing as the applicant) state that(s)he is the for the legal owner and is duly authorized to make and file this application. (Master Electrician/Licensed Installer) The undersigned further states that all statements contained herein are true to the best of his/her knowledge and belief,and that any work performed,or use conducted at the above captioned property will be in conformance with the details as set forth and contained in this application and in any accompanying approved plans and specifications,as well as in accordance with the New York State Uniform Fire Prevention&Building Code,the Code of the Village of Rye Brook and all other applicable laws,ordinances,and regulations. /` h Sworn to before me this Swo o befor me this 1,45 day of ,20 of 207,5 Signature of Property Owner Si atur n Print Name of Property Owner Print nt 11ame of pplicant ALEJANDRA LARIZZA NOTARY PUBLIC,STATE OF NEW YORK Notary Public Registration No.OILA6393118 NO Public ba Qualified in Weachester County 6/1/2024 Commission Expires 03/27/2027 STATE WIDE INSPECTION SERVICES, INC., Set-rice Ill'ith 0•0 • • SWIS JOB APPLICATION tel 845.202.7224 1 fax 914.219.1062 1 SWISNYcoml SWISTRAINING.COM Office Use Elect. Permit# P C�)5 Date Bldg Permit#— /( P� S _ ( � Scl Ft Plumbing Permit# Final Certificate# City/Village , t� l��G( b Zip Building Dept. County Address 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 1P 3P # Meters # Disconnect ❑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 R�C IEIW MAY 15 2025 1 D 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 anytime of inspection additional items have been installed,you are authorized to make the inspection and adjust the fee for the additional items inspected.The applicant declares that there is no open applications for the above address with any other inspection company.The applicant, owner or authorized agent agrees to all the above terms and conditions as set forth for the application. Email Address Name License#r/ s ( Date Signature Address City/State Zip Code Company Phone# R ID] State Wide Inspection Services 1080 Main Street [JU:Nl 2 2025 Fishkill, NY 12524 ��U � 845 202-7224 Phone VILLAGE OF RYE BROOK 914-219-1062 Fax STATE WIDE INSPECTION SERVICES ! BUILDING DEPARTMENT Email: officeCabswisny.com - Website: www.swisny.com Service With /ntegrlty BY THIS CERTIFICATE OF COMPLIANCE STATE WIDE INSPECTION SERVICES CERTIFIES THAT: Upon the application of: Upon Premises Owned by: Gene Branca Electrical Contractor Robert& Haley Wilk Gene Branca 16 Birca Lane 78 South Regent Street Rye Brook, NY 10573 Port Chester, NY 10573 Located at: 16 Birch Lane, Rye Brook, NY 19573 Section: Block: Lot: Electrical Permit Number: EP25-131 135.43 1 5.28 Certificate Number: 2025-3953 Building Permit Number: MP25-070 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: 16 Birch Lane, Rye Brook, NY 19573 The HVAC System 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 11th day of June 2025. Name Quantity Rating Circuit Type Replace Air Handler 01 Replace AC Condenser 01 (11 WS, 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. R 0 4 0 n i • 1 r J J L i R - y r. N Q. M J m 0 �2 0 TRME' Product Data Split System Cooling 5TTR5018A1000A 5TfR5024A1000A 5TfR503OA1000A/B 5TTR5036A1000A/B = =��-=�- 5TTR5042A1000A 5TTR5048A1000A/B 5TTR506OA1000A/B _ Note: "Graphics in this document are for representation only.Actual model may differ in appearance." February 2025 ODR-PRD02OA-EN � 7� A N = TECH NO LOG I ES- 0 TRME` Product Specifications Model No.W 5TTR5018A1000A STTR5024A1000A 5TTR503OA1000A/B 5TTR5036A1000A/B POWER CONNS.