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BUILD Di0i MENT
VIL of RY OOK OCT - 6 2023
938 KING ET RYE Bit ,NY 10573
q Ofj��jY 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#: //j�d3
Approval Date: OCT 1 2 2013 Permit Fee: $ r�
Approval Signature: 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: nstallation �•Removal( )•Abandonment( )/Above Ground(')•Buried in Ground ( )
1. Address: 4 P3CP"q SBL: a I Zone:
2. Property Owner&Address: N C'
Phone#:qla Ms9 � a14yp Cell#:r email:
3. Contractor&Address:��,S�T-t��P>*( e, S-l e� [_ - - NL ,),!? J <ZL�� &- r 1�
Phone#:(�1y, q3�1 -��AQO Cell#: email:
4. Applicant:
Phone#: q l q Cell#: email:
5. Indicate Fuel Type: uel Oi •L.P. Gas{ )•Gasoline( )•Other( ):
r-
6. Number and Capacity of each Tank: 'AM an y-) cA c r-cp, j C7 l
7. Exact Location(s)of each Tank: )u� pr s, — unc-'_,r d x , c&A- c- c r- oC
I -
L t
8/12/2021
C-0NotCl;cM.�— --,, \ �,0
STATE OF N &RK COUNTY OF ) as:
t? ,being duly sworn,deposes and states that he/she is the applicant above named,
(print nine of inc ideal signing as the applicant)
and further states t t(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 vJiiitect,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 . f ") Sworn to before me this
day of �M�J�'t= ,20 ti day of S"Cf 4 +� 20
Signaturc:of Property Owner Signature of Applicant
pr t me of PAoperty O Print Name o A plicant
�?-cv V Z
t� Nutary pubi' Notary Public SEAN LY7LE
=` NOTARYPUBLIG
W CRmmlistan Explrss-ALg,"1,2025
This application must be properly completed in its entirety and must include the notarizw,d
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.
LAURA J DELUCA
Notary Public-Stote of New York
NO. 01 DE4998586
Qualified in Westchester County
My Comm. Expires June 29,Count
My
2
8/12/2021
