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BUILD MENT D E C FE �}U LE '
VIL OF RY OOK
938 KING ir RYE BR ,NY 10573 FEB - 2 2023
VILLAGE OF RYE BROOK
BUILDING DEPARTMENT
APPLICATION FOR PERMIT TO INSTALL AND/OR REMOVE
HEATING, VENTILATION AND/OR AIR CONDITIONING EQUIPMENT
FOR OFFICE USE ONLY:
Approval Date: 20 Permit Fee: $
Approval Signature: Other:
Disapproved:
(ties 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.
N/ 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#Cl05.2 or Form#L126.3/or NY State workers Compensation waiver)
4. Payment ofFees/Unit: RESIDENTIAL =S100.00/unit • COMMERCIAL = S350.00/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/Sias work requires a separate Plumbing Permit&Plumbing Inspection.
***,�*,�*****�*�*,�* *** *,t*�r,a******,t*****t*,t**********,r****,t*t*******�****x**x**w*�r*w*�r*�r*,x**rw*��r•rr
Application dated, 01 3 23 is hereby made to the Building Inspector of the Village of Rye Brook for a permit for the
installation and or removal ot 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. (�J�
I. Address: 2 RobinS QooSt SBL: 05,21 — I"?j `` Zonc. L0
2. Property Owner: r'j LC(,l.J 1 S Address: �(��fn S /�das�
Phone#: "11``[[ - ��,� �OZ Cell#: email: ����y !,VLVV1i(At1
3. Contractor: tv U 11p' o H Address:bzo �'(f.( Lt�'taye, LLWJPhone#: - Cell#: email: QI A�ndrae hyvJC .
4. Applicant:at e X(M-d a (ad Address: 693 Riq LW 6'k, HarYlat Colo
Phone#: Cell#: email:MeXandraCA.I4! WVlU.Cdri
5. Scope of Work:New Installation
``!!(V .Replacement( )•Removal( )•Other( )): , rJ,,
6. List Equipment:1 I 1 1 2,UY� � Wn+- f�l Wj2 H f�, U I.l�S h I� d U c�rt-c-S S S L��
7. Location of Equipment: ( (( ha t(_.1(a /Y? _yY��f'c bed mayl, nl-M W 0
Lax
8. Method of Installation/Removal(list all equipment needed to perform job): 6n t 1 1
oiz& Co n nccC wi}h i
t
8/12/2021
ATE OF NEW YORK,CO NTY OF WESTCHESTER ) as:
being duly sworn,deposes and states that he/she is the applicant above named,
(print name of individual signing as the appl' ant)
and further states that(s)he is the legal owner of the property to which this application pertains,or that(s)he is the
Zw=cltmY 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
St Sworn to before me this 3��
day of `I�-!Mq�s 20 a3 day of 20 Z0-7- 3
14 r
�— Si A 1' t
Signature of Property Owner Signature of pp
01wri(IM Ebfi Ltt�
t Name o Appl' r
Pri t Name of Property wrier
Notary Public Nets Public
EKARENM 9ATrI5TA DANIEL TARTAGLIA
Strtt*of New]2025
Notary Public,State of New York
istate i m Registration No.02TA6323493
estCh"ter Co Qualified in W pares pr:il County
Expires Dec 1
Commission Expires Aril 20,2023
This appli,.. [on must he 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.
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8/12/2021