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BUIL11tNG DEPARTMENT NOV 2 1 2024
V D1
IL t�E OF RYE BROOK
938 KING 'I'"ET RYE BROOK,NY 10573 �---
`;(914 -0668 VILLAGE OF RYE BROOK
1 , i_ BUILDING DEPARTMENT
rookn ov -~�—�-
Application for Permit to Remove or Abandon Fuel StoraE!c Tank
(*Storage Tanks in excess of 1,100 gallons require registration with the County of Westchester)
FOR OFFICE USE ONLY: PERMIT#: ,lc�L/'�`� 3
Approval Date: 2 d24 Permit Fee:
Approval Signature: Other:
Disapproved:
(fees are non-refLndabfe)
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:
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: Removal or Abandonment$185.00 per Tank.
5. Dig Safely New York#(dial 811):
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, 1112012024 ,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 Type: Removal(4-Abandonment( )/Above Ground (Buried in Ground ( )
I. Address: 17 Highview Ave., Rye Brook, NY SBL: 141.35-2-10 Zone:
2. Property Owner&Address: Maxima Moran
Phone#: 914-479-8790 Cell#: email: normaliza.p@gmaii.com
3. Contractor&Address: Meenan Oil Co LIP
Phone#: 914-847-0295 Cell#: email: jweir@robisonoil.com
4. Applicant: Same as contractor
Phone#: Cell#: email:
5. Indicate Fuel Type:Fuel Oil k)•L.P.Gas( )•Gasoline( )•Other( ):
6. number and Capacity of each Tank: Removal only of 275 gallon above ground oil storage tank.
7. Exact Location(s)of each Tank: Basement
t
6/1/2024
STATE OF NEW YORK,COUNTY OF WESTCHESTER ) as:
Hfit. i 14 �Ick'el .being duty 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 legal owner of the property to which this application pertains,or that(s)he is the
for the legal owner and is duly authorized to make and file this application.
(indicate architect,contractor,agent,attomcy.etc.)
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 die 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 3(-1 Sworn to before me this
day of 20 _ day of „ 20
Si nature of Pry erty Owner Signature of Apfficant
t4 6 x/�'G- ��['i I'Gt t2 ke96 ` //y 1`- {� 1 —
Print Nam of Property Owner Print ame of pplicant
J"/
—. LIAN SIERRA m t!SIERRA
Notary Public Notary public-state of New York Notary Public Notary Public-State of
NO.01516280198 NO.01S16280398
Oualifled in Westches: q0unt Qualified in t'lestchester Coua'-
f:''.,(;^TTIi5in9 f•Xrir6S 't"lt .
This application must be properly complete in��trety and must include the notarized signatures) ,
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.
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