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Buiin.�rt. .f� ��rrr APR 3 2025
VIL ' E OF Rv- AR,om
938 KING RVE BR 1`',NY 10573 VILLAGE OF RYE BROOK
� 3� / BUILDING DEPARTMENT
a'r�yi':t�ab rtto�dlti�.eo�
APPLIeATION FOR PERMIT TO INSTALL AND/OR REMOVE
HEATING,VENTILATION ANU/OR AIR CONDITIONING EOUIPMENT �'1�
FOR OFFICE USE ONLY: PERMIT'#: /y�p�`��'� `✓
Approval Elate: M* � � Permit Fee:$
Approval Signature: t Other:
Disapproved:
(Pies are npo•rePoedeble)
*A#iii#iRf#*tR#ii#!i#i##till######i#kA*#if###k#lifiiiti itiiiitii*#Rr***#***##ki##iii###fik#lAiiii#!i#!#i
DO NOT START WORK or CONSTRUCITON UNTIL A PERMIT HAS BEEN ISSUED BY THE BUILDING
INSPECTOR.THE ADM M9rRATIVE FEE FOR WORK PROGRESSED OR COMPLETED WTI'HOUT A PERMIT IS
12%OF THE TOTAL COST OF CONSTRUCTION WITH A MINIMUM FEE OF$750.00
RE.UUIREMEN715 FOR RELEASE OF PF3 MIT&CERTNICATE 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. of Rye Brook must he listed as certificate horde: &Workers
Compensation Insurance on a NYS Board form(i,ami 4!C 105.2 or Form#U26.3/or NY State Workers Compen.+atwn'w aiver)
4. Payment of Fees/Unit:RESIDENTIAL $150.00/unit*COMMERCIAL S450.00/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. PluanbinglGas work requires a separate Plumbing Permit&Plumbing Inspection.
Application dated, is hereby made to the Building Inspector of the Village of Rye Brook for a permit for the
installation and or removal of tine RVAC equipment as listed below.The applicant and property owner,by signing this document
agrees that said equipment will be installed and/or removed in conforraxace with all applicable Local,County,State&Federal laws,
codes,rules and regulations.
1. Address: 57 VMndingwood Road SBL: 135.33-1-26 Zone: R 15 _
2. Property Owner: Kevin Chason Address: 57 Windingwood Road
Phone#: 646-996-SM Cell#: email: KChssonQaol.00 n
3. Gonttacton Yost&Campbell Addre6a:20 Brookdale PI W.Vernon,NY*105W
Phone# 91d-668-6461 a - Cell#: 914-44"i6i(Maude) cmail. Kehason(.e01.com
4. Scope of Work:New Installation( ) Replacement(X)•Removal( )•Offer( ): MhanaseiCyostandcampbell.corn
5. List Equipment: Mufti-speed blower 5.00 Ton,Air Handkw,and Daikin AC 5 Ton Condenser(Rephimmert)
Inside—and outside - _-
6. Location of Equipment: I t2�
7. Method of Installation/Removal(list all equipment meded to perform job): *please see specs and proposal for details`
6P1am
STATE OF NEW YORK,COUNTY OF WESTCHESTER ) as:
Yost a Campbell .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 5 r} Sworn to before me this YD
day of '•� _,20 2 S day of � gc]�E 20
4 AILI,
Signature of Property Owner Signature of Applicant
Kevin Chason —T�D/\,s �� �•
Print Name of Property Owner Prnintt ame of Applicant
W'�
Notary Public J Notary Public
LISA FITZGERALD LISA FITZGERALD
Notary Public, State of New York Notary Public, State of New York
Reg. No. 01 F16402089 Reg. No. 01 F16402089
Qualified in Putnam County Qualified in Putnam County
Commission Expires 12/231202-11 Commission Expires 12123P20--7
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.
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