HomeMy WebLinkAboutBP23-162PERMIT # /V/r z
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TYPE OF WORK
JOB LOCATION _
OWNER_
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TCO if FEE DATE
DATE
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INSULATION
PLUMBING
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GAS
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OTHER APPROVALS
OTHER
VILLAGE ,OF RYE BROOK
WESTCHESTIR COUNTY, NEW YORK
NO: 24-10:3
Certificate of ®ccupaucp
Do I 7 f
'This is to certify that 1 in Ern 1 ( 1 1�
of, R We F VV oo � , p y, having duly filed an application on
OUAE4 13, 20 (:�)24 requesting a Certificate of Occupancy for the premises known as,
Rye Brook, NY, located in a �� /� Zoning
District and shown on the most current Tax Map as Section: 1 <�"� Block: ' Lot: 5 O C,
and having fully complied with the requirements of the Building Code and the Zoning Ordinance under Building
Permit No. �It-/-//&49 , issued10 20 01J, such authority and permission is hereby granted
to the property owner to lawfully occupy or use said premises or building or part thereof listed under the following
New York State Classifications, Use: - Construction: V ,
for the following purposes:
Subject to all the privileges, requirements, limitations, and conditions prescribed by law, and subject also to the
following:
This certificate does not in any way relieve the owners or any person or persons in possession or control of the premises,
building,or any part thereof from obtaining such other permits or licenses as may be prescribed by law for the uses or purposes
for which the building or premises is designed or intended. Furthermore, it does not relieve such owners or persons from
complying with any lawful order issued with the object of maintaining the premises or building in a safe and lawful condition.
No changes or rearrangement in the structural parts of the building or in the exit facil' es shall be made,and no enlargement,
whether by extending on any side or by increasing in heAht shall be niade,nor,;W the building be moved from one location
to another until a permit to accomplish such change as o d fr th wilding Inspector. AUG 2 1 2024
Building Inspector,Village of Rye Brook: Date:
DD \�/ i BUILD `llE ENT For office use only: /
E C I r � " E PERMIT# J DD' v�
VIL OF RYE OK ISSUED: —56-33
AUG 13 2024 I 38 KING STRE YE BROOK,' YORK 10573 DATE: 8—/3—a
I ��J 14)939-0668' FEE: W was PAID P6
_
VILLAGE OF RYLE BROOD , ov
I BUII-._D_IR_G DEPARTNIEb17
APPLICATION FOR CERTIFICATE OF OCCUPANCY, CERTIFICATE OF COMPLIANCE,
AND CERTIFICATION OF FINAL COSTS
TO BE SUBMITTED ONLY UPON COMPLETION OF ALL WORK, AND PRIOR TO THE FINAL INSPECTION
tits}ii}}yk#Rtik#4##ii}i}itt##K####tint##+k##t#####r###t#####rti}i4 t}#iii##+##+**+♦#####k###i#iiiiti iii iii ti#ittiii##iii#k###
Address: 1 r SYvh L h Rn 6�k, pZ I
Occupancy/Use: tTj '"rt,1 Parcel ID#: �`. ��' 'S�� Zone:
Owner: NGi) r i'ly Address: ` Air
P.E./R.A. or Contractor: P&&CTr( 1'(r Pkilt,T_Address: 41►t' 6 t rt,horerl
Person in responsible charge: u Address:
Application is hereby made and submitted to the Building Inspector of the Village of Rye Brook for the issuance of a
Certificate of Occupancy/Certificate of Compliance for the structure/construction/alteration herein mentioned in accordance
with law:
STATE OF NEW YORK, COUNTY OF WESTCHESTER as:
)kV11 `i4 being duly sworn,deposes and says that he/she resides at
(Print Name of Applicant) 1 (No.and Street)
yV in IR`K f)"w k ,in the County of e Q�C jt(V' in the State of �e that
( ty/Town/Village)
he/she has supervised the work at the location indicated above,and that the actual total cost of the work,including all site improvements,
labor,materials,scaffolding,fixed equipment,professional fees,and including the monetary value of any materials and labor which may
have been donated gratis was:$ 34, 1 U&
for the construction or alteration of: �Cauntii9Y 6,A' '�1Vre0jj,,.t Flj p4Af/tcf
Deponent further states that he/she has examined the approved plans of the structure/work herein referred to for which a Certificate of
Occupancy/Compliance is sought,and that to the best of his/her knowledge and belief,the structure/work has been erected/completed in
accordance with the approved plans and any amendments thereto except in so far as variations therefore have been legally authorized,and
as erected/completed complies with the laws governing building construction.Deponent further understands that it shall be unlawful for an
owner to use or permit the use of any building or premises or part thereof hereafter created,erected,changed,converted or enlarged,wholly
or partly,in its use or structure until a Certificate of Occupancy or Certificate of Compliance shall have been duly issued by the Building
Inspector as per§250-10.A. of the Code of the Village of Rye Brook.
