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HomeMy WebLinkAboutMP23-111 m ■ ■ S = = a+ t � � v ■ n � � .fir y H v, P4 " pC � s 1�1 H M ap 'dy W 'en O ° 200 • coLn ti4' O 'LI o e J r 1 W \ 0 o ' Ooo s W Q M I..� p p 'C v i' ■ z V z b O 44 a a V� _ Ln N cS © ° C v V a W G7 u v i �.rA� If`T/� a ■ Wp 2 6 v t a t 0 A Fs.i cP ro o ° v � ^ A U o ? u. 0 ,50 v u V w oZ 0H 42 F� W 9 § o 4 A © �" " �•� °. BUILDING DEPARTMENT p IECIEMED VILLAGE OF RYE BROOK 938 KING STREET RYE BROOK,NY 10573 JUL 12 2023 (914)939-0668 www.ryebrook.org VILLAGE OF RYE BROOK BUILDING DEPARTMENT Application for Permit to Remove, Abandon and/or Install Fuel Storage Tank (*Storage Tanks in excess of 1,100 gallons require registration with the County of Westchester) FOR OFFICE USE ONLY: PERMIT#: zo<- PX 1 Approval Date: Permit Fee: $ el Approval Signature: i Other: Disapproved: (fees are non-refundable) REQUIREMENTS FOR RELEASE OF PERMIT&CERTIFICATE OF COMPLIANCE: 1.Application Completed by Bonded, Licensed Contractor. 2. Your contractor's valid proof of liability insurance. (Village of Rye Brook must be listed as certificate holder) 3. Your contractor's valid proof of workers compensation insurance. (Form# C105.2 or Form#U26.3/or NY State Workers Compensation Waiver) 4.Fee per Tank: Removal, Abandonment, or Installation: $185.00 per Tank. 5. Dig Safely New York#(dial 811): 6. Inspection by Building Department for removal/abandonment and/or installation. 7. Submit all Manifests&Reports(after work has been completed). 8. Certificate of Compliance will be provided when all requirements are fulfilled. Application dated, is hereby made to the Building Inspector of the Village of Rye Brook for a permit to remove,abandon,and/or install a Fuel Tank as herein described. The applicant and property owner,by signing this document agree that the subject fuel tank(s)will be removed,abandoned and/or installed in conformance with all applicable Village,County,State& Federal laws,codes,rules and regulations. Indicate Permit Type: Installation{ emova •Abandonment Above Ground (Buried in Ground( ) 1. Address: • �v /V4)✓ / wtc4v VT SBL: 1,351 Y,3—�`,� Zone: 2. Property Owner&Address: L)e�LA d C•2/C, Phone#: I- ��7`JQS S (S Cell#: email: 3. Contractor&Address: F�-/1'"v tl• Me'1,1 Ac Phone#: 9/`/ ` ye) &/-7 y Cell#: email: 4. Applicant: Phone#: Cell#: email: 5. Indicate Fuel Type: Fuel Oil M•L.P.Gas{ )•Gasoline( }•Other( ): 6. Number and Capacity of each Tank: 2 7. Exact Location(s)of each Tank: ri 1 8/12/2021 STA?OF NEW YO ,COUNTY OF WESTCHESTER ) as: �p t I I � usa� �GZ ,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 legal owner of the property to which this application pertains,or that(s)he is the ✓�i Y/t 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 cY'' Sworn to before me this L� day of ,20 5 day of ,20 Signature of Property Owner Signatur of A c t Print Name of Fro arty Owner MELANIA HRABOVSKY print 14amc ofApp 'c t NOTARY PUBLIC,STATE OF NEW YORK Registration No.01 HR63241 Public a I/1'A -71A-A/I i-Alhl) Qualified in Westchester Cou pub Commission Expires 05/04/27 �73 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. a 8/12/2021