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D `� E LE
BULL p MENT MAR 2 0 2025
V[L E'OF R OK
938 KING ET Rv�,BR ,NY 10573 VILLAGE OF RYE BROOK
(914)9 39-5801 BUILDING DEPARTMENT
I' U C
A lication for Permit to Remove Abandon and/or Install Fuel Storage Tank
(*Storage Tanks in excess of 1,100 gallons require registration with the County of Westchester)
FOR OFFICE USE ONLY: PERMIT#: �L
Approval Date: _ —�- — Permit Fee:$
Approval Signature: i Other:
Disapproved:
(fi4 ii#non-re*r,d*N,Cr).#**##*###
RE DIRE ENT FOR RELEASE OF PERMIT CERTIF CATS 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#C 105.2 or Form#U26.3/or NY Stage Workers Compensation Waiver)
4. Fee per Tank: Removal,Abandonment,or Installation: S 185.00 per Tank.
S. Dig Safely New York#(dial 811):
6.Inspection by Building Department for removal/abandonment and/or installation.
7. Submit all Manifests&Reports(after work has been completed).
8. Certificate of Compliance will be provided when all requirements are fulfilled.
Application dated, 3/10/2025 is hereby made to the Building Inspector of the Village of Rye Brook for a permit to
remove,abandon,and/or 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 removed,abandoned and/or installed in conformance with all applicable Village,County,State&
Federal laws,codes,rules and regulations.
I di a Permit T e: Installation (`' • Removal(Abandonment( }!Above Ground (�j• Buried in Ground( )
1. Address: 16 Bayberry Lame __ SBL- 129.84-2-5
Zone:
2. Property Owner&Address: Rodrigo 8� Monica Malzyner
Phone#: 914-291-4727 cell#: email: monicamalzyner@gmail.com
3. Contractor& Address: Robison oil 1 Gateway Plaza,4th FL, Port Chester, NY 10573
Phone#: 914-847-0295 _ —Cell#: email: jweir@robisonoil.eom
4. Applicant: Robison Oil
Phone#: 914-847-0295_ —Cell#: email: iweir@robisonoil.com
robisonoil.com
5. Indicate Fuel type:Fuel Oil O(-L.P.Gas( )-Gasoline( }•Other( ): _
6. Number and Capacity of each Tank: Removal and replacement of 275 gallon above ground oil storage
tank in Utility Shed.
7. Exact Locations)of each Tank: Outside-rear of home in Utility shed. U C
V
jOAS
t
6/1/2020
od OF NE) }CORK,COUNTY OF WESTCHESTER ) as:
�/' being duly sworn,deposes and states that he/she is the applicantm above naod,
m(print nae of individual s g mg 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 Cade 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 106 A
day of f gQGh ,20.25 day of 20 .7
Signature o roper•ty O ncr gn re of Ap cant
Print Name Prope Owner nt N pl' t
C" "'0' - Q—�—
Notary Public — N lic
IGY.
AMANDA K OL MSTEAD
PxPMae flEl�.� NOTARY pniJC,nAn OF NEW YORK
�,w Rcgiatra im No.01OL6417632
Quhf, d in Weatchester comfy
Comm aam F Wim 0$f3Q M
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
611/2024