i
Sworn to before me this I -K Sworn to before me this 3
day of kA-0- , 20 day of AA , 200�
DA� ____h JL
Si Lure of Property Owner SignSE a of Applic4 t
Doi) F%'\1y D'�Vj') F61k
r Name of Property Owner Print Name of Applicant
1
Notary Public NcalrKNUMLILLO
Notary Public,State of New York
No.01.ME6160063
SHARI MELILLO Qualified in Westchester County 6n-2024
Notary Public,State of New York. Commission Expires January 29,2(�
No.olME6160063
oualified In Westchester County �—'
�E BR��,
1932 BUILDING DEPARTMENT
❑ ILDINGINSPECTOR
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 . 14 c)% T c DATE: 9 - ( � - Z J L '7
PERMIT# VR 2 -5 - I b Z ISSUED:-9-2 b-241 SECT: BLOCK: LOT: S Z
LOCATION: �� Q �� ` ��2 �,A ( OCCUPANCY:
❑ VIOLATION NOTED THE WORK IS... 0--ACCEPTED ❑ REJECTED/REINSPECTION
❑ SITE INSPECTION REQUIRED
❑ FOOTING
❑ FOOTING DRAINAGE
❑ FOUNDATION
❑ UNDERGROUND PLUMBING NOTES ON INSPECTION:
❑ ROUGH PLUMBING
❑ ROUGH FRAMING
❑ INSULATION n 1 l r I
❑ NATURAL GAS
❑ L.P. GAS �� ee ti Va > 1c E—
❑ FUEL TANK (�
❑ FIRE SPRINKLER � L-3 r ; :� r L l/i A/v e,
01 FINAL PLUMBING
❑ CROSS CONNECTION
,.El--FINAL
❑ OTHER
BUILDING DEPARTMENT
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.Uebrook.org
- - - - - - - - - - - - - - - - - - - - INSPECTION REPORT - - - - - - - - - - - - - - - - - - - -
ADDRESS : I 1 �`� C ��. ��� { 1 DATE: 1 f ?
PERMIT# ,, ISSUED: I .� SECT: BLOCK: LOT:
LOCATION: �� l �_ t�/� �� �" OCCUPANCY.00101
❑ 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
�p 'Natural Gas
❑ L.P. Gas
❑ FUEL TANK
❑ FIRE SPRINKLER
❑ FINAL PLUMBING
❑ CROSS CONNECTION
❑ FINAL
❑ OTHER
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BUILDING DEPARTMENT
VILLAGE OF RYE BROOK � ' SEP Z Q N23
938 KING STREET RYE BROOK,NY 10573
(914)939-0668 VILLGr OF RYE BROOK
www.ryebrook.org BUILi�1NG ►JEF'�`,ITf�IEN art_
INTERIOR BUILDING PERMIT APPLICATION
FOR OFFICE USE ONLY: J?
Approval Date: 2 ermit#: IC�V � "!bc'*).Application Fee:$,/�t.�../"-��
Approval Signature: Permit Fees:$ C-)&-
Disapproved: Other: r�)bc)
Application dated: 1 v+G is hereby made to the Building Inspector of the Village of Rye Brook,NY,for the issuance of a Permit for the
interior alteration of an existing building,or for a change in use,as per detailed statement described below.
