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BR(�v� VILLAGE OF RYE BROOK
04 938 King St Rye Brook,NY 10573
W
Q Phone:(914)939-0668 1 www.ryebrook.gov
Building Department
Mechanical Equipment/(New Installation) Permit
Permit Set 938 KING ST P#RB25-0154 R#129.68-1-14
PERMIT INFORMATION
Address Permit number Date issued
938 KING ST RB25-0154 12/08/2025
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 2-3
Required Inspections 4
Application Materials 5
Contractor's Liability Insurance,Contractor's Workers Compensation Insurance(Showing Rye Brook 6-7
Cert Holder
Westchester Home Improvement License 8
Application Materials 9-13
Building Inspector Stamped&Signed Set of Plans 14-21
Application Materials 22-23
Electrical Permit Application 24
Mechanical Equipment Permit Application 25
Building Department.938 King St Rye Brook,NY 10573/Phone:(914)939-0668
�yC BRnv� VILLAGE OF RYE BROOK
938 King St Rye Brook,NY 10573
W �
Q Phone:(914)939-0668 1 www.ryebrook.gov
>���• 1 b2•`i�O 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
3'
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)
BUILDING DEPARTMENT
VILLAGE OF RYE]BROOK
938 KING STREET RYE BROOK.NY 10573 NOV 12 2025
(914)19-0669
\i%,\k.tyctkrookm.,gov
ELECTRICAL PERMIT APPLICATION
Westchester County Master Electricians License Required
FOR OFFICE USE ONLY 13N EF
Approval Date: Permit Fee: S
Approval Signature: Other:
i####tt##i#ttit#ft#iitiii►•ttifiiii►#►iiti#fi►iitftiiitifitt###f#fii####tf##i##ii#iit#i►if►ii►►►►►
DO NOT START WORK or CONSTRCCTION UNTIL A PERMIT HAS BEEN ISSUED BV THE BUILDING INSPECTOR.
THE ADMINISTRATIVE FEE FOR WORK PROGRESSED OR COMPLETED WITHOUT A PERMIT IS 12%OF THE
TOTAL
��''COST OF CONSTRUCTION WITH A MIN I%I M FEE OF$750.00
Application dated,NIN ,his 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.
1.Address: 132 & 11Q. TQ� tale- NY 1U>73 sBL: 2q.(a8 -I -l4 zone:
2.Property Owner: lI E tilprL-- Address:
Phone#: Cell#: email: n
aster Electrician/Licensed Installer:AA1 UPI� �tt 11 WMiJIM tl�X•�Address: .211 WIfS U . t'r ha,[ � M3
CLimpany
.#:,A41 Phone#:1q1� �"�`1��IC I Cell#: email: ill V���, (,tiIJA -ba
Name: Jchtl NI• }{QYT1t — Address: ZIA NtIft�a(]jr �(, tNy Mu
4.Proposed Electrical Work/Fixture Count: Lh lw 50 hiYIP hL R41kfg,ikyit g (3)3-C Amp
��1��ll.a� �1) �.c.�n� �c��t���rr, ��d ►►�n1Lt1��>� n��r�>y Lp.Y —
5.31 Party Electrical inspection Agency: ~ GINA M.OTT
MoNry u tc Staie oT New Yon(
-
No.01 OT6282436
«*,tt«!►w«r*:r*t«««+*«*t««««►r«*t*t*tt««t*,t«t«*«t«««**#*«*r«««t►**«ttt«t;*t*a1t itm rt«««st«rt•
STATE OF NEW YURK,COUNTY OF WEv E � ) as:
My Commission Expires
TI h �yl ,being duly swum,deposes and states that he/she is the applicant aWve named,and does further
i�nnt nwnt P tndivtduat agn' • s iltc applicant i
state that(s)he is the M for the legal owner and is duly authorized to make and file this application.
i%tauc I lvor-oan Ltcen W In.talicr)
The undersigned further states that all statement.-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 do Building Code.the Code of the Village of Rye Brook and all other applicable laws,ordinances,and regulations.
