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BUILDING DEPARTMENT AN 3 12022
VILLAGE OF RYE OROOK VILtgG
938 KING STREET RYE BI 00j,NY 10573 'V'LLA N OF RYE B
(914)"9-0669 G J)EPgRT1 ENT
www.,t�63took.org
PLUMBING PERMIT APPLICATION
FOR OFFICE USE ONLY BP#: PP#: C�v—01 13
Approval Date: JAN 3 Permit Fee: $ 17
�
Approval Signature: Other:
Disapproved:
(fees are non-refundable)
Application dated, 3" c. is hereby made to the Building Inspector of the Village of Rye Brook NY,for the issuance of
a Permit to install and/ r reVnove 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. r�
1.Address: 4 -1 c E� SBL: !�-1 T l Zone: —f
2.Proposed Work:
3.Property Owner: D �` Address: Zk , '
t�r5t+ t
Phone#: Cell#: email: -
4.Master Plumber: G C O 1 q A "G� Address: 70 0 J
Lic.#: 2 01 L—Phone#: J'l j �[j 7`( a ltd1T email: i M
r G 0 19 10 2 L ri n CL"
Company Name: 114 (.��� I-'6c /21 Address: I
INDICATE FIXTURES&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
I st Floor
2nd Floor
31 Floor
4m Floor
51 Floor
Exterior �a
5.*List Other Equipment/Provide Details: R S G CG
IV
(Notarized Signatures Required Next 2 Pages)
81IZ7021
STATE OF NEW YOR__KCOUNTY OF WESTCHESTER ) as:
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 legal owner of the property to which this application pertains,or that(s)he is the
UNy% 1y— 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.
jr S-5
Sworn to before
m�ethis 9 t Sworn to before me this I
day of �ir►l/f�lr�� ,20 Z' day of •.� ,.A ,20_Jr2�_
k4aafure-of Pr erty Qm=r kewgr Signature of Applicant
►D <vc e f K-1Y10,( ( h4y-�
Print Name of Property Owm-r, -1- Print Name of Applicant
o blic
t .., KEl! `= " )LER
Notary Put)' ? New York
N- 2
2�- �n ;cfir.sler County
on >_xpiies March zi, 20Z-2,
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_
9/12/2021
VIE
BUILDINf 6kPARTMENT R
VILGAI�k OF RYE„AROOK JqN 3 1 2022
938 KING$ LT RYE BR px,NY 10573
0 ! VILLAGE OF RYA: BROOK
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 PLUMING PERMIT
APPLICATION SUBMITTED WITHOUT THIS COMPLETED AND NOTARIZED FORM WILL BE RETURNED TO THE APPLICANT .
STATE OF NEW YORK, COUNTY OF WESTCHESTER ) as:
G N&L Ss o ,residing at, -L4- R�6 R 3766C PlA2A
(Print name) (Address where you live)
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;
P lktA , Rye Brook,NY.
(Job Address)
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.
( i re of Prope Ou�r(s)) e A . y7
(Print Name of Property Oumar s))
Sworn to before me this Aq
day of Z , 20 22.
-i-x kk�A , \(X� —
o bGc)
KFLLY SAMD1 FR
Notary PL hw c, t `Jew York
N!o. o
QI!a1ifiitd in 'i' r Go,Jnty _3_
Commission Lxpiles lviwch y, 202,,
8/12/2021
o� tip,
BUILDING DEPARTMENT
❑BUILDING INSPECTOR
-PASSISTANT BUILDING INSPECTOR VILLAGE OF RYE BROOK
❑CODE ENFORCEMENT OFFICER 938 DING STREET • RYE BROOK,NY 10573
(914) 939-0668 FAX (914) 939-5801
www.ryebrook.org
- - - - - - - - - -7'- - - - - - - - - - INSPECTION REPORT - - - - - - - - - - - - - - - - - - - -
ADDRESS : - DATE:
PERMIT# ee' ISSUED: 1 -2S T: BLOCK: LOT:
LOCATION: �U� �S 6 J Wes" 1 � OCCUPANCY:
❑ VIOLATION NOTED THE WORK IS... ACCEPTED Q REJECTED/ REINSPECTION
❑ SITE INSPECTION REQUIRED
❑ FOOTING
❑ FOOTING DRAINAGE
❑ FOUNDATION
❑ UNDERGROUND PLUMBING NOTES ON INSPECTION:
❑ ROUGH PLUMBING
❑ ROUGH FRAMING
❑ INSULATION
NATURAL GAS
❑ L.P. GAS
❑ FUEL TANK
❑ FIRE SPRINKLER
❑ FINAL PLUMBING
❑ CROSS CONNECTION
❑ FINAL
❑ OTHER
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