HomeMy WebLinkAboutMP25-075 Ln "o _
Ln 1 b
� p O O a
L Ln LO �
` Or W -
Acn -o [••�
bo
L ca O "C
M+� N U
pp a0ON
bC o v A F+i
04 �o '.o o o al WD
O W s-� O � � �•+ � � '� C � o 'C W r
h/ O
w ,%4
PLOa W w y`p; u
~ 4J U
r U
� � o � op. �
OW oo u'o w o a V =
Z U Z °' n v+ 4 _
11 47
W z a� R. Ayo •
►I--a--1 !�! O A G A a a 40. Ca =
I�
00
O d 5 >1
0 5 ^o
zv
1-4
_ w G4 0 El
w � O o O E., �� p � �
4d
I _
Ln �¢
.. o w
x � � ub
a
D E C
BUILD TMENT � 1
VIL E OF RY OOK MAY 2 l 2025
938 Knvc ET RYE BR NY 10573 I
_p Iff/ VILLAGE OF RYE BROOK
w e -:6 7 ov RLlit_OING DEPARTMENT
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#: - �J' 0 ! S
Approval Date: 5- Z 'rr 2 Q 2 S' Permit Fee: S
Approval Signature: Other:
Disapproved:
(fees are non-refundable)
DO NOT START WORK or CONSTRUCTION UNTIL A PERMIT HAS BEEN ISSUED BY THE BIIILDING
INSPECTOR.THE ADMINIST%XTIVE FEE FOR WORT:PROGRESSED OR COMPLETED WITHOUT A PERMIT IS
12% OF THE TOTAL COST OF CONSTRUCTION WITH A MINIMUM FEE OF$750.00
REQUIREMENTS FOR RELEASE OF PERMIT&CERTIFICATE OF COMPLIANCE:
1. Application Completed by Bonded, Licensed Contractor.
2. Your contractor's valid proof of liability insurance. (Village of Rye Brook must be listed as certificate holder)
3. Your contractor's valid proof of workers compensation insurance.
(Form#C 105.2 or Form#U26.3 /or NY State Workers Compensation Waiver)
4. Fee per Tank: Removal or Abandonment S 185.00 per Tank.
5. Dig Safely New York #(dial 81 1): t3S t a S - bit- `lrS 9
6. Inspection by Building Department fo remova or abandonment.
7. Submit all Manifests& Reports(after work has been completed).
8. Certificate of Compliance will be provided when all requirements are fulfilled.
Application dated, MO-t 14.L-Z-G is hereby made to the Building Inspector of the Village of Rye Brook for a permit to
remove or abandon a Fuel Tank as herein described.The applicant and property owner,by signing this document agree that the
subject fuel tank(s)will be emove r abandoned in conformance with all applicable Village,County,State&Federal laws,codes,
rules and regulations.
Indicate Permit Type: Removal (.f- Abandonment ( )/Above Ground ( ) • Buried in Ground (•�'
I. Address: s4 W°'� ^�- SBL: I ag,0 4-3-" Zone:
2. Property Owner&Address:
Phone#; g►y "-1v5 tia$S Cell#: email:
3. Contractor&Address: •2�S��t).o 1 -•
Phone#: Cell #: email:
4. Applicant: c Sti+"La,
Phone#: ��3 ` Sb```C Cell#: email: &-J6
5. Indicate Fuel Type: Fuel Oil�-<-L.P.Gas( )•Gasoline( )•Other( ):
6. Number and Capacity of each Tank: ?J
7. Exact Location(s)of each Tank:-
i
6/l/2024
STATE OF NEW PORK,COUNTY OF WESTCHESTER ) as:
U� opt. C�,c-c va ,being duty sworn,deposes and states that he/she is the applicant above named,
(print name of individual signing ns the applicant)
and further states that(s)hc is the Tank Installation Contractor for the legal owner and is duly
authorized to make and file this application.
That all statements contained herein arc 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}sire Prevention&Building Code,the Code of the Village of Rye Brook and all other applicable laws,ordinances
and regulations.
Sworn to before me this CS Sworn to before me this 1
day of 20 day of � ,20 ;?f5
Sign ture of Property Owner Signature of Applicant
�tlltName of erty Owner _ Print 1qAme of Applicant
Notary Public Mohammad Rahman Not
Commission#olFA0032973
Notary Public State of Now York OARIELLY h.Iml_I-SANTOS
My Commission Expiration:01/11/2029 Notary tnublic,Stale Ot Connecticut
This application must be properly completed in its entirety and must incl no&i�MWi0n Expires May 27,2026
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 anchor not properly signed shall be
deemed null and void and will be returned to the applicant.
z
6/1/2024