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BUILDING DiA,,RTMENT ^�
VILLAGE OF RYE OOK MAY — 2 2025
938 KING STREET RYE BR o NY 10573
(914 -0 Uri' VILLAGE OF RYE BROOK
BUILDI\'G DEPARTMENT'
I%I . oV --
Application for Permit to Remove or Abandon Fuel Storage Tank
(*Storage Tanks in excess of 1,100 gallons require registration with the County of Westchester)
FOR OFFICE USE ONLY: PERMIT#: jg, ,, �/ t
Approval Date: MAY Z _•ermit Fee: S ��"
Approval Signature: Other:
Disapproved:
(fees are non-refundable)
DO NOT START WORK or CONSTRUCTION UNTIL A PERMIT HAS BEEN ISSUED Bl•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
REOUIREMEN'rS 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#C 105.2 or Form#U26.3 /or NY State Workers Compensation Waiver)
4. Fee per Tank: emoval r Abandonment S 185.00 per Tank.
5.Dig Safely New Yor (dial 811): c`+3 eS - c o% - �--
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, JPR+'Z`,- 3a.�ZS 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 (►�•Abandonment( )/Above Ground( )• Buried in Ground(y'
1. Address: y12 �+� ' ' — SBL: ,3j c �� Tone:�'
2. Property Owner&Address: (�R � n' '0`�-►r�+c , -�� "�,�^,'�^ �� �y�- f"=�
Phone#: �cs3"b ��o t Cell#: C:A email: _
3. Contractor& Address: C;S\.1%. �L6t�
Phone#: ` 3 '3�ti 'sb`�`� Cell#:
4. Applicant: ��+2c 5�,. -,c {�f fr.+a� S-�2 :;7 r ra i- u- Aik,i.
Phone#: `�3 � 5)WA`V Cell#: email: '
5. Indicate Fuel Type:Fuel Oil(If-L.P.Gas( )•Gasoline( )•Other( ):
6. Number and Capacity of each Tank: �' � �9 b,;
7. Exact Location(s)of each Tank:
t
6/1/2024
:STATE OF NEW YORK,CjOUNTY OF WESTCHESTER ) as:
�r_-/e �i!AO/,4,//IQ 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 Tank Installation Contractor for the legal owner and is duly
authorized to make and file this appltcanon.
That all statements contained herein are true to the best of his/her knowledge and belief,and that any work performed,or use
.�-knaucted 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 bcfoke me this Sworn to before me this (Ja
day of 20 day of QJA 20_
Signature of Property Owner Signature of Applicant ` /J
rr V .t�.
_L_r"c.__ 2M C//c.(rl r0
Print Name of Property O HOPE B. VESIA Print Name of Applicant
Notary Public, State of New York
No. 01 VE5084028
otary ublic Qualified in Westchester Count Notary Publi
Commission Expires August 25,20[
DANIELLY NOVOLI-SANTOS
Notary'Public,State of Connecticut
his application trust be properly completed in its entirety and must inch M Cotn fission Expires May 27,2026
signature(s) of the legal owner(s) of the subject property, and the applicant of record in the space,-
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.