Loading...
HomeMy WebLinkAboutRB25-0052 NCN C O 0 a' O L CL Y Q O C E -0 a Ln O C1 C C Ln C C) 11 -0 ca C) O � d0 C Q CL 7 a+ cu � C1 W = m ru C`i CL a w E - LL X 0 L11 W o c/) H a v 00 v co 0 F.. . 0 W u v v s N W t Y O W Lr)E N = N 3 LO Y L O F~- Z = M > c3 QZ Q0 c ; U = y O a a �o o c DYY H W 0. ° Y � 'c O �� O V) g � oC � Z (� N I-) d m a0+ 0 $ y -0 v -i W i J O J N o a o >m } Ln � g a m � N O aZ 07 - cmc•o t m c Q a Y v 3 O Z of u CA j w — W p w w \ o M 0 0 U Q a f0 2 _ = L Q ~ �O t�i� v x �i 00 can a Y ° v U _ W m 0� •� O t I 5. Z Q W .`. o �o Lai Z (M �j a Q r-I � O W v — �O U � v , � M 0W WCOu -0� a Ca3,v OO r-1 W A N m m E o w a, wO � o� c~nao � a � ? s mw •� N C 0 a„ J N a 0 } o on cci J W = J Q � E- � m- G o v m N � = 0 --- - Cl N 00z � w ° mo } w cv� 324 F- � a N a, � o w n Z Ln O a0 cu E 3 m Ori CV C• W ^ QC F- Q W to `c y Q Lr) L c I 2 N r-i C14 0 - o L E '� o v m � pp0 � v any O o t-0 c v E W � ooa Q n V � � � � oRa = ' � 09 E C�EWyp� 0 .0 °� > � a� c Inc co p c � � o ° oEuu o � cev . yp�9d1��C a Q a a 0 a ►!- v L U 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 27000 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 124.72-1-12 PUD Classification VB Type, kW&Location of Array: Rooftop installation of 23 solar panels (9.890 kW) Occupancy; (1-Fam, 2-Fam, Commercial, Pre Construction: Post Construction: etc...) 1 Fam 1 Fam If building is located on a corner lot, which street does it front on: No Construction Type Located: If Other, please specify: Other Solar Panels Number of stories Roof Style (hip,shed,mansard, etc...) 2 Will a New Roof Be Installed: (a separate roofing permit is required to re-roof an existing uilding.) ❑ No 0 Yes Roofing Material& Number of Layers Asphalt shingle 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? 0 No ❑ Yes Will the proposed project require a Site Plan Review by the Village Planning Board as per§209 of Village Code? 0 No ❑ Yes Will the proposed project require a Tree Removal Permit as per §235 of Village Code? 0 No ❑ Yes Does the proposed project involve a Home-Occupation as per§250-38 of Village Code? 0 No ❑ Yes Solar Permit Application,page 2/2 BRnv� VILLAGE OF RYE BROOK ■. 938 King St Rye Brook,NY 10573 }❑? •� Q Phone:(914)939-0668 1 www.ryebrook.gov >���• 1 82• Building Department Residential/(Solar) Permit Permit Set 11 FELLOWSHIP LN P#RB 25-0052 R#124.72-1-12 PERMIT INFORMATION Address Permit number Date issued 11 FELLOWSHIP LN RB 25-0052 10/07/2025 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 Application Materials 4 Application Materials 5-23 Solar Permit Application 24-25 Building Department.938 King St Rye Brook,NY 10573/Phone:(914)939-0668 BR(�uk VILLAGE OF RYE BROOK 938 King St Rye Brook,NY 10573 W � Q Y Phone:(914)939-0668 1 www.ryebrook.gov >���• b2• i�o Building Department INSTRUCTIONS THE PERM IT HOLDER AND/OR PROPERTY OWNER IS RESPONSIBLE FOR ENSURING THAT ALL REQU IRED/APPLICABLE I NSPECTIONS ARE SCHEDULED AND THAT THE PERMIT IS COMPLETE 0` Ai REQUIRED INSPECTIONS Name Description Final Electric Final Electric Framing Construction of all structural framing and stairs.(Rough Plumbing and Heating passed and doors,windows& roofing installed.)Engineered drawings must be provided for roof trusses. Certificate of Occupancy Completion of ALL Work,All fees Paid and Final Survey in if required) I' Aav�rowasr'r ArrouaLoo,lac. Board o/Dtrrctors '.S BPIJr Fair Blvd. RP Brook.X I IPS': August 22, 2025 BelleFair Architectural Review Board 11 Fellowship Lane Rye Brook, New York 10573 Alex Patchen Re: Application for Solar Panel Installation at 11 Fellowship Lane Dear Mr. Patchen, The Architectural Review Board (ARB) has reviewed your application for the installation of solar panels at your home located at 11 Fellowship Lane, Rye Brook, NY, and we are pleased to inform you that your application has been