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BUIL MENT
V OK
J U L 21 2022
938 KING NY 10573
(914)9 39-5801 VILLAGE OF RYE BROOK
—BUILDING DEPARTMENT
APPLICATION TO INSTALL FIRE SUPPRESSION /FIRE SPRINKLER SYSTEM
FOR OFFICE USE ONLY:
JUL 2 6 2022bl
Approval Date: B MP#: QZ C_� Application Fee.
Approval Signature: Permit Fees:
Disapproved: Other:
V
Application dated: 02 2, is hereby made to the Building Inspector of the Village of Rye Brook NY for the issuance of a Permit to install a Fire
Suppression System asker detailed statement described below.
I. Job Address: 9;�T Ardodn,,-7 A& kxw ParcelT.D.:./,_)913j/1-yazne:A14b
2. Proposed System(Describe system in detail including suppression agent):
/7
V
3. Number&Types of Fire Sprinkler Heads:
4. N.Y State Construction Classification: N.Y.Ste,Use Classification:
5. Cost of Installation:$ ..CS.
(Cost shall include all r,matenals,fixed equipmentVrofessional fees,"materials and labor which may be donatedgnat'
6. Property Owner: -7/le. (2 42 Z�r ci� LI-Wens: 5 A-v_L j-v,
Phone 9:2/&/ q1 7- cell# email: dul7l7 r,
Applicant Z S k_k- 4y,( J;;ie Address: )f�Y� (W/I *I-'(—
Phone# email:
Architect/Engineer- Address;—
Phone# �17 —CCU# email:
General Contractor:
Phone# -W cell# !Z2V �(o�/ ,36,Q email:
V21119
This application-must be properly completed n its entirety and roust include the notarized
signature($) of the legal owner(s) of the subject property, and the applicant of record in the
spades provided. Any application not properly completed in its entirety an dlor not properly
signed shall be deemed nuh and void and will be returned to the applicant.
Pleasc note that application fees are non-refundable.
ST.AII OF NEW YOM COUNTY OF%ESTCMiTER 1 as
. Paulette Dawkins being duly sworn,deposes and states that bdshe is the applicant above nauzcd,
(prim name of indmdual dpog u u.e arpli=t)
ari L further states that (0he is the legal owner of the propez-ty to which this application pertains, or that (s)bc is :he
on a C tor
for the legal owner and is duly authorized to make and file this application,
imdieua srchizeu waz-acmr,azenti attorney,etc.)
Tfiat afl state neuts contained herein are true to the best of bis/ber lmowlcdge and be ief, and that any worts performed,or use-
coiulucted at the above captioned property will be in conformance with the details as set forth and cc grained in this application and
in any accornpanv�xg approved plans and specifications,as weL as in accordance w th the New .'ark StatcLI&otm Fire Prevennon
Building Code;t'e Code of the Village of Rye Brook and all other applicable Iaws,ordinances and regalations.
l"
Sworn to bcfore` a tais 7`'L Sworn tD before mc this� ?11 5
day of_ ��✓�{.� 2 0 vZ day of T
5ty�ai C-es
Yroixscy 7wuer si ofS,S . Cohen _ C �
1n v,'atrr• .Proixtty Ownrr PrintName orApplim=
tiot:,n he Notary Pub1 c -
5€RANA F EDWARDS
Notary Public-State of New York
NO, OlED6434559
MADE WINE C.ClTRCNE Qualified in Westchester County
Notary publlc,Stca of New York My Commission Expires Jun 6, 2026
No. 01 MA6030446
Qut111fled )I livestonv at4t County
Con,misslon Expirge Sept. 13,ao j5
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QyE BR(��,
O� 2m
Q�i� ��O•c
1982 BUILDING DEPARTMENT
❑BUILDING INSPECTOR
ASSISTANT BUILDING INSPECTOR VILLAGE OF RYE BROOK
❑CODE ENFORCEMENT OFFICER 938 KING STREET • RYE BROOK,NY 10573
(914) 939-0668 FAX (914) 939-5801
www ryebrook.org,
- - - - - - - - - - - - - - - - - - - - INSPECTION REPORT - - - - - - - - - - - - - - - - - - - -
ADDRESS: `( ?— /`tom l� e - ' l ATE: C�
PERMIT# ^t- -Z L ' (Z -Z- ISSUED: � SBCT: [2 I !t3LOCK: I LOT: l
LOCATION: OCCUPANCY: V A4
❑ VIOLATION NOTED THE WORK IS... ❑ ACCEPTED ❑ REJECTED/ REINSPECTION
❑ SITE INSPECTION REQUIRED
❑ FOOTING
❑ FOOTING DRAINAGE
❑ FOUNDATION
❑ UNDERGROUND PLUMBING NOTES ON INSPECTION:
❑ ROUGH PLUMBING
❑ ROUGH FRAMING
❑ INSULATION
❑ NATURAL GAS I �'
❑ L.P. GAS
[❑ FUEL TANK
FIRE SPRINKLER Vj CZ-U
❑ FINAL PLUMBING
❑ CROSS CONNECTION -_��
❑ FINAL U
❑ OTHER
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