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King Street Nursing Home Fire Safety Certificate 2023-2026
V 7b O O w 9 W W Ln O � � W � O c ^ ' �G 04 m W � F.[ o Ln � A � •� "ter" �'' � � 7, D, � n Q 1� 00v w „ 1 W v '� 4-0 CIO k V (A U. ►� I-� ►� �° cuo H A W z a �yE BR(�k• cu � • 1982• BUILDING DEPARTMENT pof UILDING 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 : DATE: 0� PERMIT# ISSUED: L :SECT:?,�, t E`LOCK: LOT: -) LOCATION: -�� v U , 1-Urn 'OCCUPANCY: ❑ Violation Noted THE WORK IS... PASSED ❑ FAILED /REINSPECTION ❑ SITE INSPECTION REQUIRED ❑ FOOTING ❑ FOOTING DRAINAGE ❑ FOUNDATION ❑ UNDERGROUND PLUMBING NOTES ON INSPECTION: ❑ ROUGH PLUMBING ❑ ROUGH FRAMING ❑ INSULATION ❑ Natural Gas i C ❑ L.P. Gas ❑ FUEL TANK ❑ FIRE SPRINKLER ❑ FINAL PLUMBING ❑ CROSS CONNECTION ❑ INAL OTHER QyE BRC�uk 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 Uebrook.org - - - - - - - - - - - - - - - - - - - - INSPECTION REPORT - - - - - - - - - - - - - - - - - - - - ADDRESS : 'l �� DATE: �a 1 PERMIT# tCF�- l IC�/ ISSUED: `IeCT: � BLOCK: LOT: LOCATION: 1 �J��(S n GQ "OCCUPANCY: ❑ VIOLATION NOTED THE WORK IS... ❑ ACCEPTED REJECTED/REINSPECTION SITE INSPECTION REQUIRED i`❑ FOOTING ❑ FOOTING DRAINAGE ❑ FOUNDATION ❑ UNDERGROUND PLUMBING NOTES ON INSPECTION: ❑ ROUGH PLUMBING ❑ ROUGH FRAMING ❑ INSULATION ❑ NATURAL GAS ❑ L.P. GAS c �"1 C., ❑ FUEL TANK ❑ FIRE SPRINKLER ❑ FINAL PLUMBING \ r �A ❑ CROSS CONNECTION i ❑ FINAL OTHER �� � -'t �E BR(�v� O�` tim l7 � �1 1932 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 : y DATE:PERMIT# RUED: 1 I'I V)ti SECT: ` v ,�LOCK:_�LOT:_ LOCATION: I� \n NV OCCUPANCY: ❑ VIOLATION NOTED ; ` 'O IS... ❑ ACCEPT$D REJECTED/REINSPECTION ❑ SITE INSPECTION REQUIRED ❑ FOOTING ❑ FOOTING DRAINAGE ❑ FOUNDATION ❑ UNDERGROUND PLUMBING NOTES ON INSPECTION: ❑ ROUGH PLUMBING ❑ ROUGH FRAMING ❑ INSULATION f 1 I ❑ NATURAL GAS CA A G � C�1 V���Q)�r �y�O � � 1 y S ❑ L.P. GAS o--kx Sp cn-E CL hw- �2 ) Op ca u G ❑ FUEL TANK ❑ FIRE SPRINKLER ❑ FINAL PLUMBING ` \ _ 1 ( ��� �Q�C l ` S�� ❑ CROSS CONNECTION V,? �P ❑ FINAL ❑ OTHER BUILD TMENT VILL OF R OOK Inia>(Ik�ns�p�jon�Date: ❑ Pass MICHAEL J.IZZO 938 KING ST RYE BROO , Ew YORK 10573 `Ol* Fail BUILDING&FIRE INSPECTOR (914)9 w rook.or Re-Inspection Date: ❑ Pass mizzo@rvebrook.org ��, ` 1982 ❑ Fail FIRE INSPECTION REPORT NOTICE OF VIOLATION & ORDER TO REMEDY SAME _7z_1 b Site Address: , i � \ -�� \ Zone� " SBL: Occupancy: N �' �'�� \\rYa 1 tate Use Classification: Business Owner: L.Y J (7 \ Phone: Building Owner: \ N 1 Phone: t �r Emergency Contact: n 4:;Z'e' 1 1 P Phone: Building Representative in Attendance: ------------------------------------------------------------------------------------------------------------------------------------------------------------------ Take notice that the following violations of the.N�e'� rk tpte Unifo R Prevention&Building Code and/or the Code of the Village of Rye Brook we found to exist at, f �� \ ,in the Village of Rye Brook,NY on, 20 a person or entity served with this Order to Remedy shall immediatel ommencp to corre t all listed violations and shall completely cure each violation described herein by no later than "2�1 o7►.O ,which is thirty(30)days after the date of this Order to Remedy.Furthermore, upon curing any listed violation(s),you shall immediately contact the Building Department during normal business hours to schedule a re-inspection of the premises to confirm full compliance with all applicable codes,laws,rules®ulations. BE ADVISED THAT YOUR FAILURE TO CORRECT ALL VIOLATIONS IS A CRIME PUNISHABLE BY FINE,IMPRISONMENT OR BOTH. ------------------------------------------------------------------------------------------------------------------------------------------------------------------ No YES N/A 1.PORTABLE FIRE EXTINGUISHERS (PFE's) ✓ a.906.1. Are PFE's installed throughout the space&on the premises as required by code. a. b.906.3.1.Is the maximum travel distance to a PFE 75 feet or less. b. c.906.5.Are PFE's conspicuously located&readily accessible. C. d.906.6.Are PFE's unobstructed/unobscured from view. d. e.906.7.Are PFE's properly mounted as per the manufacturers instructions. e. _ f.906.9.Are PFE's properly installed:<40 lbs.max.5'above floor;>40 lbs.max. 3.5' above floor. f._ ✓ 2.FIRE ALARM SYSTEM&SMOKE DETECTORS a.901.6.1.Is the fire alarm system inspected,tested&maintained in accordance with NFPA 72. a. _ b.907.4.2.1.Are manual pull stations located within 5 feet of exits&within 200 feet of each other. b. c.907.4.2.2.Is the height of the pull station handle located between 42&48 inches above the floor. C. d.907.3.Is a fire alarm system provided in existing buildings as per section 907.3.1 &907.3.2. d._ 3.FIRE SUPPRESSION SPRINKLER SYSTEM&FIRE HYDRANTS a.901.6.1.Is the sprinkler system inspected,tested&maintained in accordance with NFPA 25-13. a. y b.901.6.1.Are the main valves secured against tampering in the open position. b._ c.901.6.1.Are sufficient clearances maintained from fire sprinkler heads to fixtures or materials. C. d.901.6.1.Is a supply of six spare heads&a wrench maintained on the premises. d._ — e.901.6.1.Are sprinkler heads&cover plates unfinished or of factory applied finish only. e. — f.901.6.3.Are records of all system inspections,tests&maintenance reports maintained on the premises. f.