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BUILD , - ` '` MENT D
VILL� OF Ry. OOK MAY 2 4 2024
938 KING S.t�.&RYF.,BR , ,NY 1.0573
INQ ;g� VILLAGE OF RYE BROOK
vi,vw. k:ur BUILDING DEPARTMENT
APPLICATION FOR PERMIT TO INSTALL AND/OR REMOVE
HEATING VENTILATION AND/OR AIR CONDITIONINQ E UIPMENT
FOR OFFICE USE ONLY PERMIT !#:
Approval Date: NAY 2 9 � Permit Fee: $ � / 6
Approval Signature: Other:
Disapproved:
(fees are non-refundable)
DO NOT START WORK or CONSTRUCTION UNTIL 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 o1'Rye Brook must tv lined as cerlificate holder)& Workers
Compensation Insurance on a NYS Board form (Form#C105.2 or Form#U26.3/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, 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: 1(.04 �f�[ L��17 1�1�fjty SBL: -/-% 7.one: ",b
2. Property Owner: Rt k)��`� IJi ;�t?0 Address: Lp 9 6CUS Mas
Phoned: Cell#:91LI !a91, email:A4 1 6A
dj' M4 Cat"
3. Contractor: 1r Address: -)(My.n�-� � 0
Phone#: Cl Eck_ls�-�Yoic1 Cell#:Ci ii-I i- t`Z-=7,11 email: r16�,
4. Scope of Work:New Installation( •Replacement( )•Removal( )•Other( ):
5. List Equipment: tSd(
r yAia
6. Location of Equipment: A
7. Method of Installation/Removal(list all equipment needed to perform job):
1
10/30/2023
STT OF NEW YORK COUNTY OF WESTCHESTER ) as:
t`cYL being duly sworn,deposes and states that he/she is the applicant above named,
(pr naim of individua 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,
Sworn to before me this tA014 Sworn to before me this M
day of 25 20 _ day of ,20 _
Signature of Property Owne Sign re of Applicant
/0, 01d it /)�?-eob Vo
Print Name of property Owner Pnnt Name c Ap$icant
NotMNK
� Not lic
E�1
P.ALLEGRE�1 FRANK P.ALLEGR
[NOTARY PUBLIC,STATE OF NEW YORK NOTARY PUBLIC,STATE OF NEW YORK
No. 02AL4994485 No, 02AL4994495
Qualified in Westchester county Qualified in Westchester o y
Commission Expires April6 ---� Commission Expires April6 4
This application must be properly completed in its entirety and must include the notarized si nature(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 NwiII be returned to the applicant.
2
10/3ono23