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BUILDING-bEPARTMENT Im
VILLAGE OF RYE$ROOK 938 KING STREET RYE BROOK,NY 10573
(914)939-066 (914)939-5801 oo )
APPLICATION FOR PERMIT TO INSTALL AND/OR REMOVE
HEATING, VENTILATION AND/OR AIR CONDITIONING EQUIPMENT
FOR OFFICE USE ONLY: PERMIT#:
Approval Date: A U rOA,;2 Permit Fee:$
Approval Signature: Other:
Disapproved:
(fees are non-refundable)
w,t********,t*,t******,t*w*«ww*******r,t,t*,t,t,t***w*r***r�**********�*,t*,t**,►**r******+r**,t**r�*************r,t*,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 must be listed as certificate holder)& Workers
Compensation Insurance On a NYS Board form(Form#C 105.2 or Form#U26.3/or NY State Workers Compensation Waiver)
4. Payment of Fees/Unit:RESIDENTIAL=$100.00/unit•COMMERCIAL=$350.00/unit.
5. 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, 06/29/2023 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. 22 II ''
I. Address: 11 Carlton Lane SBL:JJ5,y'p2 1 10 Zone: —�a
2. Property Owner: Fabio Marconi Address: same
Phone#: 914-559-8531 Cell#: email:
3. Contractor. Robison Oil Address:
Phone#: 914-847-0295 Cell#: email: (weir@robisonoil.com
4. Applicant: Same as above Address:
Phone#: Cell#: email:
5. Scope of Work:New Installation( )•Replacement(X)•Removal( )•Other( ):
6. List Equipment: Replacement of rnndPncer& Opil
7. Location of Equipment: Outside
8. Method of Installation/Removal(list all equipment needed to perform job):
t
6/1/18
NEW
TER
�T�T Zov-1 ORKZCO�II;J�,Y�F WES g duly
sworn,
) p: pp
�}Y,�J t[l�,�j�('}'(u/((T/jJ�-}' being dui 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.agenC 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 D7)i Sworn to efor me this '-7
day of _-4s I��`-, 0 a3 day of 0
Signature of Property Owner Si of t
t Pant Name of Property weer me o pplic
amanda K olmstead
E1J1110 NOTARY PUBLIC,STATE OF NEW YO
Nora 1 e• NEw or*
No.0 1 OL6417632
No.O1ME6260063 Qualified in WF.STCHESTER Cnunt ry PubliC
Qualified In Westchester County Commission Expires08/30/2025
Commission Expires January 29,2#Ll
This application must be properly completed in its entirety and -list 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.
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