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HomeMy WebLinkAboutPP26-011 a a 6-21 0 V C14 w s c Q a LY. s a N C w ^ s PLO F CN 0-0 rq Ca r p � 00 O f 14 PLO 40, V a cn crM Oc U. N V .- 4 6 a 4;4 46 49 a a a a a a a go a a a a a a go a a 49 go 4 46 a go a a a 4 a 46 Q U 44WE419 �EaR�r,�� DIECIUVIED BUIL E MENT VIL E OF RYE OK 938 KIN a ET RYE B ,NY 10573 J A N - 9 2026 ny.gov VILLAGE OF RYE BROOK PLUMBING PERMIT APPLICATION BUILDING DEPARTMENT FOR OFFICE USE ONLY BP -­l PP#: Approval Date: JAN r Permit Fee: Approval Signature: Disapproved: (fees are non-refundable) DO NOT START WORK or CONSTRUCTION UNTl I, A PERMIT HAS BEEN ISSUED BY THE BUILDING INSPECTOR.THE ADMINISTRATIVE FEE FOR «ORK PROGRESSED OR COMPLETED WITHOUT A PERMIT IS 12% OF THE TOTAL COST OF CONSTRUCTION WITH A MINIMUM FEE OF 5750.00 Application dated, is hereby made to the Building Inspector of the Village of Rye Brook NY, for the issuance of a Permit to install and/or remove Plumbing as per detailed statement described below.The applicant&property owner,by signing this document agree that said plumbing work will be in conformance with all applicable Federal, State,County and Local Codes. �,r 1.Address: to m Q P t NIT L.cAn e SBL: � 4. �3 - 2 Zone: 5- 2.Proposed Work: �epi al!F 'Q.CiSPn�', W aW �ec-49r W i4-it Aet„? 43 ojG 11 On Wt rd w�,k�c 3.Property Owner: AmanAk Rubel-is Address: Q the Pi I V1,5 kQ At .- Lance Phone#: cllq A 1(p- S3 Cell#: email: ('Q rvra �r Z 9 5rna { , y'b'� �CU n S Address: I Q 0 A55140AS tOCJ fi�1�3�[� MY4.Master Plumber: �1 Lic.#: IS S Phone#: Cell#: email: f'T 't I�s 0,bru Cgm;r+C , Cam Company Name: 3N r'1 i come;5! Address: (0 0 @-Gr1S�,j1j U. 10C,6 INDICATE FIXTURES&LINES TO BE INSTALLED AS PER THE FOLLOWING SCHEDULE: Location Water Urinals Drinking Sinks Showers Bath Laundry Domestic Fire Sanitary Natural/ Other* Total Closets Fountains Tubs Tubs Service Service Sewer LP Gas Basement 1 st Floor 2nd Floor 31 Floor 4"Floor 5'Floor Exterior 5.* List Other Equipment/Provide Details: (Notarized Signatures Required Next 2 Pages) 6/112024 BUILDING DEP R. MENT VIL�(:F. OF RYE OOK 938 KING ET RYE ABR � NY10573 jAN - 9 2026 - OY� g P00K m � BUILDING DEPARTh9ENT AFFIDAVIT OF COMPLIANCE VILLAGE CODE §216 - STORM SEWERS AND SANITARY SEWERS THIS AFFIDAVIT MUST BEAR THE NOTARIZED SIGNATURE OF THE LEGAL PROPERTY OWNER AND BE SUBMITTED ALONG WITH ANY BUILDING OR PLUMBING PERMIT APPLICATION . ANY BUILDING OR PLUMBING PERMIT APPLICATION SUBMITTED WITHOUT THIS COMPLETED AND NOTARIZED FORM WILL BE RETURNED TO THE APPLICANT . STATE OF NEW YORK, COUNTY OF WESTCHESTER ) as: .I, Aryl G f a tiOP.fl 5 , residing at, 10 t -e eA yl 9 M ml�,P_ LQ n e (Print name) (Address tivh e you live) being duly sworn, deposes and states that (s)he is the applicant above named, and further states that(s)he is the legal owner of the property to which this Affidavit of Compliance pertains at-, M eeAi 1 _q WxAsE' Lcir► P _ , Rye Brook,NY. (!ob Address) Further that all statements contained herein are true, and that to the best of his/her knowledge and belief, that there are no known illegal cross-connections concerning either the storm sewer or sanitary sewer, and further that there are no roof drains, sump pumps, or other prohibited stormwater or groundwater connections or sources of inflow or infiltration of any kind into the sanitary sewer from the subject property in accordance with all State, County and Village Codes. (Signande of Property 0%%ner(s)) �MGACCA �u\oe/n� (Print Nance ol-Properi) Omierl-s)) Sworn to eflore me this day of , 202-& i v �1 Q�NtEL �}. �� 1 �11 r d 1 tatien No.C�B� �'YOLK (Votary Public) h[yd1b etc 0032946 6/ll2024 STATE