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HomeMy WebLinkAboutRB25-0123 DR K O .' 'G Ec� L 7, t9 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 February 4,2026 Anita Charleswell 495 Ellendale Avenue Rye Brook,New York 10573 Re: 495 Ellendale Avenue, Rye Brook,New York 10573 Parcel ID#: 141.28-1-8 This document certifies that the work done under Mechanical Permit#RB25-0123 issued on 11/19/2025 for the installation of two mini split heat pump units and one outdoor condenser has been satisfactorily completed. Sincerely, / q Steven E. Fews Building&Fire Inspector /to �E UK(��• 1982 Q 0 ❑BUILDING INSPECTOR BUILDING DEPARTMENT BMSSISTANT BUILDING INSPECTOR VILLAGE OF RYE BROOK ❑CODE ENFORCEMENT OFFICER 938 King Street . Rye Brook, NY 10573 (914) 939-0668 FAx (914) 939-5801 inn r brook.org - - - - - - - - - - - - - - - - - - - - INSPECTION REPORT - - - - - - - - _ _ _ _ - - ADDRESS : I _ ( S L� AU A L� A jI�- - ---- - -- -- DATE:-.a PERMIT# ISSUF:ll:�1'_19•��$ECr:�Z-� BLOCK: 1 - — LOT: LOCATION: _ { 1-�n Q �/ns ����CV1 - _ ._ _ OCCUPANCY' ❑ Violation Noted THE WORK IS... WIPASSED ❑ SITE INSPECTION FAILED / REI1V$PECTION ❑ FOOTING REQUIRED ❑ FOOTING DRAINAGE ❑ FOUNDATION ❑ UNDERGROUND PLUMBING NOTES ON INSPECTION: ❑ ROUGH PLUMBING ❑ ROUGH FRAMING ❑ INSULATION ❑ Natural Gas N f ❑ L.P. Gas ❑ FUEL TANK a �S ❑ FIRE SPRINKLER / OG` A -..IN ❑ FINAL PLUMBING ~' ❑ CROSS CONNECTION _ rC FINAL OTHER ��• � � C� bJ . 1iV02 � /P B PRI O � Village of Rye Brook Building Department-Inspections 938 King St Rye Brook,NY 10573 1 Phone:(914)939-0668 1 Fax:(914)939-5801 1982 ' HVAC MECHANICAL - FURNACE HEATING/COOLING Permit number: RB25-0123 Permit type: HVAC—New—Cooling Municipal address: 495 ELLENDALE AVE Legal address: Status of inspection:Active Issue date: 11/19/2025 Deficiencies DISCOVERYDATE COMPLIANCEDATE REFERENCE DESCRIPTION CONTRACTOR DID NOT SHOW UP FOR THE INSPECTION. 12/17/2025 CONTRACTOR NEEDS TO PAY FOR RE INSPECTION BEFORE NEXT APPOINTMENT Visits VISIT DATE • •• VISIT RESULT SITE CONDITIONS Alfredo(Freddy)DiVitto Failed CONTRACTOR DID NOTSHOW UP FORTHE INSPECTION. 12/17/2025,3:49 PM +19149390668 Deficiencies CONTRACTOR NEEDS TO PAY FOR REINSPECTION BEFORE NEXT APPOINTMENT Parties COMPANYNAME AND • 495 Ellend Property Ave,Rye Brook p rty owner ANITACHARLESWELL +19145366136 Michael Pettine 100 Grasslands Ave,Elmsford Applicant Bruni&Campisi,Plumbing,Heating&Cooling,LLC +18188244762 �o § � CN 2) O ) kk011 \ \ ƒ Q) / ( L \ = u = \ / // \ } « » w ._ ° � / �_ # (1) £ \ E _ k « t 9A \ � ® \ � \ E 0 \ / � } \ ¥ � u .e 7 a LLJ Ln § { / p ® \ \ } \j > m QO 2 20 LU � 2 ® 0 w / \ a3r ARE O ( � § \ 2 Q) e Ems ± * ® Eo o / ƒ k � 3 � q § \/ m a Ln R \ \ \ \ < — � uj � 7 \ 0 2 \ Ln Va Ouj = — q 4 U4 � < E § e o < * c o \ E _ \ Q V) \ r % 0 § / { / 2 ¥ g $ t 2 c e = G § 2 u 2 n \ U / \ Q ± R = 2 t J I 2 � CO ± CDCb \ \ \ { j LL m ¥ m a 3 2 Ln lu O Cl) cy,LLI ± \ Q � ® ƒ { z ® � u > J � � « 2 \ \ \ / c LLI u < E < q e ) 0_ � £§ 9 / ./ f w , o _ / ¥ ± , 3 ( > / y . A2 / g / \ / \ \ / q ^ V) ƒ » » � o � q > / � k @ O [\ \ [ ƒj m w / v_ O %f \ / 2 � / / � ® $ / a6e2 ® { R ) / } \ ) /= [ 2a � o ,g =:E r ¥ 2R= / LU 3a / / / ; 0 cc -1 _ o ® a\ \ / —Fu % F [V \ / / / co \ LLI u 0 � jE U w 0 = o .e = ; $ &% � � / \ \ /\ � )�� « a a M § - HVAC Permit Application Village of Rye Brook j. 938 King St Rye Brook, NY 10573 Phone: (914)939-0668 1 www.ryebrook.gov Building Department Project Information Scope of Work: New Installation #of Units: List Equipment: Location of Equipment: Method of Installation/Removal: 1 1.5 Ton Mini Split(Ductless) Install in Backyard Backyard (list all a ui me it needed to perform job) HVAC Permit Application,page 1/1 BRnvt� VILLAGE OF RYE BROOK ■ . 938 King St Rye Brook,NY 10573 ' W � Q Phone:(914)939-0668 i www.ryebrook.gov �O Mi 1982•i Building Department HVAC/Cooling(New) Permit Permit Set 495 ELLENDALE AVE P#RB25-0123 R#141.28-1-8 PERMIT INFORMATION Address Permit number Date issued 495 ELLENDALE AVE RB25-0123 11/19/2025 REVIEWED BY If you have any questions regarding the review of these drawings please contact: Application in general Steven Fews stevefews@ryebrook.org INSTRUCTION AND ATTENTION It is the responsibility of the Applicant to print full size the entire approved permit package and provide at the time of inspection. TABLE OF CONTENTS Coverpage 1 Building Permit 2 Required Inspections 3 Contractor's Liability Insurance 4 Westchester Home Improvement License 5 Application Materials,Details drawing,Site plan 6-7 Application Materials,Contractor's Liability Insurance 8 Mechanical Equipment Specifications pages 9-11 Site plan 12 Certificate of Occupancy,Certificate of Compliance,and Certification of Final Costs Application 13 HVAC Permit Application 14 Building Department.938 King St Rye Brook,NY 10573/Phone:(914)939-0668 BPR VILLAGE OF RYE BROOK 938 King St Rye Brook,NY 10573 W Q Phone:(914)939-0668 1 www.ryebrook.gov ��• 82•`t Building Department INSTRUCTIONS THE PERMIT HOLDER AND/OR PROPERTY OWNER IS RESPONSIBLE FOR ENSURING THAT ALL REQUIRED/APPLICABLE INSPECTIONS ARE SCHEDULED AND THAT THE PERMIT 15 COMPLETE S. 0 }� r REQUIRED INSPECTIONS Name Description Final Inspection Completion of all required items under the permit including the site grading and the surveyor's final grading certificate. Certificate of Occupancy Completion of ALL Work,All fees Paid and Final Survey in if required) 9,000 BTU/H WALL MOUNTED IDU SUBMITTAL COVER SHEET PROJECT NAME LOCATION ARCHITECT ENGINEER CONTRACTOR REFERENCE SUBMITTED BY DATE Indoor Unit(IDU): Wireless Remote PRODUCT FEATURES DRAW09F1 B Control • Wireless Remote Control with"Follow Me"Technology • Single or Multizone compatible • High efficiency SEER rating,up to 24 • Sleep Mode • Turbo Mode 24-Hour Timer Feature a , Anti-corrosive fin coating SPECIFICATIONS