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BUILDING DEPARTMENT DEC 2 8 2021
VIL E OF RYE OK
938 KIN ��XET RYE B NY 10573 VILLAGE OF RYE BROOK
�`� � _0, BUILDING DEPARTMENT
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PLUMBING PERMIT APPLICATION 1
FOR OFFICE USE ONLY BP#: PP#: 0 I--tea 3
Approval Date: DEC 2 q MN Permit Fee: S Z 5
Approval Signature: Other:
Disapproved:
(fees are non-refundable)
Application dated, is hereby made to the Building Inspector of the Village of Rye Brook NY, for the issuance of
a Permit to install and/or remove Plumbing as per detailed statement described below.The applicant&property owner,by signing this
document agree that said plumbing work will be in conformance with all applicable Federal,State,County and Local Codes.
1.Address: SBL: lop'7 ' ~3 Zone:pg-3
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2.Proposed Work:
3.Property Owner: J)c P Address:
Phone#: Cell#: ��/�- Omail-
4.Master Plumber: Address:
Lic.#: Pho #: Cell#: 6 email:
Company Name: . L-- Address:
INDICATE FIXTURE LINES TO BE INSTALLED AS PER THE FOLLOWING SCHEDULE:
Location Water Urinals Drinking Sinks Showers Bath Laundry Domestic Fire Sanitary Natural/ Other* Total
Closets Fountains Tubs Tubs Service Service Sewer LP Gas
Basement
1 st Floor
2nd Floor
3'd Floor
4rh Floor
51 Floor
Exterior
5.*List Other Equipment/Provide Details:
(Notarized Signatures Required Next 2 Pages)
-1-
8/12/2021
S E NEW YOM COUNTY OF WESTCHESTER ) as:
being duly sworn,deposes and states that he/she is the applicant above named,
(pri=er
of in 'd ual signing as the applicant)
and states that(s)he is the legal owner of the property to which this application pertains,or that(s)he is the
for the legal owner and is duly authorized to make and file this application.
(indicate architect,contractor,agent,attorney,etc.)
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 ?-7 Sworn to before me this 9 7
day ofI,"LC' V6X'r ,20—aL_ day ofIgeg,1 yi �Iw,20 0)- 1
Signature of Prope ty Owner S natu oflic
t
Print Name of Ploperty Owner Print Name f Appllcant
S c�
Nota gbePublic,State f New Ycr;c otat', blic, tate o ew
No.01 Rt151 1 y No.01 IS136510
Qualified in Westchester Count Oualified in VlJestchester County
Commission Expires Nov.7,20 Commission Expires Nov.7,264
This application must be properly 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. Applications
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-
8/12/2021
BUIL
D, MENT C F
VILE OOK DEC 2 8 202'1
938 KINGROOK,NY 10573
66$i' VILL7AG� OF RYE BROOK
�c:`' BUILDING, DEPARTMENT
AFFIDAVIT OF COMPLIANCE
VILLAGE CODE §216 • STORM SEWERS AND SANITARY SEWERS
THIS AFFIDAVIT MUST BEAR THE NOTARIZED SIGNATURE OF THE LEGAL PROPERTY OWNER AND BE SUBMITTED
ALONG WITH ANY BUILDING OR PLUMBING PERMIT APPLICATION . ANY BUILDING OR PLUMBING PERMIT
APPLICATION SUBMITTED WITHOUT THIS COMPLETED AND NOTARIZED FORM WILL BE RETURNED TO THE APPLICANT .
STATE OF NEW YORK,COUNTY OF WESTCHESTER ) as:
1, 4&( Tffa/y, ��Jf "/� ,residing at, ��,����f- /� �� K y.� �`"r'o!ft
(Print(name) (,Address where you liNC
being duly sworn,deposes and states that(s)he is the applicant above named,and further states that(s)he is the
legal owner of the property to which this Affidavit of Compliance pertains at;
I(OP 6 f(c�� Jr— iL/, ,Rye Brook,NY.
(Job Adc�rc,>
Further that all statements contained herein are true, and that to the best of his/her knowledge and belief, that
there are no known illegal cross-connections concerning either the storm sewer or sanitary sewer, and further
that there are no roof drains, sump pumps, or other prohibited stormwater or groundwater connections or sources
of inflow or infiltration of any kind into the sanitary sewer from the subject property in accordance with all State,
County and Village Codes.
x.d.r►-cs�t.�-+�
(Signature of Property()un r(Sf
(Print Name of Property Otimer(. i
Sworn to before me this
day ofJ LZIr� ,20 02 l
STEPHANIE RUSSO-Fr1.,M-_�A
Notary Public,State of New Ycr;c 3
No.Oi RL!313651
Q11af'fied in Westchester Countx
Commission Expire,Nov.7,20
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