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ECENE
BUIL>aN MENT
VIL OOK JUL - 7 2023 DD
938 KING "CT Ryt I]R' ,NY 10573
41 bj a VILLAGE OF RYE BROOK
111ro re BUILDING DEPARTMENT
APPLICATION FOR PERMIT TO INSTALL AND/OR REMOVE
HEATING, VENTILATION AND/OR AIR CONDITION E'��0INNG QUIPMENT
FOR OFFICE USE ONLY: PERMIT#: tL1
Approval Date: JUL 1 1 23 Permit Fee: $
Approval Signature: Other:
Disapproved:
(fees are non-refundable)
REQUIREMENTS FOR RELEASE OF PERMIT&CERTIFICATF_.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(Fonn#CI05.2 or Form#U26.3/or NY State Workers Compensation Waiver)
4. Payment of Fees/Unit: RESIDENTIAL=$100.00/unit • COMMERCIAL=$350,00/unit.
5. Complete specifications for each unit being installed.
6. Inspection by the Building Department for removal and/or installation. (48 how-police regtrireco
7. Electrical work requires a separate Electrical Permit& Electrical Inspection.
8. Plumbing/Gas work requires a separate Plumbing Permit&Plumbing Inspection.
Application dated, '7— is hereby made to the Building Inspector of the Village of Rye Brook for a pennit for the
installation and or removal of the HVAC equipment as listed below."rhe applicant and property owner,by signing this document
agrees that said equipment will be installed and/or removed in conformance with all applicable Local,Count),,State&Federal laws,
codes,rules and regulations. 22``
1. Address: 31 bonwit road,Rye Brook NY 10573 SBL: ��Jo�` Zone: —�
2. Property Owner: Carl Austin Address: 31 bonwit road
Phone#: 914 779_4157 Cell#: entail: Ajerrick@chubb.corn
3. Contractor: SILA LLC Address: 70 fort point street, Norwalk CT 06855
Phone#: 914 966-0800 Cell#: email: calvarado@sila.com
4. Scope of Work:New Installation( )•Replacement(X•Removal( )•Other( ):
5. List Equipment: Replacement of LENNOX condenser, oil furnace &Bradford i_
6. Location of Equipment: condenser - outside coil, furnace & water heater- basement
7. Method of Instal lation/Reinoval(list all equipment needed to perform job): condenser, coil, furnace and water heater
and miscellanious materials
t
3/3/2023
STAT NE YORK, OUNTY OF WESTCHESTEt2 ) as:
Sjj" ( ,being duly sworn,deposes and states that he/slie is the applicant above named,
(print name of individual 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 ditty
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 Sword to before me this
day of 20'c day of ,20 ' ---
Signature 6WiKperty Owner Signature of Applicant
Carl AtS.I-wi Gin &41dvoKl--� 51,44 Gc
Print tigme oofff Property Owner Print Name of Applicant
/y//
L,otary Public KoTary Public
Amanda Bucci Amanda Buccl
Notary Public-Connecticut Notary Public-Connectleat
My Commission Expiros My Commission Expires
February 28,2025 February 28,2025
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 ol'record in the spaces provided. Any
application not properly completed in its entirety and/or not properly signed shall be deerned null and void
and will be returned to the applicant.
2
3/3/2023