approved. Please remember that this approval is also expressly conditioned upon your continued compliance with all other aspects of Schedule D of the Declaration. As a friendly reminder, some alterations also require approval from the Village of Rye Brook's Building Inspector or Engineer. You are responsible for obtaining all necessary approvals and permits. The Village of Rye Brook will only review applications after BelleFair ARB approval has been granted. Please note that while ARB approval is required, it doesn't eliminate the need for Village of Rye Brook approval, and vice versa. If you have any questions, please don't hesitate to reach out to us. Very truly yours, The BelleFair Architectural Review Board 00L£'Ooz(M)L:Hd s 0£4LO rN'HVMHVW oew• " a�,, j ZL-L-ZL'OZL:#NdV Q oozz 3Ll1S W 31dUodao3 SLS 3 Qo '� n„ MG-M(LL6):3NOHd A5M3N3 AMUNl £LSO L AN'NOOa9 3A21 \\��� '3NVl dIHSMOIIaA L t ¢ X d Yul �"\� ILJ f s• £ � 30N30IS3N N3HOlVd X31V " d N 9 i w - Q o Lu a O N W z¢O~ / W �N JU �OF ..•may , a0 MFWr0' 6 .0 0 w�w ¢ aOz~OO N a y y�� I c;' .0 LL Z Z U NmQ yK Z 3w U `=iH + CO {, _h C) L)hZ6 .� , v f / w $ �FF� � W0000 .. ,� pt W =o� e �rye �Nm. x�~z r N a t M a �aaaaH:��,wwwo ; o og� Cl) . .:._ O 0 O (n } w z No =U O ` a� � z Cl) o m `,\ `` '^\cc I w C VvJ oJS� '' LL F z z Z L C F / LISm zz M C oo� J �� �\OLLJ Y ` LL LL OY ` Oy. U `� OEM \ Y b\ 4 F w z ,% J z a �\ Q w O < \`\ of O Ul 0 co � am m Rz d �2a�i � ,'RO Fow �r N L' o� w i 5 ' z %m`� `' �4zj uH H �Scw^i c�JZ HN w zm z� w coo zY � `maH ~�� mziwog w xoQ oo JS z 4 F m�i3 H� U; �wYo 44� h `b' U o o o q� PH-8U� owl Zoo � o & ova ' � EEw �o a N o 7aF5 8)` �i, FZI J d o �� U '0i O`nw ��a aa� �� `` 0� �8 � iao'o rc-- m O O mi F� 30 c9 SoQo zwy`a��F � FJS� 3� 5 �� �� -ooccc�.��� €QaQ a tii aw ww LL�c� Z p�t7iwF J o c4 >Zd ryk�ri U�a� F�z�Uw�'iiL �F 0�0� Y6 Z~ O w U O w LL z g< ij 6> 0 0 O fa n 0 a F Z 2 p K U O www02 W F Koo o a r Z g��z 3w LLzu'�`a2J moOOU � �`�oO�.mz _ oo>��3tV o4RRRR CL w r- a CL .-2a=_�aUna� 00 . . . DOLE- (M)L:14d ZL LZL'6ZL #NdV OE>LO fN'HVMHVW pQ' QY,p S Q 'oozzains'do 3ivaoda03SLS 3 eo e„ Mg-M(LW:3NOHd AN3N3 ALINUN1 i; i e y a £L90L AN')IOOUS lk1 l X E 3NV1dIHSM0113dLL �_ Q a f� Iau3f�tpijul — 30N3GIS38 N3HOiVd X31V y a cn cn UO LL d m N W WZ. Q JHM 7 O $ $ ae w U d �_m Z �C N LLJ = N o N (D i w N LLJ z to U) 0 ❑� < ❑� • g(gh}— fie � a z z IS al, �f 3M cc f=� 0 a: ZZ U O wQa cWiF �y Sw UZ�Z wZZ Z Q m O >> S Z F yy W K ZM = U a a O W a in a w 3 zz i U N QU O z w z J6 J Y, 4^, i 1IS o � O d y �p m c4 z LL ti 6 U �jw Lu 0 m $Quu'iFw ` Lu a•�S N " y5 Z 4 C g Q o= W 0 H �0 O N 0 o CL N 22_ ODLE-=(M)l:Hd 8 OE>LO fN'HVMH" {e e � ZL-I-ZL'VZl #NdV Q oozz�Llns ao aLVaodao�sLs H 3 Qo 'Z n VSLS ZV8(Lt6) 3NOHd+�au3AJE1 �3iNu3 lA�IuINlI AN—\I ' r;er s IoQ Qo°w € J� ; m = o Xo0iN � 3NVl dIHSM0113d l l LU ¢ dco 8 V•E L E �� 30NKIS3a N3HOldd X31V a C Y U') CO Ir- OU*) ti O_ Nt N cn O CV �O O CV O O o O — O CV (V O o 0 �— O 0 0 N CV N N fV CV CV CV N N N N N N N N GV O ^ N «M ~ v CN o n w W X z z O am cv w z Q J Y 1- Z O U3 Cf) *k J m ? � > � j a 0 U M N O N CLLI ) J w Q ¢ m CA ti 0 U Q J (Jj UCO Q ¢ v U - w F - O LU QJQ a z co O �7 LL O Q w oC cn w Of Q z � J cn Q Vn CDV) w J J W z N Cp W W J Z J W W J cn W X co > > > > > ::D Cl) = O CO F- �" CV CN Of W W 0 F— LU W F- J m Z Q W I-- fy_ O O Of Z v a a O UJ ~ w O o. m 2 0 Q W W z U CL Q g Q w ( co co m m � U V U m Q w(JIf - O Z Z C) Q W 2 W Z Q U) O J m � N OOLCbOZ(909)I:Hd g Of9LO fN'HVMHVW �P'I'• a �yg ZI-I-UTUINdV W w oozz3Linsa0RYvOdHOOSLs 3 'by t5L9Z48(LL6) 3NOHd �a m o V ADH3N3 AiWHNI 6 i a` t^4 3 N U901 AN N00aa lk2l = N X M 3NVl dIHSM0113d ll y o? Q 81.2 2 "\ s• E 33N3aIS321 N3H31dd X3lV a a s i iL �S ll ,' '► ' U) o ® ® o ® Lt, s i ®®®�� m ui U) BO a O LL U) h:r w cn w < Q Q O '^ 0L D D O Q r N _mc.w ■ . _ems dS=m ! | ! \\� ` MsL },\od r § _ ! k mom© ! ! t, m&a'OHB� a* , c ! — — 2 � ! KGwaA�ugw ,� if \ p § 3 mG2�1mHmq 21V CL G § )G % ( ( ) k \y — k 2 z ) fG ) 6 ±Z w * §\ ) \ \ z <( — ) \§ m } ®E « \) : x . x 0 \ Z \ % / \ ` I � I � . � I \ - \ Z - Z / y I x )6 ] 4 ^L ± / w% \k \ \ \ z ~ ® § c / \ ± 3 ` / ± / O 7 3 g � �z0S�o ,a§ / / 7 \� � ) ! / LU \ oga! Nfa+e§� / 3 f ƒ *§b�qƒe3k$ > 2 E � > � \ 2 ° L !.91z,t§b5% §�\ « / / � 2k p p,--b §� kk§= 4 < w §zl��° � R R m l2e2 ��p3a 2(Km§3 !