LINE SET REOUIREMENTS Cooling Capacity(BTU/hr) 9000 Connection Type Flare Heating Capacity(BTU/hr) 10000 Liquid 01/4"(06.35mm) Voltage/Phase/Frequency 208-230V,1 Phase,60 Hz Gas 03/8"(09.52mm) Voltage Range 187-253V DIMENSIONS AND WEIGHT Low 153 Width 319/16" Indoor Unit Air Flow(CFM) Medium 194 Unit Dimensions Depth 7 7/8" High 291 Height 115/8" Moisture Removal(Pints/day) 37.20 Width 34 7/16" Drain Port O.D. 05/8"(016mm) Carton Dimensions Depth 11 1/4" Height 1415/16" Recommended Breaker(Amps) 15 Low 23.5 Net Weight 19 lbs. Gross Weight 24.3 lbs. Sound Pressure(dB(A)) Medium 35 High 40 WAL LUMP Refrigerant P410A i In Mi u� LISTED Specifications are subject to change without notice. ©2022 Ferguson Enterprises LLC www.durastar.com 1 Form No.V1.0_10.22 1P 9,000 BTU/H WALL MOUNTED IDU I IDU DIMENSIONS- DPAW09F1B Unit Dimensions 319/16" 7 7/8" (802mm) (200mm) 115/8" (295mm) A i Mounting Plate Dimensions 15 7/8"(403mm) 91/16"(230mm) 91/16"(231mm) 71/2 (190mm) 4 3/4"(121 mm) ........................... . ...... .............................. ............. ........................ 17161, (36mm) GAD 115/8" (295mm) 0 o 17/8" 21/16" (47mm)r U (53mm) ........... .................................................................................................................. ............. 3111/16"(805mm) Left rear wall Right rear wall '0 wall'9""rear hole 2 9/16"(65mm) hole�29/1r6"0(65mm) Clearance Distances 6" (1 5cm)or more 4 3/4" (12cm) 4 3/4" (12cm) or more or more 1---1 I 1---1 ?T- I 6' (1.83m)or more Specifications are subject to change without notice. C 2022 Ferguson Enterprises LLC www.durastar.com 2 Form No.V1.010.22 18,000 BTU/H SIRIUS HEAT MULTI-ZONE HEAT PUMP SUBMITTAL COVER SHEET SIRIUS HEAT" PROJECT NAME LOCATION ARCHITECT ENGINEER CONTRACTOR REFERENCE SUBMITTED BY DATE Multi-Zone Outdoor Unit(ODU): DRA2H18M1A I j � PRODUCT FEATURES SYSTEM DATA • High heating capacity at 0°F • Variable speed inverter compressor Refrigerant Type R-410A • Low ambient heating down to-22°F Refrigerant Charge(oz.) 91.7 • Low ambient cooling down to 5°F • Quiet operation Design Pressure(PSIG) 550/340 • Included base pan heater Outdoor Coil Coating Golden Fin Coating • Auto restart • Anti-corrosive coil coating • Port adaptors included EFFICIENCY DUCTLESS MIXED DUCTED DATA CAPACITIES DUCTLESS MIXED DUCTED SEER2 20.50 19.75 19.00 Rated' 19000 19000 19000 EER2 12.50 12.25 12.00 Cooling at 5°F3 16870 16170 15470 HSPF2 9.00 9.15 9.30 (BTU/hr) Minimum 5100 5150 5200 SEER 20.50 19.75 19.00 Maximum 22700 22850 23000 EER 12.50 12.00 11.50 Ratedz 20000 20000 20000 HSPF 9.70 9.75 9.80 Heating at 5°F` 18000 18500 19000 COP at 47°F 3.60 3.54 3.48 (BTU/hr) Minimum 7900 7150 6400 COP at 5°F 1.80 1.83 1.85 Maximum 25000 16500 28000 Nominal ODU Capacity5 18000 Specifications are subject to change without notice. LISTED ®2023 Ferguson Enterprises LLC www.durastar.com 1 Form No.V1.0_01.23 18,000 BTU/H