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BUILD MENT
+ VIL OOK
938 KING A{ ,NY 10573 JUL 11 2025
`• �� VILLAGE OF RYE BROOK
BUILDING DEPARTMENT
APPLICATION FOR PERMIT TO INSTALL AND/OR REMOVE
HEATING, VENTILATION AND/OR AIR CONDITIONING EQUIPMENT
FOR OFFICE USE ONLY: PERMIT#: % /
Approval Date: .[.�
pp � 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. Properly completed& Signed Application.
2. Site/Staging Plan if Required by the Building Inspector.
3. Copy of Licensed Contractor's Liability Insurance. (Village of Rye Brook must be listed as certificate holder)&Workers
Compensation Insurance on a NYS Board form(Form#C 105.2 or Form#U26.3 I or NY State Workers Compensation Waiver)
4. Payment of Fees/Unit: RESIDENTIAL=$200.00/unit • COMMERCIAL=$450.00/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. Plumbing/Gas work requires a separate Plumbing Permit&Plumbing Inspection.
Application dated, r :�;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. I
1. Address: U SBL: r 0_j_Zll Zon :lAe—I
f
2. Property Owner: Address:
Phone#: r I U �'�1!gJ Cell#: email: AN � dr AA&4*
.(Xwx
3. Contractor:' (�6o � (��i Address:71� ����Qyv_ , Cc
v`
Phone#: �../11(. i Cell#: email:
4. Scope of Work:New Installation( ) •Replacement(pq•Removal( )•Other
ter...
5. List Equipment:
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gNay cay-45'U Hf..,T-D_qy
6. Location of Equipment: ( �A14A Qsr — ♦�U►e '4;d '—SS) cle q ql 11
—Moir — &AAG
7. Method of InstaIlation/Removal(list all equipment needed to perform job):
1
6/l/2025
STAROF NEW ,O ,COUNTY OF WESTCHESTER ) as:
� "aO ,being duly sworn,deposes and states that he/she is the applicant above named,
(print name of in vidual 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 D Sworn to before me this ( U
day of ,2 _ day of 2025
l�
Signature of Property Owner Signature of Applicant
po�s" W6 -
Print a of Prope Owner Print Name f Applicant
1
Notary Public N t -Public
ex Tina l b Tina Lopez
G Notary 9-wic-Connecticut
Notary Public-Connecticut
My Comrrlission Expires MY C June 3sian Expire
June 3012028
tiae fl, 028"
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.
2
611/2025