§■�§sk2«;!E§«Raw■§ « 4 o ■a�lg 2��£e$a! k �Ai®�®��kk§l§� ; - u &k«3b«!»�z�2z§!!w ,® : OOLE-DOZ(909)L:Hd s DewfN'HtlMHVW �Pv'� ZL-L-ZL'4ZL:#NdV Y M 'oozz 3ilnS W 3LtlHO&103 SL9 I s Qo ' hSLS-Z48(LL6) 3NOHd ;� v ASHM AIINUNI § z s - ,m s £LSO L AN'NOON9 3AM € a N x I! 3NVl dIHSM0113A LL Q N /Djau3l�;lul�ul r Q v) N E � 30N30IS3d N3HOldd X31d a w u Z= rU w� Ow w> x� xo a C O I C i w z I W Z O O o O z ��a W Z O N U NO 0 w � ��- 0 Hag W �z G Z � G C l/1 I � F � mm �� ao rvN n� mm NNN wm v iZ �� L n a g nc c N c `c y _ c c c C N �W s o W X W ] R w W I S K 2 O ¢ ° N w C 3 J ❑ �u 0 0 0 U N Y N fn 2 ,:, ' Q 3 0 LLJ c N Y U Lu c Oy U aOC9 � c7N � w~ ¢w U 2 .. W J O ~ x x w m J m Z W O' J d a > J W (n N N l+f N t'f N �+I N ]W 'z :�H F ❑ ❑ Y F Q LL 7 F a o as W W W SSSS W W W J W W w tp W W W z ❑ z ❑ 'L qa z d 2 U N m g o! ❑m ¢ z z z z z z z z z J z z z 0 w W z � OE a: a0Y0o 000 000 000 00o Y Q J 3• O LL 3 m m OE co �L 6' 2 m w H N N N N N N N N N N N N NQ 6L Z a_ Q /Z vJ r OOL£UOZ(M)t:Hd e O£9Lo fN'HVMHVW P�' a �y ZL-l-U'VU:#NdV z 'oozz3linsaa3lvaodao�sLs „ $ '61 �e xn b OM-M(LL6) 3NOHd 9 Q 3e z F m � 2 C0 U AN3N3 A JNUNI 4 s Q C) _ s` s 6L90L A 'AMIS 3.1b ,,, — E 3NVldIHSM01133ll A Q x (A t\-D,;;i.]A;tUI UI — o �Y N p E b1s Ewe 30N341S3a N3HOlVd X31V Ii 0 c� Ckfz aLU a z a z ~ d Z Qw zLU Enw � g cn a m wz LLJ w w CnCO W Q w Wa Ow zz I— Z w LLI Q 2 � = aZ Q U r C� LU Z ¢ U Z N d = co (V 07 N � w0 t1 (h ~ Z Q 0 O 2 0 z z \ 04 cn F w ':ell� WOU w a Q LU UJ a J J Q ti N 26° Z ui o N o w O O m Q� o Q J 11 Cl) U OJ Q O � W F N O O O O H ° U W N o X U) CD CV LL O LL LU O CL O O N 1 = 0 Q U) OOLC-OOZ(SY8)t:Hd $ Of9LO fN'HVMHVW pP e .D ZI-I-ZL'4ZI:#NdV 0 'Oozz 3LIns-da KV80d'dOO SLs Z4B(L l6) 3NOHd W m V A'J1pN3 AIMIHNI i s t Q a 6LSM AN NO089 3A21 z 2 X " �� o; � INVl dIHSM0113A I L d o _ W E �JJU3I1;lUI�UI — !S L r`�LLLJ + lC pdg N E � 30NMIS32 N3H31Vd X31V a LU oa m 3 3 z� rn x x a: 0 Q z zy a m 2'awNu�",0 I zw O p W Y m Z $ U' r-- jljl. I H U N Q Q Q J 0.A 18 LL' 'L' I 0 H Q T m A H C.) m N gZ U LY Z I w w N II 11 II W O Z Q W 2 Z W 0 4� I C:J w W N N N z r v z 8¢¢a W O W LL 0 ;LL g�U Wr"ll Q N I VJW X X x cn <� w N>a��> �E { E { W W z O� �LL UWH �W r J Q O W Z!n?y J�N 1' W Lu Lu Co e cn Z = I W Z X N 1 O W J J LU co D �F QQ (� O m Q i Z J G I ~ Q Q Q W NW Z J? ¢ W U ao Z r W 9 r- w g!�a o �p J N P 9 $ O Z II II II z W F SL, Lj N 2_' l'7 I W�dJ I Z— Z Om O 0- e g C ON 2 LL O o F o m `} Z�ZQ W UU I U D(n r I S m� J I x x X G '�. N Z 7�J I a!- m LL QQ QQ w -~i W � w OzaC_i i W W o ci o N F w H J It L-�'Z _ Z G I 7 Q I W a x x x a (N N w Si r zr V U V U -�I Z O I W i d 0 0 m ------ < wiz y a gog mJ O O E�-a odaZ¢ I fr Z �=) Fx- �mH NW E I i E �rn E ¢ OSa W mm C w�P: of0 N O m0a ZX0 3� u it w n $ I A o_ E a j ��] r H w j K Z U W w N O o~ y a O p N U 6.6�� 2 U r a O m z LL Z m w z 2 w tyQ, U 8 z U a O,w U C U uj j z4 N W j p W Q Jmm LL J (n N H U Z Z O z 6 i a I ZCL N --I -- --I 0 LI1 (n LU Tu vJ� 57 am w z O o W Sa0� � 0 UJ H Z Y Y w z U K c� I I G ~ Z Q r= o� w I 3 o z it w N w f K I L J I I O } O Z J Q �n x __ _-_ Ir O b W d LL U m N a w w O Q 3 I uj Z F- � .Tz u�W 7 Q U o w �a �� �_ 00LE-00Z(S")L Hd f $ OULO fN'HVMHVW oP " ""alp ZL-L-ZL'4ZL #Ndb' C 'OOZZ31U1S�1031tliJOd210�SLS 3 eo '� tSg-M(LL6):3NOHd - V A'J113N3AlINIiNI £L90LAN'N00893AN € c° m E '3NVIdIHSM0113JLL w "\� IS• E'�` a 30N3QS3N N3HOidd X31V a 2 N U r r O p W K r p U U �2 a'U r =W =z N W 2 W O W W W .r W W ?z ��'-ar ZZZ2 Z