SIRIUS HEAT MULTI-ZONE HEAT PUMP SPECIFICATIONS-DRA2H18M1A SIRIUS HEAT LINE SET REOUIREMENTS OUTDOOR UNIT DATA Connection Type Flare Width 37-1/4" Liquid 2 x 01/4"(06.35mm) Unit Dimensions Depth 16-1/8" Gas 2 x 03/8"(09.52mm) Height 31-7/8" Refrigeration Adaptors Included 2 x 3/8"--1/2" Width 42-15/16" Minimum Indoor Units Connected 2 Carton Dimensions Depth 19-11/16" Pre-Charge Length 49' Height 36-13/16" Maximum Length(combined IDUs) 131' Net Weight 138lbs. Maximum Length(per IDU) 82' Gross Weight 149 lbs. Minimum Length(per IDU) 10, Cooling Operating Temperature 5*F-122*F Max.Height Differential between 49' Heating Operating Temperature -22*F-75*F IDU and ODU Airflow(CFM) 2129 Max.Height Differential between IDUs 33 Sound Pressure(dB(A)) 61 Additional Refrigerant for 01/4" .161 Low 850 Liquid Pipe(oz./ft) Fan Speed(r/min) Med 900 High 1050 ELECTRICAL DATA DUCTLESS DUCTED Fan Motor Current Type DC Voltage/Phase/Frequency 208-230V,1 Phase,60 Hz Voltage Range 187-253V COMPRESSOR Recommended Breaker(Amps) 25 Type DC Inverter Twin Cylinder Rotary Minimum Circuit Ampacity(Amps) 20 Oil Type VG74 Communication Wire Size 14*4 AWG Stranded Oil Charge(oz.) 21(620mp Rated Current-Cooling(Amps)' 9.0 9.5 Rated Current-Heating(AmpS)Z 9.0 9.0 AHRI Rated at 95°F(AFull). 2 AHRI Rated at 47°F(H1 Full). 'Sensible Capacity:Indoor 80°F DB,670F WB H Outdoor 5°F DB,4°F WB `AHRI Rated Capacity at 5°F(H42) s If the total indoor unit load exceeds the nominal capacity of the outdoor unit,the practical output capacity of each indoor unit will be correspondingly reduced.This situation is very evident during heating mode. Specifications are subject to change without notice. ®2023 Ferguson Enterprises LLC www.durastar.com 2 Form No.V1.0_01.23 D A D 18,000 BTU/H SIPIUS HEAT MULTI-ZONE HEAT PUMP ODU DIMENSIONS-DPA2H18M1A SIRIUS HEAT- Clearances 0 a E E 0 05� lop N �� �a Et° 72„ Or)left m) 0 ?q„(6 0 Or)ri"rn) Dimensions 40-9/16"(1030mm) 37-1/4"(946mm) ED 31-7/8"(810mm) o 0 O 0 0 26-1/2"(673mm) 15-7/8"(403mm) 15-1/4"(386mm) NOTE • Illustrations in this document are for explanatory purposes.The actual shape of your mini-split equipment may vary slightly. Specifications are subject to change without notice. ©2023 Ferguson Enterprises LLC www.durostar.com 3 Form No.V1.0_01.23 1 4 .. ` - .. I ' - 49� Ak Al k 495 1,4 1 IA 497 Y � F. - 3 Y #1 Front: 0'0", Back: 760", Left: 0'0", Right: 0'0" BUILD MENT VIL Y. 0 ;. OOK 938 KING 'lXt; ,NY 10573 �a APPLICATION FOR PERMIT TO INSTALL AND/OR REMOVE HEATING, VENTILATION AND/OR AIR CONDITIONING EQUIPMENT FOR OFFICE USE ONLY: PERMIT#: Approval Date: Permit Fee: $ Approval Signature: Other: Disapproved: (fees are non-refundable) **xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxtxxxxx:t;t*xxx**xxxxxxxxxx*x*xx*xxxxxxxxxxx+rxxxxxxxxxxxx*x*xxxxxxx**x*x 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: I. Properly completed&Signed Application. 