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HomeMy WebLinkAboutMP23-105 � 4 ■ ■ Ln W O !1 N M oeq Cl ■ F+N rl e••J � W y v 7 s \ n M n p Cn G4 •� a cd 14 O ONO o Cl) 0 101. 0 V1 ■ W � 0-4V v h a M■M ' ° F� A 0 Ln tr C. CN Wcn cn a v A x o H z . w � � zo � o� h+� fi] -b W V Z © z Uz a o ` o04 c� i.,.q W A W = 6 A p °O .� W N 9 U �'' Cn Z 4 �W WA 1 w a W a ° zz � � p W O V A z z o, Z �' k ` � a W o o .a • � O va G� � y LO z A o A lip N wq H C) o ° W U a+ W •• WU ar �I a I'll 401 WWI x � � .2 BUILDING DEPARTMENT DD S C E fl V E VILLAGE OF RYE BROOK MAY 2 5 2023 938 KING STREET RYE BROOK,NY 1057 (914)939-0668 VILLAGE OF RYE BROOK BUILD114G DEPARTMENT APPLICATION FOR PERMIT TO INSTALL AND/OR REMOVE HEATING VENTILATION AND/OR AIR CONDITIONING E UIPMENT Approval Date: 0Permit Fee: $ G", Approval Signature: Other: Disapproved: d(fees are non-refundable - xx•xxx�ex*x**:r******x*�:r***,r*a****,t,r**,t**********x**,tx***t******r**********xxx�rxxx,t,t,t****xxx**x,t*,t,t***xx 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. &Workers Compensation Insurance on a NYS Board form 4. Payment of Fees/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 61—ris 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. ,,hh �/ 1. Address:�X5 &. b lb&r SBL:4•35dn-5 Zone: 2. Property Owner: 1' Address: AHiT'T� �XJ [LfC Phone#: Cell#: 7h4- 419—awf(a email• 709 3. Contractor:�0-Ne O rt aeS Address: -Phe� %I OI rv�c'd I e` emaiQ 1 q L0 O rQC1C'�J•CQo7 4. Scope of Work:New Installation( •Replacement( )•Removal( )•Other( ): 5. List Equipment:CA -kJ erS _ 6. Location of Equipment: 7. Method of Installation/Removal(list all equipment needed to perform job): hand d t 3/3/2023 STATE OF NEW YORK.,COUNTY OF WESTCHESTER ) as: ,being 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 Heating,Ventilation and/or Air Conditioning Contractor 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 d`�' Sworn to before me this day of 12 day of ,20 Signature of roperty Signature of Applicant P ' ame of Property Owner Print Name of Applicant Notary Public Notary Public SHARI MEULLO Notary PUblle,State of New York No.OIME6160063 Qualifted In Westchester County Commission Expires January 29,2tA1, z 3/3/2023 STATE OF NEW YORK,COUNTY OF WESTCHESTER ) as: ,being 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 Heating,Ventilation and/or Air Conditioning Contractor 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 day of ,20 � ..y Signature of Property Owner nature of App is Print Name of Property Owner Print Name of Applicant yrq�1�Ai67(1 Notary Public Kotary Xublic ; v GREGORY M.RIVERA Notary PUMIC,State of New York No.OIRIWI398 QuaKfied in Westchester County Convnbsbn Expires September 26,20 11 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. 2 3/3/2023