-V/PH/HZ Ib) 208/230/1/60 208/230/1/60 208/230/1/60 208/230/1/60 MIN.BRCH.CIR.AMPACITY 9 14 15/17 18 BR.CIR.PROT.RTG.-MAX.(AMPS) 20 25 25 30 COMPRESSOR CLIMATUFFO-SCROLL CLIMATUFF®-SCROLL CLIMATUFFO-SCROLL CLIMATUFF®-SCROLL RL AMPS-LR AMPS 6.9-45.1 10.3-60.1 12.5-67.1/12.7-76.1 13.5-75.1/13.5-83.1 Outdoor Fan FL AMPS 0.71 0.71 0.71 0.71 Fan HP 1/8 1/8 1/8 1/8 Fan Dia(inches) 23 23 23 23 Coil SPINE FIN- SPINE FINT" SPINE FINT' SPINE FINTI Refrigerant R-454B 3 LES.,12 OZ 3 LBS.,10 OZ 3 LES.,8 OZ 3 LES.,8 OZ VALVE CONNECTION SIZE-IN.O.D. 3/4 3/4 3/4 3/4 GAS VALVE CONNECTION SIZE-IN.O.D.LIQ. 5/16 5/16 5/16 5/16 LINE SIZE-IN.O.D.GAS' ) 3/4 3/4 3/4 7/8 LINE SIZE-IN.O.D.LIQ. 5/16 5/16 5/16 5/16 Charge Spec.Subcooling 10°F 10°F 10°F 10°F Dimensions H x W X D Crated(IN.) 42 x 30 x 33 38 x 30 x 33 42 x 30 x 33 38 x 30 x 33 Weight-Shipping(lbs.) 22D 183 220 183 Weight-Net(lbs.) 184 156 184 156 Optional Accessories: Anti-short Cycle Timer TAYASCT501A TAYASCT501A TAYASCT501A TAYASCT501A Evaporator Defrost Control AY28XO79 AY28XO79 AY28XO79 AY28XO79 Rubber Isolator Kit BAYISLT101 BAYISLT101 BAYISLT101 BAYISLT101 Extreme Condition Mount Kit BAYECMT023 BAYECMT023 BAYECMT023 BAYECMT023 Start Kit BAYKSKT263 BAYKSKT263 BAYKSKT263 BAYKSKT263 Crankcase Heater Kit BAYCCHT302 BAYCCHT302 BAYCCHT302 BAYCCHT302 Seacoast Kit BAYSEAC001 BAYSEAC001 BAYSEAC001 BAYSEAC001 Low Ambient Kit BAYLOAM103 BAYLOAM103 BAYLOAM103 BAYLOAM103 Service Valve Panel Cover TAYSVPANL0032AA TAYSVPANL0032AA TAYSVPANL0044AA TAYSVPANL0044AA Refrigerant Lineset(d) cal Certified in accordance with the Unitary Air-conditioner equipment certlf cation program which is based on AHRI standard 2IG/240. (b) Calculated in accordance with N.E.C.Only use HACR circuit breakers or fuses. M Reference the outdoor unit ship-with literature for refrigerant piping length and lift guidelines.Reference the refrigerant piping software pub#32-3312- xx or Refrigerant Piping Manual forSmall Split Cooling and Heat Pump Systems Application Guide(SS-APG006*-EN)for long line sets or specialty applications(xx denotes latest revision). (a) 25,30,35 and 50 foot linesets available.For a complete listing of lineset options available from equipment or supply stores,refer to the Trane Residential and Light Commercial Product Handbook. 2 ODR-PRD02OA-EN ® TRWE` Product Specifications Model No.0) 5TTR5042A1000A 5TTR5048A1000A/B 5TTR5060A1000A/B POWER CONNS,-V/PH/HZ(b) 208/230/1/60 208/230/1/60 208/230/l/60 MIN.BIRCH.CIR.AMPACITY 21 23/26 28/30 BR.CIR.PROT.RTG.-MAX.