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BUILD MENT SUN 13 2025
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938 KING l E BR NY 10573
VILLAGE OF RYE BROOK
4 BUILDING DEPARTMENT
APPLICATION FOR PERMIT TO INSTALL AND/OR REMOVE
HEATING VENTILATION AND/OR AIR CONDITIONLNG EQUIPMENT
FOR OFFICE USE ONLY: PERMIT#: /, J�
Approval Date: 7 V_1 — ZO Z Permit Fee:S e
Approval Signature: _ Other:
Disapproved:
(r«:en aon-mFiundable) I
*+t+aanrr++taaartaea*aa+rars aosaarsrit#�u+►AsrAeri�a$a a parr mraooa atrao-t r�awe aaarra,v saeaaa,►wr�a�►ise9o,r*,taaaasa ar tee*e
DO NOT START WQRK orCONSTRUCT10b, UN'rll.A PER N1 IT"AS SEEN ILSUF-D BY TjjE ElU[LDING I
INSPECTOR.TtIE ADMINUSTRATIVE FEE FOR WORN PROGRESSED 1•lPl E FD WITHOUT T A PE ;A T I
2% OF TIJIF TOTAL COST 0FCON5TR1jCTIQjX WITH A MINIMUNI FEE OF$75o.qU
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 Cotztractor's Liability Insurance.t Village of Rye Brn„k muy�l+clistcd pert fit tS+t It 4 &Wot'Icers
Compensation Insurance on it NYS Board foem i Fonn#c I 05.2 ur Cams n u26.3!ur NY Stutc'Wd th E'bih�It wiitSri V+'uii erl
4. Payment ofFees/Unitr RESIDENTIAL-S 150.00.unit •C'UM,NIERCLAII=5450.00,ui it.
5. Complete specifications for each unit being installed. 1 c'�' _- ,tik'•`•��i" '''•';a'f•'
6. Inspection by the Building Department for removal and/or installation.(48'I.[66iatxe'irc+ijiilre ~^"'
7. Electrical work requires a separate Electrical Permit& Electrical Inspection.
8. Plumbing/Gas work requires a separate Plumbing Permit&Plumbing Inspection.
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Application dated. VlD 2 hereby made to the Building Inspector of the Village of Rye Brook for a permit for the
installation and or remov I of the HV%C equipment as listed below.The applicant and property owner,by signing this document
agrees that said equipment will be installed and/or removed in confommnce with all applicable Local,County,State&Federal laws,
codes,rules and regulations. I r (�
1. Address: fda Fa 61 1 -rve SBL: 1 25'(,o_7' —I ' Zone: j 0
2. Property Owner.L 1 r S U Address: 19 a'I Ca 6017) 164 S Uf
Phone#:qtq a L Cell#: email:
3. Contractor. ' - lu - Address:(Q CAVf . LLOMC4WCCk
Phone#:q i LI -71 _>~j Cell#: email: l C�ClC�t'ztCa flUau 4 ' VICC'ccm
4. Scope of Work:New fnstallation O Replacement(vJ• Removal{ )•Other( ):
5. List Equipment:jf�l l� Gd6 &01 U 1 R C '
� U
6. Location of Equipment. Q
7. Method of fris allation/Removal(list all equipment mated to performjob): S_n rA 4,
Y ?1CIC IF WIAjIlCt -C_Qu,m2r1+,
t
G 1.2024
STkTE OF NEW YO COUNTY OF WESTCHESTER ) as:
Ate�(In ra [�r(� �,being duly sworn,deposes and states that he/she is the applicant above named,
(prim name of individual signing as the upplicanib
and further states that(s)he is the Hearing,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 tnte to the best of his/her knowledge and belief,and that any work perfartned,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 Fork State Uniform Fire
Prevention&Building Code,the Code of the Village of Rye Brook and all other appiicuble laws,ordinances and regulations.
Sworn to before me this +� Sworn to be fare me this
day of Mtx4_ .20 -)5 � day of MLA4 20
IS-
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Signal re of Prope O%yner t atture of Applicant �r fad, a
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Print Name of PF4erty Owtiev. 'P Print Name of Applicant /
� � ota ub[i
Notary Public
NOTARY PAllt;SM1't?op NdyY Y0ilK AMB ttYAN COTUC ow
No.01&4a=1t37 ttatary Public
1 coftrwwcut
MY Comntfsston EM*0%Dec 31,2028
This application mast be properly completed in its entirety and must include the notarized signaturcis)of
the legal owneels)of the subject property.and the applicant of record in the spaces provided. Any
application not properly completed in it+entirety and or.nut properly signed shall be deemed null and vuid
and will be returned to the applicant.
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