oOr*pW?z On �� Fw —o8�, 20 0 WWU Ow ZZZU O Z U >UoOa ¢ zar 50; -0-y p W Qawt ww ma`br' W a ¢ az� w zm 3�=mpQww�w w oy0o W U p0 K m Q O z CCN V p O V 2 U ¢ 2 O W"p] W a N N 0 p W j m W O O zO O p p= 'zoo, W F w W z r W w w U W O W W W�LL W yZ = W<(Daw��(� U OU rr Y� W O W r m r Z W J U Z¢¢ 5 WW z W Q— z W F z N W W r O Z m Q `LL=Q LLO m J W^a W N P:W— �gUW w��a—,O a'N�N�aiv oin N OOn =—W'k`W O J- =m m W m Z fAa�nIODUY W W W W Np�arNa'� wo-?r O�rU am m¢ u�OSLL�wczw- W r N th e h tp W J ZpZ W ¢2 m 2 U Z O Z 2 W 2 m ¢cr 2 .p a' r 22 Q CD wrrr yp Z „ m� p rNr - 0�7 r < ww z a m 7 m w j Q W e m 0 Q W 1. Z =p K W m O z Ua OO Uw(na cW.70a' v2i WU' �U QQ U z0 Z^Q�TW F Z U p W Z pZ. Z ¢=Z C J J W z U W e S O W — Or m Q =S ¢U' m N Z K a Z m K ?O r w 0 U 2 2 p w U m Z O 1..5 r (� U' ZZn W Z� d W rn=1w F z22 05 Wm m0 Z U_LLJ wa'm�=-1 f/l J¢r —¢ ww� Z (n W W = VJr O �w� O m W W O x Z LL W r W 2 O W'Z p b U ¢o p w o gi 0 3 0 0 z w w r — a>y z WW w p m m U w ¢ O V w �`"xr F S�-+O w W �w> O mw 2 =ZU a U Z0 w a a =H w a Z~»U M to O— OugW O w F O Y U z W Z W p w ¢ w w p o > w 0 0 5 0 W w m �m-jrQ a s m w In W w VWi w O w U f cm.� ¢O w Z 0 N OU a O N O O O U 0 i W Z— O U p W Z p W W_Oz r=p U p w LL J-x�Q r 2 U m W W z¢ ywl O Z UZ W W a. CONLL¢Ott o =�`r000 Y W m W¢f2n ww �mJOz a U¢yZ �c� z �� OgF��z o�c�pz K2=W 2Wa�w wp>O Q Z W N J U W W r W am Z_ZZ m a'W W-�r U x wf O z CC Ow m s=W Z z W�z to�Z LL=z U N p Q O p U U r W U In z=W Z V O -z �= Npp00 mUw fnz Orpx W 2jvw K~per ¢>—wZ ¢ ZU�— y�U 2p�O m0 W�aO'.1W 8-Ep Nmwtza 0 mz�0 >t7 u=iN�W�O�3=mr�c70�Zpw c00(7Qp W O mp om�3w z wmU fA p r r O o x p W m r W Z Q Q w 2 m¢W r m. p o O W r p O �, W U w ZZ O w U w p o z J w a a p w r a o f z LL 7d F r z z x O w p¢ J JJ rC7QLLw W r W r¢= W =z W W U' 0 Z O¢W ZUw W.0 m ¢m�U �N W W W O zpw W=MLpMmO02Z,w¢O.'0 W._.0 in=Nd= OZ Zr zmrLaww W ca�z>W=U OZOrO=J—ate J W =zmal.7�i O iUz W O0 V Oa'z0¢>p" O¢a�w� $ $ Z=a qW �¢w— 2� ¢_C7rp=O� zomw Uw UYU pz0w>zwOOwUQxxwzxxO z0umi2w 0 W. z��'La�O> �'^JJ g2w-00' z J �c7amW��Uwz W<n¢z rrUOUNrz—rc0r po(n�=pJa LLa. O 0 N U w LL < U A W 2 y W W C.) (n r WU x OpW Q LL W Z 0 > pp FW-m�m 2mZ O r Za' Y�>O Z 4 wU' N W Q 0 N U. r O 2 W O Z J U J r oar o � o = zc0Enr OJ 7d�O v �� m0OCW7 4a UKzp a> �ZU' K Op�Z Ud a'�tV � KN �w0 Z < o f zO W z O Q =— LL �w x= W �nw0 z o U¢ p v 0 zd U r tr,w r 3 x¢ > w¢ W a s p ¢w z 0 wW w 0 g u�Wa m =z ¢y ¢a 2 W 3 r W=0 w x U w W r a=- 3 W U z H w v r W=¢U r z o r x z w O 9 < = W J¢ W W p¢ in w 00 Q O z 3 =W p W p m w> W. o z w 0 O r m m= zi '$ Nw— Zz W zz �= WZCWI�w o<agw W OMZW ,hmt ^ R $ ffi w=w z ��� mgw> Zg m�wzcxi �w 0z z? 3p LLF= U�r O z a d O�Y ¢W <W 32 0 6~g d p LL Z W a ¢J p m 2 J r fn QQ >> U<~ zz gi w to0>W 4 S o W m O p s K m m ;w K¢ ¢w J'o O a <F z W w r LL m o LL 3?w a J U w W z w O z 8 W w Z w �ww W �0 s Y w p� 4aUzxYm JrrO Jan ZOWw m a:q]' a W x r U V r Zp 2 w w o Zp(AU W fnUa a' Q�w w >a.,gw wOLL1 C7 -pQ Or>u> N ¢Z z a m m m— Z N w'm Q w te U o¢.`r'�X ¢O w p z¢0 0 N~ 0 rz¢p w w W O p f p O 2 0 w z wwwm0 Uyr �w >g'd crj z La LLg�wrz %zx0 < WO. r� r w a�nm�i W r a W w= a w ¢�g� w�r0¢ 2 -UU a i ga=^ zap w� ¢�c9�w zw (JW w �UprU Omw W W z rrOJ2z m ma °�ypprm� Ow-5-9 W-W ¢W O 0C7zz J _ QQ Ow— w J Gi—� rp-' O Zz.__. UU U W Z K U U 2 w ¢O z O W Z J U. r O W W>i z 0—W W U O Q Q W = i O V j W p m w m r w w a' — U m >O r Z �_r m W U U' p a� ZW U "�y zwwaZZ zpW Up1w-aaa W rZzxyF ��pwaO Oz ¢�J� O Z) (7 w H Orf�¢pOU OUOz¢ tlJ w6 W W KX qaw W W W UJm Z¢pH wa JJ O r U > < r wU' U F w> Q a r¢r¢U Z Z >—W H m O g z x r zd¢x r r Z m a 2 wm U 0 w O m r < ¢two; 0 2 w w wa w=mwwaUgr r =� wOC3 W5 00 m r Z. Z z�Q p m J m x Z w r z z`2 p LLl w Q p m r w z w J=o J W wFmOp�w���3 C70m U W a m[]�uri z r W UO W W U c7 K— U p¢O m 0 > m U' 0 O Q a C0 zO W>m S rwz��crioFza JOwzwwz�FLL=Loa z UQp=pry>z ww3¢ U K Z 2 C 7 Y U O U a' z L7 Z Q Z J V J—a•U 2=4<2 �g( w w J K d o z U p r N