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BUILDa
MENT v
V1L EOOK
938 KING ENY 10573 AUG I I M5
`�
ov VILLAGE OF RYE BROOK
APPLICATION FOR PERMIT TO INSTALL AND/OR REMOVE
HEATING, VENTILATION AND/OR AIR CONDITIONING EO UIIPMENT
FOR OFFICE USE ON Y: \ PERMIT#: /Y,Q c:)V'/ c-:�-7
1
Approval Date: Permit Fee: $ oo
Approval Signature: \ Other:
Disapproved:
(fees are non-refundable)
DO NOT START WORK or CONSTRt1CTION UNTIL A PERMIT HAS BEEN ISSUED B) THE Bl ILDING
INSPECTOR.THE ADMINISTRATIVE FEE FOR WORK PROGRESSED OR COMPLETED WITHOUT A PERNIFF 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 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#U263/or
NY State Workers Compensation Waiver)
4. Payment of Fees/Unit:RESIDENTIAL=$200.00/1.111it • 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, 8-0—as 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: 118 Doral Greens Drive SBL:129.34-1-11.2 Zone: P.U.D
2. Property Owner: Barbara Struth Address: 118 Doral Greens Drive
Phone#: 914-329-6511 Cell#: email: ahstruth0956@gmail com
3. Contractor:Yost&Campbell Heating Cooling&Generators LLC Address: 20 Brookdale PI
Phone#: 914-444-9161 Cell#: email: Mhansai®yostandcampell.com
4. Scope of Work:New Installation( )•Replacement(X)•Removal( )•Other( ):
5. List Equipment: Furnace.Evaporator Coil,and Condenser
6. Location of Equipment: Inside-Outside.Furnace QUWN0u-,,F. fA(A�i3(
7. Method of Installation/Removal(list all equipment needed to perform job): 'please see propsal'
1
7/l/2025
STATE OF NEW YORK,COUNTY OF WESTCHESTER ) as:
Yost E Campbell Heating Cooling&Generators LLC ,being duly swom,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 I/" j Sworn to before me this
day of T 20 S day of
ow
P� �-
ignature of Property Owner �rgnature of Applicant
aq
' t Name of ProEZrtyOwner ame of Applicant
�t ry Public LIE 13.JALCA Notary$ CMELILL0
iV TARY Pu LIC STATE OF NEW YORIC Notary public,State of New York
WESTCHESTER No.01MIM60063
LIC.#OtJA6393703 Qualifled In Westchester Count
Y�COMM. EXP,June 24,2q-27 Commission Expires January 29,201
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.
M�I�!
2
7/l/2025