Loading...
The URL can be used to link to this page
Your browser does not support the video tag.
Home
My WebLink
About
RB25-0036
oa° N is L o 0 ❑� ,tip. N LET u TH o• E v a r� L c �0 ao a7 a) LL -0 0 v E o C CL v E W 00 a' v a m in v o. 3 a w v € v LL X �_ v w a W N L - a ate, f° a > W = Y 7 O N 2 cn 3 `o 0 ~ �- F- Z N M F- 0 v �a > c3 aZ W � QF- o j. u � O a, p D a o cn � Y .Y N � r-+ W w a o Y ° O p ^ > > } Y O L " ° L p c� Q IN - ° o v ° Z .n c z O w O o a 3 E 't N v N tv d m o a� ° C v W mm� } F- E oc T� Qv� oL O U o D a m o . LLJ coy cL- 0N �� co N � -°Yw 3 � � >Z a E oOwao UQQ o 'O o o vO N E: J Cl ; ZM 0LU � NrU = > U' NIM oteLL00 TMI O m � m Lo ° EO a, n �m Z o a L I N -0N a bA U �/ Q co � _ 'w2EEmE C y J I..L w i C � O F- ~ f° J:E 0 a1 0 v a ry Q c1 > w > 2 j mp=p � N O C } D � _ � S Z � n- � aci } p co UJ O EQ Ems • O m N N C) +_ N EZ X om O M a Cis u F- Q wLn > s Y Q c I N o ' 2 o y CN E 0 '� o v m a v y C1 O a- C y = .� Wo 0 CL o = NEW YCR 0 uaNQ- > �> oru aoe cV o - m oo � � E yE V aW v W LJ O awb Ovuaci p 0 Ix (2) v Y = = L � a: ° P 'T E Solar Permit Application Village of Rye Brook 938 King St Rye Brook, NY 10573 Phone: (914)939-0668 1 www.ryebrook.gov Building Department Solar Permit Application,page 1/2 Project Information What is the total estimated cost of construction: (NOTE: The estimated cost of construction shall include all site 20583 USD improvements, labor, material, scaffolding,fixed equipment, professional fees, including any material and labor which may be donated gratis. If the final cost exceeds the estimated cost, an additional fee will be required prior to issuance of the C/O.) SBL: Zone: N.Y. State Construction N.Y. State Use Classification 1414.27-1-21 63 Bowman Ave R24 Classification I I Type, kW & Location of Array: Proposed installation of a 7.63 kW DC/7.60 kW AC roof mounted solar array. The project includes (9) 440W solar panels, (7) 530W panels, and (1) 7.6 kW inverter. Occupancy; (1-Fam, 2-Fam, Commercial, Pre Construction: Post Construction: etc...) If building is located on a corner lot, which street does it front on: Construction Type Located: Number of stories Roof Style (hip,shed,mansard, etc...) 2 Dormer Will a New Roof Be Installed: 0 No ❑ Yes Roofing Material & Number of Layers Asphalt Shingle & EPDM. 1 Layer Will the proposed project disturb 400 sq. ft. or more of land, or create 400 sq.ft. or more of impervious coverage requiring a Stormwater Management Control Permit as per§217 of Village Code? © No ❑ Yes Will the proposed project require a Site Plan Review by the Village Planning Board as per§209 of Village Code? © No ❑ Yes Will the proposed project require a Tree Removal Permit as per §235 of Village Code? © No ❑ Yes Does the proposed project involve a Home-Occupation as per§250-38 of Village Code? © No ❑ Yes Solar Permit Application,page 2/2 BRc�4 VILLAGE OF RYE BROOK 938 King St Rye Brook,NY 10573 j► W Phone:(914)939-0668 1 www.ryebrook.gov ��• 82• i Building Department Residential/(Solar) Permit Permit Set 63 BOWMAN AVE P#RB25-0036 R#141.27-1-21 PERMIT INFORMATION Address Permit number Date issued 63 BOWMAN AVE RB25-0036 11/25/2025 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 Cover page 1 Building Permit 2 Required Inspections 3 Building Inspector Stamped&Signed Set of Plans 4-6 Engineered Plans 7 Engineered Plans 8-34 Solar Permit Application 35-36 Building Department.938 King St Rye Brook,NY 10573/Phone:(914)939-0668 BRnv� VILLAGE OF RYE BROOK 938 King St Rye Brook,NY 10573 W � .