a J¢ U O a w Z z o O w a J¢m 0 O aw O O o ti a a m—m LL a 2 ayi dJa Si oM�¢QSza J¢� �a�Utnm �KKK as�uaia a- z z Z > W tV t7 a VJ N th OOLE-M(9")I:Hd a OeFLO rN'HVMHvw U-LZL'4Zl V NdV C OOU aWS dO 3iVaodaOO GLs 3 o m'i OM-M(L l6):3NOHd cO a AMR UNUNI � € 4 �'- € Z N m � 8` � V s z a ;�, a USM AN'NMIS 3AN z w E r E o o g 3NVl dIHSMOl133 l I g ¢ UJ E "'' L " ,E �� u a 30NMISMI N3HOlbd X3W li id Ub Za i¢ N INtll JINSMOII]A I I W� N?'l�QQ(( w o Sdm3 �LU M N W H O W N Zp..r F ~ Z K Z u. J d 0— ZKZWN�O�m J u+ zG L.L 0 > i VZ5 Z �J ~ V W po»z �mQJQ W� Q o m ~tea 0¢ OC�NVidZ��0 ?OW�-,o9o2�oS OQJ=J~)�~ap m O LLlLUidla'0m) NOZ Q W U w UO IL)a:�H Fg7zp UNZWOo> Ua u 0 Z Iw �n Cn20Q Z �aF4 U) p �0E— !2 KCajz Z��w wZp0woF co wsw Wm �0w0 L) w? Q Z� Fa— O O C N= >cli a F-U) U) 0O Z O Q' w W L�LI O 0 FO q W O Ta o O J QQ < F %S�5 w O f O F o O 11 ff��F LL �Wu°U bcwi°c� O W tlI<�$O W O5 -. mj OZ z i F FO3 QS y�f°g�Fu7o 'Lf� S��aUac�lzo S � �m ppZZZZ Z_Hp��l$p$lIz Wz" �5 F 2 J N 1 0,. 'Z Q�y K U W�g �- 3 3 3 wz3 zzi 'M �NCN� �^ • • ma OQ p0m yazym� KC OUZ=O ~ a W Z = Z z UI UOO Zw U j u W > HMO, °C W .�O � w n.a i � � 28 O z J2yUQ m OF w UaOyw� ° a c o °e5 5 �UZU�F i" a3i3� imaqm $°w a i` R"ro� '_" z�°5�g°k' ou i 11 5, Fwm�N yy�Jm �ry ti-' $§§ NOFgZB € � h �ap�po �^ � � ° x R t�o� •-yOOOy� J my��W JO¢ u W J OON SOU b O W W i 2 .0 A rrQ�� U b wZ=w UILU yJj>j 2 W 02 W U2 WQ Jam= JZ�j OwQWz JOZ= JZOZ� y?W W n m S U m W U W Q O< O= ZZ KK Kew m Z� m y. U��yUZ Shic SE�o=wwmc w a p • Q� �t � � a � � . . . . . . . . ... o ! ,: m N40 tK a; i i w � � . . .•... Mom .... S S E ' V m o .F En n y $ S a =E. c $ �E$� < « � a E " LU a o � d� � (� u p o r V y D u � IA H m •� N is �� � �_ L LL _ A' a f N x a. CD ZI- N z I . -R O va CV MI ,n CL 0 3.0a .a V< F7 0 ;F o Z Fu M ? : Cl)m ar e0 R n E e - 7 o m o� i E U E n u`U �yS F ° co p�p 3 • 8 E ° .. • W E ° T 2 s o Y m o 8 u z o w 2Cc o ; F t 8 g• y€ES i Y�i;; w �� � u i•. � _ � � S U C� E � � & ^ U d �u � 8 L��4�� i a m m ka o � o p /1L �EOE�g �a9�m �� o sCCY m .E E O '� c F 5 y •� m m � .•i W der g� j ctm� U O"bEU n ohm p ca SO n E 0U � d Z co (/W V ry gU=�„ `g. O1�E m � � � � aN � • S iYYJ =N g Y s ry try m 8 s otA • �OmC 3 "s y xx Yy U o o W •� � £ E �, g 73 d m x y �,� m � O E : S � 6 } PO N N Saa t c7a U S r • c : d ; $ S o O e a u E o ' �. 0 E .� a �a o N €g Q o � i g U c cr ° S Q f Z 7 m o E a X 0 r pJ 0 3 s g�0o0 goo ' g }o m g Eat T o �e S A a 3 8 Sg o X o $ m X m m p ? 4j 3 o n o o dl a3r8 �a4V 4 � _" U 5 6 u1 :n• a h m mm $ 4 �x $ 4 3 �g $ 4 0 a x ((( 3 8 E 4 o � a U _ o s e _ to 8 N e $ o o s n � b o O a U E a P .•4 O O 3 E g 1 a - & E o = E �° yam¢ E N r� 'U• „ U S a n $ _ 9i ,z„ 0U o LJ o o a d U 4 G & u i u u K k i 4 db U 4S4 s moo.E $ o < ` �i g U- � - � nt 00 = Ds I 8a - x x • e €� Rya •� �` - � �� • y;� a £ EpR� 0 c .S o o E �4 i o1. No5q R a '� Q ]sg• � io £ ii. ,I w 6; s-o 0�� � a N W I � �� � 0 •� Bjy o o n n u o 75- . o ffi S a E €L r 3 a p g t a U h b A • ,k� m o n• E0 ao a � •0 ,^ S l U U• UJ In m IS N v m O IOI NT vVi� Cffi i N o C N Y O m U • t L 7 �c oil U • C, L EE m m m L ti 0 m 3 m uo o o O mO m N V L Lryp o m y V) L' W t O n g(n 0U C C W T acid p Nm rmN m m m N V V E Nm p m m a a E N m W mW Co 0) O Z L fn D'C OU .n W aD C C N o W- y0j� ,QC' p E O W N O O Q 0 m r O C m m J^ ° a m m ` m O :G c m c7 �p �cn v c v m >y � �O w j O a C �N W< C (0 m N N m CU N N w >m`.