— T/ g.913.5.Is the fire pump inspected,tested&maintained in accordance with this section&NFPA 25. g. h.507.5.2.Is the fire hydrant system properly maintained,operational,compatible w/NST&tested annually. h. i.507.5.4.Are fire hydrants&fire protection equipment unobstructed. i. j.507.5.5.Is a clear space of not less that 3 feet maintained around all hydrants. j._ f _ k.901.8.Are all fire protection systems' ace and mainlined unt red. k. INSPECTOR: DATE: -- Revised 2110/22 No YES N/A 4.STANDPIPE.CABINETS&FIRE DEPARTMENT CONNECTIONS a.901.6.1.Is the standpipe system inspected,tested&maintained in accordance with NFPA 25-14. a. _ A b.901.6.1.Has the required flow test been performed within the past 5 years as per NFPA 25-14. b. c.912.2.3 Are standpipe FDC threads compatible with fire department standards. C. _ _✓ _ d.905.7.Are cabinets containing fire fighting equipment unobstructed/unobscured. d. e.905.7.1.Are cabinets containing fire fighting equipment properly identified&labeled. e. f.912.2.1.Are exterior FDC's fully visible&recognizable from the point of fire department access. f. e g.912.4.Are all FDC's unobstructed and available for immediate access by the fire department. g. �✓ 5.EXITS.MEANS OF EGRESS&OCCUPANCY a. 1031.2.Are exits&exit enclosures continuously maintained free from obstructions or impediments. a. b. 1031.3.Is the means of egress free from obstructions including accumulated ice&snow. b. c. 1031.6.Are exits maintained unobstructed by furnishings,decorations,draperies,mirrors,etc... c. _ _✓ d. 1031.7.Are existing emergency escape&rescue openings maintained as per this section. d. _ ,✓ _ e. 1010.1.Are egress doors provided and maintained as required by this section. e. _ _✓ _ f. 1004.9.Are all spaces having an assembly occupancy posted with an approved occupant load sign. f. _ _✓ g. 1013.1.Are exits marked by a properly located,approved&readily visible exit sign. g. k. 1013.1.Is the maximum travel distance to any exit sign in an exit access corridor 100 feet or less. h. i. 1013.4.Are tactile exit signs complying with ICC/ANSI 117.1.provided as required by code. j. 1013.3.Are all exit signs illuminated at all times. j. k.1008.1.Are the means of egress&exit discharge illuminated at all times the building is occupied. k. _✓ 1. 1018.3.Are public aisles in group B&M occupancies maintained at least 36"wide where fixtures 1. _ _✓ _ are placed on one side of the aisle&at 44"wide where fixtures are placed on both sides. m. 1018.3.Are non-public/non-accessible aisles serving less than 50 people maintained at least in. 28"wide,or at least 36"wide where serving 50 or more people. 6.COMBUSTIBLE STORAGE&WASTE MATERIALS a.304.1.Is the building(s)and premises maintained free from accumulated combustible waste material. a. b.304.1.2.Is property free from weeds,grass,vines or other growth capable of being ignited. b. c.304.2.Is combustible rubbish stored so as not to create a nuisance or hazard to the public. C. d.315.3.Are combustible materials properly stored&separated from ignition sources. d. e.315.3.1.Is storage maintained 24"or more below the ceiling in nonsprinklered buildings, e. )Ie_ and 18"or more below sprinkler head deflectors in sprinklered buildings. f.315.3.2.Are exits&exit enclosures maintained free from stored combustible materials. f. _ _✓ _ g.315.3.3.Are boiler,mechanical&electrical rooms maintained free from stored combustible material. g. h.313.1.Is building maintained free from stored fueled equipment. (motorcycles,mopeds,mowers,etc...) h. 7.ELECTRICAL a.604.1.Is the building free from modified/damaged wiring,devices,appliances,equipment a. and maintained free from electrical hazards. b. 604.2.Are electrical service equipment areas properly illuminated. b. !� _ c.604.3.Are proper working space clearances provided&maintained for electrical service equipment. C. d.604.3.Are electrical service equipment working spaces free from any stored materials. d. _✓ _ e.604.3.1.Are all electrical control panel room doors,panel boards&disconnects properly labeled. e. f.604.4.Is the building free from unfused multi-plug electrical adapters. f. g. 604.5.Are electrical extension cords being used in a safe manner as per code. g. h.604.6.Are all junction,switch&outlet boxes fitted with approved covers or plates. h. _✓ _ i.604.6.Is the building free from open-wiring spliced electrical connections. i. _✓ _ j.604.8.Are electrical motors maintained free from accumulated oil,dirt&debris. j. k.915.1.Are Carbon Monoxide Detectors installed&maintained as required by this section and by 1103.9. k._ INSPECTOR: DATE: -2- Revised&I 117020 No YES N/A H.ELEVATORS,DUMBWAITERS&ESCALATORS a.[PM]603.1.Are elevators properly maintained,and is the current certificate of inspection on the premises. a. b.606.3.Are approved standardized,pictorial signs posted adjacent to each elevator call station on all b. _ v floors reading; IN FIRE EMERGENCY,DO NOT USE ELEVATOR,USE EXIT STAIRS c.606.7.Are keys for elevator car doors&fire department service kept in an approved location. C. _ _✓ _ d.315.3.3.Are elevator machine rooms maintained free from stored combustible material. d. _ _t-"oo' _ e. [B]3005.1.Are elevator machine room doors maintained unobstructed at all times. e. .i 9.COMMERCIAL KITCHENS a.906.1. Are portable Class K fire extinguishers installed within 30 feet of cooking equipment. a. _ b.904.12.5.Is the fire protection equipment inspected,tested&maintained as per Section 901.6. b. _v c.904.12.5.2.Are automatic fire extinguishing systems serviced at least every 6 months. C. d.904.12.5.3.Are fusible links&automatic sprinkler heads replaced annually. d. e.[RB]122-5.B.Are grease traps provided and installed as required by Village Code. e. _ I _ f.[[PC] 1003.10. [RBI 122-6.Are grease traps properly maintained as per State and Village Code. f g.[RB] 122-6.C., 122-9.Are all service,maintenance,&repair records for grease traps and related plumbing maintained on the premises as required by Village Code. g. 10.HEATING SYSTEMS �, [Pm]603.1.Are all heating appliances properly installed&maintained in a safe working condition. a. _ --L.- b. [PM]603.2.Are all fuel-burning appliances&equipment connected to an approved chimney or vent. b. _ _v c. [Pm]603.3.Are heating appliances maintained with proper clearances from combustible material. C. _✓ _ d. [PM]603.4.Are safety controls for fuel-burning equipment maintained in effective operation. d. _ _✓ _ e. [PM]603.5.Is the fuel-burning equipment provided with adequate combustion&ventilation air. e. �-- 11.MOTOR FUEL-DISPENSING FACILITIES&REPAIR GARAGES a.2303.2.Is an approved,labeled&readily accessible emergency disconnect switch provided a. in an approved location within 100' of,but not less than 20'from fuel dispensers. b.2304.3.4.Are dispenser operating instructions conspicuously posted on every fuel dispenser. b. c.2304.2.4.Are fuel-dispensers unobstructed&in clear view of the attendant at all times. C. d.2305.5.Are approved portable fire extinguishers complying with Section 906 with a minimum rating of d. 2-A:20-B:C provided&located not more than 75' from pumps,dispensers&fill-pipe openings. e.2305.6.Are warning signs provided&posted within sight of each dispenser as per this section. e. f.2305.7.Are weeds and other combustible materials kept at least 10' from fuel-handling equipment. f. g.2306.4.Are above-ground tanks provided with vehicle impact protection. 