(AMPS) 30 35/45 50 COMPRESSOR CLIMATUFFT-SCROLL CLIMATUFFT-SCROLL CLIMATUFFT-SCROLL RL AMPS-LR AMPS 14.7-109.1 17.3-126.1/19.6-118.1 21.8-143.1/23.4-134.1 Outdoor Fan FL AMPS 1.05 1.05 2.80 Fan HP 1/5 1/5 1/3 Fan Dia(inches) 27.5 27.5 27.5 Coil SPINE FINI" SPINE FINT" SPINE FIN IN Refrigerant R-454B 5 LBS., 1 OZ 6 LBS.,10 OZ 5 LBS.,15 OZ VALVE CONNECTION SIZE-IN.O.D.GAS 7/8 7/8 7/8 VALVE CONNECTION SIZE-IN.O.D.LIQ. 5/16 5/16 5/16 LINE SIZE-IN.O.D.GAS(0 7/8 7/8 1-1/8 LINE SIZE-IN.O.D.LIQ. 5/16 5/16 5/16 Charge Spec.Subcooling 10OF 10OF 10°F Dimensions H x W X D Crated(IN.) 42.5 x 35 x 38 50.5 x 35 x38 50.5 x 35 x38 Weight-Shipping(lbs.) 246 307 302 Weight-Net(lbs.) 212 257 252 Optional Accessories: Anti-short Cycle Timer TAYASCT501A TAYASCT501A TAYASCT501A Evaporator Defrost Control AY28XO79 AY28XO79 AY28XO79 Rubber Isolator Kit BAYISLT101 BAYISLT101 BAYISLT101 Extreme Condition Mount Kit BAYECMT004 BAYECMT004 BAYECMT004 Start Kit BAYKSKT263 BAYKSKT263 BAYKSKT263 Crankcase Heater Kit BAYCCHT302 BAYCCHT302 BAYCCHT302 Seacoast Kit BAYSEAC001 BAYSEAC001 BAYSEAC001 Low Ambient Kit BAYLOAM103 BAYLOAM103 — Service Valve Panel Cover TAYSVPANL0044AA TAYSVPANL0046AA TAYSVPANL0046AA Refrigerant Lineset(d) (a) Certified in accordance with the Unitary Air-conditioner equipment certification program which is based on AHRI standard 210/240. (b) Calculated in accordance with N.E.C.Only use HACR circuit breakers or fuses. M Reference the outdoor unit ship-with literature for refrigerant piping length and lift guidelines.Reference the refrigerant piping software pub r 32-3312- xx or Refrigerant Piping Manual for Small Split Cooling and Heat Pump Systems Application Guide(SS-APGO06*-EN)for long line sets or specialty applications(xx denotes latest revision), (d) 25,30,35 and 50 foot linesets available.For a complete listing of Ilneset options available from equipment or supply stores,refer to theTrane Residential and Light Commercial Product Handbook. ODR-PRD02OA-EN 3 0 TRAAFF Sound Power Level Sound Power Level A-Weighted MODEL Sound Power Full Octave Sound Power(dB) Level[dB(A)) 63 Hz* 125 Hz 250 Hz 500 Hz 1000 Hz 2000 Hz 4000 Hz 8000 Hz 5TTR5018A 73 79 69 67 70 70 64 59 53 5TTR5024A 71 78 72 69 68 66 61 58 53 5TTR5030A 73 79 69 67 70 70 64 59 53 5TTR5036A 71 78 72 69 68 66 61 58 53 5TTR5042A 71 78 72 69 68 66 61 58 53 5TTR5048A 71 81 75 71 70 68 63 58 53 5TTR5060A 71 81 75 71 70 68 63 58 53 Note:Rated in accordance with AHRI Standard 270-2008*Forreference only. 4 ODR-PRD020A-EN 0 TRANE` Accessory Description and Usage Anti-Short Cycle Timer — Solid state timing device that prevents compressor recycling until five(5) minutes have elapsed after satisfying call or power interruptions.Use in area with questionable power delivery,commercial applications,long lineset,etc. Evaporation Defrost Control — SPST Temperature actuated switch that cycles the condenser off as indoor coil reaches freeze-up conditions. Used for low ambient cooling to 30°F with TXV. Rubber Isolators — Five(5) large rubber donuts to isolate condensing unit from transmitting energy into mounting frame or pad. Use on any application where sound transmission needs to be minimized. Hard Start Kit — Start capacitor and relay to assist compressor motor startup. Use in areas with marginal power supply, on long linesets, low ambient conditions,etc. Extreme Condition Mount Kit — Bracket kits to securely mount condensing unit to a frame or pad without removing any