-'CO L. Q c C N c C m m of C - NN >.0 >.0 ism m m cp � N � E w rn O a�m� O o� i} Q � � u om a V �� v � u °.N-6 n� n° 3 O` Ul m U 1. m > O � m a m Cl V o Y m > o > n nm o Q u-NiU) 0 m Qtn a acQ oQ oQ LJ o_ d �civ 0- dm` a mEcn3om me mC LL co 7 J C C C >+r. Vl (n > m m C N N O N O O O C N O N «. N m 0 O C L n -0 O � N m o c N Q a ; m � d E m C F w o r n� N �wcn mW �.Y o NN �� M c �c c : ry N E U a ] Q CD a N lC0 U d 'O y C n- m U . W OD N� E L c N E � E E° um a �J8 E € Cl) m U y s e,� _ m o N V m c m o L p p 5 ° y c y c UQ C 7 .ca, c m jn'C-0'Np ZO O O 0 0O O & (n O N W N Cw 6 m 0 m C. m �NF. o 8 95 0> y # `m u m 0 0 >c E r �2 E ll E d p 2-9 aQm ° Uwo (IJ cm N o c ��E am >cn F T Dm � In m m N�... m= m= Z w m 002 iD ^' N'D C c0 w `N 7 x N m OU m m L. y L J N m m w O O m m prp cn L L l( m C 0 N m w w O N N m to R U m F- m F m ! U N dO `cmo ¢�O mOW m SmNU � o 110 t➢a O V L J O O U) N N t0 N m c w U U U 2 W =W j .m > N c m U o co _ _ f ' to c N J> w Q W w p H uU) H u W W U o !z x 8 j S J N :D v � 'd o Q n?C D J 0] m LLl O C C m W N U L U L Q L !JC O 0 N L Q 3 N- m L 3 (n iC a) m U 3 9 D m m C )A f L Q� 2 C Z N� w m N m m Q T m O m C7 E M' EZ.� E M U m m �� o > E N E m 2 E >J m n c cv� r�9 -0 o o np a Q m r qq n N d a U d C) �a N uj� C m c mwX � Td m O c C w C E > O a O m � N c N.o 0o s nd - Em � `m c._ a -Q., i O cu = J W j r V U) y N N O C w s D_ C L T m U�i T m D O C U Q L` t an 0 � O y m )n r g d m Em L m" m�o6 D E u m d ° a LL cm o U TZ g oV m °� a °U m� v o -j m >> 0 r a 3 E? N N c I >L t o Q o 0 N rno c o E V o mL c m o- N a C m wor yp C90 °N-m Sn.6 `? S O� $m ,� m > m W3. J E m c > m `D o m� L° c ad Ta��i C7ma m� aNi m� m 7 °cm � cmi c E 3 o o t o o a° m= E o m m a -Oy E o v m d £ ° O aZ c° Q N W N a L o C)u y o E N o(n y N N 9 N m N N t V w� a<n ��p o 2� E �p� =.5 m cn c 5 ap dL c o E LL E C O N w ° E m o .0 0 T } d a, a m � O a- -0LL c [E Z w O n N E U N N N N C m S. N i' N U E O U O: J m 0 U O a1 N C 10 m CI D O j f W tiE Q) fi E J O a O U v h N m U 3 L O C J § d Q =O G p> O C � CL F-LL O Q . __N N c z o 76 C L O 'D° 003Eo a,Ln °' (D O m 0 O d W 0) a N OL N U C C N Z' c art. U N .0 -6201< U C O O LLI lNate, a oa o 0 . o��o d m3 d .E _ c) V v N VI T a C Ji u N C tT O C 01 U C 7 N IT N N J O T w C V E m tp N vt r .0 N O1 v O > o Y N$ o v y a o N n � o,rom m i uaf Od p m v m0 �3�3 co aaa " Y o m 0 0„ Cl 00Z rn u S � wh OcSco O m v 0 E _ `� L y u '° ] �m mE a! a O °' � L m N u pNvOi O N' NpN� wOf LO.is WyN ~ CO CO. Z C u C aT+ N N.N.7 vV t O QI C U 0 0 10 ate.. 3 j 0 N 0 0 � .0 o� °a£NS° H10 rn m o 0 vo m) °u u Mtn Q L N a n N rn 3 0 ± am T c . 0t C LL a w a y c ; m o rn C Cl30: c 3 N OY v O d o m a u c L L �, d0 u C Q 0 0. 3 p C O 0 u co > d E o U) V 0) m e o N 'u^E N � v a $ r- 0 t N O u m N T a'to c � Narca a . Oc � o ' Poi ca yLUc C _p1 C L N O N C '6 yi O. C n 0 3 U 3 Y U C 7 Of 3. 0 0 0 3 y o c :° N u j > E Q u N.E Q C a E Y�yd Cdm 3 rnrn V'n yU —~ lU— , YinO CT ' Q3m��jo lnQ0 T U j 7 o M o � OOOO O 0 O L O 0c 0Ua) Lx� n — �0 E CL EM 80ao £ ° a M °a 3 ONE u p y C NGN !0 a 0 C >' LL tD N a d c ix o c an � ln ah o d ` Y o a 0= LL vt 3 ' uvE 'm oN ° o '� y o F U Q = tLn Q d .. c -OC NO M Y O a N N •� C N Imo,. d.0 N �+ O Y U • N_ N Y Na OaiS • 3�..a C a D 1 cj� • 0 �a0+� + • ++ UCy �p O LLB °' QC � a � m v0oo m >. 2a) cl>> � N V a3 U dd �'oN a� c U t0 0 3 L y� �W 0) Q M� LL 01 Of 00 4-J SD3 • O N O E a£ E o G D c r v� - /§ § G ° § u 8 ZlL \ § � ,,®32 ; § EW § 'oU §u § k2 . m § 6 / 6 § § \ ke $s CIL\ . ¥ tn § . $zzzA /zz z � $� - ~ - z ( 9 § LU � § § � § « « � k ; 2 \ 3 C k z § / � § k\ § Z � 2aoo ( ( § � � � § § � § m cy w � A § 00 OR, E | § $ \ tn pw -- � i A §�� ` ! . � ` ! ® ( § \ j�j . k § k § ` $ 10 , kco Sc < n\\\\ C § 2 + ( 9 C < � U) w / 10 > , _ j zz \ ° ) § f � _ c ! 0 2 � � � � � Imo a 2 .. z o § } § . § S as c § a - 6n Im ° i a1 � R § $ § \ / ( < !£x / \ / cca � ) _ ® � � c , eu � s 12� a- 1 CL V N AIY �5 o IA : 5 n W V ) Z N o Z ❑ t Z Q W 1• ry (J N O Q a ^ — F z LU u �[ Iral —♦p M X . V u N g `. . N e < Y z .. N♦0 "m y M 1� M O♦ ! —I C " X O Vf N m W �yN Z M NC Q w �" _. m♦D r1.y ILL Z Cl) Z w z ❑ a M ^� • It J m ry 0 OD "l y UA Oa Lo if f /e ul Z J " N LL' z W O V u 1! z ❑ ❑ O M " a q 3 K a N a m "�..--___�_-___._.... N (��T�]j Z ♦O m � W 3 ~ W z ❑ LL J N 1/S N a > M J W IL F L.LI Q ] Z Zin O Z N x co Y M U U oC X at! /J m J Q ry z w LJ r�\\ \ W " � iaX M I Oo'� ix- � r. • .. W w .