9. h.2306.5.Are above-ground tanks provided with secondary spill containment. h. 12.HAZARDOUS MATERIALS(HAZ-MATS a.407.2.Are S.D.S. Sheets for all haz-mats readily available on the premises. a. _ b.407.3.Are spaces and individual containers containing haz-mats properly labeled&identified. b. _ c.5004.2.Are stored haz-mats provided with approved secondary spill containment. C. d.5003.7.1.Are proper No SMOIQNG signs provided as per this section. d. 13.MISCELLANEOUS a.403.1.Is an approved fire safety&evacuation plan prepared&maintained for the building/occupancy. a. _ ✓ b.405.1.Are emergency evacuation drills conducted at the intervals as specified in Table 405.2. b. _ _✓ _ c.405.5.Are records of emergency evacuation drills kept&maintained on the premises. C. _ _✓ _ d.505.1.Are approved address&building numbers properly placed&plainly visible from the street. d. _ J/ e. 506.1.Are approved key boxes(knox boxes)provided,properly located&equipped with the proper keys. e. f.703.1.Is all required fire-resistance rated construction properly maintained as per code. f. g.703.1.Are openings through fire-resistance rated assemblies properly protected&maintained. g. _ _4"- h.5303.5.Are compressed gas cylinders&systems secured&safeguarded against damage&access. h. i.5303.6.1.Are compressed gas cylinder caps or collars in place at all times except when tanks are in use. i. 14.GENERAL HouSEKEFLPING a. Good b.Fair c.Inadequate 0 ' d.Poor INSPECTOR: DATE: It -3- Revised 9/17/21 ITEM NUMBER REMARKS k C: 1. rw c` S "Ito c_Q- ,�4 0 k LI=U (Y-) c-6) Y2Q ro � V r� AP n r e{(: Y, ��, S i vy _ C �N c vo sY1S ,ve c'cySsL UnC 1Orb oo Cj rpSP Ua v Co 5 C4 INSPECTOR: / DATE: 2e27- 4- Revised 6/11/2020 � © FILRbingtundo � 31D , Corp. MAY - 3 2023 PO Box 9, Hawthorne,NY 10532 Phone(914)579-0015 VILLAGE OF RYE BROOK Email: Rotundopc@gmail.com BUILDING DEPARTMENT Wlestchester County Lic.#916 Putnam County Lic.#2984 Village of Rye Brook Building Department 938 King Street Rye Brook, NY 10573 TRANSMITTAL Date: 04/28/2023 Re: Sprinkler and or Standpipe Reports-King Street Rehab Copies of Reports attached for your files. Thank you Respectfully, Marie Paulino form for Inspection, Testing and Maintenance of Fire Sprinkler Systems NATIONAL FIRE SPRINKLER ASSOCIATION INC Information on this form covers the minimum requirements of NFPA 25-1992 for fire sprinkler systems connected to distribution systems without supplemental tanks of fire pumps. Separate forms are available to inspect,test and maintain fire pumps and water tanks. Additional forms art;also available for standpipe and hose systems,private fire service stains water spray fixed systems and foam-water sprinkler systems. More frequent inspection,testing,and maintenance may be necessarN depending on the conditions of the occupancy and water supply. Owner: K fy+ Owner's Address: 757 King V e. t q00A:� Property being Inspected: Property Address: Date of Inspection: 3'01/- This inspection is(check one): o Daily o Weekly o Monthly eQuarterly ❑SemiAnnual o Annual o Third year ❑Fifth Year Note. All questions are to be answered Yes.No or Not Applicable. All"No"answers arc to be explained in the comments portion of this form All responses refer to the current inspection performed on the date shown above. Part I-Owner's Section (To be answered by the Owner or Occupant.) A. Is the building occupied? 0 Yes ❑No o N/A B. Has the occupancy classification and hazard o ontents remained the same since the last inspection? YYes c No o N A C. Are all fire protection systems in service? t�l'es o No ❑N/A D. Has the system remained in service without modification since the last inspection?l!t�es ❑No o NiA E. Was the system free of actuations of devices or alarms since the last inspection? eTY"es o No ❑N/A Part II -inspector's Section A. Inspections I.Daily,or weekly if low temperature alarms are installed L•nclrnures around dry-pipe or deluge valves maintaining a minirmun of 40°F? o Yes o No ❑N:A 2.Weekly Inspection Items A. (reaction and Deluge Valves: � R. On-Pipe Val<,: I. f•tre Iium physical damage'' o Yes �No P.'N..A 1. Free From physical damage? :t Yes Nu r V.•\?. 1 rim valves in appropriate(open or closed)position'? o Yet c No ;e<iA 2.Trim vale in appropriate:' 3.No leakage from valve seat? a Yes o No O N/A (open or closed 4.Electrical components in service? ❑Yes o No t11Q/A )position o Yes e .rFgi!1 3.No leakage from intermediate chamber?? o Yes C. Relief port on reduced pressure backflow prevention assemblies not continuously dischargin o Yes U'wu ❑N/A o No 04A J.Weekly inspection items which can be performed monthly if the items arc directly supervised or secured with locks A. Gauges on dry,preaction and deluge systems in good condition and showing normal air and water pressure? o Yes n No ❑N/A B. Control Valves:I.In normal(open or closed)position? As ❑No o N/A 2.Scaled locked or supervised? dYes o No o N/A 3.Accessible? W''cs o No n N/A 4.Provided with appropriate wrenches? o Yes a No w-4A 5.Free from external leaks'? eYes o No o N/A 6.Provided with appropriate identification? o,'Yes ❑No o N;A C. Isolation valves on backflow prevention assemblies in open position? As o No o N/A 4.Monthly Inspection items / A.Proper number and type Of spare sprinklers'? eyes ❑No o N/A B.Sprinkler wrench with spare sprinklers? P!"Yes o No c:NIA C.Gauges on wet-pipe system it good condition and showing normill a titer supply pressure? e o No n N/A t ;p/ D.Alarm devices free from ph,,sical damage and all electrical connections secure? es o No n N/A (i.Alarm Valves: / I.Gauges indicating normal supplN