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BUIL NG DEPARTMENT
VIL E OF RMA
OK JAN 18 2024
938 K1N ET RYENY 10573
{914)9 39-5801
PLUMBING PERMIT APPLICATION
FOR OFFICE USE ONLY l;P #: PP#:
Approval Date: ((71Permit Fee: $
Approval Signature: Other:
Disapproved:
(fees are non-refundable)
Application dated, —1 d_c) 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 d plumbing work *11 be in conformance with all applicable Federal,State,County and Local Codes. p
1.Address: SBL: /3-5 ""�^^-3C� Zone:/C—Q
2.Proposed Work 4 LA l ), � S �N IF
fzsC, L-C-UrN�
3.Property Owner: P0 Address: /� �r
Phone#: / � - 3 Cell#: email:
4.Master Plumber: Address:
Lic.#: Ph ne#: - e email:
.C�
Company Name:_ ,Address:
INDICAT FIXTURES INES 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
2nd Floor
3 Floor
4 Floor
5"'Floor
Exterior
5.*List Other Equipment/Provide Details:
(Notarized Signatures Required Next 2 Pages)
3/21/19
�
BUILD, IEP , MENT ! -
VIL E OF RY OK S JAN 18 2024
938 KING ET RYE BR NY 10573
(914)939; 9 939-5801 VIILC;'= OF_ `r
AFFIDAVIT OF COMPLIANCE
VILLAGE CODE 4216 - 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 YOM COUNTY OF WESTCHESTER ) as: a
.3, v1reSA fDAq 1('NZ , residing at, �(� �tC[ {f(�C�yl�,�� � �6Z�,4�"' l
(Print namrl (:'lddm-q,%whery you Ii), r 1 DS"3 8
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 ofCompliance pertains at;
/0 sq3
` dJ 0k0e-, 1 U , Rye Brook, NY.
Doh Addm-s-0
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.
S'
t (J�e�9
(Siftnalurr nl'Pm(xrt_ 11��ncn+ I
NJ
4- A a,9AC, (me
(Prod Name of lliopen%Owncr(%))
Sworn to before me this
day of GUl , 20 ILI_
ELIJAH UEMOND WARE
E
ary Public-State of New York
INnt:uti uhfic 1 NO.01WA0018286
Qualified in Bronx Countyommission Expires Dec 9, 2027
.3-
3/21/19
STATE OF NEW RK,COUNTY OF WESTCHESTER ) as:
being duly sworn,deposes and states that he/she is the applicant above named,
(print tarn of individual sifnitt as the applicmml
and further states that Whe is the legal owner of the property to which this application pertains,or that(s)hc is the
1) _ — P,t for the legal owner and is duly authorized to make and file this application.
(indic:itdlttrchitect,conuldr,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
day or o-A V hr .20 day of _ TL .20
JkW;2k
Signature of Propert Owncr Si ature of pli
17 A-GtA- 11Ys'
Print Name of Property Owner —� 'nt Name of Applicant
Notary Public N� #1P141EI=fLl4
Notary Public,State of New York
No.01ME6160063
Qualified In Westchester County
Commission Expires January 29,2t 1
This application must be properly completed in its entirety and must include the notarized ignature(s) of
the legal owner(s)of the subject property, and the applicant of record in the splices provided. Applications
not properly completed in its entirety and/or not properly signed shall he deemed null and void and will be
returned to the applicant.
ENotary
LI.IAH DEMOND WARE
public-State of New York
NO. 01 WA0018286
alified in Bronx Countymission Expires Dec 9, 2627
.2-
3/?1119
. I
�Qy6 BR(��
O ti�
19f32•
BUILDING DEPARTMENT
/9UILDING 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 : C `� �, DATE: cal � r
rah`w
PERMIT# ISSUED: ` L� -/SECT: BLOCK: LOT:
LOCATION: Cl l �f
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 I/ -
❑ Natural Gas71
❑ L.P. Gas
❑ FUEL TANK
❑ FIRE SPRINKLER �, ! C�l�J �1 �1 UD ( �
❑ FINAL PLUMBING +
❑ CROSS CONNECTION �� ►� �L'r
❑ FINAL D
❑ OTHER