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COUN"�LtCENSED BUILDING DEPARTMENT 1 MAR - 1 .4
EUECTRtG1AN VILLAGE OF RYE BROOK
REpUIRED TO ftLE 938 KING STREET RYE BROOK,NY 10573 VILLAGE OF RYE BROOK
(914)939-0668 FAx(914)939-5801 BUILDING DEPARTMENT
brook.or _T.
APPLICATION FOR PERMIT TO INSTALL AND/OR REMOVE
HEATING, VENTILATION AND/OR AIR CONDITIONING-EQUIPMENT
FOR OFFICE USE ONLY: PERMIT#: l c) V_0C1)XP
Approval Date: r,7��� T_ Permit Fee:$
Approval Signature: _ Other:
Disapproved:
(lees are non-refundable)
REQUIREMENTS FOR RELEASE OF PER.NIIT&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.(Village of Rye Brook must be listed as certificate holder)& Workers
Compensation Insurance on a NYS Board form(Form#!C 105.2 or Form#U26.3/or NY State Workers Compensation \k'aiver)
4. Payment of Fees/Unit: RESIDENTIAL=$100.00/unit•COMMERCIAL=$350.00/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, 2J27I2024 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.
1. Address: 117 Brush Hollow Crescent SBL: 129.76-1-143 Zone: )Oqb
2. Property Owner: Eileen Powell Address: Same
Phone#: 914-419-0688 Cell#: email: powellea02%maiLcom
Robison Oil One Gateway aza, >-i Floor
3. Contractor: Address: Port Chester, NY 10573
Phone#: 914-847-0295 Cell#: email: )weir@robisonoil.com
4. Applicant: Same as above Address:
Phone#: Cell#: email:
5. Scope of Work:New Installation( )•Replacement(X)•Removal( }•Other( ):
6. List Equipment Replacement of oil boiler.
7. Location of Equipment: Outdoor Utility Shed.
8. Method of Installation/Removal(list all equipment needed to perform job): Removal of existing boiler and install new
Energy Kinetics EK-1 oil fired boiler with 40 gallon hot water storage tank. _
t
6/1/1 s
STATE OF NEW YOM0XINTY04;Wl%l(1It %IItit I —
Joan tl(Ir+ .het*dulti awtwn,t"ww-wW`mate-,that he-she is the applicant at*-v mulw-1
1prsr arise of mcift Idwl use nr aw tt o-a-i
OW Jtwow Stakes that(%Ow i%Ilre loyal IM'IkY of dtc prolwil)f to which dtk appllcam pEr11 m-,,lY dkw(OhL as the
C«Kfaam fix the k-0 owncr and is duh mAhnritW tr►make and like diir applieaeion.
,..Jkm"M1�Aaz1 1R11ltwfi,Mgftd,♦Mif" di 1 -
1 hai all%tat-rrwnvi%"mminah hemon we unit to dte hem of his�hn knowk*c and beliet:tt W trim ary wrrk perfiv"MA a use
.tttxit.Kled at the ahtne 4aiptkWMI pru11L'rt)will he in con(cwmame%ith the details as sei kmth and cttnl:unni ut that applituit-
an+ ikc:rrrpwn%,-m t appmved plain%aaxl%pecifiL-alknm as Ncll m in accixdawc Nith the New YftrL Slate t nskirm Fire Pt..
11wh1mg Ctxk,the Co&of the YilIW ofRrr Brad and all other sM1K-;"r law%,ordinwcan ant rrPulatithrc
Swwsn to hritxr Inr du+ 2- S ttrn^ Yr
dV of - — -10-=—�— d of l J .Ali 2 q
AIL
Sim ttf F`roprny(4wttet.� tmature of App(cant
r l�t'J1 we .lean Weir
Pr int Nunn of PropM Ouna
1 ►-
htrtary I'ethli� hta,:ery it
SCOT T W CRAIG
NoWy Pudic of Hew York
REG NO 01CRt390667
COW&SSrOH ExPIRES 04J15a202T smands K olmstead
NOTARY PUBLIC,SIATEOh N1iW YORK
Registration No,010L6417632
Qualified in WE4TCHrSTRR County
Commission Expires 08130/2025