HomeMy WebLinkAboutMP25-081 _
r-i w 8
v �
OM 4r
" O W s
per„C7
WV
A o o w
� `� W �'d '•9 v o o Q � pq Q
We ° b A
ICj Q N 3 � O
F�1ck
0F" IS
w
4-4 w O ON
d da'
H
oo W z o
i 4
W �J N F., a � � � U
H U2 � �
(A O �} U u5 ti e4 O
� v1
N O a•� vos ° p
h�I �
U �" O zZ g `� u
z g w , Ic, ■
zo >
14
U � o � � �o � ■
V
U V1
O p wO Aga
x v U
W � � o �
M z w Z c � o � _
BUILD -DEP MENT 5
VIL E OF RY OOK 5�i 938 KING ET RATE BRQ ,NY 10573 MAY � 9 ����
066$j`� VILLAGE OF RYE BROOK
ly oy BUILDING DEPARTMENT
0- LApplication for Permit to Remove o Abandon Fuel Stora a Tank
(*Storage Tanks in excess of 1,100 gallons requir registration with the County of Westchester)
FOR OFFICE USE ONLY: PERMIT#: �d�-�
Approval Date: JUN 202. 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 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#C105.2 or Form#U26.3 /or NY State Workers Compensation Waiver)
4. Fee per Tank: Removal or Abandonment $185.00 per Tank.
5. Dig Safely New York#(dial 811):
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, ,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 K•Abandonment( )/Above Ground Cs4'•Buried in Ground ( )
1. Address: '�1 (11 Qom ;_ , SBL: —Zone: -
2. Property Owner&Address:C_�rrl� 1n 1U i
Phone#: q q.`JJ) Cell#: `email: -z(2— C.ey,,_
3. Contractor&Address: o9[1P i 7. O ,N,� _ 1 V.`1.Y (5-ceent ,\m in 69�r-,
Phone#:Srq •-,-NNk4•oc> Cell#: I email:�.eyVi�rt �i 6t° 1II•Gish.
4. Applicant:L,)e. wffl�r�R\c n.kc�C_ Al_11 +,1 l�'yX y\_
Phone#:�}��, •3�� Cell#: email:SMi Mn�au6trotpml,(e"
5. Indicate Fuel Type: Fuel Oil I •L.P. 1Gas{ )•Gasoline( )•Other( ):
6. Number and Capacity of each Tank: (�1 ) •a� C�(1
7. Exact Location(s)of each Tank: e � Y�tsP ,
6/1/2024
STATE 1E - $RK,IC,O,UNTY OF ) as:
1+ ' l'�I e��1 ,being duly sworn,deposes and states that he/she is the applicant above named,
(print name of individual Isigning 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 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 kn
Sworn to before me this
day of C; 20 `� day of ,20 5
Signatur rt wrier ignature of Applicant
many K lem
Miame of.Property O ner Print Na pplicant
�JA L
Nota?�PNb ie c,State of IVEW TOM Notary Public
No,01ME6160063
Qualified In Westchester county '7 : ,+� LYTLE
Commission Expires January 29,20—� No r.
Y. F�,13�dC
MyCOfirtals 00 ExPlas Aug.3f 2pin
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.
z
6/l/2024