panels. Use in areas with high winds,or on commercial roof tops,etc. AHRI Standard Capacity Rating Conditions AHRI Standard 210/240 Rating Conditions 1. Cooling 80°F DB,67°F WB air entering indoor coil,95°F DB air entering outdoor coil. 2. High Temperature Heating 47°F DB,43'F WB air entering outdoor coil,70°F DB air entering indoor coil. 3. Low Temperature Heating 17eF DB air entering indoor coil. 4. Rated indoor airflow for heating is the same as for cooling. AHRI Standard 270 Rating Conditions — (Noise rating numbers are determiend with the unit in cooling operations.)Standard Noise Rating number is at 95°F outdoor air. Model Nomenclature Outdoor Units 1 2 3 4 5 6 7 8 9 10 1112 13 14 15 S T T R 5 0 3 6 A 1 0 0 0 A A Refrigerant Type 2=R-22 4=R-410A 5=R 4548 TRANE Product Type W=Split Heat Pump T=Split Cooling Product Family V=Variable Speed M or B=Basic Z=Leadership—Two Stage A=Ltght Commercial X=Leadership R=Replacement/Retail L-Side Discharge Family SEER 3=13 6=16 0=20 4=14 8=18 5=15 9=19 Split System Connections 1.6 Tons 0=Brazed Nominal Capacity in 000s of BTUs Major Design Modifications Power Supply 1=200.230/1/60 or 208.230/l/60 3.200.230/3160 4-460/3/60 Secondary Function Minor Design Modifications Unit Parts Identifier ODR-PRD02OA-EN 5 I M HCXW ( PSC Air Handler q u by Flrst Co. � - Cooling or Heat Pump / HW Heat '' ..� 1.5 - 5Tons Up tp 131,700 BTUH Heating c • r Nomenclature 24 HCX W3 0 1 0 A V B 1 0 A Size 18,24 Major Revision 30,36 48 60 Options Cabinet 61 0-Standard Series HCX Options Sensors/Switches 0-None 1 -Freeze Stat Heat Option/Configuration 2-Float Switch3-Freeze Stat+ Float Switch 00-0 KW No Heat W2-2 Row HW 4-DX Coil Sensor 03-3KW W3-3 Row HW 05- 5 KW W4-3 Row HW 08-8 KW Q3-3 Row Std S 0-St Pump HW Options ns(Control) 10- 10 KW Q4-4 Row Std Pump HW T-Time Delay 15- 15 KW R3-3 Row Hiflow Pump HW 20-20 KW R4-4 Row Hiflow Pump HW B Standard Pump Control Metering Device/Coil Config Unit Type/Motor Type P-Piston/Orifice 0-PSC V-Non Bleed TXV w/Check X-ECM Multispeed(Constant Torque) V-Var Speed/Constant Airflow Refrigerant A-R410A B- R454B Voltage C-R32 1 - 120/1/60 Z-Universal Unit 2-208-230/1/60 Cabinet Options 0-Std Multi Position FIRST CO. 1 HCXW(PSC)SPEC HCXW (PSQ The HCXW(PSC)air handler is designed for use with today's high efficiency split-system condensing units, heat pumps, hot water boilers,and Tankless Water Heaters. Boiler applications:The HCXW(PSC)can be directly wired to a boiler without adding additional relays or related controls. Multiple air handlers can be connected to a single boiler to provide comfortable,efficient, whole house hydronic space heating. Tankless Water Heater applications: For Tankless Water Heater applications, install the appropriate pump for the pressure drop. Cooling efficiencies up to 15 SEER2, depending on the outdoor condensing unit or heat pump model. These fan coils are compatible with any source of hot water that doesn't exceed 1801 and is NSF/ANSI certified for use with domestic water. STANDARD FEATURES • Multi-function micro-processor circuit board with these standard features: -Blower start relay- Eliminates field installed boiler relay,allowing direct wiring from the boiler