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41
_
ECENE
BUILDING DEPARTMENTR 'D
VILLAGE OF RYE OROOK �UN - 5 2�2�
938 KING STREET RYE BROt ,NY 10573
(914)939-0668 VILLAGE OF RYE BROOK
w�Yw.t vel�rtlt�I:ny.�ov BUILDING DEPARTMENT
APPLICATION FOR PERMIT TO INSTALL AND/OR REMOVE
HEATING, VENTILATION AND/OR AIR CONDITIONING EQUIPMENT
FOR OFFICE U Permit Fee:SF ONI Y PF.Rh91T
Approval
A Pit F $ 000
PP Date:
Approval Signature: Other: ',fft:.)OQ "'Disapproved: (fees
(fees are non-refundable)
DO NOT Sl kRT WORK orCONSTRLCTION LINTIL A 11: 01IT HAS BEEN ISSUED BY THE. III lt.DEM.
I`sPFCTOR. THE ADNIINISTR.ATIVE FEE FOR WORK: PROGRESSED OR COMPLETED NVITHOUT .A PFRN111' l
12njo OF I'll E TOTAL COST OF CONST'RI I("I ION WITF{ A MINIMUM FEE OF S750.00
REQUIREMENTS FOR RELEASE OF PERMIT&CERTIFICATE 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. i VilltiLc of Rye Brook ntust be listed as certificate holder&Workers
Compensation Insurance on a NYS Board form(fora, , C 105.2 or Fornn r U26.3 or NY Stab Worker,Conlhensatioll Waj%er)
4. Payment of Fecs/Unit: RESIDENTIAL -- $200.00);milt • COMMERCIAL -`5450.110/unit"
5. Complete specifications for each unit being installed.
6. Inspection by the Building Department for removal and/or installation. (48 hour notice required
7. Electrical work requires a separate Electrical Permit&Electrical Inspection.
8. Plumbing/Gas work requires a separate Plumbing Permit& Plumbing Inspection.
Application dated,OE& ` is hereby made to the Building Inspector of the Village of Rye Brook for a permit for the
installation and or removal of the HVAC equipment as listed below.The applicant and property owner,by signing this document
agrees that said equipment will be installed and/or removed in conformance with all applicable Local,County,State&Federal laws,
codes,rules and regulations. --7
1. Address: �Z �iG x/d��_ /G�'� SBL: IUJ`/3{/o—1" / Zone:
2. Property Owner: )//L/ �'�46.*7 W Address: 4/ Aoc,..4 Grp, d S-0-
OF
Phone#l: el!V 3,7 s2y Cell#I: email:
3. Contractor: hVi ae _Address: 39$ W4 J,5 60 J
Phone#: ZQ-Q;Z!;!- /`/ff' Cell#: email: 4-0A
4. Scope of Work:New Installation O•ReplacementfX Removal( )•Other( ):
5. List Equipment: .eA /,i
! t
6. Location of Equipment: 41
7. Method of Installation/Removal(fist all equipment needed to perform job):
t
6/1/2025
STATE OF NEW YORK,COUNTY OF WESTCHESTER ) as:
,being duly sworn,deposes and states that he/she is the applicant above named,
(print name or 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 Sworn to before me this
day of U Y19, 20 /� day of lum20
S ture of Property Owner Signature of Applicant
Print Name of Property Owner Print Name of Applicant
A19r 0 A 1`1 A .In', /'1.47,-1
Notary Public Notary i is
GREGORY M.RIVERA
Notary Public,State of New York
No.01 RI6441398
Qualified In Westchester County
Co mission Expires September 26,2fl�
This application must be properly completed in its entirety and must include the notarized signature(s) of
the legal owner(s) of the subject properly, mid the applicant of record in the spaces provided. Any
application not properly completed in its entirety and:'or not properly stoned shall be deemed null and void
and will be returned to the applicant.
2
6/1/2025