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BUILD :DEPARTMENT Im
VIL E OF RYE BROOK
938 KING ET RYE BROo7i,NY 10573 4 -061G8k.Ora
:Application for Permit to Install Fuel Storage Tank
(*Storage Tanks in excess of 1,100 gallons require registration with the County of Westchester)
FOR OFFICE USE ONLY: PERMIT #: 1' QS— C�j 0 !
Approval Date: J U N l Permit Fee: $
Approval Signature: Other:
Disapproved:
(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
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: Installation: $185.00 per Tank.
5. Dig Safely New York# (dial 811):
6. Inspection by Building Department for installation.
7. Submit all Manifests& Reports(if applicable,after work has been completed).
8. Certificate of Compliance will be provided when all requirements are fulfilled.
xxxxx**xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx*xx***xxxxxxxxxx
Application dated, is hereby made to the Building Inspector of the Village of Rye Brook for a permit to
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 installed in conformance with all applicable Village,County,State&Federal laws,codes,rules and regulations.
xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx*xxxxxxxxxxxxxxx
Indicate Permit Type: Above Ground W*Buried in Ground ( )
1. Address: 7 Jacqueline Lane SBI : 135.36-1-6 Zone:
2. Property Owner&Address: Alyssa Waxenberg 7 Jacqueline Ln Rye Brook
Phone#: 917-626-5070 Cell#: email: alyssawax@gmail.eom
3. Contractor&Address: Innov8tive Environmental 392 Columbus Ave Valhalla, NY 10595
Phone#: 914-449-6608 Cell#: email: service@innov8enviro.com
4. Applicant: Innov8tive Environmental - Donald Feeney
Phone#: 914-449-6608 Cell#: email: service@ innov8enviro.eom
5. Indicate Fuel Type:Fuel Oil *L.P. Gas( ).Gasoline( )•Other( ):
6. Number and Capacity of each Tank: (1) 275 Gal AST
7. Exact Location(s)of each Tank: at the rear of the home
i
10/30/2023
ST TE OF NEW Y RK.COUNTY OF WESTMESTER ) as:
Ll" 1 - .being duly sworn,deposes and states that he/she is the applicant above named,
(print ridne of individual signing as thJ applicant)
and further states that(s)he is the legal owner of the property to which this application pertains,or that(s)he is the
Contractor for the legal owner and is duly authorized to make and file this
application.(indicate architect,contractor,agent,attomey,etc.)
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 t before me this A Sworn to before me this
day of 20 f ,20
Signatur of Property Own Si ature of ;ppanDonald Fee
t ame of Property ner t Name o, of NewYork Otary bliCNORIN ERUc.No.OIME6130833 ary Public, tat of New York
33
Qualified In Westchester Cou Lic.No.0 E t C tL
Commission Expires July 25, alified in Wes ter Co
Commission Expires July 25,200-52
This application must be properly completed in its entirety and must include the notanze
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
10/30/2023