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BUILD MENT
VIL E OF RY OOK 6RJ L,� 19 2025
938 KING ET RYE BR ,NY 10573
VILLAGE OF RYE BROOK
. ov BUILDING DEPARTMENT
Application for Permit to Install Fuel Storage Tank
(*Storage Tanks in excess of 1.100 gallons require registration with the County of Westchester)
FOR OFFICE USE ONLY: PERMIT#: "P� '0 �
Approval Date: FEB 2 6 20 _ Permit Fee: $ , —
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:
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 4 C105.2 or Form 4 U26.3/or NY State Workers Compensation Waiver)
4. Fee per Tank: Installation: $185.00 per Tank. f
5. Dig Safely New York 4 (dial 81 1): C) ` r(4(.0 L�
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, ,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 TyDe: Above Ground ;4�0 Buried in Ground ( )
1. Address: � ` �.1 SBL: D?f 7�'� �Zone:
�, �^
2. Property Owner& Address: ^�11 O V�l 1 Q G3� ) —
Phone#: ���`-���COD itll#: email:
3. Contractor& Address: Envirostar Innovation Corp., 50 Fields Lane, Brewster, NY 10509
Phone#: 845-279-9555 cell#. email: info@tankremovalservices.com
4. Applicant: Envirostar Innovation Corp.
Phone#: 845-279-9555 Cell#: email: info@tankremovalservices.com
5. Indicate Fuel Type: Fuel Oil ( • L.P.Gas( )•Gasoline( )•Other( ):
6. Number and Capacity of each Tank:
7. Exact Location(s)of each Tank:
t
6/1/2024
STATE OF NEW YORY,COUNTY OF WESTCHESTER ) as:
��t-Ot7(tl being duly sworn,deposes and states that he/she is the applicant above named,
(print name of indiv ual signing as a apply licant)
and further states that(s)he is the legal owner of the property to which this application pertains,or that(s)he is the
C,30i .Y QC3S3( for the legal owner and is duly authorized to make and file this application.
(indicate arctutect,contractor,agent,attorney,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 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 ofthe Village of Rye Brook and all other applicable laws,ordinances and regulations.
Sworn to before me this Sworn to before rite this f 3
day of ^E' t-, 20 5 day of ,20
Rk
Si /— of Pro Owner /� ` Signature of p icant
00
Name o Property O. OQ► • 1 fAppl• t
Q-. STATE
I L 0 :OF NEW YO
e o = :NOTARY PUBUQIr Public
No.01ME6160063
Qualified In Westchester County
commission Expires!lttusry 29,2027 `
This application must be properly completed in its efffi 't include the notarized signature(s)
of the le al owner(s)s of subject roe scant
g ( ) property,rty, and the app (cant 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
3/21/19