water prcssure'' 6 Ycs, t3 No o N'A 2 Free From physical damage! arlyles ❑No a NIA 3 Valves in appropriate(open or closed)position? td'Yes G Ngt"'h N;A 4.No leakage from retarding chamber at•alarm drains? m*fyes ❑tNo o N/A F.Sprinkler Pressure Regulating Control Valves. I.In open position? o Yes ❑No A/A 2.Not Leaking? o Yes o No A/A 3.Maintaining downstream pressure per design criteria? o Yes ❑No KIN/A 4.In rood condition with handwheels not broken? o Yes o No AIA 1992 National Fire Sprinkler Assocation,P.O Box 1000.Patterson,NY 12563 Sheet 1 of 7.Printed 7192 4.Monthly Inspection Items(Continued) G.Fire Departmept Connections:/ 1.Visible and accessible? Yes O No O N/A 2.Couplings and swivels not damaged and rotate smoothly? l7 Yes O No O N/A 3.Plugs or caps in place and undamaged? O'Ies ❑No O N/A 4.Gaskets in place and in good condition? ZrYes O No O N/A 5.Identification sign(s)in place? O Yes O No O N/A 6.Check valve is not leaking? O Yes O No O N/A 7. Automatic drain valve in place and operating properly?0'rfes O No O N/A (Note: If plugs or caps are not in place, inspect the interior for obstructions and verify that the valve clapper is operational over its full range.) S.Quarterly Inspection Item Hydraulic nameplate,if provided,securely attached to riser and legible? O Yes O No ❑N/A 4.Annual Inspection Items A.Visible sprinklers: B. Visible pipe: 1.Free of corrosion? d Yes O No O N/A// 1.In good condition? 0 Yes O No O N/A 2.Free of obstructions to spray Qattems? Yes O No O N/A 2.Free of mechanical damage? Yes O No U N/A 3.Free of foreign materials?spray O No O N/A 3. Not leaking? eyes O No ❑N/A 4.Free of paint? Zryes ❑No N/A 4. No external corrosion? O Yes O No O N/A Ye 5. Free of physical damage? O" s O No O N/A 5 Properly aligned? CKes O No O N/A 6.No external loads? eyes O No O N/A C. Visible pipe hangers and seismic braces not damaged or loose? eyes O No O NIA D. Adequate heat available to areas where wet sprinkler piping is located? 2' es O No O N/A{Must be done before cold weather.) S.Annual,or every fifth year for valves which can be reset without opening: Interior of dry-pipe,preaction and deluge valves passed internal inspection? O Yes ❑No 31 /A 6.Fifth Year Inspection Items A.Alarm valves and their associated strainers,filters and restriction orifices passed internal inspection? A'fes ❑No O N/A B.Check valves internally inspected and all parts operate properly,move freely and are in good condition? O'Yes O No O NIA C.Strainers,filters,restricted orifices and diaphragm chambers on dry-pipe, preaction and deluge valves passed internal inspection? O Yes O No L;�'KIA B.Testing The following tests are to be performed at the noted intervals. Report any failures on Part III of this form. 1.Quarterly Tests A.Sprinkler system main drain to t: 1.Record Static Pressure psi and Residual Pressure(01 psi. Was flow observed? 8'"Yes O No O N/A 2.Are results comparable to pressures from last test? Yes O No O N/A B.Waterflow alarm devices passed tests? I Inspectors test connection opened?(wet-pipe when not in freezing weather) eres O No O N/A 2.Bypass connection opened?(wet-pipe systems in freezing weather,dry-pipe.preaction,or deluge). eYes O No O NIA 3.Alarms actuated? QI Yes O No O N/A Was now observed? C"Yes O No O NIA C.Control Valves(except OS&Y and gear-operated ind'caung butterfly valves)opened until spring or torsion is felt in the rod,then closed back one-quarter turn? O Yes ❑No N/A D.Priming water level passed test in dry-pipe and preaction systems? ❑Yes O No YN/A E.Low air pressure signal in dry-pipe and preaction systems passed test? O Yes ❑No 04/A 2.Semiannual Test Quick opening.devices passed test? WlVes ❑No U N/A 3.Annual Tests A.Are all sprinklers in service dated 1920 or later? 2'Yes O No O N/A B.Fast Response sprinklers in service for less than 20 years? O Yes O No CION/A If"no"test sample now and every 10 years. C.Standard sprinklers in service for less than 50 years? irYes O No O N/A If"no"rest sample now and every 10 years. D.Specific gravity of antifreeze correct? O Yes O No OrN/A E.All control valves operated through full range and returned to normal position? 1'SYes O No O N/A F.Preaction and deluge valves full flow trip test:(except deluge valves where water can't be discharged) (Be sure to test all systems at the same time which are designed ro operate simultaneously in case of f re.) 1.Water discharge from all nozzles unimpeded? O Yes 0 No 0IN/A 2.Pressure reading at hydraulically most remote nozzle L psi. 3.Residual pressure reading at valve psi. Was flow observed? O Yes O No AEr-N/A 4.Are above readings comparable to design values? O Yes O No CrN/A 5.Manual activation devices passed test? O Yes O No$'N/A 6.Automatic air pressure maintenance devices passed test? O Yes O No Ul N/A 01992 National Fire Sprinkler Association,P.O.Box 1000,Patterson,NY 12563 Sheet 2 of 3.Printed 7192 3.Annual Tests(continued) 0.Dry-pipe valve partial flow trip test: 1.Record initial air pressure psi. 2 Record initial water pressure psi. 3 Record tripping air pressur psi, 4.Record tripping time (sec.). 5. Are above results comparable to previous tests:' i0 Yes O No eN/A H.Automatic air maintenance devices on dry-pipe and preaction systems passed test? 0 Yes 13 No IrN/A I Baekflow devices passed backflow test? O Yes Q No Z,1/A J Backflow devices passed full flow test? Q Yes Q No 7511A K All sprinkler pressure regulating control valves passed full flow test'' Q Yes 0 No O NIA a,Dry-pipe full flow trip test to be done every third year, A.Dry-pipe valve full flow trip test: I. Record initial air pressure psi '- Record initial water pressure psi 3 Record tripping air pressure_ psi and tnpping time (sec.).. 4 Was water delivered to inspectors test connection? O Yes O No ZINIA 5 Are above results comparable to previous tests? O Yes O No PJ'1/A 5.Tests to be done every fifth year. A.Extra High.Very Extra High and Ultra High Temperature sprinklers testsd? 