HomeMy WebLinkAboutMP25-108 DR
. 19
1�t�
V4 Vu`�i
VILLAGE OF RYE BROOK
MAYOR 938 King Street, Rye Brook,N.Y. 10573 ADMINISTRATOR
Jason A. Klein (914) 939-0668 Christopher J. Bradbury
«-w%v.ryebrookny. ooy
TRUSTEES BUILDING& FIRE INSPECTOR
Susan R. Epstein Steven E. Fews
David M. Heiser
Donald T.Krom,Jr.
Salvatore W.Morlino
CERTIFICATE OF COMPLIANCE
August 11,2025
Win Ridge Realty LLC
c/o Alena Hakanjin
24 Rye Ridge Plaza
Rye Brook,New York 10573
Re: 204 South Ridge Street, Rye Brook,New York 10573
Parcel ID#: 141.35-2-36
This document certifies that the work done under Mechanical Permit #25-108 issued on 7/9/2025 for the
installation of two new rooftop HVAC units have been satisfactorily completed.
Sincerely,
Steven E. Fews
Building&Fire Inspector
/to
�E DR(Zj�
O� y
>9t39
BUILDING DEPARTMENT
e .»ING INsx►1.{l MoR
STAN'I'RIJUDING INsx•]tc TO M VILLAGE OP RYE BROOK
p Cc►xaa�a:Nlloxcl; x�Nl(II+I+Ic;I�Iz 938 Dillg,titrmt•Rye. .-ook,NY 10573
(91.4)939-(")8 FA:X.(914)939-5801
Y-ww a mfir.wokors
- - - - - - - ---- - - - - - - - -- -- - - INSPECTION REj)-O. T - - - - - - --- - - - - - - - - - - -
1
A.DDREBS:
�J
PERMIT# 2
hr1 -. __. o Isst-n+l>:7-Q-4 SECT: °11 .3,f_BLOCK: 2 L01': 3�o
LOCATION: o d t_ OccUrANcY:_ _
17 Violation Notcd '11m,WOIm Is... PASSED ❑ FAILED REINSPECTION
❑ SITIa INsx►m-rioN REQUIRED
❑ FOOTING
❑ FOO'xTING.T)R.A.INAGI3
❑ FOUNDATION
❑ UNDURGROI NI►PLUMBING NO TMS ON INSPECTION:
❑ ROUGH PLATM11ING
❑ ROUGH FR.A.MxrN,
❑ INSULN"ON
❑ Natund Gas N E l� ��,� .��G�
❑ L.P.Gas •
❑ FUEJ, FAN __---
❑ Fxlxla 11►RxNlwl,l,xc. - '�"��S /yS�(�+L._v_�S o a L ��_-��.
❑ FxNAI,l'I,ilMltlNc;
❑ CROSSC(►NNECTx0N •T-
y_r FxNmr,
Er O'rulSK
•G
I
r
•. 1 1 �.�1 1:.
�J
T
.S
ti
I'
t
r
h�
r
T
r,
1�
, ,��»�I�I������Il�ll�l����lll��lillllllt;il<<,��„r�r•� ,. ., „ : . ,,
h�
Y
f
t
41
r'
i
r r
�,
�'�
`r ' �.
�'
,�� �.
����
,� , ; .
�.��.�.
,...�.
Y'
_'
�� - .
._.
r
Sy .
�.,.
�. �ra,,
r.
.�� �� �
z =
a =
00 +• �
N W
N o
N
r^ y
~ W rr V/ � L � ✓ � �w/y�
w �
z _ LO 3u vi.
sa (J}
00.
zUb o
00o
0-4
W V)
A z V V Q aCo
V
1-4
z z -d "o '
v � W
OC O V d O a. v U0-4
Q V) F 0 M to x
O o F cw 'o N
04 v o
a,
oo
� � b
BUILDING DEPARTMENT D [ECIEMED
VIL6�E OF RYE BROOK
938 KING STREET RYE BROOK,NY 10573 JUN 2 5 2025
(914)939-0668
ww I ov VILLAGE OF RYE BROOK
BUILDING DEPARTMENT
APPLICATION FOR PERMIT TO INSTALL AND/OR REMOVE
HEATING, VENTILATION AND/OR AIR CONDITIONING EQUIPMENT
FOR OFFICE USE ON Y: PERMIT #:
Approval Date: 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=$200.00/unit•COMMERCIAL =$450.00/unit.
