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BUIO�t
MENT VILC938 KINGNY 10573 APR '5 2022
(914)939-5801 VILLAGE OF RYE 'BROOK
BUILDING DEPARTMENT
Application for Permit to Remove, Abandon and/or Install Fuel Storage Tank
(*Storage Tanks in excess of 1,100 gallons require registration with the County of Westchester)
FOR OFFICE USE ONLY: PERMIT#:
APR - 5 2021
Approval Date: Permit Fee: S
Approval Signature: Other:
Disapproved:
(fees are non-refundable)
REQUIREMENTS FOR RELEASE OF PERMIT& CERTIFICATE OF COMPLIANCE:
1. Application Completed by Bonded,Licensed Contractor.
2. Your contractor's valid proof of liability insurance. (Village of Rye Brook must be listed as certificate holder)
3.Your contractor's valid proof of workers compensation insurance.
(Form#C105.2 or Form#U26.3 /or NY State Workers Compensation Waiver)
4. Fee per Tank: Removal,Abandonment, or Installation: $185.00 per Tank.
5. Dig Safely New York#(dial 811): DAm--M I--i qu
6. Inspection by Building Department for removal/abandonment and/or installation.
7. Submit all Manifests&Reports (after work has been completed).
8. Certificate of Compliance will be provided when all requirements are fulfilled.
Application dated,McLrr-V% 3 ,o'Oa;L,is hereby made to the Building Inspector of the Village of Rye Brook for a permit to
remove,abandon,and/or install a Fuel Tank as herein described.The applicant and property owner,by signing this document agree
that the subject fuel tank(s)will be removed,abandoned and/or installed in conformance with all applicable Village,County, State&
Federal laws,codes,rules and regulations.
Indicate Permit Type: Installation •Removal(Abandonment{ )/Above Ground ! _ Buried in Ground Off
1. Address: 207 Ivy Hill Lane SBL. 129.76-1-6 Zone: 1-(4b
2. Property Owner& Address: Ni 1lcR.r-y RpSS e��'1 V,y ►1 L�aLf-#-- Q�k-- Piro0(L. O11 16513
Phone#: Cell#: 17' 1 1(o a r7 email: hr O SSC A-. t!cLLi-
3. Contractor&Address: Innov8tive Environmental Services 392 Columbus Ave Valhalla, NY 10595
Phone#: 914-449-6608 Cell#: email: Service@innov8enviro.com
4. Applicant: Innov8tiev Environmental Services
Phone#: 914-449-6608 Cell#: email: Service@innov8enviro.com
5. Indicate Fuel Type: Fuel Oil ff•L.P.Gas( )•Gasoline( )•Other( ):
6. Number and Capacity of each Tank: Removal of(1)300 Gal UST and Installation of (1) 220 Gal AST
7. Exact Location(s)of each Tank: Removal from under the uni-lock patio and Installation in the storage shed
at the rear of the home.
i
6/1/2020
{STATE OF NEW YORK,COUNTY OF WESTCHESTER ) as:
"I Y'U g ,being duly sworn,deposes and states that he/she is the applicant above named,
(print name f 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,attorney,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.
Swornto before me this 3t� Sworn to before me this 31 st
day of ty I Y� cT 202� day of I t II mY ,20 ZZ
Signature ofP pe Owner Signature of
H iM R as s l�o�na . ye.2.nt?u
int Name ofrope er nt Name ofApplic
i
NgR[Nlitl�lill`blic No ry Pu tc NORINI ME1i'III
Notary Public,State of New York Notary Public,State of Ne
Uc.No.01ME6130M Lic.No.01ME61
Qualified in Westchester Coin Qualified in Westchester
Commission Expires July 25,201r. Commission Expires July 25.2o_
This application must be properly completed in its entirety and must include the notarizeU 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
6/1/2020