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BUILD INt-r_��LRTMENT 0
VILE*OE 01t 16111R00K Al1G - 6 2025
938 KMG MT R1i�rilt:,NY 10573
lk $Y VILLAGE OF RYE BROOK
BU1Dia,1G DEPARTMENT
gov
APPLICATION FOR PERMIT TO INSTALL AND/OR REMOVE
HEATING VENTILATION AND/OR AIR CONDITIONING EQUIPMENT
FOR OFFICF. USE ONLY: PERMIT
Approval Date: -- AU 20 1 Permit Fee:$
Approval Signature: Other:
Disapproved: _
(fees are non-refundable)
*#k*###**##****##*#******#k*************#k******k**k*k**#k*******k**##*#k**###*#*#*k#**k#*#**##******##
DO NOT START WORK or C:ONsTRUCFION UNTIL A PERNIFF HAS-BEEN ISSUED BY TILE BL,I LDING
INSPECTOR.THE ADMINIS11"RATIVF FEE FOR WORK.PROGRESSED OR COMPLETED WITIfOUF A PERMIT I5
12%OFTIIE TOTAL.COST OF CONSTRUCTION WITH A MINIM N1 FEE OF$750 00
REQUIREMENTS FOR RELEASE OF PERMIT&CERTIFIC'ATF OF COMPLIANCE'
1. Properly completed&Signed Application.
2. Site/Staging Plan if Required by the Building Inspector.
3. Copy of Contractor's Westchester County Home Improvement License, Liability Insurance. (village of Rye Brook must
be listed as cenificate holder)&Workers Compensation Insurance on a NYS Board form (Forn,#C105.2 or Porn,#U26.3/or
NY State Workers Compensation Waiver)
4- Payment of Fees/Unit: RESIDENTIAL=$200.00/unit- COMMERCIAL.=S450.00/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, 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.
1. Address: 16 Holly Lane _ __SBL: 129.59-1-35 Zone: R-15
2. Property Owner: Davina Zebli Address: 16 Holly Lane
516-445-1451 D2vinaZebli@gmail.com
#: Cell#: email: @gmail.com
3. Contractor. Yost&Campbell Heating Coding,and Generators LL_C Address: 20 Orookdale PI Mt.vemm,NY 10550
Phone#: 91 "9161 _ Cell#: email: Mhanasai@yostartdcompbell.com
4. Scope of Work:New Installation 00-Replacement( )-Removal( )-Other( ):
5. List Equipment: Replacing old equipment--(2)furances,(2)Evap coil, (2)condenser
6. Location of Equipment: Indoor-Outdoor
7. Method of Installation/Removal(list all equipment needed to perform job): please see proposal
I
711/2025
STATE OF NEW YORK,COUNTY OF WESTCHESTER ) as:
Yc*&Campbell Heeling Coding,ardGeneralan LLC_,being duly sworn,deposes and states that he/she is the applicant above named,
(print name of 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_ y Sworn to before me this _
day of 20D-S day of ,24_)
Signature Property Owner St ture of Applicant
2t to l 0 CP
Ct� �.
acne of Property ne Pri 'Name of Appli it
No blWiARI MELILLO Mft
�y Not bl'
Notary Public,State of New York
No.01ME6160063 GREGORY M.R14ERA
Qualified In Westchester County, Notary public,State of New York
Commission Expires January 29,20� No.Public,
StOIR1ate
of N
Qualified In Westchester County
Commission Expires September 26,204
'['his application must be properly completed in its entirety and must include the nntari7.ed 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 nul I and void
and will be returned to the applicant.
2
7/l/2025