2. Site/Staging Plan if Required by the Building Inspector. 3. Copy of Contractor's Westchester County Home Improvement License,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 n 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. 8. Plumbing/Gas work requires a separate Plumbing Permit&Plumbing Inspection. xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx�********xxxxxxxxxxxxxxxxxxxxxxxxxxx**�xxxxxxxxxxxxxxxxxx**xxxxxx Application dated, 11/6/2025 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. I. Address: 495 Ellendale Avenue, Rye Brook, NY, 10573 SBL: 141.28-1-8 Zone: 2. Property Owner: Russell Fulmore Address: 495 Ellendale Avenue,Rye Brook, NY, 10573 Phone#: (914) 536-6136 Cell#: email: russfulmore2ll@gmail.com 3. Contractor: MICHAEL PETTINE Address: 100 Grasslands Road 130, Elmsford,NY, 10523 Phone#: 818-824-4762 Cell#: email: SMOSELEY@IPERMITUSA.COM 4. Scope of Work:New Installation(X)•Replacement( )•Removal( )•Other( ): 1.5-TON MINI SPLIT(DUCTLESS) 5. List Equipment: INSTALL IN BACKYARD 6. Location of Equipment: BACKYARD 7. Method of Installation/Removal(list all equipment needed to perform job): 1 7/1/2025 STATE OF NEW YORK,COUNTY OF WESTCHESTER ) as: MICHAEL PETTINE ,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 6th Sworn to before me this 6th day of Novembers 12025 day of November ,20 25 Signature of Property Owner Signature of Applicant Russell Fulmore MICHAEL PETTINE Print Name of Property Owner Print Name of Applicant r Notary Public Notary Public C•1tLOS TREVIRO suu w T•u, ' "'r. CARLOS TREVINO ' Comm E,p.-07477079 P�'• Note Y Pu01rc.Stale oI Taus �,::•�' Notu,1013319M74 ry+�: •lC; Comm Eapaes 07-07-2029 k ``•'° Notary 10 133195424 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. i i I a 7/1/2025 �t� `r 1�!a�'` '•" �fa.�i �`khl L, .:� :...�1" ,rjY sf.• �1 NI CO t-. N c's o > o v 00 c- y rn is O x w U U Q r .t3 r ' O it �: • o � o � � I - j U o v) . W z z N o fiction Of o U Quo (n W W O � ZLL 60 co C/) x yye ' : W 4-4 �L g w o -`fie �a • „ 3 d p W 00 r Q Cn r X wp Z d a: v5 �--�t• A m o � i• LO 04 ! 3w N u '~ Z M p o ���► �yj r,,�� �'�•-ra �.�,,r.,... r,r.. � �i r r_� a tr , '-s.1y�+;-- ��R�f). /! x ^ 1��'Il �/�A� �, /"�' jj Ire■. An�� A Q■Ae� '.yi,�'. : s 'ti',� � jfi �.,]:?1� .4. ;'. fl .. •,, �.r ]I �'•�.- SP✓a' - .: 1 ,.rui.' 4, l ® /Y DATE(MM/DDYYY) ACORO CERTIFICATE OF LIABILITY INSURANCE `� 10/24/2025 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(ies) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: Certificate Unit Edgewood Partners Insurance Center PHONE 404 781-1700 FAX 100 Montgomery Street AIc No: Floor 20 Suite 2000 ADDRESS: apexcerts@epicbrokers.com San Francisco CA 94104 INSURER(S)AFFORDING COVERAGE NAIC III License#:OB29370 INSURER A:AIU Insurance Company 19399 INSURED APEXSERI INSURERB:Upland Specialty Insurance Company 16988 Bruni&Campisi Plumbing, Heating, &Cooling, LLC 100 Grasslands Road