to the air handler -Blower-on fan delay-(heating mode)-preheats the HW coil for 45 seconds. -Blower-off fan delay-(heating and cooling models)- blower continues to operate for 45 seconds after thermostat is satisfied,for increased efficiency - 120V or 24V zone valve control-The micro-pro-cessor powers either 120V or 24V field supplied motorized zone valves -Factory or field installed R-410A TXV(cooling or heat pump operation)(non-bleed type) • Manual Air Vent on hot water coil • Blower door shut-off switch(except 60/61 HCXW(PSC)) • Slide out hot water coil for easier service • Copper tube heating and cooling coils • Compatible with all major brands of split condensing units and heat pumps •Attractive baked-on powder coated cabinet • Primary and secondary condensate drain connections • Easily accessible 1"filter • Cabinet air leakage is no more the 2%when tested in accordance with ASHRAE 193 OPTIONAL ACCESSORIES - Freeze Protector- Reduces the possibility of the water coil freezing by switching the unit to the heating mode if the water temperature is nearing freezing conditions. • High capacity Flow Control Module for Tankless Water Heater applications(#940-2CV) First Co's customer is ultimately responsible for confirming which fan coil models are compatible with selected outdoor unit(s)and which expansion valves(if ark are required. To determine certified indoorloutdoor combinations,go to www.ahridirectory.or¢ FIRST CO. 2 HCXW(PSC)SPEC HOT WATER COIL 7/8'O.D.CONNECTION (1-1/8 O.D.on 60HC(W) HCXW (PSC) I —G—►I WATER 3'--, I40--H—.I I �1 OPENING ♦ WATER_ — DX COOLING OUT ============ '" ============ HW HEATING HOT WATER COIL ---�------�--- o 24V WIRING i ELECTRICAL COMPARTMENT POWER SUPPLY HORIZONTAL i (K.O.(boih sides) A CONVERTIBLE ' �pTeler#,f DRAIN PAN i AIRFLOW; COOLING COIL DIRECT EXPANSIONT o.o `� Ii __ ` C Us -6 FILTER (LISTED CO(ALLL''SWEAr) I 0 —E�I I F (See P.4 for Model Numbers) DRAIN CONNECTINS 3/4 MPT BLOWER DATA UPFLOW/HORIZONTAL ONLY UNIT MOTOR MIN. MAX. MOTOR CFM vs.EXTERNAL STATIC PRESSURE MODEL HP-AMPS CKT. CKT. SPEED (120V) AMPACITY PROTECTION CONN. 0.05 0.10 0.20 0.30 0.40 0.50 HIGH ACCESSORIES MED. 810 780 715 650 580 500 18HCXW*O 1/5-2.8 3.5 15 MED. 680 655 600 545 490 420 (field installed) LOW 530 505 460 415 360 295 LAW 350 325 270 220 160 FLOW CONTROL MODULE HIGH 950 920 855 790 720 645 24HCXW*O 1/5-5.1 638 15 MED. 860 835 785 720 650 580 PART NUMBER FOR LOW 780 755 705 650 590 510 940-2CV 18-60HCXW*0 HIGH 1120 1095 1045 995 940 880 30HCXW*0 1/5-5.1 6.38 15 MED. 850 840 810 780 740 690 NOTE: LOW 680 670 655 625 585 510 Flow Control Module is required when HIGH 1340 1310 1250 1190 1120 1050 1 connecting to individual Tankless Water 36HCXW*0 1/2-8.5 10.63 15 MED. 1290 1260 1200 1140 1080 1000 Heaters.Contact factory for assistance. LOW 1200 1170 1120 1070 1010 940 HIGH 1810 1780 1720 1660 1590 1530 46HCXW*0 3/4-10.7 13.38 15 MED. 1570 1550 1510 1460 1400 1340 EXPANSION VALVE KITS LOW 1280 1260 1220 1180 1130 1050 (Field installed)(cooling only or heat HIGH 2160 2125 2055 1980 1895 1810 pump) 60HCXW*0 1-11.5 14.38 15 MED. 1865 1840 1785 1710 1620 1525 PART NUMBER LOW 1560 1540 1490 1435 1365 1260 R22 FITS HIGH 2180 2145 2075 2000 119151 1830 61HCXW*0 1-11.5 14.38 15 MED. 1885 1860 1805 1725 1635 1540 9EVR22-4 18/24HCXW*O LOW 1575 1555 1505 1450 1380 1275 9EVR22-5 30/36HCXW*O NOTES: 9EVR22-6 42/48/60HCXW*O 1. All models are approved for installation with 0"clearance to combustible materials. 