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Bu LDtNG D1�PA-1WTMENT JUL � 2 2022
VILlttET
E OF RY>�*OOK
938 KING RYE BR(�dK,NY 10573 VILLAGE OF RYE BROOK
(914)96$ (914)939-5801 BUILDING DEPARTMENT
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w .r-�.' �rato"rg
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)1
1 3 2022
FOR OFFICE USE ONLY: JUL ERMIT#: Mod - //
Approval Date: D 11 Permit Fee: $ 370f)d,
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): 07062-002-132
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,71 is hereby made to the Building Inspector of the Village of Rye Brook for a permit to
remove,abandon,an 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 Tvne: Installation (r a Removal Abandonment( )/Above Ground Buried in Ground Q
1. Address: 1004 King Street SBL: 129.43-1-3 Zone:
2. Property Owner&Address: Hiro Sakata
Phone#: 914-939-3695 Cell#: email: hiro@sakatany.com
3. Contractor&Address: Innov8tive Environmental Services, Inc.
Phone#: 914-449-6608 Cep#: email: service@innov8enviro.com
4. Applicant: Innov8tive Environmental Services, Inc.
Phone#: 914-449-6608 Cell#: email: service@innov8enviro.com
5. Indicate.Fuel Type:Fuel Oil L.P.Gras( )•Gasoline( )•Other( ):
6. Number and Capacity of each Tank: Removal of 1000 Gal UST from front of property and install a 330 AST
in the basement of the home.
7. Exact Location(s)of each Tank: Removal of UST from front, left of property. Installation of AST in basement,
mechanical room.
t
6/1/2020
STATE OF NEW YOM COUNTY OF WESTCHESTER ) as:
Donnie Feeney ,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
contractor 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.
Sworn to before me this 1` Sworn to before me this
day of JJA4 20_Zl__ day of AU114 20 Z7-
Signature of Property Owner Si ature of Applicant
Hiro Sakata Donnie Feeney ,
P ' t Name of Propert Owner t Name of Applicant
Notary Public NORINE MEYER Notary Puhlic NORINE R
ry Public,State o1 New York Notary Public, of New York
c.No.01ME6130833 Lic.No.01 130833
Ou ed In Westchester County Qualified in Westchester Count
Commission Expires Juty 25,20&A Commission Expires July 25,20�
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.
x
6/l/2020