0 Yes 0 No O�N/A B Gauges checked against calibrated gauge or replaced? O Yes O No-6 N/A C. Maintenance 1,Regular Maintenance Items A.If sprinklers have been replaced,were they proper replacements? Q Yes Q No rJ NIA B.Air leaks in dry-pipe system resulting in pressure loss more than 10 psi/week repaired? 0 Yes O No GYN/A C.Dry-pipe systems being maintained in dry condittiio}�? Q Yes O No eN/A W D.Were any of the following discovered? O Yes No O N/A If yes.conduct an obstruction investigation mtd/lush the jvstem. I.Defective intake screen for pumps taking suction from open sources. 2 Obstructive material discharged during waterflow tests. 3.Foreign materials found in dry-pipe valves.check valves or pumps. 4.Heavy discoloration of water during drain test or plugging of inspectors test connection. 5 Plugging of sprinklers found dunng activation or alteration. 6.Plugging found in piping dismantled during alterations. 7.Failure to flush yard piping or surrounding public mains following new installation or repairs. 8 Record of broken mains in the vicinity. 9 Abnormally frequent false-tripping of dry-pipe valves. 10.System is returned to service after an extended penod out of service(greater than one year). 11 There is reason to believe the system contains sodium silicate or its derivatives. 2.Annual Maintenance Items A Operating stem of all OS&Y valves lubricated,completely closed,and reopeyyed? Cl Yes Q No 2 N/A B.Inienor of dry-pipe,preaction and deluge valves cleaned'' O Yes 0 No W// C Low points drained in dry-pipe,preaction and deluge systems prior to the onset of freezing weather? O Yes Q No Q*NIA D Sprinklers and spray nozzles protecting commercial cooking ipment and ventilating systems replaced except for bulb-type which show no signs of grease buildup? Q Yes 0 No cooking Pa rt III - ComrnentS (Any "No"answers,test failures or other problems found with the sprinkler system must be.explained here.) Part IV - Inspector's Information V Rotundo Plumbing Corp. 95 Marsh Hill Road Inspector: Company: Putnam Valley, NY 10579 — Company's address: Phone(914)579-0015 1 certif t e information on this fo t at the timc and piact:of my inspection,and that all equipment tested at this time wac t i er ona con lion n c ion of this inspection except as noted in Part[I]above. S,guaturc of lasPextor 01992 National Fire Sprin r Association,P.O.Box 1000,Patterson,NY 12563 Shcct 3 of 3,Pnntcd 7192 Eorm for Inspection, Testing and Maintenance of Fire Sp rinkler Systems rrnrpnet FIRE saaamtFrt Information on this fot-m covers the minimum requirements ofNITA 25-1 9q-)for fire sprinkler systems INC connected to distribution systems without supplernental tanks of tilt Pumps. maintain fire pumps and water tanks. Additional tarns arc also available for standpipe P p separate fonds are available r inspect,fire set and water spray fixed systems and foam-water sprinkler systems.More frequent inspection,testing. n depending lin. and hose systems,private fire service mains p g On the conditions of'the Deco f'�+��ir star supply. Ownm 1 S lnln t71VRCr�S Address' $7 Kf r11 S"�"' ep. D V [E D Property being Inspected: �/< Properly Address: 0 Date Or Inspection: VILLAGE OF RYE BROOK This inspection is(check one): opail -- -- MEIN y 0 Weekly o Monthly arterly 0 SemiAnnual o Annual 0 Third year NOW All questions are to be answer ed 3 are to Ycs,No or Not Applicable. All"No"ans%vc tx czplatntd to the commentspvni y on of this filrr,Fifth Year All respunseg rel`er to the current inspection performed on the dale shown above. m. Part I -Owner's Section (To be answered by the Owner or Occupant.) A. Is the building occupied? ('Yes 0 No 0 N/A B. Has the occupancy classification and hazard off,nients remained the same since the last inspection? &r1f es C. Are all fire protection systems in service? ef�es 0 No o N/A D. Has the system remained in service without modification Since the last inspection? No N A E. Was the system free of actuations of devices or alarms since the last inspection?p des o No 0 N/A Part If -Inspector's Section 0� o N�o 0 N/A A. Inspections I.wily,or weekly if low temperature alarms are installed drv-P fncl)'Inspection items Pe or deluge vnlv,:,maintaining a minimtfm of•It)'F? D Yes o Nx, a 1TA =.13'celdy Inspection Items A. Preaction;wild Deluge Valves: 1,Free I?um physical damagr;I _ R. Dn-Pipe Vale .: 2. Rim valves in appropriate(open or closed)pu es C:No 1 I. Free fr In physical damage'? :r Yes 3.No leakage iron valve seat? o Yes p No 2. Trim unit in a 4.Electrical components in service? 0 yes No 0</A appropriate'! (open or closed}position o Yes u Nn 3.No leakage from intermediate chamber'? �^ C. Relief port on reduced pressure backllow prevention assemblies not continuous) dischar in 3•Weekly inspection items which can be y o No�g-NyA A. Gauges on d perrdrmed months g o Yes , -90 o NIA ry,preaclion and deluge Y if the items are directly supervise!or secured with lucks R• Control Valves: g systems in good condition and showing normal,air and water pressure?I. In normal(open or closed Yes Position? p 0 YeS t7 No NIA 2.Sealed locked�oy' �upervised? 0 0 �t7A 3.AceCssibli:? lR Yes o No o N/A.. ❑N0 o N/A a.Provided with appropriate wrenches? o Yes a N,v d<A 5.Free ftoril external leaks? Vies 0 No o N/ 6.Provided with appropriate identille+ttion? Yes n No o N;A C. Isolation valves on backflow prevention assemblies in Open position? / 4,Monthly Inspection Items nlYrS o No o NIA A.Proper number and rvpc Of spare Sprinklers? As o No o N/A R.Sprinkler wrench with spare sprinklers? Yes o No a NIA D.Gauges on wet-pips sysicm in good condition and showing normal water su Iv pre urc? D.Mann ,,Rues:free front physical damage and at electric:fl cdnnectium secure'?,t'f Yes n No e NIA r. PP. p ' tea r.I No t�N7,q G.Alarm V,tfves: ).tiatrges indicating normal supply water pressure,, ef<I o No n N.A 2.Free film,physical damage? l;rYcs a No :j'NJA J.Valves in appropriate(open or closed)position? e'�es r,No r,NIA 4.NO leakage from retarding chamber or alarm drains'?-dye; ONO n N/A l`•Sprinkler Pressure Regulating Control Valves. I.In open position? 0 yes o No &IN/A 2.Not Leaking? o Yes 0 No P-NIA 3.Maintaining downstream pressure per design criteria? o Yes 0 No N/A 4.In good condition with handwheels not broken? 