2. Use 48HCXW*0 for 3.5 ton applications and field-convert fan motor to medium speed. R-410A PHYSICAL DIMENSIONS 9EVR410-3 18/24HCXW*O UNIT FILTER 9EVR410-4 30/36HCXW*O MODEL A B C D E F G H SIZE 9EVR410-5 42/48/60HCXW*O 18HCXW*0 40 20 20 18-112 16 2 18 16 18 X 20 X 1 NOTES: 24HCXW*0 1. Above expansion valve kits are approved 30HCXW*0 42 23 20 21-1/2 16 2 18 19 20 X 22 X 1 for both cooling only(non heat pump)and 36HCXW*0 heat pump applications. 2. Valves are non-bleed type. Field added. 48HCXW*0 48 28 21-1/4 26-1/4 17-1/4 2 18 24 20 X 25 X 1 Hard start kit may be required. 3. Valves have screw-on connections. 60HCXW*0 52 28 2S-1/4 26-1/2 21-1/4 2 22 24 14 X 24 X 1 (2 required) 61HCXW*0 58 28 25-1/4 26-1/2 21-1/4 2 22 24 14X24X1(2 required) FREEZE PROTECTOR KIT NUMBER FOR COIL CONNECTIONS 941-1 18-60HCXW*0 UNIT LIQUID SUCTION SIZE WARRING AVERMSEMENT A0V=tN0 M 18/24 3/8 5/8 c.K,. R.pro _."r VT�30/36 3/8 3/4 C.�c. c.C ,13 w R.�� � 48/60/61 112 7/8 Data is subject to change.Please verify current information at 3 HCXW IPSC)SPEC HCXW (PSQ MODEL NUMBERS FACTORY INSTALLED TXV MODEL SIZE MODEL MODEL (BTU) (PISTON) (R-41OA TXV) 18,000 18HCXW*0 18HCXW*0 R410 TXV 24,000 24HCXW*0 24HCXW*0 R410 TXV All TXV's are approved for cooling only or 30,000 30HCXW*0 30HCXW*0 R410 TXV heat pump operation (non-bleed type). 36,000 36HCXW*0 36HCXW*0 R410 TXV NOTE: 48,000 48HCXW*0 48HCXW*0 R410 TXV Expansion valve requirement depends on the selected 60,000 60/61 HCXW*O 60/61 H0(W*0 R410 TXV outdoor unit.Go to:www.firstco.com or contact the factory for assistance. PERFORMANCE DATA UNIT NOM. MOTOR CFM BTUH(1000)AT ENTERING MO EL COOLING SPEED 0.3 (RPWfR) WATER TEMPERATURE UTUH CONN. ESP 120"F GPM 140°F GPM 160'F GPM 180*F GPM 2.0 18.0 1.8 25.2 2.5 32.4 3.2 39.6 4.0 HIGH 650 1.1 11.2 1.7 24.1 2.4 31.0 3.1 37.9 3.8 0.5 15.9 1.6 22.3 2.2 28.7 2.9 35.1 3.5 2.0 16.3 1.6 22.9 2.3 29.4 2.9 35.9 3.6 18HCXW*O 18,000 MED. 550 1.1 15.7 1.6 22.0 2.2 28.2 2.8 34.5 3.5 0.5 14.6 1.s 20.5 2.1 26.3 2.6 32.2 3.2 2.0 14.0 1.4 19.6 2.0 25.2 2.5 30.8 3.1 MED.LOW 420 1.1 13.5 1.4 18.9 1.9 24.3 2.4 29.7 3.0 0.5 12.7 1.3 1 17.8 1.8 1 22.9 1 2.3 27.9 2.8 2.0 20.3 2.0 28.5 2.9 36.6 3.7 44.7 4.5 HIGH 800 1.1 19.4 1.9 27.1 2.7 34.9 3.5 42.7 4.3 0.5 17.9 1.8 25.0 2.5 32.2 3.2 39.3 3.9 2.0 19.2 1.9 26.9 2.7 34.6 3.5 42.3 4.2 24HCXW*O 24,000 MED. 725 1.1 18.4 1.8 25.7 2.6 33.1 3.3 40.4 4.0 0.5 17.0 1.7 23.8 2A 30.6 3.1 37.4 3.7 2.0 18.0 1.8 25.2 2.s 32.4 3.2 39.6 4.0 LOW 650 1.1 17.2 1.7 24.1 2.4 31.0 3.1 37.9 3.8 0.5 15.9 1.6 1 22.3 2.2 28.7 1 2.9 35.1 3.5 7.5 25.9 2.6 36.3 3.6 46.7 4.7 57.0 5.7 HIGH 1000 3.6 24.4 2.4 34.2 3.4 44.0 4.4 S3.8 5.4 1.0 21.1 2.1 29.6 3.0 38.0 3.8 46.5 4.7 7.5 22.4 2.2 31.3 3.1 40.3 4.0 49.2 4,9 30HCXW-0 30,000 MED. 780 3.6 21.2 2.1 29.7 3.0 38.2 3.8 46.6 4.7 1.0 18.5 1.9 26.0 2.6 33.4 3.3 40.8 4.1 7.5 19.6 2.0 27.5 2.8 35.3 3.5 43.1 4.3 LOW 625 3.6 18.7 1.9 26.2 2.6 33.7 3.4 41.1 4.1 1.0 16.6 1.7 