5. Complete specifications for each unit being installed.
6. Inspection by the Building Department for removal and/or installation.(48 hour notice required)
7. Electrical work requires a separate Electrical Permit&Electrical Inspection.
$. Plumbing/Gas work requires a separate Plumbing Permit&Plumbing Inspection.
Application dated, ll� z3 Z is hereby made to the Building Inspector of the Village of Rye Brook for a permit for the
installation and or rem vai bf 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.
Tn _ Lr v
1. Address: �+ 5. 1• U%� 5 SBL: I`7I� `cp��� DZone:�-�r
2. Property Owner:YV i� ,T Address: Z4-Al C f�l Wf �k-�` �+�y�
Phone#: 914 n'A ,1"►p�,�� Cell#: yr t d e'maiI::,�f,�'d, 1 rA�pj.L�/'�V,l��'WNAff-r4
3. Contractor:CO `jt n6�.M Vt.tl rfi V��NJ)C 1 INC-Address:�fU r1F11 lin I VA�r l�wc�-�JI.F# 11�xf�
Phone#: ZO*3—���-. 5353 Cell#: email: W0 Cyr ■w'Ivl�,�[r{40t CCN
4. Scope of Work:New Installation( )•Replacement •Removal( )•Other( ):
5. List Equipment: 1,J rZ'H'E Irz`T V J Uv/ GH 5 t-1,7 .
6. Location of Equipment: -FOP LO C4 -Ttp tJ
7. Method of Installation/Removal(list all equipment needed to perform job):
r
6/l/2025
STATE OF NEW YORJK,COUNTY OF WESTCHESTER ) as:
DMI70 a,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 2 Sworn to before me this
day of , V f�C. ,20� day of J utit, ,20 2�
'4A —10-4 r—V3��
14�i e of Pr perty OWIYer hyw—1 Signature of Applicant
WC "UT'S4 r)w-vt +o i3+EYi�rz>F� rro
Fri t Nagle of Prope Owner Print ame of plicant
otary Public U Nbkary Public
AIENA HAKANJIN ALENA HAKANJIN
NOTARY PUgLJC STATE OF NEW YORK NOTARY PUBLIC,STATE OF NEW YORK
Registration No.OI NAO013645 Registration No.01 HAO013645
Gusliflod in Westchester County Qualified in Westchester County
Cawntiesbn Expires Wtw2027 My Commission Expires 911912027
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
6/l/2025
� M •
00 .�
■, � N N M
N N
W H •-+ = •
:J \I J
�' a y W W � � i =' .� O •
c W
f w Ad c x
H
z �= A
Ln
r N
�' ,�/ � � � '""'' (� �• "t �„ QQ �, Fri
00
U
oe
� z
M00
n/ z OLO
a
�y•� rr+��l J W
,. �..
Lei F � ✓? � z z �
F
v w o xg x
Lei o z w Q a o
U �
F
�I a z w = �
16
5 D
JUL 21 2025
13[1Cr, nllfl'A ;1 M1�NT VILLAGE OF RYE BROOK
VIL�,h�'; ;fir=YtY�,� �ti )()Ic BUILDING DEPARTMENT
938 KING
?far ltvil3[ c NY 10573
t:4 �9 0 ��
W�ty5f}C11r1�1'lin ny_,(;il��
ELECTRICAL PERMIT APPLICATION
Westchester County Master Electricians License Required
FOR OFFICE USE ONLY 0( El,fl. &3
Approval Date: Permit Fec: $
Approval Signature: Other:
#######q;r�,t�;:t:,cN3#####kph*4####a+b#N#*###�I####bh# is8�r,syx�x:k,;rMi:�:hth#r.::Nt•xFir#####kk##1:i:3:#i+k############
1)0 NOT S'PAR1'11+ORK m•CONSTRUCTION lJN'111,A 11EI1M1'1'II AS 11EEN ISSUED BY TII1:B U I LDING INSPEC'1'0It.
