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A C7 U A 000 W rx " p oo cy o � Z a 16. 0 V er W A w x w H o0 w � � R-+ � � o o a Lo O*N a t a D OR 1 BUIL MENT NOV 9 2022 Ga' F"<= VTI,St rT:QIC YT:i OK VILLAGE OF RYE BROOK 938KF� YYiII.; ,NY 10573 BUILDING DEPARTMENT I I w "yl9L'J� PLUMBING PERMIT APPLICATION ICATION I FOR OFFICE USE ONLY BP#: PP#: Approval Date: Permit Fee: S Approval Signature: Other: Disapproved: (recs are non-refundable) Application dated, - "' j - is hereby made to the Building Inspector of the Village of Rye Brook NY,for the issuance of a Permit to install andior remove Plumbing as per detailed statement described below.The applicant&property owner,by signing this document agree that said plumbing work will he in conformance with all applicable Federal,,State,County and Local Codes, � A 1,Address: � '��`�3�'l_ �1� `� �SBL: 913 7 -�-1 � 2oc�e:y/'UL� 2.Proposed Work:C"�l�'�� ' � 'F I Y3r_�_ t Vl Ci JG.1-G- 7—({� 3.Property Owner: 00tj gmlflS":7&))r.!�V' fj t rJ�t/'Ad ress: C� e�CAi1 /� i1/C /C702-Z Phone Cellg: f rat email: 4.Master Plumber: �' ( [l� Address: � ' Pa l+J'4 (0 Lie. : /�Phone•# � 7 $" f5 1� Cell#:qtq' 44�' j3J( email:('�1!} ((AeQC't� ,'�Ct�Alr-04 'n Company Nanae:t,:4-1 6G{,bA XLV1 Rt W P�f yl�F' L' t[JAddress: .,SCZ140- e'+ ? INDICATE FIXTURES&LINES TO BE INSTALLFD AS PER THE,FOLLOWING SCFIEDUI.F,: Location Water Urinals Drinking Sinks Showers Bath Laundry Domestic Firc Sanitary Natural/ Other* Tatat Closets Fountains Tubs Tubs Service Service Sewer LP Gas Basement r 1st Floor• 2ud Flonr 316 Floor 411'•Floor 5"'Floor Exterior 5.*List Other EquipmenJProvide Details: b � L 'Roo l I (Notarized Signatures Required Next 2 pages) 9il%F02Y f STATE OF NEW YORK,COUNTY OF WESTCHESTER ) as: Sn"4r55A/ 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)be is the legal owner of the property to which this application pertains,or that(s)he is the ,&.212- 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 aRth the details as set forth and contained in this application and in any accompanying approved plans and specifications,as well as in accordance Arith 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. C� Sworn to before me this Sworn to before a is day of Ai±al/t ✓ c 24 day of �lt��m ,20 Sip4ageity Owner Signature f ph t Namd of Property Owner Print Name of Applicant Notary-Public taf�E3t:l_iN I�BONG No GUGAR 14U1ary Public, State of New York Notary public,State of New York No, 01 MA6030446 No. 01SU4,90dG8� Qualified ill Vtlnstchester County, Quaiitit9d in U49O Cou Commission Expires Sept. 13, 201�5. Commission Expire s This application must be properly completed in its entirety and roust 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 BUIlLP 0EPARTMENT Vffii Ar�E OF RYE J%�POK N©y - 9 2022 933 KING SYi REST-RYF]B+RO'OIG,lam'10573 _{914)939-06§8. VILLAGE OF RYE 13ROOK v, , ret��o4lc.cr BUILDING DEPARTMENT AFFIDAVIT OF COMP LANCE VILLAGE CODE §216 m STORM SEWERS AND SANUARY SEWERS THIS AFFIDAVIT MUST BEAR TEM NOTAF.IZSD SIGNATURE Or THE LEGAL PROPEP,TY OWNER Alm BE SUHMITTzD ALONG WITH ANY BUILDING OR PLUMBING PERMIT APPLICATION. PM BUILDING OR PLU11,MI11G PERMIT APPLICATION SUBMITTED WITHOUT THIS COMPLETED AND NOTARIZED FOPM T41LL BE RETURNED TO THE APPLICANT. STATE OF NEW YORK, COUNTY OF WESTCHESTER ) as: residing at, (Print narnc) Address wpere you li e) 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; �l /q-7,vt)&g r � ) , 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 crass-connections concerning either the storm sewer or sanitary sewer, and fitrther 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. (Signature of Pr erry Qwua�s]] (Priest*lame of Property Owncr(s)) Sworn to before me this ` �� MADELINE C. CITRONE day o 20 Notary Public, State of New York / No, 01 MA6030445 Qualified in Westchester County / Qomrnis�.ion Expires Sept. 13, 20�5 o tbmc -3- 8JIM021