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HomeMy WebLinkAboutMP23-078 O en ,Zr _ v m T ■. w v a w W c", ■ �� � y7 O bi C by �i O W O ■ W z w C? •� Q W Gti [—� °° a 3 � �•- o cowCD 'o 04% Z v 0-4 cq CSC} as N A z 0 � o � 0 ■ �fM. w a a w x 9 � b BUILDING DEPARTMENT R [ [C E Q VILLAGE OF RYE BROOK 938 KiNc STREET RYE BROOK,NY 10573 MAY 18 2023 (914)939-0668 M2 +�ryebro4k.erg 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: SAY 1 9 7023 PERMIT#: I�'�/",/�d)3 — 07&7 Approval Date: Permit Fee: $ _Ab Approval Signature: Other: Disapproved: (fees are non-refundable) +r�F***v.*+t#,t+r+rf++**�p,trr**tr,t,t*****,t,t,t*,t***ir,t*r►,►,t,t*******,t,t,t****t,t***�F***,r,r*****,t****+r#**�*,r,e***,t,k**,k+r+r*#*,t* 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 roust be listed as certificate holder) &Workers Compensation Insurance on a NYS Board form(Form#C 105.2 or Form#U26.3/or IVY State workers Compensation Waiver) 4. Payment of Fees/Unit: RESIDENTIAL= $100.00/unit- COMMERCIAL=$350.00/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/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&FederaI laws, codes,rules and regulations.1. Address: 7'R? U t LLAtJiJ A L Alb SBL: 1,30,77— Zone: 2. Property Owner: Address:_�_k &e 1 i4 t 4 f\,A r p Ali.y� Phone#: )t '?ebb C� CA#:STY z-Q S'Y?�}email: LALV J Ui)(3 tSIL i.( )fVA 3. Contractor: Address: ( 4 A� � y f . �L Phone#: i . C�� Cell#:�2 ;) ''�.�,� email: S CAaC I S l Lik C(] 4. Scope of Work:New Installation O Replacement(" •Removal( )•Other( ): 5. List Equipment: 6. Location of Equipment: 7. Method of Installation/Removal(list all equipment needed to perform job)_* 1 3W023 STATE OF NEW YORK,COUNTY/OF WESTCHESTER ) as: C ! = Z �� fJf1t eing duly sworn,deposes and states that he/she is the applicant above named, {print name of individual signsng as the a plicant) and further states that(s)he is the Master Plu ber 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 before me this day of 20 cp� day of S gn of P e er S gnature of Applicant Print Name of Property Owner Print Name of Applicant — otary msitdE pr�anda' B��cci; Suocl Notary PQbPc-con ter,tc,ary Publ c CGnne:xlca? My C©rnrnlss;on tdcut Iv3y yumrrikssiGsn Expires F9bry r �xplrgs i rouruat.yZ8.2Q &=. - 0 v2$,2n2b_ Ilyis ai?IJ+'i��`,���'i3nti`st be properly completed in its entirety and trust include theno(arized sionaf st`of the legal cwner(s)of the subject property, and the applicant of record in the spaces provided. ,'Applications not properly completed in its entirety and/or not properly signed shall be deemed null and void and will be returned to the applicant. _2_ 3/3nO23