Sworn to before me this Sworn to before me this
day of ,20 day of .20
Signature of Property Owner Signature o Ap licant
Print Name of Property Owner Pri t ame of Applicant
11
Notary Public Notary Public
6 1/2024
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AI RQQ SMITEH Nov 12 2025
.*es n right the hra n
November 5,2025
Village of Rye Brook
ATTN:Building Department
938 King Street
Rye Brook,NY 10573
Re: New Cingular Wireless PCS, LLC("AT&T")Construction Permit Application("Application")for Equipment Changes at the
Existing Wireless Telecommunications Facility("Facility")located at: Site Address-938 King Street, Rye Brook,NY 10573/
FA##: 10107450/PTN:2191 AI ERRL!Site Name: Rye Brook/SBL: 129.68-1-14
To Whom It May Concern:
Airosmith Development is an authorized representative/agent for AT&T Mobility. AT&T is a Tenant at the above noted site and is
seeking to modify its existing telecom installation. We are submitting this application as an eligible facilities request under Section 6409.
referenced below.Please find enclosed the following documents in support of our amendment application to revise the building permit:
• Building Permit Application
• Electrical Subcode
• (3)Copies of signed,sealed construction drawings
• (1)Copy of the Fit Analysis(is a single page document)
• COI with Worker's Compensation and Disability insurance from the General Contractor
o Nett expire ii H3t3025. Art apdated copy#yes heew fegnested•at +viiF be i►y e-
received CLUAV(!�1 Qa1d,In(.1u0 U FdI 10���1Ni1h�1\T�'UWW141 M
• Westchester County Electrician License copy from the lectrictan.
• Note:permit payment will be remitted for Construction Permits upon receipt of written request from the Village.
Section 6409 of the Federal Middle Class Tax Relief and Job Creation Act("Section 6409")was adopted in 2012. Under Section
6409,your city retains discretionary zoning review over the construction of new towers,but simple collocations and/or equipment upgrades at
existing telecommunications facilities must be approved. The new law provides that:
"a State or local government may not deny,and shall approve,any eligible facilities request for a modification of an
existing wireless tower or base station that does not substantially change the physical dimensions of such tower or base
station."
The federal law defines an"eligible facilities request"as"(A)collocation of new transmission equipment:(B)removal of
transmission equipment;or(C)replacement of transmission equipment."
Also,the Federal Communications Commission issued a Wireless Infrastructure Report and Order on October 17,2014("FCC
Order")which established regulations that clarify and streamline the municipal approval process for eligible facilities requests under
Section 6409.A copy of the FCC Order is enclosed herewith.
The FCC Order clarifies that municipal review of an eligible facilities request is limited to determinist;�%hether the request falls
within Section 6409:
"a State or local government may require the applicant to provide documentation or information only to the extent
reasonably related to determining whether the request meets the requirements of this section[Section 64091. A State
or local government may not require an applicant to submit any other documentation,including but not limited to
documentation intended to illustrate the need for such wireless facilities or to justify the business decision to modify such
wireless facilities."47 C.F.R. 1.40001(cX 1)(Emphasis added).
The FCC Order also specifies that the term"base station"includes any structure that"supports or houses"communications
equipment. Since this structure already supports communications equipment,it is considered a"base station"under Section 6409.
AT&T's Application Ls an Elieible Facilities Request under Section 6409
AT&T's application qualifies as an eligible facilities request under Section 6409 because the proposed installation involves"a
modification of an existing wireless tower or base station that does not substantially change the physical dimensions of such tower or base
.tation."