� Phone:(914)939-0668 1 www.ryebrook.gov > �O ��• 1 02 • Building Department INSTRUCTIONS THE PERMIT HOLDER AND/OR PROPERTY OWNER IS RESPONSI BLE FOR ENSURING THAT ALL REQU IRED/APPLICABLE I NSPECTIONS ARE SCHEDULED AND THAT THE PERMIT IS COMPLETE a, .a o� 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) `o 0 (V c n O � � N o � L 00 N + O> ` ri v v c n v v ii y 'a 0'Y Cc W to OL 'v v ra - y E W c ~ LA m a v a 3 x ~ w > a o>U A W LLI N V L c m y `° s a > L O at v � r °�' v v H LLj u .�2 -0 t Z w F- t �e � o Lu N 2 7) 3 `o -E2 F- F v+ o oL0 0 _ O O Y� N a>- oo sOua, Z L 00 F- o ; 000 a cYW ww o L E ZW . Ow $ -p ' 3E °t a, "' am Olu via jw O J N R o f0 O E o 5w vr' j = g < v C > ao m L Q a YLU ^, W c cZ OZ � (Av � > p W co W v w � U a Q E O O "o `✓ � o L � O a d Y C v To ea � v, o cn yU3L N Wu „ � m C, a (� u o m Z p w � v L c c w `v L m w � ; v .O a m ZM o � M 0 U � Y a � 'oa' wO 060 E °' > LL c0 e-1 m a' � o ° v E OMo, N a m, Zv, � io w 0` `� C) C) N a v i r .o m +- (� . 1 `o Q 00 o c v c U •V � Y L � = 000aN _ ._ Q m J 0 -0 m V m �' � ? c as d } o ; O p c N o N_ O a0 E '� W r-I Z u y N �C •- c 3 m m c > N 2 U Q 7 axi > s O M d ° tB J fC u F- Q u+ V) +, Q LLOOUJ 0 0 o rl (V O ,� O L +• N E � Nav m 2 $ v Q a ar r ` «. o a W o 0 a ZA U + m 0 M v V 0ELL c o ao m m Z i > EE c N ~ W J W O 0 c a�i a�i c b U F- coE � t' v) •� p �/ moo: LL i L ' L�.r 0 !� W p au r Q a a � aL �, L si Electrical Permit Application Village of Rye Brook 938 King St Rye Brook, NY 10573 Phone: (914)939-0668 1 www.ryebrook.gov Building Department Project Information SBL Zone 141.27-1-21 R-2F Proposed Electrical Work/Fixture Count 3rd Party Electrical Inspection Agency Elec hookup of a 7.67kw DC/7.60kw AC solar system. 16 panels, 16 optimizers, 1 AC &1 DC disconnect, 1 inverter Master Electrician/Licensed Installer Information Name Lic# Address email Phone# Cell# Frank DellaGala 1163 8 Livingston Road, Carmel, NY 10512 ladel.susanb@gmail.com 914-287-6400 Company Name Company Address Ladel LTD Address of Work? Homeowner Information 63 Bowman Ave, Rye Brook, NY 10573 Electrical Permit Application,page 1/1 �y BPR VILLAGE OF RYE BROOK �u/ 938 King St Rye Brook,NY 10573 .� Phone:(914)939-0668 1 www.ryebrook.gov . 1982. i Building Department Electrical/Panel(Remodel)Permit Permit Set 63 BOWMAN AVE P#RB25-0108 R#141.27-1-21 PERMIT INFORMATION Address Permit number Date issued 63 BOWMAN AVE RB25-0108 11/18/2025 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 Cover page 1 Building Permit 2 Required Inspections 3 3rd Party Electrical Inspection Form 4 Electrical License-Photo-Westchester County 5 Electrical Permit Application 6 Building Department.938 King St Rye Brook,NY 10573/Phone:(914)939-0668 �y BRnv� VILLAGE OF RYE BROOK V 938 King St Rye Brook,NY 10573 W � O� Phone:(914)939-06681 www.ryebrook.gov 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 IS COMPLETE E; ti 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. Rough Electric Rough Electric Final Electric Final Electric STATE WIDE INSPECTION SERVICES, INC. SWIS •" • • JOB APPLICATIONe Office Use Elect Permit# Date 11/4/25 Bldg Permit# Sq Ft Plumbing Permit# Final Certificate# City/Village Rye Brook zfp 10573 Building Dept. Rye Brook County Westchester Address 63 Bowman Ave Cross Street Section 141.27 Block 1 Lot 21 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 Transferswjtch SERVICE Amperage #Panels iP 3P #Meters # Disconnect ❑Underground ❑ New ❑ Reconnect ❑ Repair 16 1,A 1DC ❑Overhead ❑ Upgrade ❑ Disconnect Utility ID# ❑✓ Con Ed ❑NYSEG ❑Central Hudson ❑Orange/Rockland PHOTOVOLTAIC SYSTEM PV Modules Inverters AC Disconnect Junction Box Combiner Box Load Center PV Monitor Energy Storage System DC Disconnect ❑Legalization ❑ Safety Inspection ❑Consultation Scope of Work Elec hookup of a 7.67kw DC/7.60kw AC solar system. 