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VILLAGE OF RYE BROOK i OCT 16 20"25 i
BUILO NG DEPAkTMENT
938 KING ST)t u,RYE E�OOK,NY 10573
(914)939-OM8 vvwiv_ri ebrooknv.ov
APPLICATION FOR PERMIT TO INSTALL,MODIFY AND/OR
REMOVE MECHANICAL E UIPME ,
OFFICE USE ONl� ,� 5 '-
Permit#: /' �S Building Inspector:
Application Fee: Date of Approval: OCT 1 6 2025
Permit Fee: r Bldg/Use Class: Res. O;Comm. ( );
SOT START WORK t>r CONSTRUCTION UNTIL A PE&%IITH ;�BEEN ISSL I?D BX UHE
BL'ILDL'+IG!_)SPEIr TOR,TYU AD.MLNIST :ATIV_ E FEE FOR WOi,K PROGRESS!,D OR CQNlFT.ETEV
WITHOUT A PER-MIT IS 12% OF THE TOTAL C0$T OF CONSTRUCTIQ WITH A HIN"AUM FEE
OF$50.00
REOUQ2E.MENTS FOR RELEASE OF PERMIT: (A CERtfficATE of CO.wL iAmm is REQLum To CWSE Out Tars PMWT)
1.Properly Completed&Signed Application.
2.Payment of Application Fee: Residcntial=$10U.(N,: Commercial S250.00 Gees are non-refundable)
3.Site/Staging Plan as required by the Building Inspector.
4.Sealed Construction/Installation Documents&Specifications as required by the Building Inspector.
5. Copy of Licensed Contractor's Liability Insurance. (Village of Rye Brook must he listed as certificate holder)&
Workers Compensation Insurance on a NYS Board form
(Form#C 105.2 or Form#U26.3/or NrY State Workers Compensation Waiver)
6.Payment of Permit Fee:
Residential- S 18.00/1000.00 of Construction,^.viaterials Cost with a minimumm fee of$150.00.
Commercial = $25.00/1000.00 of ConstructionNaterials Cost with a minimum fee of$275.00.
7. Inspection by Building Department for removal and/or installation. (48 hour notice required)
8. Any electrical work requires a separate Electrical Permit and Electrical Inspection.
9.Any gas/plumbing work requires a separate Plumbing Permit and Plumbing Inspection.
***xxxxxxxx***xxx*xxxxxx*xxxxxxxxx,xxxxxxx*x*xxxxxx***x*x*xtr,r*x**#**,r****,�k,r*�r***,r**�r,r*
Application dated, -1 -l is hereby made to the Building Inspector of the Village of Rye Brook,NY,for a permit
for the installation,modification,and/or removal of the specific Mechanical 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 the
approved plans,and with all applicable Local,County,State&Federal laws,codes,rules and regulations.
1.Address:317 ��r/y�L _- -1G/�G _ SBL: `l/. y3 '^z"3 Zone: ��
2.Property Owner:0 /e y,GC /J/��d/� Address:
Phone#:9� ���' �T�3 Cell#: email: QV
3.Contractor:G/ �/r/.�i� _ LI-eveW _ Address: fi-ad Z /_ `0e_ v lv
Phone#:/Zy" Glgly�Cell#: - -_ — -- email-At�T, �1�L LPG•S�i�i�✓,f/t�C:l�/�
4.Scope of Work:New Installation( )•Replacement( •Removal( )•Other
5.Type of Equipment: .cLTE� AifTfl
6.Location of Equipment: y f�ir� GO/L-.4-
7.Cost of Equipment including Installation Cost:S__
] 6/1R024
STATE OF NEW YORK,COUNTY OF WESTCHESTER ) as:
l,�L /y�X7 _ _,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 Mechanical Equipment 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 a this 'b Sworn to before e this/6
day of Q r ,20_Z� day of Gf�1<G 20 2 f
Signature of Proper Owner Signature of Applicant
Name of Prope Own of Applicant
DRE rn. CASS
Notart AI M.RNERA Notary Public NOTARY PUBLIC.STATE OF NEW PORK
Netxy Public,State of New York Registration No.01 CA6298761
No.01RI6441398 Qualified in Sullolk County
Commission Expires 17 March 2026
Qualified in Westchester County
periy 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 6/1n024