INSURERC:National Union Fire Ins Co of Pittsburg_ 19445 Elmsford, NY 10523 INSURERD: INSURER E INSURER F COVERAGES CERTIFICATE NUMBER:506226482 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. ILTRR ADDLITYPE OF INSURANCE INSD Wvn SUER POLICYNUMBER MM/DDY EFF Mao EXP LIMITS B X COMMERCIAL GENERAL LIABILITY USPCLO284125 8/10/2025 8/10/2026 EACH OCCURRENCE $2,000,000 CLAIMS-MADE X OCCUR PREMISES Ea occurrence $100,000 MED EXP(Any one person) $Excluded PERSONAL&ADV INJURY $1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $4,000,000 POLICY JECTPRO ❑LOC PRODUCTS-COMP/OP AGG $4,000,000 X IRI- OTHER: $ C AUTOMOBILE LIABILITY 9812741 (AOS) 4/1/2025 4/1/2026 COMBINED SINGLE LIMIT $5,000,000 Ea acc dent _ 1X ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY Per accident _ B UMBRELLA LIAB X OCCUR USXCLO100925 8/10/2025 8/10/2026 EACH OCCURRENCE $4,000,000 X EXCESS LIAR CLAIMS-MADE AGGREGATE $4,000,000 DIEDRETENTION$ 1 $ A WORKERS COMPENSATION 020396018(AOS) 4/1/2025 4/1/2026 X SPER TATUTE ER A AND EMPLOYERS'LIABILITY YIN 020396020(WI) 4/1/2025 4/1/2026 ANYPROPRIETOR/PARTNERIEXECUTIVE E.L.EACH ACCIDENT $1,000,000 OFFICER/MEMBEREXCLUDED? NI NIA (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $1,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,maybe attached If more space Is required) Town of Yorktown,to the extent required by written contract.is an additional insured. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Village of Rye Brook ACCORDANCE WITH THE POLICY PROVISIONS. 938 King Street Rye Brook.NY 10573 AUTHORIZED REPRESENTATIVE ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD THIS CERTIFICATE SUPERSEDES PREVIOUSLY ISSUED CERTIFICATE PORK Workers' CERTIFICATE OF STATE Compensation Board NYS WORKERS' COMPENSATION INSURANCE COVERAGE 1a.Legal Name&Address of Insured(use street address only) 1 b.Business Telephone Number of Insured Bruni&Campisi Plumbing,Heating&Cooling,LLC 914-946-5558 100 Grasslands Rd Stel30 Elmsford,NY 10523 1c.NYS Unemployment Insurance Employer Registration Number of Insured 8831360264 Work Location of Insured(Only required if 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 88-3136026 2.Name and Address of Entity Requesting Proof of Coverage 3a.Name of Insurance Carrier (Entity Being Listed as the Certificate Holder) AIU Ins Co. 3b.Policy Number of Entity Listed in Box"1 a" Village of Rye Brook 020396018 938 King Street 3c.Policy effective period Rye Brook,NY 10573 04/01/2025 to 04/01/2026 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"T'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: Don Bailey (Print name of authorized representative or licensed agent of insurance carrier) Approved by� .: 10/28/2025 (Signature) (Date) Title: CEO North America Telephone Number of authorized representative or licensed agent of insurance carrier: 212-770-7000 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