318 West Avenue,Saratoga Springs,NY 12866 ,,�,�„•^d WOSB
Office 518-306-1733-Fax 519-306-1711 l✓I�K 7�
www.airosmithdevelopment.com
A I ROO SMITH
DEVELOPMENT
Y*&rt,pM Hr i-i-
As shown on the plans prepared by B+T Group dated October 28,2025,AT&T's proposed installation consist principally of the following
elements:
• Remove and replace(6)antennas
• Remove and replace(6)triplexers with(6)diplexers
• Minor ground work changes to support the new tower top equipment
Accordingly,AT&T's installation involves the"replacement or transmission equipment-/'removal of transmission equipment"that
will not increase the height of the installation nor the dimensions of the equipment compound. As a result,the installation"does not
substantially change the physical dimensions of such tower or base station." Therefore.these proposed equipment upgrades constitute an
..eligible facilities request"under Section 6409 and must be approved.
timeline for Review and Approval
We would like to highlight an important timing requirement for processing this application. The FCC Order determined that a
in unicipality must act on an eligible facilities request within sixty(60)days of receiving the application. 47 C.F.R. 1.40001(cx2)
(Emphasis added). (Note,the sixty(60)-day period is also known as the"Shot Clock"). Thus,the city must approve this application within
sixty(60)days of its receipt. The FCC Order provides that upon a municipality's failure to act prior to expiration of the Shot Clock,the
"request shall be deemed granted"and AT&T will be legally entitled to proceed with construction. 47 C.F.R. 1.40001(ex4)(Emphasis
added).
Note that the FCC Order does allow the Shot Clock to be tolled if an application is incomplete. However,in order to do so,a
municipality must provide written notice that the application is incomplete within thirty(30)days of the submittal. 47 C.F.R. 1.4000l(cx3►(i).
The notice must"clearly and specifically"describe the missing documents or information,47 C.F.R. 1.40001(ex3)(i),and,as previously
mentioned,such documentation must be necessary to the determination of whether the application qualifies as an eligible facilities request. If
the municipality requests additional information after the first thirty(30)days have passed,we will still provide any"reasonably related"
information allowed under the FCC Order,but the Shot Clock will not be tolled.
In light of the foregoing,AT&T respectfully requests that its proposed collocation be approved. In the meantime,if you have any
questions,please feel free to call or email me. Thank you for your cooperation.
Sincerely,
n
II
Tiffany Street
Site Acquisition Specialist 11
Airosmith Ue%elonrnent
Alrosmitb Development is an uuthurized repre wnta/ity ul".4TA 1'iluhilitt-
318 West Avenue,Saratoga~print;,, N1" 12866
(805)701.3905 cell
tstreeha_airocmiIhdc%e lop men1.com
Enclosure
2 � !
Docusign Envelope ID 7AF1D598-725D-4B13-8210-994C59AF50F9
NOV 1 2 2025
at&t
August 2 l st,2024
Airosmith Development
318 West Avenue
Saratoga Springs,NY 12866
RE: New Cingular Wireless PCS,LLC("AT&T Mobility")
Letter of Agency
To Whom it May Concern.
On behalf of AT&T Mobility,this Letter of Agency provides written approval for Airosmith
Development Inc., its agents,employees and contractors to negotiate and apply for any necessary
permits or any other approvals which may be relevant to the completion of this project regarding
a telecommunications facility.
Should you have any questions or concerns, please do not hesitate to contact me at (716)393-
7768. Thank you for your time and attention to this matter.
Sincerely,
0m.s.0—d by ,�^
ttLrSSA St^t� �"tvj"
r.EId"BaWa1-M
Melissa Semidey Finley, Esq.
