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BUILDkNG D9PARTMENT NOV 17 2025
V1LLA E OF RYE rOK
938 KING ST ET RYE BR NY 10573
(4) -06 8,<f
Application for Permit to Install Fuel Storage Tank
("Storage Tanks in excess of I,100 gallons require registration with the County of Westchester)l/ ,,,
Approval Date:
PP
Permit Fee:$ _
Approval Signature:_ Other
Disapproved:-
(fees are non-refundable)
kkA#A+R*k*A***#A+kA**#R#*#**kR##AA ##k*kR**RA*RRkRR*RRRlA*#AR#ARkkkAiA**##*##**R*AAkRR/k#kk**Rk k*##RA*#
DO NOT START WO1 or C:O«1'RUCTION L�N'Cll,-�NEitlll'f HAS BEEN ISSCF;D Bl'THEB1 Il,l)I\!;
INSIIFC'f()R.'TILE:ARMINISTRATIN'L FEE,FOR WORK PROGRESSED OR t'ONIPLE I'ED WITHOUT,� 11F,IINICl IS
12%0L I'll t;TOTA1,COST OF CONSTRUCTION N'ITFI A aNIINi,'*11 :NI FEE OF S750.00
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)A---
3. Your contractor's valid proof of workers compensation insurance. v
(Form#C 105.2 or Form # U26.3 or NY State Workers Compensation Waiver)
4. Fee per Tank: Installation: S 185.00 per Tarn).
5. Dig Safely New York (dial 81 1):
6. Inspection by Building Department for installation.
7.Submit all Manifests& Reports(if applicable,after work has been completed).
8.Certificate of Compliance will be provided when all requirements are fulfilled.
Application dated, 11/17125 is hereby made to the Building Inspector of the Village of Rye Brook for a permit to
install a Fuel Tank as herein described.The applicant and property owner,by signing this document agree that the subject fuel tank(s)
will be installed in conformance with all applicable Village,County,State& Federal laws,codes,rules and regulations
Indicate Permit Tyne: Above Ground(X)R Buried in Ground( )
I. Address: 32 Roanoke Ave, Rye Brook SBL 141.35-1-40 zone. JZ0-
2 Property Owner&Address: Yolanda Pa tlino 32 Rnanak Avt-, R e-B ok,-NY 10573
Phone#: 914-830-21 9,9 Cell�: _ Y email: =Ianrlanai iliool011_��il.corn
3. Contractor&Address: FINS 61
Phone#: 845-255-4900 Cell email: erhodes@e2g.us
a. Applicant: C2G Environmental Cons. LLC/ 83 SPutt Corners Rd, New Paltz, NY 12561
Phone#:$45- 55-4c100 Cell tt: email:-6tktiode�9 uS
5. Indicate Fuel Type- Fuel Oil()o•L P. Gas( )•Gasoline( )•Other I ) #2 heating oil
6. Number and CapacitN of each Tank old - 275/new 275
?. Lxact Location(s)ofeach Tank:OUtSide_lunder-deck
I
6 1 202-11
STATE OF NEW YORK,COUNTY OF A v ) as:
Chrissy Rhodes/Agent C2G ,being duly sworn,deposes and states that helshe is the applicant above named.
(print name of tndttiduat signing as the applicants
and further states that(s)he is the Tank Installation Contractor for the)egat 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. q✓�
Sworn to before me this
B 0 Sworn to before me this f
day of�t'2fl_.��t�s.� 20 day of A)_d V41t i .20 2,�—
S natur of Property Owner Signatur�co Aplican�t
fi,
___t1 _� __.._ Chrissy Rhodes/Agent C2G
Pratt Name of Prop mer Print Name of Applicant
Ton
Notary Public 111oL an N07ARYpU817C,S q ?ublic
Coulmissioplf o)iItA9932973 Registration t o.01H 294662
PORK
Notary PtlblicStttte of New York Quat+ged in Ukler ccau`y
My Commission Expiration:01/17/2029 C—iss+on Exaves i�ecomber 28.201.4
This application 1111aSt he pre pQrly completed in its entirety and mttst inc a notarized
si<,nature(s) of the legal ouncr(s)of the subject property.and the applicant of record in the spaces
provided.An}, application not properly completed in its entirety and/or not properly signed sllall be
deelr,d mall and void and %vIII be returned to the:applicant.
2
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