1 23.3 2.3 29.9 1 3.0 36.5 3.7 7.5 28.8 2.9 40.3 4.0 51.8 5.2 63.3 6.3 HIGH 1200 3.6 27.0 2.7 37.9 3.8 48.7 4.9 59.5 6.0 1.0 23.2 2.3 32.4 3.2 41.7 4.2 50.9 5.1 7.5 280 2.8 39.2 3.9 50.4 5.0 61.5 6.2 36HCXW*0 36,000 MED. 1740 3.6 26.3 2.6 36.9 3.7 47.4 4.7 57.9 5.8 1.0 1 22.6 2.3 31.7 3.2 40.8 4.1 49.8 5.0 7.5 27.0 2.7 37.8 3.8 48.6 4.9 59.4 5.9 LOW 1070 3.6 25.5 2.6 35.7 3.6 45.8 4.6 56.0 5.6 1.0 22.0 2.2 30.8 3.1 39.6 4.0 48.4 4.9 3.8 48.2 4.8 67.5 6.8 86.8 8.7 106.1 10.6 HIGH 1660 2.1 45.5 4.6 63.7 6.4 81.9 8.2 100.1 10.0 0.8 40.7 4.1 57.1 5.7 73.4 7.3 89.7 9.0 3.8 44.7 4.5 62.6 6.3 80.5 8.1 98.3 9.8 48HCXW*O 48,000 MED. 1460 2.1 42.3 4.2 59.2 5.9 76.1 7.6 93.0 9.3 0.8 38.0 3.8 59.3 5.9 68.5 6.9 83.7 8.4 3.8 39.1 3.9 54.8 5.5 70.4 7.0 86.1 8.6 LOW 1180 2.1 37.1 3.7 52.0 5.2 66.9 6.7 81.7 8.2 0.8 33.7 3.4 1 47.2 1 4.7 60.7 1 6.1 74.2 1 7.4 5.1 58.5 5.9 81.9 8.2 105.3 10.5 128.6 12.9 HIGH 1980 33 56.1 5.6 78.5 7.9 100.9 10.1 123.4 123 1.9 52.5 5.3 73.5 7.4 94.5 9.5 115.5 11.6 NOTES: 5.1 53.6 5.4 75.1 7.5 96.5 9.7 117.9 11.8 (1) Heat BTU is at 651 Entering Air Temperature. 60HCXWM 60,000 MED. 1710 3.3 51.6 5.1 721 7.2 92.8 9.3 113.5 11.4 (2) Based on 20°F Delta-T.Velocity not to exceed 61HCXYWO 1.9 48.5 4.9 68.0 6.8 87.4 7.4 106.8 10.7 Oft./sec. 5.1 47.9 4.8 67.0 6.7 86.2 8.6 1os.3 10.5 (3) Units are shipped with motors connected to Low 1430 3.3 46.1 4.6 64.6 6.s 83.1 8.3 101.5 10.2 high speed for cooling and medium speed 1.9 43.6 4.4 61.0 6.1 78.5 7.9 95.9 9.6 for heating. Data is subject to change.Please verify current information at www.firstco.com. FIRST CO. 4 HCXW(PSC)SPEC APPLICATION GUIDELINES (FOR BOILERS) ZONE VALVES Install a motorized valve with each air handler to control flow to that zone as required. TYPICAL WIRING SCHEMATIC FOR MULTIPLE ZONE CONNECTIONS WITH ZONE VALVES 24 VOLT 4 CONDUCTOR 24 VOLT CLASS 2 WIRING CLASS 2 WIRING CLASS 2 WIRING T -0. / .-._---------------IT ...........-i..., G G ' . G G W - - - W FAN COIL i i i FAN COIL W - ----- W R R 24VAD---------- i i i -------411 24V R - R 24V-9 0--24V Y - C y y C Y 24V REMOTE BRN T BRN� 24V REMOTE THERMOSTAT PIGTAIL LEADS FOR TAIL LEADS FOR THERMOSTAT MOTORIZED VALVE MOTORIZED VALVE NOTE: CAP OFF Bpi NOTE: CAP OFF BROWN IF NO 1 1 BROWN IF NO CONDENSER \ CONDENSER CONDENSING UNIT i CONDENSING UNIT / CONTACTOR CONTACTOR IS USED � IS USED � 24V MOTORIZED 24V MOTORIZED _ ZONE VALVE ZONE VALVE TYPICAL WIRING SCHEMATIC FOR MULTIPLE ZONE CONNECTIONS TO TACO SR-5041506 SWITCHING RELAY 24 VOLT 24 VOLT CLASS 2 WIRING CLASS 2 WIRING CLASS 2 WIRING ------•---G G G ....... G W W FAN COIL i FAN COIL W ------------ W R R [2411-0- i i i i f x4v R --------- R C 24V-00. .0-24V C Y ---Y BRN BRN 24V REMOTE } m 9 9 m 9 6 O O } 24V REMOTE THERMOSTAT SR 50 zone, zone: zowe, zone. THERMOSTAT SWITCHM i NOTE: CAP OFF oe.ee ee 9B eo m NOTE: CAP OFF OWN IF NO CONDENSER BR 1 : : ..................: I BROWN IF NO � CONDENSER CONTACTOR CONDENSING UNIT / Inv T� \ CONDENSING UNtf / IS USED CONNECTIONS CONTACTOR IS USED i BOILER T Catalog No.HBXB-HW321 (Replaces HBXB-HW420) FIRST CO. 5 HCXW(PSC)SPEC r � FIRST CO. P.O. BOX 270969- DALLAS,TEXAS 75227 PH. (214)388-5751 1 FAX(214)388-2255 WWW.FIRSTCO.COM JUNE 2024 AC� DATEIMM/DO/YYYYI �. 