16 panels, 16 optimizers, 1 AC& 1 DC disconnect, 1 inverter This application is valid for one m year from the date received by SWIS This application is intended to ove the above listed items to be inspected if at any time of inspection additional items have been installed,you are awhwized to make the inspection and adjust the fee for the additional items inspected.—he applicant i—I-1— that there is no open applicatimu for the above address with any other Inspection company.The applicant,owner nr authorized agent agrees to all the above terms and conditions as set forth for the application Email Address ladel.susanb@gmail.com Name Frank DellaGala License# 1163 Date 11/4/20 Signat Address 8 Livingston Road City/State Carmel, NY-"*' Zip Code 10512 Company Ladel LTD Phone# 914-287-6400 State Wide Inspection Services 1080 Main Street Fishkill, NY 12524 845 202-7224 Phone X0 914-2194-219-1062 Fax STATE WIDE INSPECTION SERVICES VILLAGE OF RYE BROOK Email: office@swisny.com Service With Integrity BUILDING DEPARTMENT Website: www.swisny.com BY THIS CERTIFICATE OF COMPLIANCE STATE WIDE INSPECTION SERVICES CERTIFIES THAT: Upon the application of: Upon Premises Owned by: Lade[ Ltd Marc Chasnov 8 Livingston Road 63 Bowman Avenue Carmel, NY 10512 Rye Brook, NY 10573 Located at: 63 Bowman Avenue, Rye Brook, NY 10573 Section: Block: Lot: Electrical Permit Number: RB25-0108 141.27 1 21 Certificate Number: 2025-8732 Building Permit Number: 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: 63 Bowman Avenue, Rye Brook, NY 10573 The Photovoltaic 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 12"day of December 2025. Name Quantity Rating Circuit Type PV Modules 16 Optimizers 16 AC Disconnect 01 DC Disconnect 01 Inverter 01 Officer: Frank J. Farina This certificate may not be altered in any way and is validated only by the presence of a seal at the location indicated.This certificate is valid for work performed on the date of inspection only. p � � c liJ 3Nf1Q1d0�IdYlOd711 1NIB y 1066MMI-3Naa CC VSn'CL901 AN 710088 3Aa p Ix r��l� i�S� , • i 3AV NVWM08£9 `� d AONSVHO OHVVY U 1 90 y Q ` ct wot Wt1j w� �a �� a 0 uj ° H zua«a W - Z, W V W Q W W W - e J aaaaaaza _� ��`�v,= a >u 3 village of Rye Brow architectural Revl w Board C Y° Approval Date. L� .-- G �YY Z�W Chairman -_------` co 3 Ln ■Y$ D ----- co iris < -- W (D U Ool"Wa � J 7 15, ,� �1. as ,�� oCD o aaaa w } o Z uj � U LIJ� C) U uj H U o W Lu 1 Oco U � 5 C C W !� K - - , ' eta 2111 ::.... .. S.... W A ON303l o: AN 3N11W1dO*b3MOd3O 1NM m I '066MV16l-3NOwd 1=,Lt1,1NdVwmQ` N dSf1'fLSOI AN'H002l8 3Atl C x W � 3AV NVnMOB E9 � i E ! �I AONSVHOOWW village of Rye 131110N p i HIZ �W Architectural evie Board q W Y` YY a Approval Date: o � �W Y :a Chairman:, ------ ~— Z w Z _ z IM511 Hilo. ri o s Q al ti f• 0 Q ?k z •S UJ # • oZ Z [✓_ J 7 m g t'J CO Q i A„ g tl W Li A x _.� W O D wZ _ m o \ E- x z z LU � b g. ga w ato w o a H- wZ N •- Q�4 x J 6 3 0 8 r. � Q '. � 8...i....... . i... ` ` O L3N'3NnNOidO®1i3MOd3n-UVn3 w 106666S6161+:3NOHd (� y a W LZ-I-LZ LVI:NdV a m T X 1 vsn'£L501 AN'AOO8G 3AN j O Z_ a A 4 u7 3/�d NHWM09£9 i Q AONSVHO ONVW W pJJO PH 3o z = - ; a Q �YOPK � LAN' Q �Z W �w �� a WWZ y= W } Hzm °w < uJ�aQQ�ia W g I ui i �~W<��W C 2 �>� G �o W 0-0 g5�2 Fw CKy� U C { N W W j y� U) LO HUM H D Z 22UW Z_< O I W W O m O W O 1 U(00 q l g t W Q c) (n Z. W �m Z� LN � LL�LL wy w 3 w N 5 <m W U U y Mhum W. _ Z �7 A �y -_-- �o I $u�Wg"a W z061 o zzim it 1 o � � o0 0 �,-) o � , m ON } Z 0 1 Y 2 U w0 � 0 cnw I--' F- J w � w � OJ w > I --'- 1awY O z Z. O om WW O � �< a s Y a ° tv I _ soMM11 k il 96 W 3Ws jabs Y 1 .... .. 