1. Job Address: `f" = 4 SBL:�JJ, �—"5' one:
2. Proposed Improvement.�(Describe in details- ., NoAl wrs�l��t �} }��%��I fyw �'v)!AS cr SJ,V '�'
- ]&)wr it j,.\' IY 2w �t4�ra�r��T yI�t„!`►.1 L'\" cV (�'iFvZn �W`l�l�ktl2 �h} kAT rtj,, -f wwr4m.
L\ry �tyt"'4-c � —!� �/wro"r/ 1— �,, �I��1 �1° 5_t`L� �� i rkl. �L'WA0 �rrQNI�,I�'
N ��—�;'�—,—
3. Does the proposed improvement involve a Home-Occupation as per§250-38 of the Code of the Village of Rye Brook?
No: Yes: If yes,indicate: TIER 1: TIER II: TIER III:
4. Will the proposed project require the installation of a new,or an extension/modification to an existing automatic fire
suppression system(Fire Sprinkler,ANSI,System,FM-200 System,Type I Hood,etc...):No: Yes:
(If yes,please submit a separate Automatic Fire Suppression System Permit application&2 sets of detailed engineered plans)
5. Occupancy;(1 fain.,2 fain.,comm.,etc...)Prior to Construction: After Construction:
6. N.Y State Construction Classification: N.Y.State Use Classification:
7. Property Owner: �c v, Ro Address: r i Ira Lh
Phone# S—1 b 2 J S 7 6 00 Cell# email:
8. Applicant: J"t kf lwf Address:
Phone# Cell# email:
9. Architect: Address:
Phone# Cell# email:
10. Engineer: Address:
Phone# Cell# email: `1 1
11. General Contractor: ctte ,IVAVIII'n
IAddress: 10 IUCW
Phone# Cell# 70 � q4 asA� email: 1AU IJ1cA%,
12. Estimated cost of construction $ 'J (1 U'3
(NOTE:The estimated cost shall include all labor,material,scaffolding,fixed equipment,professional fees,and material and labor which may be donated
gratis.) L 3^ �} l ,
0. Job Timetable: Start: LIuW Finish: VCL'. �r cW
(1)
6/l/2023
a_% u
BUILDING DEPARTMENT
VILLAGE OF RYE BROOK SEP 2 0 2023 1 .J
938 KING STREET RYE BRoox,NY 10573
(914)939-0668 VILLAGE OF RYE BROOK
ww�y.ryebroyk.ar� 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. Amy 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:: r
I, 0U,v� F\t\Iv ,residing at, t
(Print name) (Address where you live)
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;
Lk , 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.
- /)_-� -u
(Signs of Propertf Owner(s))
r-)A\f I) F,n AM
(Print Name of Property Owner(s))
Sworn to before me this �J
day of ICJ (h - 20
jis��41 I L, t�
(Notary blic)
GREGORY M.RIVERA
Notary Public,State of New York
No.OIR16441398 (2)
Qualified In Westchester County
Coenrriss Expires September 26,
$/12J2021
This application must be properly completed in its entirety and must include the notarized
signature(s) of the legal owner(s) of the subject property, and the applicant of record in the
spaces provided. Any application not properly completed in its entirety and/or not properly
signed shall be deemed null and void and will be returned to the applicant.
Please note that application fees are non-refundable.
STATE OF NEW YORK,COUNTY OF WESTCHESTER ) as:
4d rd f"nMr _ _ ,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
0 n zr, 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 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.
By signing this application,the property owner further declares that he/she has inspected the subject property,and that to
the best of his/her knowledge there are no roof drains, sump pumps or other prohibited stormwater or groundwater
connections or sources of infiltration into the sanitary sewer system on or from the subject property.