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 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 requdre an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER NAME: CLIENT CONTACT CENTER FEDERATED MUTUAL INSURANCE COMPANY PNE AH/OC.No,Ext):888-333-4W -T,A/C,moo:507�446�4664 HOME OFFICE: P.O.BOX 328 CNVATONNA,MN 55060 AiL ADDRESS:CLIENTCONTACTCENTER®FEDINS.COM _ INSURERS AFFORDING COVERAGE NAIL III INSURER A:FEDERATED MUTUAL INSURANCE COMPANY 13935 INSURED IItSURER B:FEDERATED RESERVE INSURANCE COMPANY 16024 ARCTIC MECHANICAL INCORPORATED INSURER 460 N MAIN ST - PORT CHESTER,NY 10573-3310 INSURER D: INSURER E: —7 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. ILTIRNSR TYPE OF INSURANCE /NOR SUBBIR POLICY NUMBER MML�YEFF MMID YYYY LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE S1,000,000 CLAIMS-MADE I X�OCCUR L_ Aa TORENTED PREMISES EM $1 0(),000 MED EXP(Any one person) EXCLUDED A N N 1887386 01/18/2025 01/18/2026 PERSONAL{ADV INJURY $1,000,000 OENL AGGREGATE LIMIT APPLIES PER:-' GENERAL AGGREGATE $2 000 ODO X POLICY I ��T LOC I PRODUCTS 8 COMPIOP ACC u',000,000 OTHER. 111 _ AUTOMOl0.E LIABILITY COMBINED SINGLE LIMIT $1,000,OOO (Es acciden0 JANY AUTO BODILY INJURY(Per Person) AOWNED AUTOS ONLY SCHEDULED N N 1887386 Ul/1112021 (11118/2026 BODILY INJURY(Per Accidanq HIRED AUTOS ONLY AUTOS QED LY FO RTY AMAGE �UMBRELLA LIAR X OCCUR EACH OCCURRENCE S5,000,000 AEXCESS LIAB CLAIMS-MADE N N 9907994 I 01/18/2021 01/18/2026 AGGREGATE $5,000,000 DED I X RETENTION S10,000 WORKERS COMPENSATION AND EMPLOYERS'LIABILITY YIN X PER STATUTE BTHER ANY PROPRIETORIPARTNER!EXECUTIVE E.L EACH ACCIDENT $1,000,000 g OFFICERIMEMBER EXCLUDED+ NIA N 9298530 01/18/2025 01/18/2026 --- -- (Mrrritory in NH) El DISEASE fA EMPLOYEE S11000,000 U yes,dow.ba under $1,000,000 DESCRIPTIOIPTIOElN OF OPERATIONS below E DISEASE�POLICY LIMIT I I � i i I I DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be aSWud A more 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. AUTHORIZED REPRESENTATIVE k> 1988-2015 ACORD CORPORATION All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD 1 YORK Workers' CERTIFICATE OF STATE Compensation NYS WORKERS' COMPENSATION INSURANCE COVERAGE Board 1 a.Legal Name&Address of Insured(use street address only) 1 b.Business Telepnone Number of Insured (914)934-8301 Arctic Mechanical Incorporated 286-468-4 460 N Main St Port Chester NY 10573-3310 1c, NYS Unemployment Irsurance Employer Registration Number of Insured Work Location of Insured(Only required if coverage is specifically limited to 1d. 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 Of Rye Brook 938 King St 3b. Policy Number of Entity Listed in Box'1 a" 9298530 Rye Brook NY 10573-1226 3c. Policy effective period 01/18,2025 to 01/18/2026 3d.The Proprietor. Partners or Executive Officers are X❑ included. (Orly heck box if all partners/officers nctuoed, 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 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 cf aauthorizea representative or licenseb agent of insurance cameri Approved by: � /lB,La� 12/14/2024 t5ignatu ) (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