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BUILDkN DIW IRTMENT
VILLA E OF RYE rOK
938 KINGS ' ET RYE BR oie,NY 10573
�( 4) -0 8j
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)
,ll i mpaS i boa
Approval Date: `� �\ Permit Fee:S �1
Approval Signature: Other:
Disapproved: _
(fm arc non-is I undablc)
DO NOT S'I ARTWORK or CONSTRUCTION UNTIL A PERMIT HAS BEEN ISSUED Bl TIIE BUILDING
INSPECTOR, TIIE. ADMINISTRATIVE FETE FOR WORD PROGRESSED OR COMPLETED WITHOUT A PERMIT IS
12%OF"HIE TOTAL COST OF CONti TRUCT10N WITII A \MIN I'%U NI FEE OF S750.00
REQUIREMENTS 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 i)i_ ,,,,k
5. Dig Safety New York#(:i l.d ',:i 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.
*#*#*#*N#**k*kk*k#****#**#*************#***k*k***k*********+#*#*#**k***##*#*******#*****#*k##k*******#
Application dated, 1%1 1171DS 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.
*******#******#***k*********k**********k**k***#k*k*************#*++#*a+*a**+aaa##k##a*a+#«##a#*##**aA#
Indicate Permit Type: Removal Abandonment( )/Above Ground Buried in Ground ( )
I. Address: 32 Roanoke Ave SBL: 141.35-1-40 Lone
2. property Owner&Address: Paulino Yolanda_32 Roanoke Ave Rye Brook, NY_10573_
Phone#: 914-830-2159 Cell a: email:yolandapaulino1011Qgrnail.eom
3. Contractor&Address:.0 - 83 S Putt Cure rs Rd, New Palt7, NY 12561
Phone#: 845-255-4900 Cell n: email: crhorles@c9g us
4. Apphcanr.C2G / 83 S Putt Corners Rd, New Paltz, NY 12561
Phone#: 845-255-4900 . _ Cell 4. email: erhodeSQc2g.us
5. Indicate Fuel Type: Fuel Oil O• L P.Gas( )-Gasoline( )-Other 1 )4 2 heating nil
6. Number and Capacity of each Tank: . i)_27�
7. Exact Locations)of each Tank. outsirlWunrierrieck
t
6 1 '20?5
1/15 STATE OF NEW YORK,COUNTY OF WEA R ) as:
ChrissV Rhodes/Agent C2G being duly sworn,deposes and states that he she is the applicant above named,
(print tame of individual signing as the applicant)
and further states that(s)he is the Tank Removal Abandonment 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 perforated,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 Sworn to before me this
day of 20 day of �c/aJ���,� ,20
_ C
Signature of Property Owner Signature of Ap ' ant
Chris lk-4-1 A- nt
Print Name of Property Owner Print N e atlt
=PUBLIC.
okanson
TATE OF Nt VU.01H0c2 466Notary Public Ulster County iota Publics Decernber 23,20
This application mast be properly completed in its entirety and must include the notarized
signature(s) of the legal owner(s) of the subject propetly. and the applicant of record ill the spaces
provided. Am application nol properly completed in its entirely andlor not properly sinned shall be
decilled null :1nd %:yid and N\ill be returned to the applicant.
i
611(2025