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HomeMy WebLinkAboutMP22-050 a =� _ a Ln `� ■ � N M p�' v � ■ a N N a N a w 0" _ Vi W `ti jy C� V 1 a w +3 ICE C/� Ln Ln� QCN a O o72 d O � z ti T• o p v '�,� ..e d o v � :: � W � W ~ O � ] V � o •� � M a ►� o00 vo V = V W O [` C o M AQ O a � x a Q w p� C y ~ GOCY 14 W a o ff u ° N a+ v eye w to 00 W w r0� W O c °zo a O F, $ w � .y •� Y� iA � v � Vr c7 O W A O >" .4 N 1-4Ey W `n �4 od1 o 10.4 w xof a . �I op ►� a� a w BUILDING DEPARTMENT D VILLAGE OF RYE BROOK APR _4 2022 938 KING STREET RYE BROOK,NY 10573 (914)939-0668 VILLAGE OF RYE BROOK www.ryebrook.ori! BUILDING DEPARTMENT APPLICATION FOR PERMIT TO INSTALL AND/OR REMOVE HEATING, VENTILATION AND/OR AIR CONDITIONING EQUIPMENT FOR OFFICE USE ONLY: PERMIT Approval Date: PR — 1022 Permit Fee: $ Approval Signature: Other: Disapproved: (fees are non-refundable) REQUIREMENTS FOR RELEASE OF PERMIT&CERTIFICATE OF COMPLIANCE: 1. Properly completed& Signed Application. 2. Site/Staging Plan if Required by the Building Inspector. 3. Copy of Licensed Contractor's Liability Insurance. (village of Rye Brook must be listed as certificate holder)&Workers Compensation Insurance on a NYS Board form(Form#C105.2 or Form#U26.3/or NY State Workers Compensation Waiver) 4. Payment of Fees/Unit: RESIDENTIAL=$100.00/unit• COMMERCIAL=$350.00/unit. 5. Inspection by the Building Department for removal and/or installation. (48 hour notice required 6. Electrical work requires a separate Electrical Permit&Electrical Inspection. 7. Plumbing/Gas work requires a separate Plumbing Permit&Plumbing Inspection. Application dated, is hereby made to the Building Inspector of the Village of Rye Brook for a permit for the installation and or removal of the HVAC equipment as listed below.The applicant and property owner,by signing this document agrees that said equipment will be installed and/or removed in conformance with all applicable Local,County, State&Federal laws, codes,rules and regulations. //� 1l,, 1. Address: t Re.e C 5BL: 9r 7�—�5lPZone: N� 2. Property Owner: ,6I 2 0 / Address©: Phone#: Cell#: '� O email:9 Q /,, 0,L•�dm 3. Contractor: D u � /? �N 1-�-C Address: 5 WlN•9N5 XV 97 , y,vTAI 1 Phone#: / / Cell/#: i -� email: 0�4�u•s r?`y fd Lr v e.girl 4. Applicant: e f e/4 Address: Phone#: Cell#: 5,-}9 ? a email: ,5,*n � 5. Scope of Work:New Installation( )•Replacement 4Q•Removal{ )•Other 6. List uipme t: / /U UN /.J S�`,L K,rac"O/� llv 7. Location of Equipment: eA S IA,) 7-TIC- 4,ef.4 �- S ,2 ` k o vu_s, /- Zl.--: 'VI de {' A /© 8. Method of Installation/Removal(list all equipment needed to perform job): t/ -1 �Yvs f""w zL C atiG j Se /N / 5 ti l t % Pc es'S,4,e ca Al c -e AS 71 e S� Gy2�9ii� Cp, Azr� L"Ilk vq� G'C!Le �N d ailvzo21 STATE OF NEW YORK,COUNTY OF WESTCHESTER ) as: ,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 legal owner of the property to which this application pertains,or that(s)he is the for the legal owner and is duly authorized to make and file this application. (indicate architect,contractor,agent,allemey,etc.) That all statements contained herein are true to the best of his/her knowledge and belief,and that any work performed,or use conducted at the above captioned property will be in conformance with the details as set forth and contained in this application and in any accompanying approved plans and specifications,as well as in accordance with the New York State Uniform Fire Prevention&Building Code,the Code of the Village of Rye Brook and all other applicable laws,ordinances and regulations. Sworn to before me this �l Sworn to before me this day of ,20� day of 20 Signature of Pr perry at Owner Signature of Applicant tt e o Property Owner Print Name of Applicant I El�ll.p� HA LI Notary PWMry Public, Stag of New York No.01 t,,iE6160063 No. 01 t;'iL61 GC63 0�lalified in Westchester County O!Aalified in WestcheEter CountyYy�� Commission Emires January 29.20 Commission Expires January 29.20v�3 This application must be properly completed in its entirety and must include the notarized signature(s) of the legal owner(s) of the subject property, and the applicant of record in the spaces provided. Any application not properly completed in its entirety and/or not properly signed shall be deemed null and void and will be returned to the applicant. 2 8/12/2021