OF NEW YORK,COUNTY OF WESTCHESTER ) as: �Cul1 , being duly sworn,deposes and states that he/she is the applicant above named, (print name of individual signing as the applicant) and further states that(s)he is the Master Plumber for the legal owner and is duly authorized to make and file this application. That all statements contained herein are true to the best of his/her knowledge and belief,and that any work performed,or use conducted at the above captioned property will be in conformance with the details as set forth and contained in this application and in any accompanying approved plans and specifications,as well as in accordance with the New York State Uniform Fire Prevention&Building Code,the Code of the Village of Rye Brook and all other applicable laws,ordinances and regulations. ENOT,k'R)y NA BARON-DAMEL BLIC,STATE OP �y PORK ration No.01 BA0032946 ecf in Westches[ tYon Expires worn to b fore me this Sworn to efore me this day of ,20 day of 202-4_ An, rc,l � ,�ins Y-- Si re of Property OA4��L Z Si attire of Applicant "- �ejk brLAVA i— Print Name of Property Owner Print Name of Applicant a Notary Public Notary Public 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. Applications not properly completed in its entirety and/or not properly signed shall be deemed null and void and will be returned to the applicant. -2- 6/1/2024 BRADFORD WHI TEE W A T E R H E A T E R S rw Residential Power Vent Gas water Neater The TTW Models Feature: ■ ENERGY STAR'Qualified—Some models meet or exceed requirements for ENERGY STAR'per the latest ENERGY STAW 1 criteria revision, as well as most utility rebate programs. ■ Bradford White ICON System'—Intelligent gas control with spark to pilot ignition system eliminates the constant burning pilot.This results in savings of pilot gas during standby periods (120 VAC). — Enhanced Performance—Propnetary algorithms provide enhanced First Hour Rating and tighter temperature differential. —Advanced Temperature Control System—Microprocessor constantly monitors and controls burner operation to maintain consistent and accurate water temperature levels. — Intelligent Diagnostics—An exclusive green LED light prompts the installer during start-up and provides ten different diagnostic codes to assist in troubleshooting. — Pilot On Indication—Flashing green LED provides positive indication that pilot is on. — Separate Immersed Thermowell—High-strength advanced polymer composite thermowell provides isolation between electric temperature sensor and surrounding water. No need to drain the tank when removing gas valve. ■ Power Vent Water Heater—Designed for installations where atmospheric units cannot be used. Exhaust gases are vented under positive pressure directly out of the building through the roof or the wall. ■ Powerful Slower Motor—Our significantly quiet design has greater resistance to outside winds and the power to vent in many difficult venting situations. — Ten Foot(3 meter)Power Cord—Included(120 VAC). ■ Horizontal and Vertical Venting—PVC,ABS or CPVC(Maximum equivalent vent length on reverse side). ■ Advanced ScreenLok'Technology Flame Arrestor Design—Flame arrestor is designed to prevent ignition of flammable vapor outside of the water heater(excluding RG1 PV55H6N &RG2PV75H6N). ■ Flammable Vapor Sensor—Electronic sensor prevents burner operation if flammable vapors are detected. The sensor will also prevent operation if there is ongoing flammable vapors burning inside the combustion chamber(excluding RG1 PV55H6N &RG2PV75H6N). ■ Maintenance-Free—No regular cleaning of air inlet openings or flame arrestor is required r b under normal conditions(excluding RG1 PV55H6N&RG2PV75H6N). F?