Sworn to before me this V Sworn to before me this
day of fy) , 20 day of ,20
ViRr.a Prolifty Owner Signature of Applicant
LV,I F,Ak
Print Name of Property Owner Print Name of Applicant
Notary Pubic Notary Public
GREGORY M.RIVERA
Notary Public,State of New York
No.01 RI644f 398
Qt aNfkd In Westchester County
Cotnrttfssion Expires September 26,2&
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BUILD, ISE 'ARTMENT OCT - 6 2023 ID
VILLAGE OF RYE BROOK
938 KING,W1#ET RYE BRO(k,NY 10573 VILLAGE OF RYE BROOK
39= i' BUILDING DEPARTMENT
ELECTRICAL PERMIT APPLICATION
Westchester County Master Electricians License Required
FOR OFFICE USE O BP#: 03—/ C- EP#:
Approval Date: �0 te�\�� Permit Fee: $ Z60 /
Approval Signature: LL Other:
Application dated, �� "d� 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 electrical equipment,wiring, fixtures, or to perform other high or low voltage electrical work as per
the detailed statement described below. By signing this document, the applicant & property owner agree that all electrical work
performed will be in conformance with all applicable Federal,State,County and Local Codes.
LAddress: 14- Ro2cN Lo QyC l3eOOv- NY 10573 SBL: Zone: �S
2.Property Owner: DAv i D F 11s►C Address: 14 131 QC H LN 2Ye BPOJ K N y JOY 73
Phone#: 6510 g15- 7(,0to Cell#: email: t7A y 1 D.C3. FIN K 9 61A/2. G0 r1
3.Master Electrician/Licensed Installer: JGQ(-PE, (4e2-1AS UBPDQA Address: 18 Deu Si Fie 2 scurY Nou w N
Lic.#: 19 79 Phone#: Cell#: �K)07-W75- email: -/MmC-4EcmcCa IcLouD vjt7
Company Name: 114-1-C t-j &Z c TP_i . Address: 18 DELL 5 t FLJZ 2 5LEE Py 40U Ok1 nj y WS-91
4.Proposed Electrical Work/Fixture Count:
eEPuaCt A•a0 P LocATt a614T F1,kn2ES A20u►-ja TW 14co e
9--PLACC SwiTtN . 'D-t`tj6eS 4zoJmD 774c Nou,
E0011 NATt U6H-TS AN`> 0766 ?7bc.LCYS; 49-Wrn1 J —, 4-C &Wi4 c
5.31 Party Electrical Inspection Agency: 5 LJ( 5
*********************************************************************************************************
STATE OF NEW YORK,COUNTY OF WESTCHESTER ) as:
JOWE HUC4ZTAS C49Qrre,1 being duly swom,deposes and states that he/she is the applicant above named,and does further
(print name of individual signing as the applicant)
state that(s)he is the OASrC2 ELECT21U4 J for the legal owner and is duly authorized to make and file this application.
(Master Electrician/Licensed Installer)
The undersigned further states 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 C
day of ,20 day of CA-L� ,20_L3 _
Signature of Property Owner fja_ a of Applicant
J 0_&E IUE-Z74S CgaeF_2.a
Print Name of Property Owner Pr t ame of Applicant
SL
Notary Public Notary Public
SHARI MELILLO
Notary Public,State of New York
No.O1ME6160063
Qualified In Westchester County 3/3/2023
Commission Expires January 29,2021
STATEWIDE INSPECTION SERVICES, INC.
Service With baegrif.v
1:1 Main Street,Fishkill, NY 12524 1 emoil:• •
SWIS JOBAPPLICATION tel845.202.7224 • • 1. • • •
Office Use Elect.Permit#� !) � 3_ / `' Date I I f_ c
Bldg Permit# 112 \ Utility ID# .
Final Certificate#
City/Village y E V Zip G J r Township County s t f C `_.TT(�.