0.....CUD, ON3031 ONE i § _ 13N 3NI1N01d0@H3M0d3W 11VVG W66699V M-3NOHd r a s N i= LZ-L-LZ L%INdtl Y1 W m ti m N ! c vsn'ESU AN'HOONG 3Aa g � W Z X L d i g w '3AV NVWMOG E9 CL W Q = A0NSVHO OZIM ~ e m > w wF 'Mu Wa w J � 03 L Q LU J 0 �uoy_�529w W Z_ €rcrc � _ cow u�w�na�tl1 y Q z w�;zzw<>z w J Z omg X Q oT,wo u9w S�3'vi aa2aa >m0 11yy W�w�Z yWo=j Z� Z ZO �FIRE c9 �F�wm 8 �pw <53� O • t. Mt W W - Q Q ' J _ w J Z = W Q m J Q J U) = � J o _r D o Five 0 QuRE LU J 2 Li Z Co a ~ X > Q z Z a' Qo o J�I QQ a°° W oQ WJ � c� N w z mo — ` , z gig X Q a ZO -� yg ° !'7.:�}'. it `6: 3€✓S pppgp ��p°'g � HIH usd ile �gil, � > i � a :. . $... ....... €... �. ON3931 o z | 1.3N'_<IdO@__.!_ e __mW_Hd z | | | §/ os*: LML J� §=k | n | | | ■ ` } /z «nggL m'oe�a � § §d/ � § § - !0 '¥mwm@ , «� »<� § � Lu AONSVHO QIJvm ' E ... .�. }im§M § i\j�jkl§|l u \ \ §( ( §| /] w < I |) k< o !-�•� w Z � HMSO _ 7§ \ �■2�!|§ k| } o§ § w \ §E / § CL � �*| §/ /o LL < m ©§E||| e LL ?<w = m z w § #i K o LL % ■ - j § u § w ) LL o f \ a. \ _ � W_ w » 0 O § @ § � zj W w (n / O LLI C4 \ § } 0 ° ca � \ § ƒ Co § 2 w w § 2 $q E �_ zq \ kw z § \ j �0 w � a W U) 2 2 2 \/ LLI2 W \M 3, U§ LU | | _maw_Od»!_ e ____H z _ | ■ ° mLm_ § §2 q=k • , � ) ) «nggIAN oe»a ( § W [§x � § K '¥awoe i < § !<� a. aONSVHQ QN¥WEjil: ' < |. !(|§ | ■yPHI , §�;2|�■ |m ■��§\)} (K §�§|§k§ � ■§||His |2 .� .; »�■§|2 |0 "Him |m!§ || Z § / \ \ /- / ` � ® w G � \ _ m � e , c \Ln �§ Iz § )� ®4 o . . z( ~ § 2 R c � § I) 2§ - � � $jo « � W a F- 2 W � � «z �$ Q; ;g 6 13N 9NnNOldoft3MOdOW:IIVn3 �B b o W66695K61-:3NOHd W f « 'sjwpw.l6 k � z Z-L LZ L4l:Ndtl z w 7_ �r i1 3C i VSfI'£LSOLAN'N002183A2i _cn W'x a r e�y g o 3AV NVNMOS£9 >ad W 3 , `n: j a �` � u7 0 •- p T no go �a o zW-�Z z yew$ 3 3 W,'o oW �LLJ W" o O N z 0 a �N U= W NN z a5 W �z w g 3 < v < w W � z m!• !iaa ip@ a z Q �t9 RS2 n. e < Y pW z 4 W Z z� O #! R aad R' -?�7 6 � 8 6Ciii�W i=Gi� yLu xLu zo Y ylU �G'f 7AlwoZ� W?I�L. fV�i o R R Ply W.H All 8 $ G L o wW L Jz = # F_ M ui ch V "z to - S 1 . I a .* Y � I + z � Z W CVB Hrv� q - o$6 nl UNZ Y �z O w g� m� i 13N 3NIlNO1dO@N3MOd3V VlIVW3 Cl) O �p 10666999L6L+3NOHd O �Fu + N LZ-L-LZI WV < CD W e,;, y m r ± o VSn'£L90 L AN'NOMA 3Aa W Z x W j g� '3nV NVWMOS£9 a 3- C.) ,T, a a f I e AONSVHO O�JM U zi 6t�g 5 � c c Oi UUa UN� �" F `,{ O 0-X SinceNn cFidg��W as O� 8l U q u �Wf�WZ N ?N V 11l7 F CW N �( y)>y1I��Z`p U c c i a HOB a �y Yf OZ 1yII�//�W WI<J III6VIYyyyyI(U�a>> _ el e� <_% �H>yY W2(*2�K_�M m NQ A(jY "tp �WW <!7m ULL wy UO 'NV V, 3 rr W U)jG II�{u �1i1uu aW;W;O Wmcy 2m UaL) UaU tZy� Uz -.1�.3 W J N"7c 6 le two ` x x m o �Wi9OJIWO O > >>> O > o 0 FcwilS N2 Wo f� 9 $ m «w > z O Y �gmU 4 U S= UUS UN WQQ Sj gg aS S v�¢4 c�S gggggggggg ci N� s�M m Z0352.>ZJJ�JJ�YW6I ci ci of ry —WL . — J o z L'U QSI'f F aL) �M m_ OU) UU OU(90U W <z Q= N SUIiYi W 8.81 p u > >> « �w V$II NU U>N Ujp 1 G 1x" N W >j>> 2 cS �FF Z J EE > 2b < < $ 2 m0 W O m $ a p m F 7 w V u) E c p� a7 O w 7` g=g O O < y' U N NWwmg O< �`N OU'de my m c c m—�8$ z (7 S H a o g W Z R W w W$y C d W. FF Y pp ��d$$ W F Z O O�% F y� �Eoa' ~ > > gg O LLR ) a� x53 m W 7 p�� g o Op .0 mU ruw i on Oz iJ <�>y�17i W W >ZUmYYY wm z TW SO U) 57g� I;aU �1 7 X $O all F x N � � d > < w Y Y O U 1,Z m 0 wwQQO�SiaZ CO m wW 0 < <LL '^ Epp w�UN 2ywjUZLL \ 0 mm �pWwwFt7zi sx,.g U p_D Q Z_ O Fbme wi OUWO upai 3 =yoo m a �omUw �goZp O�U)tl) U)N ev O �=N�uNy Cl) -Op W W opts Oz� OUP J- W W > > Z��Rz ->' zwm Z Y Z XU UUZWZ O O > V� c«c IyW6U'<S JJ UNC7 l� � 10 HIhO� �� py 00 pF�2 