� ■ Sight Window—Offers a view into the combustion chamber to observe the operation of the `vlo! pilot and burner. ■ Factory-Installed HydrojetP Total Performance System—Sediment reducing device that sr, also increases first hour rating of hot water while minimizing temperature build-up in tank. MOM 4%ft E ,4 4 ■ Vitraglas®Lining—An exclusively engineered enamel formula that provides superior tank filift *ANN _ protection from the highly corrosive effects of hot water.This formula(Vitraglas") is fused to the steel surface by firing at a temperature of over 1600'F(871'C), R Insulation System—Non-CFC foam covers the sides and top of the tank, reducing heat Photo is of loss.This results in less energy consumption, improved efficiencies, and jacket rigidity. RG2PV5OH6N ■ Water Connections—374" (19mm) NPT factory-installed true dielectric fittings extend water heater life and simplify water line connections. FEATURING: E 3/4" (19mm)NPT Side Connections—(RG2 PV50H 6N, RG1 PV55H6N, and RG2PV75H6N Ib©W ��.r��� only). liti '� ■ Factory-Installed Heat Traps—Design incorporates a flexible disk that reduces heat loss in -Systern, . piping and eliminates the potential for noise generation. ■ Protective Anode Rod—(RG1 PV55H6N has 2). '�lsdi l�tV Jx� t ■ T&P Relief Valve—Installed. ■ Thermostatic Mixing Valve(ASSE Approved)—Included (RG1PV55H6N only). ■ Low Restrictive Brass Drain Valve—Durable tamper proof design. ■ NOx Emissions—Less than 40 ng/J. S or 10-Year limited Tank Warranties f B or 10-Year Limited Warranty on Component Parts. ��. For more information on warranty. please visit www,bradfordwhite.com \��✓�J For products installed in USA,Canada,and Puerto Rico-Some states do not allow fimitations on warranties.See complete copy of the warranty included with the heater. MANUFAMREU UNDER ONE OR MORE OF THE FOLLOW=US.PATENTS;5.682,666;7.634.976.5.660,165:5.954,492.6.056.542:6,935,280:5,372,185;5,485,879;5,574,822.:7,971,560:7.992,526:6.684,821:T334 419:7,866,168: 7,270,087,7,007 748.,5.596:952.6 142216,7 699.026.5,341.770.7.337.517 7.M5211 7,665210 7.063.132.7.D53133,7.5%293,7,900,589:5.943.984.8,082.888.5,988,117.7.621.238.7,650,859;5,761,379,7,409,925,5,277,171, 8,146,772.7,458,341,2,262.174.OTHER U.S.AND FOREiGN PATENT APPUCAPONSPE14DING GJRRE.NTCANAAIANPATEM..2,314,845;2,504,824;2,108,186;2,143,031;2,409,271;2,54.AW2.112.515:2.476.683:2,239.007:2,092AM 2.107,012.Detei Safely System',Saearkok",rW,Mai and HydrW are reqidered trademarks of BradMrd Wh11W CorporaOm. 1261-C-0:322 Residential Power Vent Gas Water Neater Power Vent Models Meet or exceed ASHRAE90.1to(current staedard)C.E.C.Llsted HATU94L 6AS AND LWD PROPANE GAS W%Recauery Efficiency Model Nominal DOE R�ooreryat IAadel Speninal DOE Recoreryat Number Gal. Rated first 90ornieq' Number Lola Rated First 50°CRise' Capacity Storage LP Harr Uniform LP LP Capacity Storage LP Hour Uniform LP US, Imp. Volume BTUiHr BTUM. Rating Energy U.S, Imp US. ImilL Volume kW kW Rating Energy liters! Lltend Get Gal (Gat) Input Input (Gal.) Factor GPH GPII GPH GPH ILHersl Yrput Input (Liters) Factor Harr Hour RG1PV40S6N 40 33 38 40,000 38,000 62 0.61 43 36 41 34 RGIPY40SBN 151 144 11,7 11.1 235 0.61 163 155 RGIPV5CS6N 50 42 48 40n0n 38,000 77 0.63 43 36 41 34 RGlPV50S6N 199 182 11,7 11.1 292 0.63 1 163 155 *RG2PV4OS6N 40 33 38 40000 38000 70 0.67 43 36 41 34 *RG2P14OS6N 151 144 11.7 11.1 265 0.67 163 155 *RG2W50S6N 50 42 48 40.000 38000 75 0.70 43 36 41 34 *RG2 !im 159 182 11.7 11,1 294 0.70 163 155 *RMQT6N 40 33 38 40,000 40,000 75 0.68 43 36 43 36 *RMW4OT6N 151 144 11.7 11.7 284 0.68 163 163 *RG2PV5cT6N 50 42 48 40,000 40,000 71 0.67 43 36 43 36 *RG2PV50T6N 189 