�. N " ri t ... tn L, O " g = ❑ Q2 &Z c� _I U v QF f f N U0, F� M "Lc) LL Y = I " O01 C 0 U L a 8 IL N Yf U \� F w w " 3 ❑ u u u u u O Y M 10 3o� a� o� oQaGnQg fA G 2' 8❑ O J'.Z Z Z Y Z Z •• a. w Z > W 3 W N ,�.CA US Vl " In o Vm) < coO 1 ^' a Z _ u a u F a CO z of w w G � u 3 z , w | � k )$ .¥ | J� - - ) �h C6 ■ /& � / �� k § z � � kU) >u § -G 5 - X§ - - - e § % in $ { / ? » ~ § § / f # \ CO z ( 9 , m � . � a\ ] /0 lzn B « )/ § ) x x ) § ( _A \ \§ \ . q . Suu ; u z | ka - , § R . 0 - 3 § ! E ttix (A . kjzk0 § §§ ) § ( kB � E ' zk }kk § � $- - - - ( � ( j 2 . $ ] luli 5 G L $ K . � @ § 0 ) LU § � 6 10 \ / § # A § � B ] § \ \ o w oUn © 6 g G ; � t . j § \ i \ � [ E ! m - § u . � � $ _ 0 Ln , � .. �Fr \ Lu / E - ; ( � � j (n § �. bm § � ro § §u f.—u k � — § Ct In K z Q1, � , . w} — Z . ® ' — � j } _ $@k , z 3: uj \ kB � \ w � ' § - - 5 — § u , / co K ` §/ j j 'S- §70\ , 2 e § N r, - - . £ § } 2 mo 2 § ] > § k ■ ! � e m - 77 [ &� } ■� � . CL w u CL \ § 0a o , E z ■ 2 § 7 � § § § { _ § § () § � k � / � � ~ - § � § ` � � § § kkK \ .. � - }3 � ' u f § < C, - - - - E § k kz / E tn § 2 § @ § k in # B � � § ~ § /\ § 0 , § 0 7 ® K K ~ In c to o } / § 0n A w ) § § D § � A / k § ce 2 z | @aeu . t n�A, tr14. 4tti c^w' t crt t • • • •♦ v ♦• • h �•♦• • •• v f �;,ci It t d� +1)owZ �!(ts)�� s.Y'A`,11 1'it �-rem 11�11 s?�:���sss:til hC v`t� 11�11'Ca� "- i •-111�11�:`�F e'+..'11�1��:3�••t< ,�.\1111�1f'�� <(�cf>,.1 � a H W ►� �Rs�-:: Q -oQM J �Poo m o z CO u 100% G� Q actionui W kX P4 V O cn Q 3 y° � y y.r LZr Fw— O = N o O cn LL 72 rA u u ; r e is ,tr'C cc 3 o rA40 - *`�� 3 .+ .... - -- — <o)> �+ o ,y az �1 1 ly Ili cl,l- 1 01/+ T �p ccy� �,�Icy y� , A! ® DATE(MM/DD/YYYY) �.. CERTIFICATE OF LIABILITY INSURANCE 04/01/2025 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 Sean Greening 9 Provident Protection Plus Incorporated PHHCONN Etl, (973)579-6776 aC No: (973)579-0111 96 US Highway 206 E-MAIL sean.greening@ProvidentProtecbonPlus.com ADDRESS: PO BOX 4 INSURER(S)AFFORDING COVERAGE NAIL# Augusta NJ 07822 INSURER A: Gotham Insurance Company 25569 INSURED INSURER B: Selective Way Insurance Co. 26301 Infinity Solar Systems,LLC INSURER C: Endurance American Insurance Company 10641 575 Corporate Drive INSURER D: StarStone Specialty Insurance Company 44776 Suite 2200 INSURER E Mahwah NJ 07430-2330 INSURER F COVERAGES CERTIFICATE NUMBER: 2025-2026 Master#1 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 POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER MWDD MM/DD/YYYY LIMrTS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 2.000,000 CLAIMS-MADE ®OCCUR PREMISES Ea occurrence $ 100,000 MED EXP(Any one person) $ 5,000 A GL202500014906 01/01/2025 01/01/2026 PERSONAL BAOVINJURY $ 2,000,000 GEN'LAGGREGATE LIMITAPPLIES PER GENERALAGGREGATE $ 4,000,000 POLICY ®PRO- ❑ JECT LOC PRODUCTS-COMP/OP AGG $ 4,000,000 OTHER: Per Project Aggregate $ 5,000,000 AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000 Ea accident ANY AUTO BODILY INJURY(Per person) $ B OWNED SCHEDULED S2390880 01/01/2025 01/01/2026 BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY Per accident E UMBRELLA LIAB OCCUR EACH OCCURRENCE $ 1,000,000 C EXCESS LIAB CLAIMS-MADE EXT30076080500(Over Auto) 01/01/2025 01/01/2026 AGGREGATE $ 1.000,000 DED I RETENTION$ 0 $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY Y/N STATUTE I JER ANY PROPRIETOR/PARTNERIEXECUTIVE ❑ E.L.EACH ACCIDENT $ OFFICERIMEMBER EXCLUDED? N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ Installation Floater Limit $250,000 B S2390880 01/01/2025 01/01/2026 Deductible $10,000 DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached If more space is required) Certificate Holder is included as an Additional Insured to the above captioned General Liability,Business Auto,and Umbrella Policies on a primary and non-contributory basis for work the insured is performing provided a written contract exists requiring such a status.Additional Insured also applies to product completed operations with respect to the above General Liability policy.Per the terms of the policy,coverage for an additional insured is contingent upon an underlying written agreement with the named insured requiring such coverage.Waiver of subrogation applies to the above General Liability,Umbrella Liability,and Business Auto Policies. 