THG ADNIIN15'r11A'1VR FGE FOR NNIORK 11ROGRPSSED 0it CO11PI,k11M IV1'rHO1l'1'A I'[,'IZN11'1'IS 12%01-'111E.
'11'0•1',u,COS'r 01- CONS'fRl)C'rlt)i\vrl'11 A NHINIMLIM Fi>'0FS75O.0(1
Application dated, Zl 2- is hereby made to the Building Inspector of(lie Village of Rye Brook NY,for the issuance of
a Permit to install and/ r Yen ove electrical equipment,wiring, fixtures,or to perform other high or low,voltage electrical work as per
the detailed slalcmenl described below. By signing this document, the applicant R properly owner agree that till clectrical work
performed will be in conformance with all applicable
Federal,,State,Comity and Local Codes.
1.Acchcss: Zv� J
Zonc:
2.Property Owner:_y�i,����e_ Pc.\I,l t.LC Address:_L:LP,,}_�,?',_���� Pla2c
Phone ff: Ll 11I. 1 UI- �t(1coS Cc1I it: cmlail:46laxa�tl-1 �w'r,�Y',
3,Master Electrician/Licaiscd lnstallcr: bogy C.n'c liinonr> Address:4k S- Nc,a,2nrl, I A,If 6vf
Lie.ff: 31 Phonefh. q lei 12 • Ili Cell ff: email:n,cY�n1N� is alScyv a p,�l Ior,K.ro ,,
Company Name:1�11tK�F�Pf�r,E 1 SPav;c.t AdLtc Address:4fr Cv-U !-A. No.r•,1_�e,LJ-P LetjYJ���
4.Proposed`Electrical Work/Fixture Count: c FG '� Z
uk 1, j s A✓1 rC l h { �i /� C l e C.f Yl C,--� ' lr 2 a X c v f'1 4
o"t
5.YJ Parly Elech'ical Inspection Agency:
*>'x*f;A•k irA it r:*uxfr it*irx?rfr it fr itir*it rr,:frr.xx*{****ir**:Fr.**AkRie i:i:*Ai:i.it r.it?rxx..is*,iR f.':»xr.wi:>r::fr i:>;*F*>':**:'r**ir r:is*>'e i<*ir**R*ii:y*#9r
S'I'ATr-OF NEW YORI(,COUNTY OF WESTCHESTER ) as:
Ar,-j Co-5cti't riew V ,being duly sworn,deposes and stales that he/she is tlic applicant above nanccd,and does lurlhcr
(print name of iodi'idual signing as lhe efpli Icm«)
stale Ihat(s)hc is tlic iV\OSAA -- f c-Vt(c,0 for the legal owner aid is duty ati lcoriud to make and file this application.
(Master Ficcuichn/Liccnsrd histaller)
The undersigned f titlicr stales dial all slalenicnts coulaincd lietcin arc tnm to the best ol'histhm knowledge and belief,and that any work
perfonued,or use conducted at the above captioned properly will be in conformance with file details as set froth and contained in this
application and in any accompanying approved plans and spccificnlions,as well as in accordance with the Nc,v York Slate Uniform Fire
Prevention R Building Code,the Code of the Village of Rye Btook and all older npplicnblc laws,ordina ices,and tegulalions.
Sworn to fore t le this I Sworn to fore nic this z 1 S+
lof�� 20 day o > " 20 agnal u•c of Pr perry Owner jtC Signatt re o D licai -.
