HomeMy WebLinkAboutMP24-029 O�
N °
N �w
v
w :
,Z A o
p r\� p p Q o o A -
O
W 44
10, v 'n° c
CN
US
o
CN
L
aW Wu ° `o` a� -
w
, a O- � x 00 av
O �►p00
� o � .° � -
00
M � o Q � av
z � ! o :
OR
o00
v ° V
c+')
W U � o � W
O p
z
99
v
off
BUIQRYE
MENT DIECIENED
C
OUNTY LICENSED IL
938 KINGOF oNY 10573OK MAR -5 2024
ELECTRICIAN REQUIRED TO FILE VILLAGE OF RYE BROOK
BUILDING DEPARTMENT
APPLICATION FOR PERMIT TO INSTALL AND/OR REMOVE
HEATING, VENTILATION AND/OR AIR CONDITIONING EQUIPMENT
FOR OFFICE USE ONLY: PERMIT#: �/�c�+�/ ` D C)L�
6 f)d
Approval Date: MAR ll Permit Fee:$ r
Approval Signature: Other:
Disapproved:
(fees are non-refundable)
�*aa***,t****��+t**,t,t****�****************,r*�,�***,ra*�*��******�***,t��,t,t,t,t,trt,t**+t**Aa,►+t,�,r**,r*a**,�**,�***,t**k
DO NOT START WORK or CONSTRUCTION LINTIL A PERMIT HAS BEEN ISSUED BY THE BUILDING
INSPECTOR.THE ADMINISTRATIVE FEE FOR WORK PROGRESSED OR COMPLETED WITHOUT A PERMIT IS
12%OF THE TOTAL COST OF CONSTRUCTION WITH A MINIMUM FEE OF$750.00
REQUIREMENTS FOR RELEASE OF PERMIT&CERTIFICATE OF COMPLIANCE:
I. 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#C105.2 or Form#U263/or NY State Workers Compensation Waiver)
4. Payment of Fees/Unit: RESIDENTIAL =$100.00/unit•COMMERCIAL =$350.00/unit.
5. Complete specifications for each unit being installed.
6. Inspection by the Building Department for removal and/or installation. (48 hour notice required
7. Electrical work requires a separate Electrical Permit& Electrical Inspection.
8. Plumbing/Gas work requires a separate Plumbing Permit& Plumbing Inspection.
Application dated,3 5 3 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. �^I. Address:t Y'�lrw C Ra SBL:1 a4.13 -I ' Zone:I'"r'/y
4
2. Property Owner:90 6 + Mk gory e_ �)QS Kow Address: [Ia 5alkf
Phone#: Cell#: � Yq�'lql� email: M4.'. ", rl( in ,� pry
3. Contractor:y'es-con Address: MS
Phone#: ?/t�-3'_�"7- Y 0 r)- Cell#: email: re S co n h Uac COM
4. Scope of Work:New Installation( )• eplacement Removal{ )•Other( }:
5. List Equipment: C
6. Location of Equipment: '9C6nq ¢ � ��I i
h t!"r,Q.
7. ]Method of Installation/Removal(list all equipment needed to perform job): V\Q6,A
t
10/30/2023
STATE OF NEW YORK,COUNTY OF WESTCHESTER ) as:
being duly sworn,deposes and states that he/she is the applicant above named,
(print nan 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.
jL._
Sworn to before me this 2 Sworn to before me this '29
day of ,20 _ day of 20 2,L'
Signa�operty Owner Signature Applicant
K
Print Name oT Prop er Print N of Applicant
Notary Public N Public
JENNIFER• RANSOM
NOTARY PUBLIC-STATE OF NEW IORK
ROBERT A DASHOW No.Oi RA6288703
NOTARY PUBLIC,STATE OF NEW YORK OvalifiedinWestchester County
Registration No.02DA4993926 My Commission Expires 09-09-2025
Qualified in Westchest • ty
Thi lctit in its entirety and must include the notarized signature(s)of
the egaal owner(s) o t e 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
10/30/2023