QOC<O ZOZp r U) r JJJO HH X kYG ��pzCyayyO<�LL O } II 0a5z UU Y R �1ggm� Niw-iOrcW �i re o _= Z LU 2m Y mbiOpO°m$z04 Q Ip�09Z WU 22 � V Ow°4�omw"dw U c ar I—W OO , c �$o> �"mU Uzm�007m W~ UU !z 0 Y ma U)7J¢S�INOm—�wRm J :WOQCD rnr z Ww Ow� zV?ma� + �WOO(� LL tL � � _>N Fmmzd Uw FZK `� Q mwW 00 zoo 5 =� Zm U 5 �rz<g zZ n m Ja wc�iz�?I�{��Iyy�gQ�SS luz 0 v11.IFm� UUS U)O H H _ U9: z Ai NafWN OU ZH Z,N 4X = F_ IT why z N AN 3NIlNO1dOft3MOdOW ClTM3 $$ = W666M4 61-3NOHd cl !E W 2-t-LZ'LK:Ndtl m r i W s tlsn'CLSOL IN Nooae 3,ka W z x = j _ ��. - g 3Atl NtlWM09£9 g ,�,Q = n- h \ u7 e noNseHO Oadw a o W ■ ■ate UO U'lL, Z U w a, O V � LLo LL❑ wm O Q = = BOWLLW ° nvE Z N Z $O ZQ Imo-I t O n o Y W O 3 O 1❑L =W=W w LU C9 Q O (n JU JU 'sN N 1 9 O Z w N F N LL 2 O>3❑ U UZ �n N OF^>'j� Ja OZJ� LL > 3 co �wmm�4p ❑ �LU LU W Q wN W�03 ZS C Ww W wOZ Ct U��� > wW UZJNc(3 Z o li.�wMp>i P �sa�ai �= O O w . U NZK S ylWi w? V/>�W V1F w J LL W f y LL a�_ LL Z y¢y N w � Q vain �w�amww 1113 OILJv)GW VO Z �a ��rvi❑1i coaOw,�D)WW Q Q N Z Z W N J ❑ O FOz QzQWOw zdwv W�xaz¢C0 Lu 30 w m �C'iW wz° ��a�W'oZQ❑ZQw gRio a m0W W O in C?LL fA2tn�W 2� V1 Da co 0 U Z R P a In m � a W o CL z CY 0. w W z J F1— ZZ ggJ¢ O N F 3OOp U^ w Zaa^i O V W rr W c W Z z0. N m Z • a>> • ? g°, <w wi y • z fn d 1 =f 0.Wo� • a Oda r yQQ r `` �QN/ 0�w i Z Wr / I.L 0 yU z� Z Z❑ N v �- N m Z O7}��>❑ Ri • a O a z w C9 Q❑co w X 9 H a = O S C Y W O LL W • 'Qi 3 4�Zoz„� l¢lw wzX ¢� H_ dQ�vo+z❑�� ¢Uz Y {LLL y K Q~Q wpp� J LL J LL N U w Q 2 CC 1 p� 2 U W W LL • Ja.K VJ 6 rw I? vJ L) 9M oJx J / iLL p y O ZK W W W W WSW w W a a 7 w N W W O O W O W 3�� S00QUWO. 5o'aaoo mo in mNo W �H qa L) gU �DU G7 ® n O K w � z O > a co Nay a ZZ v vi O Z wW2 U Z m w0m y� � L zo$ 0 5 w • oaf Wvi o8�, �No $ �_ 8 Hwy $ •QQ >H N � • UU ❑ • LL • W 7 (OYJ y� ZZ ZUw r r • ❑�G r U r UU r L-Fr N • z N Z O w= N Z O N • • _ 0�5 N • • Z K f V `. pOa U pU 0Fz¢ O OFU O��'FU OOU Q�L FUw"z • Fwz • Fwzp> Z FwZ • FrZww • FEW 9 ayzj.. zomy.. az aoozz oZ a aay�y� �„ CL oo� � oo • �za0z >} • U Z J a O W f•� J W • • J U 7 K W - J a'w J O Q a'w J g W F J FFF W W aE Ud❑0 W❑ W Wa0W❑ - • W W❑ • w ❑ w 7 w 38 �L) 3 �� � tom � 3a$� 13N'3NIlNO1.dO@N3MOdOW:lIVW3 Z F y W666BS6L6L-:3NONd w Z O mz ! it 12-L-LZ LVL NdV i W Q 5 3 } vsn'6LSOL AN'HOOi19 3.1a LL W z X IF ; X�i 3ndNHWM09E9 q O LU aa� m a w W i W d nONS`dHO O2lVW D qq XF yy pJ Q q g„ F 5 :nC�i ■ a x� zE 19, jD 0 Olt 4 4= t its lu 5 jY� M pp `y b b bi 4 g� e II h= 5ZR = C L J � oZ Co� Y � Y m F { g E aZ 11 z = CA) t 04 �i ��3 - 13N'3NIlNO1dO0N3M0d3W INVO z c L0666894L6L.3NOHd a Z O W i a N LZ-L-LZ L9L NdV < uJ Q q M CO ` X+ ' Vsn £�so��N'NOOae 3na t a LL W z= '3AV NVWMOG£9 Cl w Q a ai W a nONSb'HO ObHW eta Y R e � g rr 3 a J'o —,— pq p� 4 6a i I t .���. I . 104 J LLin J_ � " A3 W ' ° A E z v a $ a z y z & o O F- —J W C Q O E d z c t 2 z � m% Z. f V W W _ Q m G 2 x J E E III W W W z V V i 13N3"nNO1d0@a3MO,101111"3 Z E A = W666859161+:3NOHd W Z O I is lz•1-cz/Y1:Ndv 1 �LJ g m 1 2 ! a vsn'EL9M AN'Noose 3Aa a LL W Z x 3nv Nvwnnoe ss ;¢1: o ! ! AONSVHO OUVV4 w N vi S V t0 V�i B L Vl •pgg•g�g7 LL¢ WD �h m gR c8 vi w 4 E gA O U =` - A S? t� .Z #a 6 sp R a c m li C Ysi g! 3 tt{ A W Z5� a 9i � INVERTERS a $ • =�o �+ 0 c L L. tA j n r X E CC N Ln N C v, `n °c N v s 8 LL o m ° � E - ao EtA ; F > _ .Z ` ° ` ° ` O ° u 7 w w l _ � .q = E s EC E ° °a+ a °- �+n Q M n 0 3 - g LALLJ W 10 r y nN t cXX; g o c q Z LLI O iN A do A �•p$ E L O • � E ° q E vcn L Fi O 0 m ► C N o z 5 LL _ H A | AN_���»�.,_ ¥ § § | __L6�-__ 2 | | . e m_ | LUG 9■k | o | | E! | )\ «nq@gym'oe»a [ a § §Z/ � > �| | ■ . '¥aA�ee , s s � 1: §�§§ | ` 3ONSVHO Q�vm ' �CY\ ~ ° . e , , i ! !