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pECEN
BUILPJ MR:I RTMENT OCT 13 2022
VIL 'E OF RYEi$tOOK
938 KIN 6T RYE B NY 10573 VILLAGE OF RYE BROOK
BUILDING DEPARTMENT
www or
PLUMBING PERMIT APPLICATION
FOR OFFICE USE ONI.Y BP#: PP#:
Approval Date: ` O� ZU2Z Permit Fee:
Approval Signature: Other:
Disapproved:
(fees are non-refundable)
**************************************************************************************************
Application dated, ld j I 2Z 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: 4(.R 1 K-(� C'7 r6f'* SBL: Zone:
2.Proposed Work: rcoW e f- Uty* Act- Aas
d "? To- * _
3.Property Owner: a. l g Vw"'v) Address: �� �S,�v-e
Phone#: �l�"l* yet� Cell#: email: J�by,,ia Lm c*W
4.Master Plumber: �- �Q� Address: 6 J S a pQ�
Lic. #: `"17> Phone#: �L11 Cell#: ll4 1�} email: rh IDUAllbiKAQ &V
Company Name: {����1�/Vl�l "a1 4 Iil(,Q{ Address:
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
3Pd Floor
4'h Floor
5'h Floor
Exterior r
1
5.* List Other Equipment/Provide Details:
(Notarized Signatures Required Next 2 Pages)
-1-
8/12;2021
BUILD Y MENT 2ECIEW/ E
VIL E OF RYE OOK
938 KING `.ET RYE BRUi)7C,NY 10573 OCT 1 3 Z022
(9 '.
VILLAGE OF RYE BROOK
BUILDING DEPARTMENT
AFFIDIAVIT 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:
�.�'n , residing at, La
("Print n.3me) (Addre,��where tiuu li%:)
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;
1 k 6 Ul G� S'�PL , 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.
C�
'' . ' & , �trQiiv
(}Tint Na3ne Of Proprrt)-
(?wner(sli
Sworn to before me this f
da of C)
(i`oiary Public)
SHARI MELILLO
Notary Public,State of New York
No.O1ME6160063
Qualified In Westchester County _3_
Commission Expires January 29,202-3
8/12/2021
STATE OF NEW YORK,COUNTY 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
for the legal owner and is duly authorized to make and file this application.
(indicate architect,contractor,agent,at(orney,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 Sworn to before me this
day of ,20��� day of r ,20 Q
Si of Property Owner Signature of Appli
Print Name of Property Owner Print Name of Applicant
And
Not"/[MWOELILLO Notary Public
V,tary Public,State of New York SHARI MELILLO
No,01ME6160063 Votary Public,State of New York
Qualified in Westchester County No.01ME6160063
^ommission Expires January 29,20 Qualified In Westchester County.
i:tttnn+►4ssion Expires January 29,20�
This application must be properly completed in its entirety and mast include the notarized signatures) 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
t7
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 : G DATE:
PERMIT# �q '��� ISSUED: SECT: BLOCK: LOT:
LOCATION: ��� ( �L-7 OCCUPANCY: Z `�
❑ VIOLATION NOTED THE WORK IS ACCEPTED ❑ REJECTED/REINSPECTION
❑ SITE INSPECTION REQUIRED
❑ FOOTING
❑ FOOTING DRAINAGE
❑ FOUNDATION ��✓'
El PLUMBING NOTES ON INSPECTION:
❑ ROUGH PLUMBING
❑ ROUGH FRAMING
❑ INSULATION c NATURAL GAS
❑ L.P. GAS
❑ FUEL TANK
❑ FIRE SPRINKLER
❑ FINAL PLUMBING
❑ CROSS CONNECTION
❑ FINAL
❑ OTHER
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