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BUILDING DEPARTMENT
VILLAGE OF RYF BROOK
938 KING Sm.F:r RYF.BR()OK,NY 10573
(914)939-0668
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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 OFFk-T..tISF ONLY: I'I R1%I1 1 0: MP Pd" 5-1
Approval Date: 10 �\ Permit Fee:S
Approval Signature: Other:
Disapproved:
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DO NO] SIARl'WORK or CONS1RUCTION UN Ill,A PERMIT IIAS BEEN ISSI ED RN'THE Nl'II.DING
1Ns1'FC IOlt. HIE ADMINISTRATIVE FF.F FOI(WORK PROGRESSED OR COMPLETED WFF1101 I .%PERMI I IS
12%OF THETOFALCOS-1 OF'CONS IRI ("IION WI111 z% MININII'%I I•FF OF S150.011
REOVIRFMENTS 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#C105.2 or Form#U26.3/or NY State Workers Compensation Waiver)
4.Fee per Tank: Removal or Abandonment S??�.00 her I ank.
5.Dig Safely New York#(dial 81 1): '`,I")
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, SF-r,-r61` Z`�,Z��.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(vf-Abandonment( )/Above Ground(Buried in Ground( )
I. Address: �t SBL:155,�>40 ie/ Zooe: � o
2. Property Owner&Address: - '
Phone#:I Au�(`f"I Q Imo _ Cell C (A0 4qQ(A 600 email: (0 K. l( C7 MI
3. Contractor&Address:
Phone#:;)--3-3�s� Cell#: email` ��oC=�-��,2�Sl,«.w.
4. Applicant: ,Rc 6,&-J
Phone#: 3 38c Cell#: email:
5. Indicate Fuel Type:Fuel Oil(vyeL.P.Gas( )•Gasoline( )'Ocher( ):
6. Number and Capacity of each Tank:
a ofeadrTank:
7. Exact Location( )
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STATE OF NEW XORK,COUNTY OF WESTCHESTER ) as:
Leron(Af� Ch%CGV)'o ,being duly sworn,deposes and states that he/she is the applicant above named,
(Prim erne of' qi�M 60 swum)
and further states that(s)he is the Tank Removal/Abandomnent 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 dt Building Code,the Code of the Village of Rye Brook and all other applicable laws,ordinances
and regulations. l
Sworn to before me this .,1 Sworn to before me this .2
day o f 202_ 20 a 7
Signature of Property Owner Signature of Applicant
Leor,oro< /RQCh.c 10
�Nl ame of
Prope Owtxr Print N e of AppliaotY NOVOLI-SANTOS
No b ry?GU x,State of Connecticut
u c,State of New York
No.OIME6160063 My Commission Expires May 27,2026
Qualified In Westchester County
CotI his rUsaappltcation must try v9 rog4 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.
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