0 Yes o No •�s?f•]/A 1942 National Pire Sprinkler Assocarion,P.O. Box 1000:Patterson,NY 12563 Sneel I Of 3.PnnIN 7192 6� 4.Monthly inspection Items(Continued) G.Fire Department Connections:// (�'I I.Visible and accessible? Qf Yes ONO O N/A � 2.Couplings and swivels not damaged and rotate smoothly? to•-Yes O No ❑N/A 3.Plugs or caps in place and undamaged? O yss O No O N/A 4.Gaskets in place and in good condd''�''on7 Yes Q No Q N/A 5.Identification sign(s)in place? ?Yes Yes O No O N/A 6.Check valve i6 not leaking? Q'yes O NO O N/A 7.Automatic drain valve in place and operating properly?eyes O No O N/A (Nora• If plugs or caps are nor fn place,inspect the Interior for Obstructions and verify that the valve clapper is operational over its full range,) 5'Quarterly Inspection Item Hydraulic nameplate,if provided,securely attached to riser and legible? O Yes 0 No O N/A 4.Annual Inspection Items A.visible sprinklers: L Free of corrosion? O'yes O No O N/A B.Visible pipe: 2.Free of obstructions to spray patterns? O'4cs O No O NIA I.In good condition? 3"Ycs O No Q N/A Free of mechanical damage? O'Yes ❑No O NIA 3.Free of foreign ma erials? eyes O No O N/A 2. 4.Free of paint? Yes O No O N/A 3.Not leaking? AL-Yes O No O N/A 5.Free of physical damage? (dyes O No O N/A 4. No extemal corrosion? ayes O No U NIA S. Properly aligned? O`Yes O No U N/A C.Visible pipe hangers and seismic braces not damaged or loose? 6•No external loads? O'Ves O No 0 N/A No U D.Adequate heat available to areas where wet sprinkler piping is located?ed? O^yes ON No O N/A(Must be done before cold weather.) 5.Annual,or every fifth year for valves which can be reset without opening: Interior of dry-pipe,preaction and deluge valves passed internal ins pection? Oyes El No 8rN/q 6,Fifth Year Inspection Items A.Alarm valves and their associated strainers,filters and restriction orifices passed internal inspection? G)"Yes ❑No O N/A B.Check valves internally inspected and all parts operate properly,move freely and are in good condition? O'Yes O No O N/A C.Strainers,filters,restricted orifices and diaphragm chambers on dry-pipe preaction and deluge valves passed internal inspection? B.Testing O Yes O No [WYA The following tests are to be performed at the noted intervals. Report any failures on Part III of this form.1.Quarterly Tests A.Sprinkler system main drain to I.Record Static Pressure psi and Residual P 2,Are results comp ara ressure blc to pressures from lost teat? psi. Was flow observed? ales O No O NIA B.Waterflow alarm devices passed tests? (�yas Q No 0 N/A 1.Inspectors test connection opened?(wet-pipe when not to freezing weather) ics O No O N/A 2.Bypass connection op�Crted')(wet-pipe systems in freezing weather,dry-pipe,preaction,or deluge), cry—es O No O N/A 3.Alarms actuated? Q(Yes O No O N/A Was now observed? Yes O No O N/A C.Control Valves(except OS&Y and gear-operated indicating butterfly valves)opened until spring or torsion is felt in the rod,then closed back one-quarter turn? 0 Yes O No RIA D.Printing water level passed test in dry-pipe and preaction systems? O Yes O No EM/A E.Low air pressure signal in dry-pipe and preaction systems passed test? 0 Yes O No�NIA 2,Semiannual Test � Quick opening,devices passed test? ❑►Y's p No U N/A 3.Annual Tests A.Are all sprinklers in service dated 1920 or later? eyes O No U N/A B.Fast Response sprinklers in service for less than 20 years? O Yes O No 9'114 If"no"test sample now and every 10 years. C.Standard sprinklers in service for less than 50 years? irYes O No O NIA If"no"rest sample now and every l0 years. D.Specific gravity of antifreeze correct? O Yes 0 No kM/A E.All control valves operated through full range and returned to normal position? eyes O No O N/A F.preaction and deluge valves full flow trip test:(except deluge valves where water can't be discharged) (Be sure to test all systems at the some time which are designed to oper re simultaneously in case of fire.) I.Water discharge from all nozzles unimpeded? 0 Yes U N„ ?�IeA 2.Pressure reading at hydraulically most remote nozzle — psi' 3.Residual pressure reading at valve _ C psi. Was flow obs d7 Q Yes O No Wl�/A 4.Are above readings comparable to design values? U Yas O No$NIA 5.Manual activation devices passed test? O Yea O No a</A / 6.Automatic air pressure maintenance devices passed test? O Yes 0 No t?I NIA 01"2 National Fire Sprinkler Association,P.O.Box 1000,Patterson,NY 12563 Sheet 2 of 3.Printed 7/92 - r 3.Annual Tests(continued) G•Dry-pipe valve partial flow trip test; 1.Record initial air pressure psi. 2.Record lnitial water pressure 3.Record trippingpsi. air pressur psi. 4.Record tripping time S.Are above results comparable to previous jests? Q Yes 0 No N!A li,Automatic air maintenance devices on dry-pipe and Preach n systems passed test? 0 Yes 0 No dN/A I Becktlow devices passed backflow test? Q Yes Q No rJ N!A 1 Backflow devices passed full flov%,test? Q Yes Q No -e-41A K All Sprinkler pressure regulating control valves passed full now test'4.Dry-pipe full flow trip test to be done every third year. Oyes 0 Nto 3'N/q A.Dry-pipe valve full now trip test. L Record initial air pressure psi. Record initial water pressure p s, 3 Record tnpptng air pressure psi and tripping time t Was water delivered to ins --� 5 Are above results comparable o previous tests? Q o s 0 Yes 0 N�/A/A 5.Tests to be done every fifth year. A.Extra High. Very Extra High and Ultra High Temperature sprinklers tested? 0 yes Q No erN/A B Gauges checked against calibrated gauge or replaced? 0 Yes 0 No 2rN/A C. Maintenance 1.Regular Maintenance Items A.If sprinklers have been replaced,were they proper replacements? Q Yes Q No 2'1�/A B, Air leaks in dry-pipe system resulting in pressure loss more than 10 psi/weck repaired? O Yes 0 No J�N/A C.Dry-pipe systems being maintained in dry condition? Q Yes 0 No,g N/A D Were any of the following discovered? Q Yes @' cr Q NIA/f yea, conduit an obsln�rttOn invesrrgarion rant!flush nc�r,srcm 1 Defective intake screen for pumps caking suction from open sources. 