Associate Director-Network Design Engineering
AT&T Mobility
Mobile: 716-393-7768
ms329vg?att.com
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�f✓Li �` VILLAGE OF RYE BROOK
BUILDING DEPARTMENT NOV 12 2025
938 KING STRFET,RVE BROOK,NY 10573
(914)M3940668
www. Wbrooknv.eov
APPLICA'HON TO INSTALL WIRELESS OR ATTACHED WIRELLSS
TEL-COM FACILITY OR EQUIPMENT
(Special Use Permit Required for Initial Approval)
OFFICE USE ON'
NOV 2 4 2025
Permit#: Building Inspector:
Application Fee:$_ _ _ Date of Approval:
Permit Fee:$ — NYS Use Class:Res.( );Comm.( );
B.O.T.Approval Resolution Attached: Other:
Application dated, �)�( ;I(C>t?,{t� is hereby made to the Building Inspector of the Village of Rye Brook for a Permit to install a
Wireless or Attached Wireless Tel-Com Facility,or to install new components to an Existing Tel-Com Facility in accordance with
Chapter§250-39 of the Code of the Village of Rye Brook.The applicant,by signing this document declares that all devices,and
equipment associated with the subject permit will be continuously maintained&utilized in conformance with all applicable Local,
County,State&Federal laws,codes,rules and regulations,and that any work performed in association with such installation(s)will
also be in conformance with such regulatory standards.Please attach copies ofall FCC,orotherrequired testing,inspection,regulatory
or maintenance reports hereto. tit
1.Site Address: ' W '1(/� !Wt. � E' �Vy (OC 1, SBL: (��, Zone:
2. Property Owner: I jk�ha�,Q�UQ V:YD(L Address: 13g t!114PA &J. �1A�WW�-,N 0CAJ
Phone#: Cell#: email:
mw N C FrrVA t
3.Applicant fE � Let Address:RJR MjfAVMjV NNr�Lhal jVj IjW, N� 12�t'o4
Phone#: Cell#: XDS)l0I 3�'IDJ email:tjbRt,jN(OsmtjljAeLetMfl ,Lom
4.Installation Contractor: bCT Address: 12D- II 21 11418
Phone#:(119)GC2.-b21C2 k I t7(o Cell #: ('12(f)402-g 7lC_) email: tlfYliY)il r��Lt-- Ylet
5.Carrier(s):
6.Type of Equipment:
7.Location of Equipment: W&IA ij k�L kp�(ulij lmu 2a Q'W'1 11`m'y
8.gqEstimated Cost of Installation:
(NOTE The esumated cost shotl include
all labor.ntatenak.fixed cywpnan..catluldutg.professional Ira.and any labor&material.�Olich may Ix doitnttd gratis.)
9.Estimated Job Duration: Start: q l►! -� Finish:
6/tn024
STATE OF NEW YORK,COUNTY OF ) as:
(phni name of individual signing application)
being duly sworn,deposes&states that hpishe is the applicant of record above named,and that he/she is the legal owner of the subject
property,or that he she is the�ftA t TJkVAJ acting as agent for the legal owner and is duly authorized to
make& file this application. (Indicate architect attomey.contractor.etc. )
That all statements are true to the best of his/her knowledge and belief.and that any work performed or use conducted at the subject
property will be in conformance with the details as set forth and contained in this application and in any accompanying approved
plans,as well as in accordance with the New York State Uniform Fire prevention&Building Code,the Code of the Village of Rye
Brook,and all other applicable laws,ordinances and regulations.Sworn to before me this Sworn
n to before me this tL
day of , 20 day of NnVPm�&Y ,20__,�Q,5 _
Notary Notary
i
Signature of Property Owner Signature of Applicant
Pont Property Owner's Name Pnnt Appl s Name
GINA M.OTT
Notary Public-State of New York
Ito.Ot OT6282436
Oualified in One o y
My Commission Expires - i�
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 andlor not properly
signed shall be deemed null and void and will be returned to the applicant.
Please note that application fees are non-refundable.
6/1/2024
-2-
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
129.68-1-14
Proposed Electrical Work/Fixture Count 3rd Party Electrical Inspection Agency
9-50 AMP DC BREAKERS, 3-35 AMP DC BREAKERS, 2- SWIS
20AMP DC BREAKERS AND 1-5 AMP DC BREAKERS
Master Electrician/Licensed Installer Information
Name Lic# Address email Phone# Cell#
JOHN HERRICK 341 219 WOLFS LN INFO@ALLELECTRICAL.BIZ 9144945101
Company Name Company Address
ALL COUNTY ELECT&INTEGRATED SYS INC.