P 1 co
N c of Prop rty cl AT. Prig(Name Applicant
_ L'1 N� KRISTIN M MC n)L a
Notary Ptiblic NOTARY PUBLIC,STATEPM 0 NH ARK
tAIENANAK4NJIN Registration No.01MC6348554 t5na024
lY►ueuC,ITATE OF NEW YORK
Istrotlon Ho.OIHA0011/45 Duelffled In Bronx County
llned In woolchostar Countyyt 3,��omcnits E>• Ir46 111111912037
21 STATE WIDE INSPECTION SERVICES,
swis JOB APPLICATION r 0.
Office Use Elect Permit# . Date 7/21/2025
Temp N
Utility ICI d
Final Certificate M
City/Village Rye Brook 1iP 10573 Township Rye Brook County Westchester
Address 204 S Ridge Street Cross Street Section Block t,a
Owner Name/Address of dirleem than An!) Win Ridge Realty LLC Contact Number (914)701-4005
Basement 1st FI ❑2nd PI. 3rd Fl. More Than 3 FI Garage ❑Attic Outside Residential Q Commerual
Receptacles Special Recept GFCI AFCI Switches Dimmers Smoke Alarms Carbon Monox Hood Trash Compact
Anil Amps
Range(s) Cooktop(s) Oven(s) Dishwashers Refrigerator Disposal Microwave N/ann Draw
Incandescent Fluorescent
SERVICE
Amperage Voltage IF, 3P 0 Meters If Disconnect Underground New Reconnect
❑Overhead ❑Change
11 Visual Re-Inspection Safety Re-Inspection Re Inspection
Additional information
Disconnect electrical for the 2 existing roof top Unit and reinstall electrical for the 2 existing roof top unit
r� 1
JUL 2 1 2025
1� I
1 VILLAGE OF RYE BROOK
BUILDING DEPARTMENT
1 hh fapli,afl t-1,d to,one(i l yea,bony the date received by SwIS.This appkitoon h intended w cove the above hired items to be inspecad,it at any time of Inspection adhtbn m al Items have been instaged,yw are
authorized to make the inspet lion and aqust the Me for the add,ilanai hems inspected the appikand,faela,es that lhe,e is eso open applk alkh,s for the above address wxh any other,n"ctk)n company The applkant,ovine,
w authorued agent agrees to all the above tams and conditq i n W bith loi the oppkation
Inspector Date Finalized Inspector M
Contractor Nicks Electric Service of NY,LLC. Date 7/21/25 Signature
Address 48 Grand Street city/State New Rochelle, NY 'p e 1
license 1 337 ID 0 Phone N (914)723-1133
State Wide Inspection Services
1080 Main Street
Fishkill, NY 12524
TOM"U S AUG - 4 2025 845 202-7224 Phone
914-219-1062 Fax
STATE WIDE INSPECTION SERVICES Email: office@swisny.com
Website: www.swisny.com
Service With /»tegrity
BY THIS CERTIFICATE OF COMPLIANCE STATE WIDE INSPECTION SERVICES
CERTIFIES THAT:
Upon the application of: Upon Premises Owned by:
Nicks Electrical Service of NY, LLC Win Ridge Realty LLC
Anthony Coschigano 204 South Ridge Street
48 Grand Street Rye Brook, NY 10573
New Rochelle, NY 10801
Located at: 204 South Ridge Street, Rye Brook, NY 10573
Section: Block: Lot: Electrical Permit Number: EP25-188
141.35 2 1 36
Certificate Number: 2025-5075 Building Permit Number: MP25-108
A visual inspection of the electrical system was conducted at the Commercial occupancy described
below.The electrical system consisting of electrical devices and wiring is located in/on the premises
at: 204 South Ridge Street, Rye Brook, NY 10573
The Exterior was inspected in accordance with the NYS and NFPA 70-2017 and the detail of the
installation,as set forth below,was found to be in compliance on the 30'day of July 2025.
