HomeMy WebLinkAboutMP23-074 _
7
s =
lit
(— w � s
■ 0 N � W -a � ■
. � N N o„�,a O ■
�3y ae y ° cu W
Ln � .�, C _
Ll, � r�
CA cf)
04
z a .E (u V1 ,
■ rFr w � - ILv.I U �"� 0 "" —� �" h�l .
: 1:4CA
r�� 'eta a. ' ` `O ■
: 3
in u N g W
4zA 0 3 -
n to
0014
Trl
uj z
W d
u s
N a
■ (� A � Hr�� w a z � � w � � : a co
� .
= W oo V z p O w0 - o o v
�T1 C z u z o
5.
� d- 5 � a �� c � ■
00
■
o r,
rr
a� �r
z F p.
o
Fri % Q fay O V F n �u MCI
firkw i � � a
C7 Q Z a cn y a
°
i-r to �""" � �T+ d' " v C •� `
A O V
� (U -
BUILD ! _ MENT MAR 2 0 2623
VIL. OF R OOK
938 KING S ETRYF BRA,NY 10573 VILLAGE OF th4'c 13 GOf4
BUILDING DEPARTMENT
APPLICATION FOR PERMIT TO INSTALL AND/OR REMOVE
HEATING,VENTILATION AND/OR AIR CONDITIONING EQUIPMr'ENT
FOR OFFICE USE ONLY: PERMIT#: -�r✓
Approval Date: M A Y p23 Permit Fee: $ c2c
Approval Signature: Other:
Disapproved:
(fees 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.
3. 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#C 105.2 or ronn 4 U26.3/or NY State Workers Compensation Waiver)
4. Payment of Fees/Unit:RESIDENTIAL=$100.00/unit•COMMERCIAL=5350,00/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.
T Plumbing/Gas work requires a separate Plumbing Permit&Plumbing Inspection.
Application dated, 3 2 G2.3 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.
I. Address: Z J \ SBL �.3 � ��- � Zone: lc
2. Property Owner: It, t�k' �rga I ,r,A Address: Z S W+
Phone#: Cell#: 990-7 email:
3. Contractor: t. bJrlo�xr Address: S- c 06
Phone#: (its _-La -1go0 Cell#: email: xr.;isCaTwcb t .C��
4. Applicant: ,I�)t�locr Address:M6 JQ1 5r=.�.a �t (at(I
Phone#: C�u6 L65-tgro Cell##: email: Pe :}s(5,7-r ebl�r•C_v,
5. Scope of Work:New Installation( )•Replacement 4Q•Removal( )•Other( }:
6. List Equipment:No je, h)C3-ZgQll to
7. Location of Equipment: Mlecl,o^�ca� �oo+•.
8. Method of Installation/Removal(list all equipment needed to perform job):Zmaue,
t
B/l2/10z 1
STATE OF NEW YORK,COUNTY OF WESTCHESTER ) as:
AAF6-PA AMA- 4W AW,41VNObeing 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
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 10 Sworn to before me
this I
f_
day oM/Jt lC ,20;L, day of//JQ V -1l 0 3
Signature of Property Owner Signature of App icant'
-RUn
t Name of Property Ow er int Name of,Arpp � ant
�l 1
otary Public otary Pub M ti ney
PATRICIA A.SAI�dTORA notary Public,state of new YOk
1ugistnetton No.: OIT16045084
N0TARYPUBLIC Q"P WeO In Dutthess County
MY COMMISSION EXPIRES JAN,31,2020 Commissw Expires: July 2026
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.
Z
8/1212021