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BUILDING DEPARTMENT U
VILLAGE OF RYE BROOK JUN Z 6 2024
938 KING STREET RYE BROOTk,NY 10573
(914)939-0668 VILLAGE OF RYE BROOK
w v.ry ebrooWili+.eov BUILDING DEPARTMENT
Application for Permit to Remove or Abandon Fuel Storage Tank
(*Storage Tanks in excess of 1,100 gallons require registration with the
County
lof�Westchester)
FOR OFFICE USE ONLY: PERMIT #:
Approval Date: Permit Fee: $
Approval Signature: Other:
Disapproved:
(fees are non-refundable)
DO NOT START WORK or CONSTRUCTION UNTIL A PER IT 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 S750.00
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: Removal or Abandonment$185.00 per Tank.
5. Dig Safely New York#(dial 81 1): 0 (r, 7 Sal - 0 0 �:t- // 7
6. Inspection by Building Department for removal or abandonment.
7. Submit all Manifests& Reports(after work has been completed).
8. Certificate of Compliance will be provided when all requirements are fulfilled.
Application dated, 1 :Zy �A is hereby made to the Building Inspector of the Village of Rye Brook for a permit to
remove or abandon 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 or abandoned in conformance with all applicable Village,County,State&Federal laws,codes,
rules and regulations.
Indicate Permit Tvbe: Removal Abandonment ( )/Above Ground( )- Buried in Ground (➢,<
�1. Address:_ � 6 16r4- C>61_J tViL SBL: 1d-1/1 i ,pf—3 Zone:
2. Property Owner&Address: C �Phf l/a —5-A _9 , ���,t 1� 4 C 57
Phone#: //`/ 15 7 7' '�S W2, Cell#: email: —,-Se-c r 0 r C C,
3. Contractor&Address: V M .1)t"(,ec 4 j A- _1 75, 4:d11- h r,>* AX y
Phone#: 9jy yty- 32_5t Cell#: 2-q, �F4 -ESL _ email: /Y) /5cl,n-f �C ( � off- Ic.--
4. Applicant: V1* -J"4-43 P hie74 AOle," ---t1 -,.4 y
Phone#: 51 Y 8t_Y - 3;z,-5 C Cell#: eJr5r fst y-Azz 5 9 email: a,C_ e r,
5. Indicate Fuel Type:Fuel Oil(/j•L.P. Gas( )•Gasoline( )*Other( ):
6. Number and Capacity of each Tank: -# / S b S ga k l a JM-
7. Exact Location(s)of each Tank: Z>Q r*c.,J E eJJ .5
t
6/l/2024
STATE OF NEW YORK, COUNTY OF WESTCHESTER ) as:
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 Tank Removal/Abandonment 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 ta Swom to before me this �r
day of 20 day of J
�{y '��' 20
Signature of Property Owner Signature of Applicant
fi f
Print Name Prop caner ;PrAifitNNgofA otary P ltc R
tary u lic, ate NY
No.01 CA6022369
Qualified in Westchester County
This application must be } rF�rr�lpieetin g's 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.
STEPHANIE RUSSO-PASTILHA
Notary Public,State of New York
No,01 RU6136519
Qualified in Westchester Coun
Commission Expires Nov.7,20
2
6/1/2024