Name Quantity Rating Circuit Type
Rooftop HVAC Units 02
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.
CAD/BIM
All Csteg4dt S>hack g6d Ges(Elec►ric>RGE.G Berl_ej>Item 4 RGECZT072ACU
Item # RGECZT072ACU, RGECZT Renaissance Line Packaged Gas/Electric
REQUEST INFORMATION
PJrnta4Le Purge Email.ibis.P.a
• Nominal sizes:3.6 Tons VIEW CAD DRAWING
• 3-5 Tons:Up to 16.2 SEER2!12 EER2
• 6 Tons:14.61EER/11.0EER
4PP
ZT Models:2-stage cooling
ZR Models:1-stage cooling
• Convertible airflow—vertical downflow or horizontal sideflow
31)
• Cooling operation up to 125`F
• Coil Type:Fu!I MicroChannel
• Optional PlusOne@ ClearControlT^VOptional PlusOne®HumidiDryt®
Specify ations C;colincl Perorniance Comprb;;;oi C tdoo: jr! ncloo Coil r)u!doai Fan Indoor Fan I 20 Front View
iFilter11 Dimensions Features
I Sound Level 83.3 dB
o
2994 g 2D L@ft Side View
Refrigerant Charge
i
105.6 oz
' Voltage 208 to 230 V
f
Frequency 60 Hz I
� j 2p.9InM Slde Wavy
Number of Phases 3 `
Minimum Circuit Ampacity 33 A
I
Minimum Overcurrent Protection Device Size 40 A
� � 2D TQ� Vi Iew
Maximum Overcurrent Protection Device Size 50 A
Drive Direct Drive High Static Constant Torque Q
Weight 264 kg 2D Bottom View
582 lb
lb
Shipping Weight 281 k
81 kg — _ —
E 2D Bade View
�,_0
Rauh Model
DOWNLOADS
® B2YI1f.A9%Y.Q2VA1k2Sd
I i . —
o
if
j
'fi iftz
gym.: me
t —
, I a•'�3'i: �I_;, ...;�in, 1 j�!; �..I.. hI 1 I r f •s.- - .-'si- �
r tt¢¢
f y
![-
r '.
f
,mom IunwwluuwufNl�MIauMU,�6'IgbrMNMnfN11MnMMNa+NNMNIWMNMr'rwfq�wu:fp»Ifflwuuuuumummnr, _ ..:. ...;.. _: _—
CD
it j
14 f-- •ffi!i.
1116 jr
I lit
I r.vn"jN.� �: ,•,ff nn"I�,,plNINMIfNNhNU��n ,.,�:j h
' • i 1a
�I��: n Ili�Nlfgf
III
* i
I
I QN�KrNI'�Illil '!1
Ilulll11n ' 1 .��
i
t =-
all
COASMEC-02 PSUZIO
ACORU CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDIYYYY)
1/22/2025
THIS CERTIFICATE 13 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 lieu of such endorsements.
PRODUCER AcT Paul A.Suzio
AssuredPartners New England,Inc. H wo 03 514-7863 FAX N 203 514-7863
100 Beard Saw Mill Road ( E4 ) I=. o).( )
Shelton,CT 06484 Voq�s:PaulSuzbJr@AssuredPartners.com
INSURERIS]AFFORDING COVERAGE NAIC u
INSURER A;Cincinnati Insurance Co. 10677
INSURED INSURER R:Cincinnati Indemnity Company 23280
Coastal Mechanical Services, Inc. INSURER C.
40 Hathaway Drive INSURER D
L I Stratford,CT 06615
INSURER E
INSURER F;
COVERAGES ERTIFICATE NIIIIABER: 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.
