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HomeMy WebLinkAboutMP23-155 s : Ln M w M N N w v N � a Q C 00 A w O x a x Cf) ow v Z 0AOo ° s v� �1 C p W ON Ln Ir , 00 co C'7 w �, w a v o z Uz � b v � ° � A N U Wd oto' v v M zz .0 cu a a W w O � '^ o � ° a 0 ' U � o © Z z � ,� v PO i..� o O o � a vs y a. p M G7 W 0 A p �" . °' �"+ w H o o b xcn BUILD MENT p [ECEJWIE VIL E OFRY OOK 938 KING t" ET RI'E BR ,NY 10573 OCT 17 2023 -0 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 Approval Date: OCT 2023 Permit Fee: S Approval Signature: Other: Disapproved: fees arc non-reCundablc) 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#C 105.2 or Form#U26.3 /or NY State Workers Compensation Waiver) 4. Fee per Tank: Remova , bandonment, r Installation: $185.00 per Tank. 5. Dig Safely New York# (dial 811): 3 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,Curb 3L- i t• Z�>7.3 ,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 ( )• Removal( ) • Abandonment Above Ground ( )• Buried in Ground M� I. Address: M 3 �z� `'`� "'tik Lca ,, 1 C14St.�iT SBL: 1Q%76-1-1 Zone: 2. Property Owner&Address: 'QsR amp S Phone#: "tl'� ' `'i39 - -`{ Cell#: email: 3. Contractor&Address: ;��2n�ti,1 Wit- `�jo {�yC�f=►tt Sr;rtTics���,eD lam. CYbblj Phone#: Cell#: email: ��� �n�':�`=S� •'� ,�'►'� 4. Applicant: nw bSk"LA-D �(' Phone#: °'�' 3�6 G6Lk`fi Cell#: email: LL) 't-b 5. Indicate Fuel Type: Fuel Oil(-)"- L.P. Gas( ) •Gasoline( )•Other( ): 6. Number and Capacity of each Tank: 3oo_ (oAAL_^ 7. Exact Location(s)of each Tank: t 8/12/2021 STATE OF NEW YORK,COUNTY OF WESTCHESTER ) as: Dip.n i C I BQ r-,� ,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 A O h tart ;,:d,.n-� for the legal owner and is duly authorized to snake 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 Sworn to before me this 01_4-obc r" day ofSt2 m h e to .20 day of 11 20 023 Signature of Property Owner Signature of Applicant f Prinq9lie of Pro pert O er Print ame of Applicant i Notary Publi Notes Public 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. DANIELLY NOVOLI-SANTOS Notary Public,State of Connecticut My Commission Expires May 27,2026 [AURA J DELUCA Notary Public-State of New York N0.01DE4998586 Qualified In Westchester County My Comm. Expires June 29, a A/12/2021