Address 14 131w4 Lx Cross Street Section Block Lot
Owner Name/Address(if different than above) �; ,�i J i N Contact Number i�/( ) /;i_ 7600
❑Basement ®1 st FI. ®2nd FI. 3rd FI. ❑More Than 3 Fl. ❑Garage ❑Attic ❑Outside Residential ❑Commercial
Receptacles Special Recept GFCI AFCI Switches Dimmers Smoke Alarms Carbon Monox Hood Trash Compact
/ Amt Amps
Range(s) Cooktop(s) Oven(s) Dishwashers Refrigerator Disposal Microwave Warm Draw
Incandescent Fluorescent
SERVICE
Amperage Voltage 1 P 3P #Meters #Disconnect ❑Underground ❑New ❑Reconnect
❑Overhead ❑Change
❑Visual Re-Inspection ❑ Safety Re-Inspection ❑ Re-Inspection
Additional Information
eL.ALk_ AND Q.t lA Ct4TE U 6 H 1 F"1 x i LeCs A E.ou N D T44E 4Qu IG
e ��P�QCsr swITcNIES ;J)MI c pfLO�nf> Ts E FUv�C—
riIQOUNJ ��tE /-�cl$�
ELIMINA+ C16(-�15 L1rJJ �1f 7. t ICS e
D [EC IEW
DI
OCT - 6 2023
VILLAGE OF RYE BROOK
BUILDING DEPARTMENT
This application is valid for one(1)year from the date received by sWls.This application is intended to cover the above listed items to be inspected,It at any time of inspection additional items have been irwalled,you am
authorized to make the inspection and adjust the fee for the additional items Inspected.The applicant declares that there is no open applications for the above address with any other Inspection company.The applicant,owner
or authorized agent agrees to all the above terms and conditions as set forth for the application.
Inspector Date Finalized Inspector#
Company Name I Date I Signature
Address I City/State N Zip Code 7 r
vi LL �; r L ` 'LLt t'I wt L'L_-.v �I
License# I .> Phone# ; Ll ,1 Yi - 'V L
State Wide Inspection Services
c k o R
1080 Main Street
AUG - 9 2024 Fishkill, NY 12524
as
202-7224 Phone
VILLAGE OF RYE BROOK 914-219-1062 Fax
STATE WIDE INSPECTION SERVICES BUILDING DEPARTMENT Email: office0swisny.com
Website: www.swisny.com
Service With Integrity
BY THIS CERTIFICATE OF COMPLIANCE STATE WIDE INSPECTION SERVICES
CERTIFIES THAT:
Upon the application of: Upon Premises Owned by:
Matem Electric David & Emily Fink
Jorge Huertas Cabrera 14 Birch Lane
18 Dell Street- Floor 2 Rye Brook, NY 10573
Sleepy Hollow, NY 10591
Located at: 14 Birch Lane, Rye Brook, NY 10573
Section: Block: Lot: Electrical Permit Number: EP23-218
135.43 1 5.29
Certificate Number: 2024-4944 Building Permit Number: BP23-162
A visual inspection of the electrical system was conducted at the Residential occupancy described
below.The electrical system consisting of electrical devices and wiring is located in/on the premises
at: 14 Birch Lane, Rye Brook, NY 10573
The First Floor Kitchen and Second Floor Bathrooms (3) were inspected in accordance with the NYS
and NFPA 70-2017 and the detail of the installation,as set forth below,was found to be in compliance
on the 2nd day of August 2024.
Name Quantity Rating Circuit Type
Replace Ceiling Fixtures 15
New Switches 04
Removal of Receptacles 04
Officer: Frank J. Farina
This certificate may not be altered in any way and is validated only by the presence of a seal at the location
indicated.This certificate is valid for%vork performed on the date of inspection only.