C6, TYPE OF INSURANCE Wvp AODL eR POLICY NUMBER- ---— POLICY EXPLim LIMBS
A X COMIrERCIAL GENERAL LUUIURY 1,000,000
E/�li OGCURRENGE
CLANS-MADE X OCCUR EPP 0701539 12117/2024 12/17/2025 DAMAGE 300,000
_ X X IenFWAGR ff.erd----'
MED EXP &I Im Rawl S 15,000
PFRSONA_a ADV INJURY_- $_ 1,000,000
GEWL AGGREGATE LIMIT APPLIES PER. GENERAL AS,GR*GATE f 2,000,000
X POLICY n ma ❑LOC PRODUCD-MWP*P AQ.G !j 4000,000
H R
A AUTOMOBILE LIABILITY - _ car8 sNIGLe Lrrn 1,000,000
ANY AUTO X X 'EPP0701539 12/17/2024 12/17/2025 BODILY INJURY Px Person) I
OWNED X SCHEDU_ED -
XrAUTOS ONLY AAUgT�OpSWry�[� BODILY INJURY(Per _
AUTO6 ONL Y X AUT()5 OM Veen14AMAGE ——
A X uraRELLALAa I X OCCUR EACH OCCURRENCE 5.000,000
EXCESS LAa CLAIMS MADE X X EPP 0701539 12M712024 12117/2025 AGGREGATE 5,000,000
DIED RETENTIONf -- - H--
B WORKERS COMPENSATION X PtcR OTH-
AND EMPLOYERS'LIABILITY --
ANY PROPRIFTORIPARTNERIEXECUTIVE XEM 07015" 12M=2'4 12/1/2025 1,000,000
P=R�IJMZWEXCLUDEDI NIA E.L.EACH ACCIDENT
tory n NMH1l E.L.DI -EA EMPLOYEE ��000,000
11 yes,describe under
nFSCRIPTION OF OPERATIONS — E.L.DISEASE-POLICY LIMIT 1,000,000
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 11" Addltiooal Remarks Schedule,may be sandaled If more space to n"lrbed)
The Certificate Holders Win Ridge Shopping Center-DE LLC;Win Plaza-DE LLC;VYin Ridge Shopping Center South-DE LLC;Win Ridge Realty LLC;Win
Properties,Inc.clo Win Properties,Inc.,Rye Ridge Park,LLC;&Athene USA,and Its subsidiaries its Successors and for 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.
CERTI ICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICES BE CANCELLED BEFORE
Village of Rye Brook THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
9 Y ACCORDANCE WITH THE POLICY PROVISIONS.
938 King St
Rye Brook,NY 10573
AUTHORIZED REPRESENTATIVE
ACORD 25(2016103) G 1988-2015 ACORD CORPORATION. All rights reserved.
The ACORD name and logo are registered marks of ACORD
NEW Workers'
PORK CERTIFICATE OF
STATE Compensation
Board NYS WORKERS' COMPENSATION INSURANCE COVERAGE
to Legal Name&Address of Insured(use street address only) 1b. Business Telephone Number of Insured
oastal Mechanical Services, Inc. (203)963-3732
0 Hathaway Dr.
tratford , CT 06615 1C NYS Unemployment Insurance Employer Registration Number of Insured
ork t ocation 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
06-1450112
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"1 a"
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 pannemofricers mduded;
Dail excluded or certain partners/officers excluded
This certifies that the insurance carrier indicated above in box"3"insures the business referenced above in box"1 a' for workers'
compensation under the New York State Workers'Compensation Law (To use this form,New York(NY)must be listed under Item 3A
on the INFORMATION PAGE of the workers'compensation insurance policy). The Insurance Carrier or its licensed agent will send
this Certificate of Insurance to the entity listed above as the certificate holder in box"2".
The insurance earner 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 forth, 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. Suz•o er�e1
°ocoS1W"PAanie of authorized represer•tanve or ncensed agent of insurance carrier
Approved by sw, tO' 1 1/22/2024
iSignature) (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 NOT
authorized to issue it.