182 11.7 11.7 269 0.67 163 163 *RG2PV5OH6N 48 42 46 65,000 58,000 116 0.fig 70 58 fit 52 *RG2PV50H6N 182 174 19.1 17.0 440 0.68 M235 RG1PV55HGN 55 46 55 78.OGO 78A00 125 0.68 1 84 70 84 70 AWPV551H6N 208 208 22.9 22.9 474 0.68 318 317 POW5H6N 75 62 72 76,000 75.500 121 0.69 1 82 68 81 67 RG2PV75H6N 1 294 235 1 22.3 22.1 459 0.69 1 310 307 Morel A E C D E F G H J If L M R S Approx. Number Floor to Jacket Vent Floor to Floor to Floor to Floor to Depth CIL Floor ro Hoar to Water Space Gas Shipping Van, Dia. sae TRIP Gas Top of Water of Water Space Heating Space Heating Cam. Heating Cam. Weight Conn, Conn. Conn. Heater Conn. Conn. Inlet Outlet RPT Com.Sitt Size in. In. in. In. in. In. in. in. In. in. In. In. In. In. Bas. RG1PV40S6N 57'h 20 2 or 3 40 11112 461h 49 251-'N 8 WA WA 3h WA '12 140 RG1PV50S6N 58 Vic 22 2 or 3 40 ala 11112 41 50'h 273116 8 WA WA 3f4 WA 11, 166 *RGM40UN 57,13 22 1 2or3 40116 11% 47 116 49 271h 1 8 WA WA 314 WA I % 142 *RG2PV50S6N 58"h 24 2 or 3 40513 111h 483f16 50112 283/6 1 8 WA WA 11, WA 'h 168 *RWV40TBN 61 20 203 491,116 11lh 56Ib 58 25,115 8 WA WA 314 WA % 146 *RG2P1150T6N 671/1 22 2 or 3 50 IN 11 it? 571/16 58 27311e B WA N+A 314 WA % 173 *RG2PV5OKN 661h 22 3 or 4 49fl1 113k 56N4 57114 2515fs 11 13,16 49316 314 314 11a 187 RGSPV55H6N 649A6 22 3ar4 47Wis 11% 543h 56 273Ae 7114 1331s 471116 114 11, It, 219 RG2PV75H6N 69112 26 3or4 1 511'1,4 13.51.E 59'1h6 6031, 30"N 11 16'V=6 51'S1-c 314 lb 1; 260 Model A B C 0 E F 6 H J K L M R S Approx. Number Floor to Jacket Vent Floorto Floor to Floor to Floor to Depth CA Floor to Floor to Water Space Gas Shipping Vent Dia. Sae TdP Gail Top of Water of Water Space Heating Space Heating Conn. Heating Conn, Weight Cann. Cam. earn. Heater Conn. Can. Inlet Outlet NPT Conn.Sae Size man. MM mm. no. MM. mm. MM. mm, W. mm. MM. mm. mm, Min. kq, RGIPV4DS6N 1461 508 51or76 1016 292 1181 1245 659 203 WA WA 19 WA 13 64 RGIPV5OS6N 14B4 559 51or76 1032 292 1224 1283 691 203 WA WA 19 WA 13 75 *RG2PV40S6N 1461 559 1 51or76 1019 292 1199 1245 689 1 2D3 WA WA 19 WA 13 64 *RG2PV5p56N 1486 610 51or76 1032 292 1244 1283 733 2D3 WA WA 19 WA 13 76 *RG2PV4OT6N 1703 508 51or76 1262 292 1441 1473 562 2W WA WA 19 WA 13 66 *RG2PV5OT6N 1724 559 51or76 1284 292 1462 1473 691 203 WA WA 19 WA 13 78 *RG2PV50H6N 1689 559 76or102 1267 292 1441 1467 684 279 340 1267 19 19 13 85 RGiPV55H6N 1640 559 76or102 1218 292 1391 1422 691 197 340 1218 19 19 13 99 RG2PV75M 160 6W 76or102 1319 354 1516 1543 7T9 279 424 1319 19 19 13 118 Propane models feature a Titanium Stainless Steel propane burner. For Propane (L.P)models change suffix"N"to"X". For 10 year models,change suffix from "6" r-c to"10" (Not available on RG1 PV5511i'Based on manufacturer's rated recovery efficiency. 120 VAC Required for Power Venting/ 120 VAC, 6OHz., 3.1 Amperes. Uniform Energy Factor and First Hour Rating is based on the latest AHRI directory listings. H M B *=ENERGY STAR'Qualified. I LJ�3' R- M RClW49S6H RG1PY5056N R62PY501I6N RG2PV5OS6N RG2PY4OT6N 2"(51mm) 3"(75mm) RGIPV55HSN 3°(76mm) 4"(102mm) RGIPV40SON RG2P'1r5OT6N Vent Pipe Vent Pipe R62Pv?SM Vent Pipe Vent Pipe G Max.Equivalent Length t50 It t 15.2m tl20Ili t37.Om Max.Eq uivalesM Length t50 ft,V 5.2m tl80 rt t55.Om A Min.Equivalent Length 7 R 2Am 15111. 4.6m Alin.Equivalent Length 7 R.. 2.1 m 15 tt 4.6m Number 1 45 R. 13.7m 115 ft. 35.Om Number 1 45 ft. 13.7m 17511. 53.3m F of 2 40 R 12.2m 1101t. 33.6m of 2 40 ft. 12.2m 170 ft. 52.Om D8 L 90°FJbc xs 3 35 ft 10.7 1 105 fL 32.Om 90°Elbows 3 35 ft. 10.7 1 165 R 50.3m Subtract 51t.