<. < ,. !l,,, - 2, \!■ § Oil C� ( � I # ! !t E�C ~ � � I /� f\ i � ! • B�! ° §| h � | � \ � : b LU t o u. @ |- $ | «r| j§b $ ! / » ! �a«� ! g , , !■ ! :�|�w !|� 13N'3NIlNO1d0ft3MOd0H:-irvm Z o Z 10666ML6L*:3NOHd W Z O . W +7 N! LZ-L-LZ l4L Ndtl , LULL x; vs £ O NN0080 3A d zv t ; W 3Ad Nt/WM09£9 ^ W W nONSdHO 02i`dW a. s�aprr Ip# # �6a r elm x ..i SF x� e CD EN c � o O \ i� FffU iliFt� N Ln zg �� � Y� r POWER OPTIMIZER E—'' E o E p E _ N ° r R. 3 d � N M �o 9 a N tA E x a LLE LL - N .� O {H m N L o •— Ln E St {.+ t LnLA 22 O �A a _ a L L t/1 LY paa | m _ r,\ z ) \- � L\ Ndov^ / \ � � qn�@gym'me#� & � m Kz\ % > § | �vmwmg = R ] -�— _ CL AONSVHO Diva U § | k ' ■! �) | f/ � |! l - _ l E | !)| !!r | !!! | §� §§! | \ ) § i | \ I | | ! �� \`- ! �■ | �t ` LLA ! ! / | 0 � � � � § § ■ | — � W § 13N 3NnNoidoft_»-M3 z | ____ z / m: u < |■k3 � \ #�} ) i «nq@�m'oe�a � 9 ) §�§_ � » ~ � CL | '¥mwoe k \j ■« x � AONS¥HO ON¥W LU 0- � §H� x � ■ � ! ! , § r ! �;|4, � ® - i } , : ■ |!| | \ tA CL - | ){ ))� � | m � z | ■ �_m| . | , \�rm � j { §�§ � § | qn' /m'moe»5 § CL �)x / � | | | ( , } '�«mw m G & § <� � .|||� § \ x : - |||||||| | AO N SV H O Dcva LJ % . , � , , . - ! B § ! • � • • « ! \ � / f ! _ � . � ■ ; ) . ! : � ) § I § § � § ! , ! ■ : � | ! | | | | | | | | ! | ; ] , | ■ | | | ■ | ■ | | | | | - � . } § ! ■ § ! . § | ; ® � ° \ § - ` | , ■ ! | j § . . ! f { � \ | ! > |f � � \` I 0 !§ ! 13N'3NIINO1dO@83MOd0A'IIVW3 Z F W P.z 10666MS B-:3NOHd w Z O W i • tl Lz-vtz't>�:Ndv Q Lcu Q m 1� LA W w Z L •1�� !� ! S e o vsn'EL901 AN NOONG 3Aa C a U u W Z x W ' 3Av NVWM09£9 T W e Q� ww a ll: I �l � _ AONSVHO OUVW Wa. D$ 8 d K e S� tt t 2 A £ 6 � � k 3yEFa v D''fyyyjjj El ■ - s � s= n � _ a 9 � a ry N ~ J 3 a r5� W � B a : � ■ _NOi.O§M_»a_ z \ M~'® _ | . mL mN ■ w& �mkf §\ An'ESOLm'oe»a , �§ ��x 2 § f '¥mw o e 0 uj &«� xIwt uj |||!|||| | AONS¥HO Obvn ! � { r ! | � § � . | ! I ® )§ f \ |� ■ . { � ! � � � � � | !ƒ I ; ! ! ! ! ! ! ! ! | , � 4 ! B / ■ / | } \ ! ! | ! | ■ 3N_NOidOO_Od3.o_ z ■ ■ | ' § / t:^ 7 �§ 9ca ( \ qn' a m'mega L � wz l '¥mwma kKw . 3ONS¥H3 D@vW w CL � � ! ! � | � § � | � ! |\ ,| !| §� f f| . • f ! i \ � ._ h_, jw IK 0 _\/ e ui2 d §■§ Goqn' /q'mme»a § a ) �)x � » � , § ■ < �. § § '3Avqw ma & \ § ��� x � AONSVHO MJVA |||||||| m \ { }_ ! � \ � < | ; \ f } � 2 ! | � � { \ ! : | / $ \ � } 2� | � 13N 3NIINO1dOOa3MOdOW:lNYV3 Z N O Z w666MOL•:3NOHd W Z O W f b • N LZ-L-[Z'Lbl Ndb' i w Q m CI vsn'£LSOI AN'NOOae 3A2J W a W x �� lltl� �• a 3nvNbWM08£9 m U qQ� = a Lu AONSVHO ObVV4 Lu a . CO mmomm 0 e a v 0 a � F 0 0 n 0 0 7 E3� ill IF d€# Q 13N 3NIINOLdO@lJ3MOd3h'IIVW3 Z C L0666ML6L+:3NOHd ~ 0 6 E m N 1 LZ-L-LZ'M:NdV W ~Q m P (V EI: dsn'EL50L IN'�OOiiB 3 l2i d i w Z X ; g p�1 3ntlNdWM08£9 C0J i �l�il AONS`dHO O2JVA w ( i M Eo C O 5 9 R K T QQ t 6 1' O IK L C s � b � R k �i 13N'3NIlN01d0oM3M0d3W VlrV"3 Z W6669S6 M,:3N0Hd ~ O M • N LZ-L-LZ L6L:NdV < LU Q m N e! L906 AN'MOONS BAN xvsn'£ aLL CL '3AV NVWM08£9 AWZ - I a ' { w d I i AONSVHO ObJVNEl: b a P C byY R 3 E 2 t L3N-3NllNOidOCN3MOdOW:l1V"3 F O i „ W = W666M4 61+:3NOHd w Z 0 W 3 s �z ez�e�Ndr a W �m F m N ! " VSfI'EL901 AN'NOOMe 3 la w z X = i w '3AV NVV MOS E9 i D U a Q— W d 4 ! AONS`dHO OUVVY "' U)i Ell x x a 99 ?pa � yp a F g 6 ff s g P stl 9 L i� XX 6 Sys tt g Y�gg g� B^� j[ EFg m ggg ppy,y 5, � C F F e r E f x 3 F $2 c K : b a � lit) _ 0 ❑ OIL | AN_NOIdO@.3MO_am - ' P \ ~ 33 $ 9©§ § q • , AnggLm'oe7a § CL ) �)x / » | § ! k } '¥NVA«o■ ) \j <� � IL ® Hill § . GONSVHO 9�vm % | � \ \! � {� ! ! |> G ;; �§��|| � ���� � • ��|!■■| 7 |t|�!! ! - .. .