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BUILD INq DEPARTMENT D [E C E M
VILLAGE OF RYE BROOK SEP 17 2024
938 KING STREET RYE BROOK,NY 10573
(91.4)939-0668 VILLAGE OF RYE BROOK
%iw-A.riebrookuy.gov BUILDING DEPARTMENT
Application for Permit to Install Fuel Storage Tank
(*Storage Tanks in excess of 1,100 gallons require registration with the Countyy�of Westchester)
FOR OFFICE USE ONLY: PERMIT#: /"/ l'd 7"'� 0
Approval Date: SEP 2024 Permit Fee: -
Approval Signature: I Other.
Disapproved:
(fees are non-refundah1t)
DO NOT START WORK or CONSTRUCTION LNTIL A PERMIT HAS BEEN ISSt.ED 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:
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#C105.2 or Form#U26.3/or NY State Workers Compensation Waiver)
4. Fee per Tank: Installation: 5185.00 per Tank.
5.Dig Safely New York h (dial 811):
6. Inspection by Building Department for installation.
7. Submit all Manifests& Reports (if applicable, after work has been completed).
8.Certificate of Compliance will be provided when all requirements are fulfilled.
Application dated, oer ww4 ,is hereby made to the Building Inspector of the Village of Rye Brook for a permit to
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 installed in conformance with all applicable Village,County,State& Federal laws,codes,rules and regulations.
Indicate Permit Type: Above Ground Buried in Ground
1. Address: 34 TALCOTT ROAD SBL: 135.50-1-6 Zone: R-12
2. Property Owner&Address: PAMELA D'AMBROSIO 34 TALCOTT RD RYEBROOK NY 10573
Phone#: 914-636-0022 Cell#: 914-522-9214 email. PAM.BUDDYAMBROSIO@GMAIL.COM
3. Contractor&Address: Northeast Environmental Inc 225 Valley Pl Mamaroneck NY 10543
Phone#: 914-777-1930 Cell#: email: dmonaco@neenviro.com
4. Applicant: Dwayne Monaco for Northeast Environmental Inc.
Phone#: 914-777-1930 Cell#: email: dmonaco@neenviro.com
5. Indicate Fuel Type:Fuel OiRJ L.P.Gas( )•Gasoline Other( ):
6. Number and Capacity of each Tank: ONE (1) 275 DOUBLE WALLED AST
{�,VS " SC (e DVS 5 QC Q ,-\CR
7. Exact Location(s)of each Tank: EXTERIOR RIGHT HAND SIDE OF RESIDENCE
t
6/l/2024
STATE OF NEW YORK,COUNTY OF WESTCHESTER ) as:
DWAYNE MONACO ,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 Installation 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 5- V- I Sworn to before me this l
day of 2.0 ' }20 g day of ,20
J � JA;Y�N�E
tgnature of Property Owner Applicant
05 o MONACO
Print Name of Property Owner :Print Namea pp an
Notary Public �,Esateof New YorkKATHLEEN KILLINGBACK Registration No.01BA6171381
(Votary Public, State of New York Qualified in Westchester County
Qualifi:. in Westchester County Corrrmission Expires July 23,20 0� 7
ID # 01 K 5071
This applicatlfdmppu7;�af �jltcSfiiagfntirety and must include the notarized
signature(s) of the legal owner(s) of the su jec 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.
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6/1/2024