(1.5m)for each additional 90"elbow 3 t For high altitude installations,consult the installation instructions. AE__: General:Meets NAECA or EPACT Requirements,as applicable.All gas water heaters are certified at 300 PSI E ( 2068 ki test pressure and 150 PSI(1034 kli working pressure.All water connections are Y4' (19mm)Ni all gas connections are 1/2"(13mm).All models design-certified by CSA International(formerly AGA/CGA),ANSI Z21 A 0.1 and/or Z21.10.3 and peak performance rated. Dimensions and specifications subject to change without notice in accordance with our policy of continuous product improvement Suitable for Water(Potable)Heating and Space Heating.Toxic chemicals,such as those used for boiler treatment,shall NEVER be introduced into this system.This unit may NEVER be connected to any existing heating system or components)previously used with a non-potable water heating appliance. -BRADFORD WHITE IS- AME=-RlCAN Sales:800-523-2931 In Fax 215-641-1612 STRONG_ 2417 Technical Support.800-334-3393■Email techservabracifordwhite.com Products made by Bradford White are manufactured In the United States using the finest raw materials and components from around the world. Built to be the Best 1261-G-0322 [%2022.Bradford White Corporation,USA.All rights reserved. Printed in U.S.A. DATE(MMInwyy 1Y) AC CERTIFICATE OF LIABILITY INSURANCE 1W912025 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 CONTANAME: Certificate Unit _ Edgewood Partners Insurance Center P"ONE 404-781-1740 FAX 100 Montgomery Street IA1 EMI;E-MAIL {AIC No: Floor 20 Suite 2000 ADOREss: a excerts a icbrokers.com- San Francisco CA 94104 INSURERS AFFORDING COVERAGE NAILS Licensek(1�370 INSURER A:AIU Insurance Company 19399 INSURED APEXSERI INSURER @:Upland Speciatty Insurance Company 16988 Bruni &Campisi, Plumbing, LLC INSURERC:National Union Fire Ins Co of Pittsburg19445 100 Grasslands Road Elmsford, NY 10523 INSURERD, INSURER E INSURER F: COVERAGES CERTIFICATE NUMBER: 1615477053 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. ILT R TYPE OF INSURANCE ADDLSUBR Ic POLICY NUMBER MYfdQ EFF MMIDOY EXP OMITS LTR B X COMMERCIAL GENERAL LIABILITY Y USPCL0284125 80012025 &'10 2026 EACH OCCURRENCE s 2,000,000 DAMAGE TO REN_TElT___ CLAIMS-MADE C OCCUR PREMISES Ea occurrence $100,000 MED EXP(Any one person) f Excluded PERSONAL&ADV INJURY E 1,000,000 GEN'L AGGREGATE LIMJTAPPLIESPER: GENERAL AGGREGATE $4.000.000 POLICY❑PRO JECT L LOC PRODUCTS-COMPIOP AGG $4,000,000 X OTHER t AUTOMoelLE LIABILITY Y 9812741 (AOS) 4/1/2025 4/112026 EO aBradeMSINGLE LIMIT $5,000,000 X ANY AUTO BODILY INJURY(Per person) 3 OWNED SCHEDULED BODILY INJURY accident) $ Y(Par AUTOS ONLY u AUTOS 4 HIRED 'NON-OWNED I PRDPERTYDAMAGE $ AUTOS ONLY AUTOS ONLY Per acciden! — $ B UMBRELLA LIAB X OCCUR Y USXCLO100925 811012025 8110/2026 EACH OCCURRENCE $4,000,000 X EXCESS LIAR l CLAIMS-MADE AGGREGATE $4,000,000 DEO RETENTION S S A WORKERS COMPENSATION 020396018(AOS) 411/2025 4/112026 XPR TH_ A AND EMPLOYERS'LL4SILITY YIN 020396020(WI) 4M12025 41112026 STATUTE ER ANYPROPRIETORIPARTNER'EXECUTIVtiE E.L.EACH ACCIDENT $1,000,000 OFF ICERIMEMBEREXCLUDED7 [NJ NIA --- (MandatoryinNH) E.L.DISEASE-EA EMPLOYEE $1,000,000 If yes.describe under - - DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $1,000,000 DESCRIPTION OF OPERATIONS f LOCATIONS!VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Village of Rye Break,to the extent required by written contract, is an additionai insured with respect to general liability and auto liability.Umbrella is fallow form over the General Liability,Auto Liability and Employers Liability. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Village of Rye Brook 938 King St. AUTHORIZED REPRESENTATIVE Rye Brook NY 10573 1988.2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD ISTNEWR Workers CERTIFICATE OF ATE Compensation NYS WORKERS' COMPENSATION INSURANCE COVERAGE Board 1a.Legal Name&Address of Insured(use street address only) 1b. Business Telephone Number of Insured 914-946-5558 runi&Campisi Plumbing, LLC 100 Grasslands Rd Ste 130 1c.NYS Unemployment Insurance Employer Registration Number of Elmsford. NY 10523 Insured 8831360264 Work Location of Insured(Only required ifcoverage is specifically limited to id Federal Employer Identification Number of Insured or Social Security certain locations in New York Stale. i e., a Wrap-Up Policy) Number 92-0299696 2.Name and Address of Entity Requesting Proof of Coverage 3a. Name of Insurance Carrier (Entity Being Listed as the Certificate Holder) AIU Ins Co. Village of Rye Brook 3b. Policy Number of Entity Listed in Box"la" 938 King St. Rye Brook, NY 10573 020396018 3c.Policy effective period 04101/2025 to 04101/2026 3d.The Proprietor,Partners or Executive Officers are X❑ Included.(only check box if all parinerslofficers included) all excluded or certain partnerslofficers excluded. This certifies that the insurance carrier indicated above in box"T' insures the business referenced above in box"1a"for workers' compensation under the New York State Workers'Compensation Law. (To use this form, New York(NY) must be listed under Item 3A on the INFORMATION PAGE of the workers' compensation insurance policy). The Insurance Carrier or its licensed agent will send this Certificate of Insurance to the entity listed above as the certificate holder in box "2", The insurance carrier must notify the above certificate holder and the Workers'Compensation Board within 10 days IF a policy is canceled due to nonpayment of premiums or within 30 days IF there are reasons other than nonpayment of premiums that cancel the policy or eliminate the insured from the coverage indicated on this Certificate. (These notices may be sent by regular mail.) Otherwise,this Certificate is valid for one year after this form is approved by the insurance carrier or its licensed agent, or until the policy expiration date listed in box"3c", whichever is earlier. This certificate is issued as a matter of information only and confers no rights upon the certificate holder. This certificate does not amend, extend or alter the coverage afforded by the policy listed, nor does it confer any rights or responsibilities beyond those contained in the referenced policy. This certificate may be used as evidence of a Workers' Compensation contract of insurance only while the underlying policy is in effect. Please Note: Upon cancellation of the workers'compensation policy indicated on this form, if the business continues to be named on a permit. license or contract issued by a certificate holder,the business must provide that certificate holder with a new Certificate of Workers' Compensation Coverage or other authorized proof that the business is complying with the mandatory coverage requirements of the New York State Workers' Compensation Law. Under penalty of perjury, I certify that I am an authorized representative or licensed agent of the insurance carrier referenced above and that the named insured has the coverage as depicted on this form. Approved by: p o n Bailey Print n -ne o onzed representative or licensed agent of insurance canner) Approved by: _ 05/12/2025 (Signature) 0 (Date) Title: CEO, North America Telephone Number of authorized representative or licensed agent of insurance carrier: 212-770-7000 Please Note: Only insurance carriers and their licensed agents are authorized to issue Form C-105.2. Insurance brokers are NOT authorized to issue it. C-105.2 (9-17) www.wcb.ny.gov