- ■ ! �"- -" | � 13N'3NIINO1d0®a31IOdOVI:-1IVW3 Z ec L06668S1,M,:3NOHd u+ Z O s W LZ-L-LZ'M:NdV f cW E W W Z L U `• 4 s f/Sn'ELSO L AN')1OOaB 3 la U Ww zQ X '3AV NHWM08£9 D= N w a AONSVHO 02]V" W_ ;a JEW r ' m N C 9 N ' ' IIII II O o f - E I cu u N ? Y O �,N Hq m aB c r o f%1 LL o q m Y J LL m> 7i O N S E Q O ¢ ¢O O g Qgcg mg ¢ cu E m cm gg1i. 3 xc S Xg iw3 mE rn mrn4 c v mE dram t'� m c m E c `"wci 'o �tA'I cpDn �w c o mZ Z a n t7 U� m �° a w m i6 Viz`✓ of o c 'g a c m I r$ 8 E m o e a $E $ ¢ Ec o g rn o g E ° $ S E R pp ° « `m m a a p m z o s�c . . . o i � In rn c mU w o`- E $ �o c .�8 c $ L5 m cc _ c '3mm m° a � U c3 a�3S gmB E>3 'o � m I LL8 L o° U L v m 0 0 o q E m g m� m 3m � L@ g_ o S r ip Ll M U LL Z LL w U t LL id ti 2 C O C C O d m m E m n.0 m m E m O 8 � m �' n m m c r °e i � t $� E m o `c o Is H c t 1 F' o c o m m o w m m t m E gi ,Fi 8c 'm mai m o O t m m . a- umL t° ; m o � >. t Ed 15 w 8 m LU m >m a o� R N N L m C U J l0 a �a E m U m o m E a C ? U N U O a o 4 0 m E ocmj W O = ?C d m O no `i ' E m v- m `° map a� b m N m 0 N ¢ m K N j 7 A L m F d C E m �? E Z y � nm Q v 'b1 m 0 1 £ m ° c E N m rn N m m jo n mo a U cif w� 6 �n c ° F C m 3 m m N c T Q� O 13N'3NIlNO1dO@M3MOd3W:1IVW3 Z E = L066669tM-:3NOHd w Z — 2 p p yF• p X LZ-L-LZ314:NdV i W ~ m C £ w i 2 ( p_� N I f ! b vsn'MM AN NOON9 3Ai! d LL W N X s _ �• X p, 3AV NVNMOS E9 m D U Q = d ! p li AONSVH3 ONVIN !p 0 0 N ice C', w d « Cc, N O • ti CO CL CV) N • o Q > m • Z N • • N w • N N 3 � g N oE CD 0 Q 1- Yo to Z cm N C3 � - 0ca ~ Ua n ( °0 u • a. a. • iv ca m d Nod s m coo 3 � a > > uie b• o � ,c1 ® Z �a f o c Cu �i �i AN 3NIlNO1dOVV3MOdOW:IIV"3 O O L066669 4L6L*:3NOHd W Z s iC i+ �s q �d'• N W Z•L-LZ'LI N" a Lu ~U Ni SLO N �OOaB 3a WVSf '£L ZX 3 wo ay X � = w aAONSVHO Oadw UJ Gnfl- " a 3 c C2, y w LL � t m� ° _ � � o. a E m E L g+ °Q� nL � z .�. w u m C 3 s �z c v- 'E .Aa+g E N C O � c Nf 7 v 3 v 3 u z c o � ado- 'S" °a �� w E `o o E E Cl. O Z. c� ti9 '� o m v" ° cam; `� � SLo CD21 tw �� ? ' E z� =r W J o E � � y o rna u E u rn o t E � -Ae � Cc E E uc ip 0 jv° � aE nN o o � do od . 3 ; Eo CD Mc � 2� v� Ac° ,, A m `ov CD u CD �+ V A O y� n Y W N m C_ | | m ��_wham wz | ■ | 0666__ \:^ z e | ' - ■ - � |§ LIJ < §�§ © § k qn' a m'me»a = a. ) =z Z. § & § | '»¥mwmg ! 22 |<� § � AONS¥HQ MNA |||!|||| m k ` tE Q) 7 = »� 8, E �\ ;/\ cE E/ e ! �[ kaf22 �■■ - Efk �/ }t § mm §/ � 7» K3 . § !& )§rkƒ ; |a ! E= : \\))} � k /}\ E /)}\ i\ ■ _ �\/ � }/}\ k 'a - & ; & I � § / 6Er { ( { ({ / EE c zz =a ( ({ [ \r \)\ ƒf {ƒ } } ( $ t § } (/\)# O - \ 2 ° ) ( � `o ° E 2 ) E\)k {\ }a & !i± (faea & ([ � [�_ a )f , E \ rtet ; \ 2 ;» Gr � \ \ /\ \ \ ) ; k (/} CD /i \� § //5 \{; ) 2 \ &/ k 9 f ±§ I § «� O 2 7} }\\ {{) f2! {f5, � (] § \ 5 (\ ; t27{A �. 4 & Eoe & u. ' : Em . . } )b /kw �' � .rf'A'Ee <v� .rXi:°��fiN '�i M .�+� 4"i^• •1 1 v� �•r. $s�Ar A�j ;�n�t liy�n�j i,..- y;iyOg(,'at,._' ..:� ,`� � '. z• Yy Rol. � � �10 •1� : 4 � 41a � �a(0)1,, " o/{ 11_ 1 1 j.,�"�'v� Vim.ilk •iai1�11f_ -.'ems'- r�F.�1 �:i IIiAl.3:a �i`Iw (0)>� _ aM ,. � :A > " O ti,x C Q' N• C ` cu O {- y V .. ;hPI41 o Z H / Q w co u CA `•� 1�1 W Q .cod �-+� y .�+ JO U •° oC section J L i/1 Z Z N E V 4� W - �(o» m t w V W Z W4-4 N ` m00 Q = F ire ao O Z w . Y. tF w Of zCIO t •y� vV �1 v � N � � coma 72 ca 1 E oOD }� aU z Qj V tu • an cu <(0)> ^^T,.�r1*.--9c."` .e-••i-�--};%?•--•—ate -i,i1�1 •s--; en'isT`��-.