2 Obstructive material discharged during waterflow tests. 3.Foreign materials found in dry-pipe valves,check valves or pumps. 4. Heavy discoloration of writer during drain test or plugging of inspectors test connection. S Plugging of sprinklers found during activation or alteration- 6 Plugging found in piping dismantled during alterations. �-' 3.Failure to flush yard piping or surrounding public mains following new installation or repairs. 8 Record of broken t'nains in the vicinity. 9.Abnormally frequent false-tnpptng of dry-pipe valves. 10 System is returned to service after an extended period out of service(greater than one year). I I There is reason to believe the system contains sodium silicate or its den vatives 2.Annual.Maintenance Items 4 Operating stem of all OS&Y valves lubneated,completely closed,and reop edg ❑ Yes ❑No �/A 9.Intenor of dry-pipe, preaction and deluge valves cleaned? 0 Yes 0 No o N/A C Low points drained in dry-pipe,preaction and deluge systems prior to the onset of freezing weather? 0 Yes 0 No ARM/A D Sprinklers and spray nozzles protecting commercial cooking aQuipment and ventilating systems replaced except for bulb-type which show no signs Of grease buildup? 0 Yes Q No WN/A Part III - Comments (Any"No"answers,test failures or other problems found with the sprinkler systim must be explained here.) Pert IV - I'nspector's Information Rotund0 Plumbing Corp. _ w Po Box 9 Inspector: Company: Hawthorne, NY 10532 _ Company's Address: 914-579-0015 I certify a information on wile le Mn of my inspection,and that all equipment tested at this time q ition n comp`Ie of this inspection except as noted in Pan III atmve. ' _ Siguature of lospector QCJI 92 National Fire Sprinkler Association,P.O.Box 1000,Patterson,NY 12563 Sheet 3 of 3.Printed 7/92 * w . , . . , . . . . , . w aN §c§k 9 (k z £ @ # ) § RB /®z=o � o *$ K � o � � m u ~/ƒ g o ' ou §§ @ §< L, § ƒ AR \ w2 4 ■ . q )k kk / � A § § G 0 § § e 2 2 0 (+ §SC - u § § # u9R cl) 3/) 7 CN 6 MAY C)o LL $ 2 ; J7 �. � �- � z JLUY � ® a m % ZCo / q _ Q . g\! +® ■ § AUG � w n � � G2~ L" mm � _ e - uj ■ p2 ® � � 2 � 2 §m§ � § § LLUJW M / Q � 2 SEPT Rƒ § � � ��\ � k § 2 § � § � § cm OCT \ / � � c Ie a S � � q � ¢ s Ac u � m � » � - 3mv } 2 q U \ \ ❑ 0 co, . , , . , . . . , k DEC PAT{0� C9 . OT RO*I ` 9 rr u'SHARY �) PARLOR �tQ OILED fg WMITATIO SHOWER NU 9 R 1> LAUNDRY , I RODDMM i DWW3 EOM I . Nlb a KrrCHEN M BOILER 6 IAL ROOM S � Nlb .rP A R •.� Off PATIO I SHOP KING.STREET NURSING HOME • SASE. , 1 ST LEVEL EXIT �'rs ��rt(G�_FLcb2 h�L4ht,S Q0�1r NfS 077413hj �GJ SPRINKLER SYSTEMS 3PECTIONS A ppro om OF r-iRF sPRINkzaR S TO Ato r_yIs7/A/6 NFPA-/3 S STF M 6S Nor!_=Q I IV pLjO S LI P.E. NALENGINEER SCALE:AS NaTG-A APnRovsDor. DRAWN er 774r- rRATION DATE: -- 3—/3 REVISED 767 _14ING sT 1/z 914-591-5996 R F R OOP- A/, FAX 914-591-5996'51 KING STR E F I IUK LNG ORS/�G1ao��14QB� DRAWING NUMB" 03 2q/3 FRONT ENTRANCE xr A INISTRATI MINISTRATIO AD NISTRA NFERENC FRONT LOBBY 6 IN OFFICE PERSONEL ' OFFICE E TE ACE C9 ^ PATIO � 6 s b ENCLOS h 0 j FACE o CREA E0 TERRACED R O EA DIRE 'a OR R TM Ilit I �Ji 00 1rL SROOM HOWER W ST NG ,' EAT G sHOwER NU ING NfT • � NUR 1NO 1T ROOM CO OOM PA r " SNF DINING ROOM 143 C SA M BOOM RN UPERVISO RN )s PERMS ao AT R S I Nq SNU INGY 01 �9 i TERRACE ay Jj PATIO DI TO DF R G 6IRDNEST GREENHOUSE KING STREET NURSING HOME 2ND-MAIN ENTRANCE LEVEL --- - NTS - CAA; THUM PA no I I • 1 AUQrMRIUM PATIO �• - � tip' - 1 BUILDN4RTMENT VIL AGE OF RYE" OOK AUG 2 9 2022 DD 938 KING ET RYE BRo'o ,NY 10573 I4 _ OfB_,� VILLAGE OF RYE BROOK r�t7kV, BUILDING DEPARTMENT FIRE INSPECTION / OPERATING PERMIT APPLICATION,� ,�,, FOR OFFICE USE ONLY: I _% `�C `'/ Fee Paid: S (� 0 — Inspection Date&Time: Tex�y 310i 00 FEE SCHEDULE: Re-inspection Date& Time: Triennial & Private School Annual Inspection: =$450.00 Public Assembly Annual Inspection:<100 People=$525.00/>100 People=$775.00 Application,dated c — e� is heresy made tc he Building Inspector of the V illagc of Rye Brook NY,requesting that a Fire Inspection be conducted at the building and premises listed below for the purpose of issuing a Permit to Operate the business, private school and/or place of public assembly in conformance with the Code of the Village of Rye Brook,the New York State Uniform Fire Prevention & Building Code, Title 19 NYCRR Part 1201, and all other applicable local, County, State & Federal laws, rules & regulations,as per detailed statement described below.I. Address: 7 u k_1 f'1c, s / SBL: r130, 7 2—/3Q Zone:X_`9_LS 2. Business/Occupaan N me: C / ee NYS Use Class: 3. Property Owner: �� I i'i e f' Address: qj kj a� S j �v1Q pfo vko� Phone# & Cell# email: 5. Business Owner: PO �e�� W r���� Address: Phone# Cell# email: 6. Emergency Contact: / / e f—Address: Phone# t'J 1 U N ro 1# email: AWI)er(DA f l 7. Inspection Escort: b)� ,� t �� Title: ce l' Phone#:? ( 37 f?Dell#: email: 8. Provide a brief description,outlining the current and/or intended use of the property: ,V o r5 I t1!i /1 U Yl^4e— 9. List all Hazardous Materials: 10. Occupant Load: Existing: Proposed: Other: 11. Date& Disposition of Previous Fire Inspection: ❑ Pass ❑ Fail i S 4 12 2021 This application must include the notarized signature(s) of the legal owner(s) of the above mentioned property, in the space provided below. Any application not bearing the legal property owner's notarized signature(s) shall be deemed null and void, and will be returned to the applicant. STATE OF NEW YORK ) COUNTY OF WESTCHESTER ) as: fLO� �Q L ,being duly sworn, deposes and states that he/she is the applicant above named, (print name of individual signing application) and further states that he/she is�thee,legal owner of the property to which this application pertains,or that he/she is the �iC�`NQ ( L , for the legal owner and is duly authorized to make and file this application. That all (i dicate architect,business owner,attorney,agent,etc.) 