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ECEME
BUIL ? EP• I MENT
VIL E OF RYE OK _
938 KINQ ET RYE B ,NY 10573
OCT 7 2022
VILLAGE OF RYE BROOK
ticvz�3t9 � �L. ?te BUILDING DEPARTMENT
�a
PLUMBING PERMIT APPLICATION
FOR OFFIC F. USE ()NI, Iil'
OCT 1 NO -�'
Approval Date: Permit Fee: $
Approval Signature: Other:
Disapproved:
(fees are non-refundable)
Application dated, /o-7-- 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 confonnane/e)with all applicable Federal,
,State, ,County and
QLocal Codes.
1.Address: 1 17 16le rs Sr A,4,- �`D�/1�► - SBL: .l,St��i Zone:/O
2.Proposed Work: t
3.Property Owner: r-e/t' lLt7 _Address: /�
Phone#: email: /It
4.Master Plumber: _ _AL Address:
L � .�� ee?#:
B L5-12 email:
Company Name: �+-�p �� l.� /�� Address: f, —"&�"&i i,4
INDICATE FIXTURES& LINES TO BE INSTALLED'APER TAE 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
3'd Floor -
4'h Floor
5d'Floor
Exterior i
5.* List Other Equipment/Provide Details: qr L
(Notarized Signatures Required Next 2 Pages)
8/1 NO I
STATE OF NEW YORK,COUNTY OF W!JT)HESTER ) as:
Ut A,
/�►� .-Alakl� NSft�� ,being duly sworn,deposes and states that he/she is the applicant above named,
(print nafne of individual signing as the applicant)
and further states that(s)he is the legal owner of he property to which this application pertains,or that(s)he is the
!J/L &' for the legal owner and is duly authorized to make and file this application.
(indicate architect,contract ,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 7 74
day of O L r ,20 Z L day of 120 727—
Signoure of Property Owner Si-nature of Applicant
Amu Rkink-6 5;0, 1f4xI i , ,
Prink Name of Property 0— Print N
ame of Applicant
Notary Public ,O'NtAir MOsL*40 Notary PubJ,ptAF T S MO
6tate of YOB YOB
h'ubtiC, 11261 +NO 01�MW1 l�YtffjV
NdQWAY
in NNE1 �a,t0 r�;�++'liltad i,�W�9t�3.V-7G
'.n E i t1 aq IV
l his application must he properly completed in its clttirety and nttlSt include the notarized sipnatmv(s) ol'
the legal okmer(s) ol'the sOrject property. and the applicant ot'record in the spaces pro�-idcd. ,Application.,
not properly complcted in its cl}tiretG mid or 11ol propc.rl�, sll<.ill he (icelliv't null anal \oti l and ��ili Nti
returned to the applicant.
-2-
S/12/202 l
f
BUILD "G DEPARTMENTRVi E OF RYr 4400K OCT - l ZOZZ
938 KING 2ET RVE BROC}Y+,NY 10573
(914)939-0668 VILLAGE OF RYE 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 PLUMBING PERMIT
APPLICATION SUBMITTED WITHOUT THIS COMPLETED AND NOTARIZED FORM WILL BE RETURNED TO THE APPLICANT .
STATE OF NEW YORK,COUNTY OF WESTCHESTER ) as:
17
X, Amv residing at, 177 Be-15y `B.aon Jeond. hye galt, VN /laS7�
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;
177 &e475,/ 15rn,i,•i Roc,,rj , Rye Brook, NY.
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.
iNri�itni!iiCl'r ��hrtyll+�nrri.,t; --�
Sworn to before me this 7 7
day of 7 20 ? z tt►�d.r qt�s�� '
(�ot�in Puhli�)
an 2/2021
�E BRC�k
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.rytbrook.org
- - - - - - - - - - - - - - - - - - - - INSPECTION REPORT - - - - - - - - - - - - - - - - - - - -
ADDRESS : DATE: tO Z Z.-Z-
PERMIT# (�Z'' t �� ISSUED: ECT: BLOCK:_LOT:
LOCATION: {�-�- y T+ OCCUPANCY: 21
❑ VIOLATION NOTED THE WORK IS... Ef ACCEPTED ❑ REJECTED/ REINSPECTION
❑ SITE INSPECTION REQUIRED
❑ FOOTING
❑ FOOTING DRAINAGE
FOUNDATION
UNDERGROUND PLUMBING NOTES ON INSPECTION:
%❑ ROUGH PLUMBING
Cl ROUGH FRAMING
❑ INSULATION
❑ NATURAL GAS �-w =--22 l A- CFI --j 1
❑ L.P. GAS
❑ FUEL TANK p
❑ FIRE SPRINKLER pit �� �Q[� c-
❑ FINAL PLUMBING
❑ CROSS CONNECTION
❑ FINAL
❑ OTHER