Address of Work?
Homeowner Information
Electrical Permit Application,page 1/1
4P �
Mechanical Equipment Permit Application Village of Rye Brook
' 02
938 King St Rye Brook, NY 10573
Phone: (914)939-0668 1 www.ryebrook.gov
Building Department
Project Information
Scope of Work: If Other, please specify:
Other Remove and replace
Type of Equipment: Location of Equipment: Cost of Equipment including Installation
Remove and replace 6 antennas and Within flagpole concealment stealth Cost:
remove and replace 6 diplexers tower 25000
Mechanical Equipment Permit Application,page 1/1
AG�R� CERTIFICATE OF LIABILITY INSURANCE DATE(MM
111/05/2025_
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 INSURERIS). AUTHORIZED
REPRESENTATIVE OR PRODUCER AND THE CERTIFICATE HOLDER
IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policyliesi 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 ` Fatma Shamsi
ROYAL STAR INSURANCE BROKERAGE CORP °NOjii�NEN. 718 205-2900 718-205-4600
98-09 Asturla Blvd s amsfCDaro a starfnsurance.n c
Flushing, NY 11369 INSURERISi AFFORDING COVERAGE NAIC0
GREAT AMERICAN RISK SOLUTIONS 35351
DIGITAL CONSTRUCTION TECH INC INSURER 0 NATIONAL SPECIALTY INSURANCE CO 22608
120-11 89th Ave INSURER C CENTURY SURETY COMPANY 36951
RICHMOND HILL, NY 11418 INSURER 16754
INSURER F Y OF LONDON 1579r-
-907r-1
COVERAGES CERTIFICATE NUMBER REVISION NUMBER
!HISS TO CERTIFY THAT THE POLICIES OF INSJRANCE ..-E-^.BF,-'A— E BEE%c" .,EO TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
NDICATED NOTWTHSTANDING ANY REOUIREMEN7 TERM bR L N Co A,.. _-N'RACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POUCIES 3ESCRLBED HEREIN 6 SUBJECT TO ALL THE TERMS
_wCLJS+ONS AND CONDITIONSOF SUCH POUCiES LIMITS SWNA MAY HAVE BEEN REDUCED Br PAIL: AAAS
-• 51 -R TYPE OF INSURANCE v _V-`-
X COMMERCIAL GENERAL LIABILITY EACH OC RRENCE f 1,000,000
CLAIMS-MADE El JCC_GPREMISES fjin-a�i $ 50,000
MEC ExP AnwcIIII pew, f 5,000
PNYE784189-03
I'13/2S PER NAL a ADV N;�R f 1.000.000
— EGATE LIMIT AG>L'-FE- ENERAL A REGAi f 2,000,000
DPRO. ❑L" PRODUCTS- OMP/OP AC.Q. s 2,000,000
- `JMOB+LE LIAai,�T+ f J6,VW%P,000
X ANYAUTO BODILY INJURY(Per Potion) f
Cve'; M SCHEDULED CAR3100000076-3 9/14/25 /14/26
ALIT". PrLY AUTOS 7 BODILY INJURY(Pot ecoOMR) f
IYRE:. N)NAWNED f
AUTOS ONLY AUTOS ONLY
f
UMBRELLA LJAS x OCCUR EACH OCCURRENCE f 5,000,000
C X EXCESS LIA9 ua DE Y Y AGGREGATE S 5,0 , 00
CCP12331634 11113/24 11/13/25
WORKERS COMPENSATION H.
