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ENT D p
VILOOK
938 KING ,NY 10573 FEB ' 2 2�VILLAGE OF RYE BROOK
BUILDING DEPARTMENT
APPLICATION FOR PERMIT TO INSTALL AND/OR REMOVE
HEATING, VENTILATION AND/OR AIR CONDITIONING EQUIPMENT
FOR OFFICE USE ONLY: PERMIT#: ,k/ CAS— 0/9
Approval Date: FEB 14 20a Permit Fee: $ / 5— —/-
Approval Signature: Other: 4/ c,:�S E7/p /" j �p
Disapproved: C-)00 /0 ,41 A
(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
RE UIREMENTS FOR RELEASE OF PERMIT&CERTIFICATE OF COMPLIANCE:
1. Properly completed& Signed Application.
2. Site/Staging Plan if Required by the Building Inspector.
3. 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#C 105.2 or Form#U26.3/or NY State Workers Compensation Waiver)
4. Payment of Fees/Unit: RESIDENTIAL = $150.00/unit • COMMERCIAL = $450.00/unit.
5. Complete specifications for each unit being installed.
6. Inspection by the Building Department for removal and/or installation.(48 hour notice required
7. Electrical work requires a separate Electrical Permit& Electrical Inspection.
8. Plumbing/Gas work requires a separate Plumbing Permit& Plumbing Inspection.
Application dated, -Zf is hereby made to the Building Inspector of the Village of Rye Brook for a permit for the
installation and or removal of the HVAC 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 all applicable Local,County,State& Federal laws,
codes,rules and regulations. �j��,/�' /r
I. Address!Z ��� �h !'� hPi� SB ��"�/� rJ�/�_' Zone:
2. Property Ownerr// r /'a i /�L /�R'� � Address:
Phone#: Cell#: �� �CO� emaill:: / C,:^
3. Contractor: Address;,70 / i /'�G� d¢<i alit'/611 j
Phone#: ? 14 8C 0 r Ca,.►��f�{�0C (.fOrl
D Cell#: email: � .�(, �SFnw
4. Scope of Work:New Installation(,)r-Replacement • Removal( )•Other( ):
5. List Equipment: rd o an 4' r"nl f,v L -rO a �-,v e
v�•►tx e ', 9U'of Go flomK
6. Location of Equipment: Mad r-a r kor
7. Method of Installation/Removal(list all equipment neVic
to perform job): 4r4•yf-
Vfh�� KILO �w r�s ip SV+V
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 Heating,. Ventilation and/or Air Conditioning 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 11 Sworn to before me this It
day of \U(� ,20 -LS day of tWY\AN ,20
?Aignature of Property Owner C-P Signature of A nt
� 1 r
Prin Name of Property Owner Print me of A icant
P ►'h' PP
XK-�'
otary Public Notary Public
E
A. KEANE GRACE A. KEANE
TATE OF NEW YORK NOTARY PUBLIC,STATE OF NEW YORK
o. 02KF-6424O70 Registration No. 02KE6424070
estchester County Qualified in Westchester County
s October 25 2025 Commission Expires October 25 2025
This application must be properly completed in its 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.
2
6/I/2024