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 St AUTHORIZED REPRESENTATIVE / Rye Brook NY 10573 ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD NEWWorkers' CERTIFICATE OF STATE Compensation NYS WORKERS' COMPENSATION INSURANCE COVERAGE Board la.Legal Name&Address of Insured(use street address only) 1b.Business Telephone Number of Insured INFINITY SOLAR SYSTEMS LLC 1c.NYS Unemployment Insurance Employer Registration Number of 575 CORPORATE DR LBBY 2 Insured MAHWAH,NJ07430-2330 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 27-1255670 2.Name and Address of Entity Requesting Proof of Coverage 3a.Name of Insurance Carrier (Entity Being Listed as the Certificate Holder) Indemnity Insurance Co.of North America VILLAGE OF RYE BROOK 938 KING ST 3b.Policy Number of Entity Listed in Box"l a" RYE BROOK,NY 10573 C7230908A 3c.Policy effective period 10/1/2024 to 10/01/2025 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"3"insures the business referenced above in box 1a"for workers' compensation under the New York State Workers'Compensation Law. (To use this form,New York(NY)must be listed under Item 3A on the INFORMATION PAGE of the workers'compensation insurance policy).The Insurance Carrier or its licensed agent will send this Certificate of Insurance to the entity listed above as the certificate holder in box"2". The insurance carrier must notify the above certificate holder and the Workers'Compensation Board within 10 days IF a policy is canceled due to nonpayment of premiums or within 30 days IF there are reasons other than nonpayment of premiums that cancel the policy or eliminate the insured from the coverage indicated on this Certificate. (These notices may be sent by regular mail.) Otherwise,this Certificate is valid for one year after this form is approved by the insurance carrier or its licensed agent,or until the policy expiration date listed in box"3c",whichever is earlier. This certificate is issued as a matter of information only and confers no rights upon the certificate holder.This certificate does not amend, extend or alter the coverage afforded by the policy listed, nor does it confer any rights or responsibilities beyond those contained in the referenced policy. This certificate may be used as evidence of a Workers'Compensation contract of insurance only while the underlying policy is in effect. Please Note: Upon cancellation of the workers'compensation policy indicated on this form,if the business continues to be named on a permit,license or contract issued by a certificate holder,the business must provide that certificate holder with a new Certificate of Workers'Compensation Coverage or other authorized proof that the business is complying with the mandatory coverage requirements of the New York State Workers'Compensation Law. Under penalty of perjury,I certify that I am an authorized representative or licensed agent of the insurance carrier referenced above and that the named insured has the coverage as depicted on this form. Approved by: Lex Smith rint na of authArized presentative or licensed agent of insurance carrier) Approved by: 09/11/2024 (Signature) (Date) Title: Assistant Program Manager Telephone Number of authorized representative or licensed agent of insurance carrier: 214-721-6248 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 Acct#:2215771