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BUILDING DEPARTMENT OCT 10 2023
VILLAGE OF RYE BROOK VILLAGE OF RYE BROOK
938 KING STREET RYE BROOK,NY 10573 BUILDING DEPARTMENT
(914)939-0668
www.Eyebrook.org
PLUMBING PERMIT APPLICATION
FOR OFFICE USE ONLY BP#: d 13` d-- PP#: t�)3—j
Approval Date: OCT _1 0 Permit Fee: $ Soo —P 6
Approval Signature: V V Other:
Disapproved:
(fees are non-refundable)
Application dated, 0 /o Z� 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: / / �/�C/� 7 Z41 SBL:ISS, -9 1 5i c)/ Zone: —/�S
2.ProposedWork:
3.Property Owner: e4' yi0 /�/�iC Address: `� el,-,-C/l Lti
Phone#: Cell#: email:
4.Master Plumber: ,57 a'V=n/ Address: /c> S
Lic.#: 4/14� Phone#: Cell#: 5'90- `��G-r email: Co CAyGCC.a �CurliJiyG
Company Name: ,61L6 10"4::�e- LCC Address: CS�yE G�/�iC • Cory
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
1 st Floor
� L'i�•- C,e'
2nd Floor
3'd Floor
01 Floor
51 Floor
Exterior
5.•List Other Equipment/Provide Details:
(Notarized Signatures Required Next 2 Pages)
3/3/2023
STATE OF NEW YORK,COUNTY OF WESTCHESTER ) as:
r—xy;� Pt I ,being duly swom,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 Master Plumber for the legal owner and is duly authorized to make and file this application.
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 av Swornto before rae this \ v
day of 20 day of - ,20 r
Sip4re of Pr perty Owner Signature of Applicant
Print Name of Property Owner PAName of Applicant
Notary PubWEGiAM RNERA Notary Public
Notary Public,State of New York SHARI MELILLO
No.01R16441398 Notary Public,State of New York
Qualified In Westchester County No.OIME6160063
Commission Expires September 26,20� Qualified in Westchester County
Commission Expires January 29,20
This application must be properly completed in its entirety and must 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-
3/3/2023
R
EC� IE �� �
BUILDING DF.PARTMENT
VIL�,AGE OF RYE.BROOK OCT 10 2023 DD
938 KING STREET Ryt BROOK,NY 10573
(914)939-Obb8 VILLAGE OF RYE BROOK
BUILDING DEPARTMENT
r _
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 OFNEW YORK, COUNTY OF WESTCHESTER ) as:
35 residing at, / Q I N LI
(Print name) (Address where you live)
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;
h , 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.
I) J
(Signatur operty Owner(s))
(Print Name of Property Owner(s))
Sworn to before me this j
day of ( , 20
VJJ
Su ,�� l
&'i�"-Y)
(Notary Public)
GREGORY K RIVERA
Notary Public,State of New York
No.01 R16441398 -3-
Qualified In Westchester County
Commission Expires September 26,2 8/12/2021
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.Building Permit Check List&Zoning Analysis
\
•Address: � Ck 1-C, e SBL: ) b I - - -zi
Zone: 2_1'S Use: --LQ Const.Type: then:
e
Submittal Date: Revisions Submittal Dates:
Applicant:
Nature of Work: c�\1 ck ki v C\
Reviews:ZBA: S E P 2 5 2023 pB• BOT• other. scS'
4) ES:Filing:--��—�BP•��C/O Flood Plane: Legalization:P: Dated: / Notarized: SBL: Truss I.D. Cross Connection H.O.A.:
( ) ( ) Scenic Roads: Steep Slopes: Wetlands: Storm Water Review: Street Opening:
( ) ( ) ENVIRO:Long Short Fees: N/A�
( ) ( ) SITE PLAN:Topo: Site Protection S/W Mgmt.: Tree Plan: Other.
( ) ( ) SURVEY:Dated: Currents Archival• Sealed: Unacceptable:
( ) ( ) PLANS:Date Stamped Sealed Copies Electronic Other.
( ) ( ) License: Workers Comp: Liability Comp.Waiver Other.
( ) ( ) CODE 7S3#: Dated: N/A:
( ( ) HIGH-VOLTAGE ELECTRICAL:Plans: Permit N/A: Other.
( ) ( ) LOW-VOLTAGE ELECTRICAL:Plans: Permit: N/A Other.