AND EMPLOYERS LIABILITY
ANY PROPRIETORMARTNERrEXECUTIVE
OFFICERAI48MER EXCLUDE01 N.A E�.EACH ACCIDENT f
(MeIldMary M NN) E�EA EMPLOYEE f
R deeatbe Lndw
2ND EXCESS PES-XS-01-3327 11/13/24 1/13/25 EACH OCC/GEN $ 5,000,000
E PROFESSIONAL LIABILITY Y Y ANE5120990.25 3/28/25 /28/26 EACH OCC/GEN
$2,000,000
F DISABILITY I I ILB6045000 3/11/25 �/11/26 STATUTORY LIMIT
••F!IONOF OPERATIONS'LOCATIONS VEHICLES(ACORD 101 Addoonal Remens SCIwAM May beeaecnedF muespeunrew,ed}
AS PER ALL POLICY TERMS CONDITIONS & EXCLUSIONS CERTIFICATE HOLDER IS NAMED AS
ADDITIONAL INSURED, ALL LOCATIONS ALL COVERED OPERATIONS.
R,.
VILLAGE OF RYE BROOK
938 KING STREET SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF NOTICE WLL BE DELIVERED IN
RYE BROOK, NY 10573 ACCORDANCE WITH THE POLICY PROVISIONS
AUTHORIZED REPRESENTATIVE
O 1988 5 ACORD CORPORATION All rights reserved
ACORD 25(2016/03) The ACORD name and logo are registered marks of , ORD
row Workers'
"°ATE Compensation CERTIFICATE OF
Board NYS WORKERS'COMPENSATION INSURANCE COVERAGE
I a.Legal Name&Address of Insured(use street address only) 1 b.Business Telephone Number of Insured
Digital Construction Tech,Inc. (718)502-6262
dba Digital Construction Tech,Inc.
Ic.NYS Unemployment Insurance Employer Registration
12011 89th Ave
Number of Insured
Richmond Hill,NY 11418-3235
York Location of Insured(On/Y required if coverage is specifical/p I d.Federal Employer Identification Number of Insured or
limited to certain locations in New York Srate.i.e.a Wrap-Up Policy) Social Security Number
814767884
2.Name and Address of Entity Requesting Proof of Coverage(Entity 3a.Name of Insurance Carrier
Being Listed as the Certificate Holder) Continental Indemnity Co.
Village of Rye Brook 3b.Policy Number of Entity Listed in Box"I a"
938 Icing St
Rye Brook.NY 10573 46 369707-01-07
3c.Policy effective period
Attn: Project Manager
04A)8/2-5 to 04108/26
3d.The Proprietor.Partners or Executive Officers are
X included.(only ch«ltkniraaportnaxk rcenmckWedt
all excluded or certain p:rmem/officem excluded.
I hi.certifies that the insurance carrier indicated above in box"3"insures the business referenced above in box"la" for workers'
compensation under the New York State Workerc Compensation law. ITo use this form.New York(NY)must be listed under
Item 3 on the INFORMATION PAGE of the workers'compensation insurance policy). The Insurance Carver 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 orw-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 he
named oo a permit,license or contract issued by it certificate holder,the business must provide that certificate holder with
a nv% Certificate of V►orkern'Compensation Coverage or other authorized proof that the business is complying'Aith the
mandator} coverage requimments of the New York Stale Workers'Compensation Law.
I. nder penalty of perjury,1 certify that 1 am an authorized representative or licensed agent of the insurance carrier
refervneed above and that the named insured has the coverage as depicted on this form
1ppro,6ed b_-, •Fodd Bro%n_
(Print namc t IH rnA'd rcprcscntative tw licenceci agent of insurance carricv)
Approved by: 07/24/2025
(Signature) (Date)
Title: Authorized Representative
Telephone Number of authorized representative tw licensed agent of insurance carrier. (877)2344424
Please Note:Only insurance carriers and their licensed agents are authorized to issue Form C-105.2. Insurance brokers
are NM authorized to issue it.
C-105.2(9-17) www.wcb.ny.gov