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BUILD � I ` MENT D E C EW E
VIL E_OF RY �OOK
938 KINGkL) ET RYE BR ,NY 10573 AUG 2 5 2025
Q. -0 `r
. ov VILLAGE OF RYE BROOK
BUILDING DEPARTMENT
Application for Permit to Remove or Abandon Fuel Storage Tank
(*Storage Tanks in excess of 1,100 gallons require registration with the County of Westchester)
FOR OFFICE USE ONLY: PERMIT#: 5-135
Approval Date: S - 21 — 20 Lr Permit Fee: $ fY
�c
Approval Signature: 7--t� N> Other:
Disapproved:
(fees are non-refundable)
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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
REOUIREMENTS FOR RELEASE OF PERMIT& CERTIFICATE OF COMPLIANCE:
1. Application Completed by Bonded, Licensed Contractor.
2. Your contractor's valid proof of liability insurance. (Village of Rye Brook must be listed as certificate holder)
3. Your contractor's valid proof of workers compensation insurance.
(Form#C 105.2 or Form#U26.3 /or NY State Workers Compensation Waiver)
4. Fee per Tank: Removal or Abandonment $225.00 per Tank.
5. Dig Safely New York# (dial 811):
6. Inspection by Building Department for removal or abandonment.
7. Submit all Manifests & Reports(after work has been completed).
8. Certificate of Compliance will be provided when all requirements are fulfilled.
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Application dated, ,is hereby made to the Building Inspector of the Village of Rye Brook for a permit to
remove or abandon a Fuel Tank as herein described. The applicant and property owner,by signing this document agree that the
subject fuel tank(s)will be removed or abandoned in conformance with all applicable Village,County, State&Federal laws,codes,
rules and regulations.
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Indicate Permit Type: Removal •Abandonment( )/Above Ground (g- Buried in Ground ( )
1.
2.
Phone#:q�y 1p� •��\ Cell#: o,^ email:KO.Z�t,\ �;
3. Contractor&Address: Qi 2 (b,'CSC. , W N , `� Pr Yt ��5 -P�`l�l►P�/�
Phone#: 29 Cell #: X2>-�\ email:
4. Applicant: Fu-s 1 Co, kc,
Phone#: 4 400 Cell#:2n•cj'SN �
5. Indicate Fuel Type: Fuel k5 • L.P. Gas( ) • Gasoline( )•Other( ): --JJ 2 p�,
6. Number and Capacity of each Tank: a1 5 40.1�t3r1 �S7
7. Exact Location(s)of each Tank:2M Ntr-1,0_4
t
6/1/2025
STATE OF NEWALO K,COUNTY OF ) as:
4 o r - kk-r-n^ ,being duly sworn,deposes and states that he/she is the applicant above named,
(print name of individ I signing as the applicant)
and further states that(s)he is the Tank Installation 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 b ore me this h Sworn to before me this 070�h
day of 20 _ day of Sf ,207
Si a of Property YOwner SignaturJ o APPlicant
I�w P 11A t Print Name of Propel;; .v er Print Name licant
otary.ublic Notary Public
SEAM LYTLE SEAN LYTLE
NOTARY PUBLIC NOTXRk PULBLIC
STATE OF CONNECTICUT STATE OF CONNECTICUT
MV C M15 ON EXPIR �Y CO MI &I f�EXPiRES A".11,2030
This app3icafion rnu IS8 1 �44Prly completed in its entirety and must include a no
signature(s) of the legal owner(s) of the subject property, and the applicant of record in the spaces
pr<)vided. 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.
z
6/1/2025