FIRE ALARM/SMOKE DETECTORS:Plans: Permit H W.I.C.:_Battery _Other
(�( ) PLUMBING Plans: Permit Nat.Gas: LP Gas: N/A/ Other.
( ) ( ) FIRE SUPPRESSION:Plans: Permit: N/A Other.
( ) ( ) H.V.A.C.: Plans: Permit: N/A Other.
( ) ( ) FUEL TANK:Plans: Permit: Fuel Type: Other:
( ) ( ) 2020 NY State ECCC: N/A: Other
( ) ( ) Final Survey. Final Topo: RA/PE Sign-off Letter. As-Built Plans: Other.
( ) ( ) BP DENIAL LETTER: C/O DENIAL LETTER: Other.
( ) ( ) Other.
(1)ARB mtg.date: approval• notes:
( )ZBA mtg.date: approval;- notes:
( )PB mtg.date: approval• notes: APPROVED
REQUIRED EXISTING PROPOSED NOTES . SEP 2 5 2 0 2 3
Date.
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AC�g DATE IMM1--YYrl
r✓ CERTIFICATE OF LIABIUTY INSURANCE 082912023
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE MOLDER.THIS CERTIFICATE
DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND.EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW,THIS CERTIFICATE OF
INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE
CERTIFICATE HOLDER.
IMPORTANT It the certlftcate holder Is an ADDITIONAL INSURED, the pDllcy(lee)a" have ADDITIONAL INSURED provisions or be endorsed It
SUBROGATION IS WAIVED. subject to the terms and conditions of the polky,caEtaln policies may re4Are an endarsanrrR. A stall Swlt On this
certificate does not confer rights to the certlflcale holder In How of such erldpRaRtaltl(aI.
PROa R NAMNI CLIENT CONTACT CENTER
ACT
FEDERATED MUTUAL INSURANCE COMPANY --�
HOME OFFICE:P.O.BOX 328 wMt .aw:SM333400 We.a.7:SOT-444094
OWATONNA,MN S5000 ' µ"-.CLIENITCONTACTCENTERRFEDINS.COM
WOMERS AFFORDING COVERAGE NAIC, _
_ INsum&FEDERATED MUTUAL INSURANCE COMPANY 113035_
INSURED _- - —_---_ --_ _. .--319.939-2 i"KiniB Es _
PALETTE PRO PAINTING&RENOVATION INC
13 BENT AVE ----— ---- --- ----
PORT CHESTER,NY 105734454 Rrewnt M
an&ORER E:
COVERAGES CERTIFICATE NUMBER:153 REVISION NUMBER:A
THIS 19 TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED
NOTWITHSTANDING ANY REQUIREMENT. TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE
ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF
SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. _
IN TYPE OF NESURAf10E mw POLICY NUMBER ' Y FF ► Y XP
OMITS
X COMMERCIAL GENERAL L AINUTY EACH OCCURRENCE $1=000
CLMMS-MADE I�OCCUII AMAOETO ENTEDpwaials $100.000
NED EXP IAny err Fem" EXCLUDED
A Y N 0941594 11112/2022 11l1212023 PERSONAL 4 ADV INI__- _ 1000
OENl AGGREGA(T�Eltlr NAPPLAN PER:
X POLMY I__f LOO PRODUCT&E COMPFOP AGO 12,004000
OTHER
AUTOMOBILE LIABILITY ONNI AEG SINGLE UWT $1,000,000
X Y AUTO DOOR.Y INAIRy 1Par PMaN4
A OWNEDAlITC160IL� Uy-``-D N N 094159E 1'112=2 11l12P�1 BotNLV Immy irw AslrnO
HRED AUTOS ONIV PRO
AOWONNLV i 1pr.KAcsiyN70A*AW—_-
X RELLA LIAR XOCCUR EACH OCCURRENCE s1.D00,000
A rLx-CE BLIRB N N 6056072 1'0212022 11M21=1 AGGREGATE f1,000.000
DED I X IRETENTION I'0.000
WOItKERI COMPENSATION
AND EMPLOYERS'LMUBRATY PER STATUTE I OTHER
ANY PRO►R ITORIPARTNIM EXECUTIVE 91 EACH ACCIDENT
O"ICERIME%IR EXCLUDED7 NIA
IMendN.ry In NHI 91 ONiEASE EA EMPLOYEE
I yet."WIN-ft
DESCRIPTION OF OPERATIONS 41— E.L DISEASE POLICY UNIT
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DESCRIPTION OF OPERATIONS I LOCATONS I WHICURS(ADGRO W.AeORRI■wa ke 5dMdM a,r w he aftft H RNA.•SO N raearMl
ADDITIDNAL DEED ALSO INCLUDES DAVID FINK, 14 BIRCN LN, RYE 31R001(, W 18573.