•n �(0)->` ii111�11i4� i'ifl�lf i x dflf/tl 1 J�1r1l/�i� t��111i (�yg 11//tijt ( 71►1I � IIIYiI y 111/1� p ♦Ili y� g �11�� / R"AN+ •• Ai�( ♦♦ �A��Ir •• ASK ��> �A[ L�t• I>A �> sAl ., •• A '�ufv A .w •a�v, �i�y.,b � �,•J,�'� � "•Y"�tJ:�'Qrx Q •,G'�r�l+a. O {•�'l+htiL� �f �,Q,�Iti�f�•ife Q "b��,�nss+f yJU� 0 K vj•�J ��,. . •+i�,M n��� r • '. N. VN. j+�ti �.,�•a+ rr�y„r ti ��. ;".tY. AC"R" CERTIFICATE OF LIABILITY INSURANCE DATE 09/1111//2025025 Y) 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 Krystal Cyphers NAME: Brown&Brown Metro,LLC PHONE (856)552-6330 FAX (856)840-8484 A/C No Ext: A/C,No 10 Lake Center Drive E-MAIL Krystal.Cyphers@bbrown.com ADDRESS: Suite 310 INSURER(S)AFFORDING COVERAGE NAIC# Marlton NJ 08053 INSURER A: Southwest Marine&General Insurance Company 12294 INSURED INSURER B: Selective Insurance Company of America 12572 Green Hybrid Energy Solutions,Inc. INSURER C: 11 Washington PI E INSURER D INSURER E White Plains NY 10603 INSURER F: COVERAGES CERTIFICATE NUMBER: 25-26 MASTER No NY 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 AUUL tit.JLIK POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER MM DD YYYY MM DD YYYV LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1.000,000 CLAIMS-MADE Fx_�OCCUR PREMISES Ea occurrence $ 100,000 MED EXP(Any one person) $ 5.000 A GL202500015127 02122,2025 02/22/2026 PERSONAL&ADV INJURY $ 1.000.000 GENTAGGREGATF LIMIT APPLIES PER GENERAL AGGREGATE $ 2.000,000 POLICY ❑X PRO ❑ 2.000,000 JECT ❑LOC PRODUCTS-COMP/OP AGG $ OTHER $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1.000,000 Ea accident X ANYAUTO BODILY INJURY(Per person) $ B OWNED SCHEDULED S 2532098 02/22/2025 02,/22/2026 BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY Per accident X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 2.000.000 A EXCESS LAB CLAIMS-MADE EX202500001784 02/222025 02.'22/2026 AGGREGATE $ 2.000.000 DEC I I RETENTION$ $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY Y/N STATUTE I I ER ANY PROPRIETOR/PARTNER/EXECUTIVE ❑ N/A E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS LOCATIONS VEHICLES (ACORD 101.Additional Remarks Schedule,may be attached if more space is required) 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 AUTHORIZED REPRESENTATIVE Rye Brook NY 10573 @ 1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(20161/03) The ACORD name and logo are registered marks of ACORD Docusign Envelope ID:6EF9431F-1286-4F2C-9414-OB6E2EC182EO YORK Workers' CERTIFICATE OF STATE Compensation Board NYS WORKERS' COMPENSATION INSURANCE COVERAGE 1a.Legal Name&Address of Insured(use street address only) 1b.Business Telephone Number of Insured Green Hybrid Energy Solutions Inc. 914-949-4900 11 Washington Place White Plains,NY 10603 1c.NYS Unemployment Insurance Employer Registration Number of Insured 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 27-2994933 2.Name and Address of Entity Requesting Proof of Coverage 3a.Name of Insurance Carrier (Entity Being Listed as the Certificate Holder) New Jersey Manufacturers Insurance Company Village of Rye Brook 3b.Policy Number of Entity Listed in Box"1a" 938 King Street W43404-3-25 Rye Brook. NY 10573 3c.Policy effective period 7/31/2025 to 7/31/2026 3d.The Proprietor,Partners or Executive Officers are x] 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"Y insures the business referenced above in box 1a"for workers' compensation under the New York State Workers'Compensation Law. (To use this torm, 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: Danielle Polonczyk Print name of authorized representative or licensed agent of insurance carrier) ocuSigned by: Approved by: Vatn at, uO"/ L 7/2/2025 18n6e85PS4WLke) (Date) Title: Insurance Broker Telephone Number of authorized representative or licensed agent of insurance carrier: 856-552-6330 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