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BUILIa.'
ENT n [E C IE��E
VILOOK U
938 KING ,NY 10 JUL 3 12025
ov VILLAGE OF RYE BROOK
BUILDING DEPARTMENT
APPLICATION FOR PERMIT TO INSTALL R MOVE
HEATING, VENTILATION AND/OR AIR CONDITIONING EQUIPMENT
FOR OFFICE USE ONL PERMIT#: '
Approval Date. L Permit Fee: $ C/
Approval Signature: Other:
Disapproved:
(fees are non-refundable)
****,r*x***max******+t*********�*#***** ,e**+****,►*******r***,r******,�**t********�.******************a:�****
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 CONSTRU(1 ION 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 Contractor's Westchester County Home Improvement License,Liability Insurance.(Village of Rye Brook must
be listed as certificate holder) & Workers Compensation Insurance on a NYS Board form(Form#C105.2 or Form#U26.3/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.
$. Plumbing/Gas work requires a separate Plumbing Permit& Plumbing Inspection.
Application dated, Z110/2 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. 2 �f
I. Address: ( 1)O /S , SBL: r J5-o 3 7�/—,33zone:
2. Property Owner Address: S
Phone �" Cell#: email: 4
TI m
3. Contractor: Arc L ec k n Ca I Address:1W /t�(�
Phone#: I y, Q3y, W.3 C>r Cell#: email:
4. Scope of Work:New Installation( )•Replacement{ • Removal( )•Other( ):
5. List Equipment: C �dPn5 f'Y' , [('t 4 ra r')4 CZ
6. Location of Equipment: on k + nuf
7. Method of Ins! hon/Removal(list all c ui ment needed to perfornt job):
I PmouP �- epl
t
7/1/2025
STATE OF NEW RK,fOQNTY- OF WESTCHESTER ) as:
NM 06__ Ql_keT`T7 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 Sworn to before me this S�
day of (1 U 20 e7- day of rCL 20
Sign@ tuK
'.qf*'roperty Owner Signature of Applicant
J N Q r K— �GLl l� � ►
Print a of Properwner Print Nam
e of lice
C -
M
Notary Public Public
LORI LOCKS LORI LOCKE
NOTARY PUBLIC,STATE OF NEW YORK NOTARY PUBLIC,STATE OF NEW YORK
NO.01 L00039106
NO. 01 WESTCL0003HESTER
QUALIFIED IN WESTCHESTER COUNTY
QUALIFIED IN WESTCHESTER COUNTY M
MY COMMISSION EXPIRES JULY 3,2029 Y COMMISSION EXPIRES JULY 3,2029
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
6/l/2025