CERTIFICATE HOLDER CANCELLATION
VILLAGE
OF RYE BROOK 153 a
NLLAGE SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED
938 KING ST BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN
RYE BROOK,NY 10573-1226 ACCORDANCE WITH THE POLICY PROVISIONS.
AI.THORITrD REPRESENTAT lr
a 1968.2015 ACORD CORPORATION AE rlgirts reserved.
ACORD 25(2018103) The ACORD name and logo are registered marks of ACORD
NYSIF
New York State Insurance Fund PO Box 66699,Albany,NY 12206
1 nysif.com
CERTIFICATE OF WORKERS' COMPENSATION INSURANCE
A A^A A^ 472709745
PALETTE PRO PAINTING&
RENOVATION INC
13 BENT AVE ❑
PORT CHESTER NY 10573 SCAN TO VALIDATE
AND SUBSCRIBE
POLICYHOLDER CERTIFICATE HOLDER
PALETTE PRO PAINTING& THE VILLAGE OF RYE BROOK
RENOVATION INC 938 KING STREET
13 BENT AVE RYE BROOK NY 10573
PORT CHESTER NY 10573
POLICY NUMBER CERTIFICATE NUMBER POLICY PERIOD DATE
W2559 777-4 613457 11/12/2022 TO 11/12/2023 8/29/2023
THIS IS TO CERTIFY THAT THE POLICYHOLDER NAMED ABOVE IS INSURED WITH THE NEW YORK STATE INSURANCE
FUND UNDER POLICY NO. 2559 777-4, COVERING THE ENTIRE OBLIGATION OF THIS POLICYHOLDER FOR
WORKERS' COMPENSATION UNDER THE NEW YORK WORKERS' COMPENSATION LAW WITH RESPECT TO ALL
OPERATIONS IN THE STATE OF NEW YORK, EXCEPT AS INDICATED BELOW, AND, WITH RESPECT TO OPERATIONS
OUTSIDE OF NEW YORK, TO THE POLICYHOLDER'S REGULAR NEW YORK STATE EMPLOYEES ONLY,
IF YOU WISH TO RECEIVE NOTIFICATIONS REGARDING SAID POLICY,INCLUDING ANY NOTIFICATION OF CANCELLATIONS,
OR TO VALIDATE THIS CERTIFICATE,VISIT OUR WEBSITE AT HTTPS:NWWW.NYSIF.COM/CERT/CERTVAL.ASP.THE NEW
YORK STATE INSURANCE FUND IS NOT LIABLE IN THE EVENT OF FAILURE TO GIVE SUCH NOTIFICATIONS.
THIS POLICY DOES NOT COVER CLAIMS OR SUITS THAT ARISE FROM BODILY INJURY SUFFERED BY THE OFFICERS OF THE
INSURED CORPORATION.
PRESIDENT
RODRIGO VASCONCELLOS
VICE PRESIDENT
RAFAEL VENTURA
PALETTE PRO PAINTING&
RENOVATION INC(2 OF 2)
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS NOR INSURANCE
COVERAGE UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER
THE COVERAGE AFFORDED BY THE POLICY.
NEW YORK STAT SU NCE FUND
7 �V
DIRECTOR,INSURANCE FUND UNDERWRITING
VALIDATION NUMBER:966133149
U-26.3