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BUILDING MENT D `�
VILLAGE OF RYE. BROOK 3D
938 KING STRUT RYE BROOM,NY 10573 APR - 3 2023
(914)y39-0668 VILLAGE OF RYE BROOK
�rut>lc.c+r BUILDING DEPARTMENT
APPLICATION FOR PERMIT TO INSTALL AND/OR REMOVE
HEATING, VENTILATION AND/OR AIR CONDITIONING EQUIPMENT
I t )k 01 1 ICL t!Si. (.)NI.Y: PERMI I #: -0,3
Approval Date: 20 ermit Fee:
Approval Signature: Other:
r
Disapproved:
(fees are non-refundable)
REQUIREMENTS FOR RELEASE OF PERMIT&CERTIFICATE OF COMPLIANCE:
I. Properly completed & Signed Application.
2. Site/Staging Plan if Required by the Building Inspector.
3. Copy of Licensed Contractor's Liability Insurance. (viilage of Rye Brook must he listed as cetliticate holder) & Workers
Compensation Insurance on a NYS Board farm (Form t#C 105.2 or Form 4 t J26.3,1 or NY State Workers Compensation Waiver)
4. Payment of Fees/Unit: -: A,; .:nit • C'OM1 IFRC'1;11_ W0.0041nit.
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. 7 2
I. Address: 7uln !—fin SBL: /J5, --73—/A Zone:
2. Property Owner:li Cj - Address:
...
Phone#: ��} r �" , 0 �G �j(�� Cell#: email: Xinbe q61 yahnn.
3. Contractor: _ u U4ital Se-ryf GCS Address:
Phone#: 667-q222 Cell#:q Ji4 •- H15 —q%14 email: _
4. Scope of Work: New Installation (11�• Replacement( )••�'Reemoval( )• Other( ):
5. List Equipment: 4fjk fiTU Neal Punwn r�,ry Xf z,. ISk. L ail,"eyat ,Joor um'i InX ASVhIS No
`4. 67V w I Mayd Unif ,4suueaLPAS A ATv tlr l amw inhor-yay,
-
6. Location of Equipment: 6ftJoRaft ,I &dA-_ am&,, "(
1S+1� ��t�,�d iah,Wuoi,
7. Method of'Installation/Retnoval (list all equipment needed to perl'onn job): R.410 A Lint S8�f Line ft CMEC !lent
1 `
1
3/3/2023
STATE OF NEW YORK,COUNTY OF WESTCHESTER ) as:
msce, A&VA ,being duly sworn,deposes and states that he/she is the applicant above named,
(print name of individuM signing as the applicant)
and further states that(s)he is the Heating, Ventilation and/or Air Conditioning Contractor 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.
Sworn to before me this Sworn to {j1-
/b�for me this y�
day of 3r��' ,201_ day of 20 -�
Signature of Property Owner Sing a ic ture of App ant
►'n QU L.P�fi� e
Prin Name of Property wrier Prm 't r me of nt
Not ub
DEBRA ISAACS
DEBRA A ISAACS
NOTARY PUBLIC-STATE OF NEW YORK NOTARY PUBLIC-STATE OF NEW YORK
No.01IS5069916
Qualified in Rockland County No.014S5069916
My Commission Expires 06-03-2023 Qualified in Rockland County
My Commission Expires 06-03-2023
'llyIIcatloll flillsi he prohcrl% completed III its cntiret) �tncl must inClude [tic notarized signaitn•c(5) of
Oic Icoal o",ner(�,j of the sub..iect propert�,. and the applicant, of record .in the spaces provided. All1
upplic.ttitm not properly coniplet d in it.s C ttirety �.tnd%or nol. properly signed steal[ be de need null and void
and ti ill he returned to the applicant.
z
3/3/2023