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. -fL-- Sworn to before me this yq Sworn to before me this day of 14ye of T , 20 Z Z day of , 20 Notary Public Notary Public Signature of Propertv Owner Signature of Applicant 'per f ��` W l c_1. Print Name of Property Owner Print Name of Applicant UN SMINILT NO ARY PUBLIC State of Connecticut Cdrrnnission fes Fab-211,2027 8 12 2021 This application must include the notarized signature(s) of the legal owner(s) of the above mentioned property, in the space provided below. Any application not bearing the legal property owner's notarized signature(s) shall be deemed null and void, and will be returned to the applicant. ****#***�*��***�*****��**,:**�*��*t**�****,.,�*******�,►*�*��****����x..r**:�.�******��,�*�:�***tom*****�*******x�� STATE OF NEW YORK ) COUNTY OF WESTCHESTER ) ash: Y���7�T �I 0 being duly sworn,deposes and states that he/she is the applicant above named, (print name of individual signing application) and further states that he/she is thee legal owner of the property to which this application pertains,or that he/she is the k2Ke_T_ V v t Ut r ,for the legal owner and is duly authorized to make and file this application. That all (indicate architect,business owner,attorney,agent,etc.) statements contained herein are true to the best of his/her knowledge and belief,and that any work perfonmed 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 Z9 1— Sworn to before me this day of f'f---Fi vfT ,20 2 Z day of ,20 Notary Public �— Notary Public Signature of Property Owner Signature of Applicant Print Name of Property Owner Print Name of Applicant N A Y PtlBLt State of Connecticu Commission Feb.6. 2 H"12n_n21 � m CID 8D f\ I' ,o - Y 9 ` g El D El El o • ro f � 0 rn N gLGL 4.LnL annn na) a Tan) \ 0� ƒ ) \§\ {{$ cc OE cm 2 O ; cz ) »77f «m] � E � )/ )k\\ƒ Irl {2 =oo e nn ) 2 \ k) - � { Q z\ )f ) (\ ) o t }{ ! \ j / \§§])]{/`- 2� { wno\co or 2 m Ir m ] > / / / § • \ A 7r c 2 \ ® _ Cl) \ { / \ 02 %/ — G \ { � ® 2 � Z5 \ G § ( = = 02 � C 5\ o S = 2 f % { a = § am Qca + ) \ \ Qom \ _ mpg = � _ e \ 2 2 § 0 2 ) 2 7 ° r Q)U) / 0 7 � \ \ / \ , ■ }■ ■ \ \ � �\ \ L\ \ §a a _ Q o Li C7 0 N otf o ca Z ° U s B c E c O� _ iLaDa a r- _ o _ c O z _ @0 W N � 2 w _ 2 m �- W 0 -o W22 >-o W W Z c O Z O Y a WZ00O _ a � co0 o � Jm m a J m CD W m N ru Q' ru a (7 ru Q)ru co — Z Y Q- cn 0 a cn Ln a Cl) ru O to U acu y o Cl)cn Ln �? Q c o =Da t� 1911 406 a nftwmm* VILLAGE OF RYE BROOK MAYOR 938 King Street, Rye Brook,N.Y. 10573 ADMINISTRATOR Jason A.Klein (914) 939-0668 Christopher J. BradburF -vvN,.-Nv.ryebrook.org TRUSTEES BUILDING & FIRE INSPECTOR Susan R. Epstein Michael J. Izzo Stephanie J. Fischer David M. Heiser Salvatore W.Morlino July 29,2022 Via Pt Class Mail King Street Nursing Home c/o Lindsey Wilner 787 King Street Rye Brook,New York 10573 Re: 787 King Street,Rye Brook,New York 10573 Dear Ms.Lindsey Wilner, It has come to the attention of the Building Department that it has been over three years since the premises located at the above captioned address has undergone and successfully completed a Fire Inspection.Please note that you are required by Rye Brook Village Code§91-4.B,to undergo and successfully complete a Fire Inspection for this location at least every thirty six (36) months. In order to avoid a violation,please complete and submit the attached Fire Inspection/ Operating Permit Application form, remit the correct application fee,and schedule your triennial Fire Inspection with the Building Department by no later than, August 29,2022,which is thirty(30) days after the date of this notice.Please note that the property owner's notarized signature,as well as the business owner's notarized signature must appear on the application form in the appropriate spaces. Upon successful completion of the Fire Inspection,you will be issued a Fire Inspection Certificate valid for three(3)years. Please remember that you must schedule your Fire Inspection every three (3)years by filing a Fire Inspection/Operating Permit Application,remitting the applicable fee,and scheduling your Fire Inspection with the Building Department at least thirty(30) days prior to the expiration date listed on your Fire Inspection Certificate. Thank you. Michael J.Izzo Building&Fire Inspector mizzoQUebrook.org cc: Steven E. Fews,Assistant Building&Fire Inspector /to BRCS L`CY V- t Wy J+w�y� OY 404 annftwwaW VILLAGE OF RYE BROOK MAYOR 938 King Street, Rye Brook,N.Y. 10573 ADMINISTRATOR Jason A.Klein (914) 939-0668 Christopher J.Bradbury www.ryebrook.org TRUSTEES BUILDING & FIRE INSPECTOR Susan R Epstein Michael J. Izzo Stephanie J. Fischer David M. Heiser Salvatore W.Morlino July 29,2022 Via 1st Class Certified Mail King Street Nursing Home c/o Lindsey Wilner 787 King Street Rye Brook,New York 10573 Re: 787 King Street,Rye Brook,New York 10573 Dear Ms.Lindsey Wilner, It has come to the attention of the Building Department that it has been over three years since the premises located at the above captioned address has undergone and successfully completed a Fire Inspection.Please note that you are required by Rye Brook Village Code§91-4.B,to undergo and successfully complete a Fire Inspection for this location at least every thirty six (36)months. In order to avoid a violation,please complete and submit the attached Fire Inspection/ Operating Permit Application form, remit the correct application fee,and schedule your triennial Fire Inspection with the Building Department by no later than, August 29,2022,which is thirty(30) days after the date of this notice.Please note that the property owner's notarized signature,as well as the business owner's notarized signature must appear on the application form in the appropriate spaces. Upon successful completion of the Fire Inspection,you will be issued a Fire Inspection Certificate valid for three (3)years. Please remember that you must schedule your Fire Inspection every three(3)years by filing a Fire Inspection/Operating Permit Application,remitting the applicable fee,and scheduling your Fire Inspection with the Building Department at least thirty(30) days prior to the expiration date listed on your Fire Inspection Certificate. Thank you. Michael J. Izzo Building&Fire Inspector mizzoQryebrook.org cc: Steven E. Fews,Assistant Building&Fire Inspector /to