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HomeMy WebLinkAboutMP23-003 MH ~Vi L © 1-0 G+ _ � H S d• _S � N ` \ g'o e „ a c, W a aZ0. A aC u a w o - = a W W a 1 b _ •=i r..i x v v x a W QO a Zo o cc) �I Q rig Lin �+ c . . o ON o Q Ln Z ozb C1 to < w 0 • cxo W 00 U � � � .� O'4 a� o bill-, ic 08 tn H O z Z U d L V O o W z p W A 0 >1 .� ° o " a .10 A U p W W : av BUILDING DEPARTMENT VILLAGE OF RYE BROOK R JAN 10 2023 ID 938 KING STREET RYE BROOK,NY 10573 (914)939-0668 VILLAGE OF RYE BROOK www.ryebrook.org 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 #:� 3-003 Approval Date: 2023 Permit Fee: S ,/ o Approval Signature: Other: Disapproved: (fees are non-refundable) **#*****#***#*****##*#*****#*#***#********#########**#######****#*#************************##********** REOUIREMENTS 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#C 105.2 or Form#U26.3/or NY State Workers Compensation Waiver) 4. Fee per Tank: Removal,Abandonment, or Installation: S 185.00 per Tank. 5. Dig Safely New York#(dial 811): 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, i a a 3 ,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 (V *Buried in Ground( ) 1. Address:a t=� 1 M Wo\ "�!' SBL: S Zone: 2. Property Owner&Address: L ' — ! ArvU Phone#:"I 1`1 (; - a �,A Cell#: email: 3. Contractor&Address: U f Q r\ / �. Phone A(A 'may --&agL2--Cell#: 1� _`thy-1, y(,t mail: Pr f(, V to krOc°� OFL 4. Applicant: C �,"f ory` Phone#: Cell#: email: 5. Indicate Fuel Type:Fuel Oil(rJf.-L.P.Gas( )•Gasoline( )•Other( ): 6. Number and Capacity of each Tank: t Wo �? 3 �rl \tA3 rol u 9 iy n a (D\\ 7. Exact Location(s)of each Tank: 1 8/12/2021 -tST T$OF N8W Y CO 1NI-Y(JF WESTCHESTER ) as: •_ being duly sworn,deposes and states that he/she is the applicant above named, (print na e o individual siguiug as the lic nt and furth states that(s)he is �i�er of the properly to which this application pertains,or that(s)he is the for the legal owner and is duly authorized to make and file this e lication.(indicate architect,aoatructor,ageat,atwmy.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. r -t(n Sworn to before me this � � Sworn to before the this day of 20 of nl-) Si a Property Owner - Signature of Applicant Print N e of Prop erty Owner C' Ptini ama ofApplirant n � o Public Notary bloc This application must be properly completed in its entirety and must include the notarized signatln-e(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. BRF_TT M. MILCHMAN GREG©RY M.RIVERA Notary Public,State of New York Notary Public,State of New York Reg.No.02MI6404695 No.01R16441398 Qualifred in Westchester County CkmUfied In Westchester County '+ Commission Expires 07J24/20,, CtttttM"on Ezplres September 26,20,�t' 2 8/12/2021