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VILL F BROOK D
BUI -'.NG LIEP MENT
938 KnvG T YE K,NY 10573 JAM 2 3 2025
(914)939 rookn . nV
VILLAGE OF RYE BROOK
APPLICATION FOR PERMIT TO INSTALL MO IPARTMENT
REMOVE MECHANICAL E UIP
OFFICE USE M's
�SPermit##: Building Inspector:
Application Fee: Date of Approval: r
Permit Fee: Bldg/Use Class:Res.( );Comm.( );
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 MINIM 111 FEE
OF$750.00
1RF.QUIRF.MENTS FOR RELEASE OF PERMIT: (A CERTIFICATE OF COMPLIANCE Is REQUIRED TO CLOSE OUT THIS PERMIT)
1. Properly Completed& Signed Application.
2.Payment of Application Fee: Residential = $100.00, Commercial=$250.00 (fees are non-refundable)
3. Site/Staging Plan as required by the Building Inspector.
4. Sealed Construction/Installation Documents& Specifications as required by the Building Inspector.
5. 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#C105.2 or Form#U26.3/or NY State Workers Compensation Waiver)
6.Payment of Permit Fee:
Residential=$18.00J1000.00 of ConstructionfMaterials Cost with a minimum fee of$150.00.
Commercial=$25.00/1000.00 of Construction/Materials Cost with a minimum fee of$275.00.
7. Inspection by Building Department for removal and/or installation. (48 hoar nonce required)
8. Any electrical work requires a separate Electrical Permit and Electrical Inspection.
9.Any gas/plumbing work requires a separate Plumbing Permit and Plumbing Inspection.
Application dated, s hereby made to the Building Inspector of the Village of Rye Brook,NY,for a permit
for the installation,modification,and/or removal of the specific Mechanical 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 the
approved plans,and with all applicable Local,County,State&Federal laws,codes,rules and regulations.
1.Address:A O�Jr c'Ak �2 134,4SBL: Zone: - �-
2.Property Owner: ( Q N�<o r�AR'�C/n/ Address: 3 a(� -
Phone#: Cell#: S�) Z10-•0`'X- email: �.riC', ��� (�,��.(. te.•1
3.Contractor. Ale.e r 1 C a- CAA Address: 6 /u ^4 Pox OeLuTd•—
Phone#: Cell#: email:}.a R42!3 /��2t i is/ .�o1i�r✓ �--�C.,ti
4. Scope of Work:New Installation( )•Replacements•Removal( )•Other( )
5.Type of Equipment: I gAIV4 of'.-o.— S wP9
6. Location of Equipment-. L
7.Cost of Equipment including Installation Cost: $
1 6/1/2024
STATE OF NEW YOM COUNTY OF WESTCHESTER ) as:.
,being duly swom,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 Mechanical Equipment 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 Q Sworn to before me this �
day of ,20 day of ,2�
Si ap e o roperty,,Owner i of Applicant
%-- 10�) t
Pri Name Property O Print Name of Appli t
77�-
/ 1I
Notary KqbRY M.RIVERA Notary GORY M.RIVERA
Notary Public,State of New York Netary Public,State of New York
No.01 R16441396 No.01 R16441398
Qualified In Westchester County Qualified in Westchester County
Commission Expires September 26,
This application must be properly completed in its entirety and mus��M ����'i�8 R i��hel (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.
2 6/l/2024