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STATE OF NEW YORK,COUNTY OF WESTCHESTER ) as:
M(C 14eq t L /L(An!1 11/6 r ,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 �G r� Sworn to before me this & '41
day of T ,20 ZS day of Q C7r— 120 2- 5
Signature of Propet wner ignature of Applicant
&L�7'0 QCC //V/ /�I C NA P
Print Name of Property O e Print Name of licant
A G.ELA COTTA'A /
Mary Public Stato c.'Nava York
b I No.01 C060439E7 Notary Pu '
Bronx County
Corn.Explres98�2806 ANGE COTTAM
Notary Pub' Stato PIew York
g J-11 No. 1 COE043307
Bronx County
Com.Expires eowt2ttM6
d I21' 702 g
This application must be properly completed in its entirety and must include the notarized signature(s)
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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