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BUILDING DEPARTMENT
VILLAGE OF RYE BROOK FEB - 2 2024
938 KING STREET RYE BROOK,NY 10573 I
(914)939-0668 VILLAGE OF RYE BROOK
www.ryebrook.org BUILDING DEPARTMENT
INTERIOR BUILDING PERMIT APPLICATION
FOR OFFICE USE ONLY:
Approval Date: Permit#• Application Fee:$ cp.
Approval Signature: ` Permit Fees:$ Q—Jo/ ��6� ,
Disapproved: Other:� ✓
� 5o � jQ--+
Application dated: E.A 2. is hereby made to the Building Inspectorof the Village of Rye Brook,NY,for the issuance of Permit for the
interior alteration of an existing building`,or
for a change in use,as per detaille1,ed statement described
below. p�
1. Job Address: l�`L I W�, 2' . SBL: 136.. ri L4- I U Zone:
2. Proposed Improvement.(Describe in detail): *L-ALAIZ,C 15 IQQOM� - CO#-Abin1r--'
r x I'<5 Ire(:� ECOCK� bu s fj�a
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 L TIER 11: 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,ANSL System, FM-200 System,Type I Hood,etc...) :No:—C _Yes:
(If yes,please submit a separate Automatic Fire Suppression System Permit application&2 sets of detailed engineered plans)
5. Occupancy;(1 fam.,2 fam.,comm.,etc...)Prior to Construction: Aber Construction:
6. N.Y State Construction Class�tLication: N.Y.State Use'Classification:
7. Property Owner: tC.y I-{r1-1t,L LL L Address: [�q o1 W E=AA E9 AE-
Phone# q 1'41 9 7-a loI,y scelI# email:,91 L41A Uc2PIAbLrAu,i'..•czFA
8. Applicant: Address:
Phone# Cell# email: J
9. Architect: It Iy�K�3 Address: -55 �
Phone#LIX - '5tCt s,�eeu# CRANK i�AI�1k�111.1ER�1tac�113t t'S. c°.°.1`3{'
10. Engineer: Address:
Phone# Cell# email:
11. General Contractor:Lj�C'9A' EE, Address: 11 P (ZN l ptl f >h `rl' I s y
Phone kcnt H •Ll3y . 1610 Cell# email: IOW 3
12. Estimated cost of construction $ - p�I ���
(Non:The estimated cost shall include all labor,material scaffolding,fixed equipment,professional fees,and material and labor which may be donated
gratis.)
M Job Timetable: Start: �'�P Q Finish: OA-N—%
(I)
6/1/2023
BUILDi N d ' ARTMENT D C rQ � V Lam,
DD
VILL 0I OF RYE BROOK FEB - 2 2Q24
938 KING STREET RYE BROOK,NY 10573
(914)939-0668 VILLAGE OF RYE- BROOK
www.rvebrook.on! 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:
I r __,,residing at, 1A3
(Print name) (Address where you Ii%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;
big rslu iC ,Rye Brook,NY.
(Ir,b 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.
t�-
(Signatu ol'Property O' .11,1 i
C s u erS b)A A Lk L-R t✓ oTEZ. L Le—
(1'rmt Name o1 Properth Omwrk)i
Sworn t before me this
day of G 20
-4-
(Nu[un I'ul>f 1 �
y.
GREGORY M.RIVERA
Notary Public,State of New York (2)
No.DIR16441398
Qualified In Westchester County f
COm tiSSIon Expires September 26,To�A 8/122021
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:
,being duly sworn,deposes and states that he/she is the applicant above named,
(printnameofindividual 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
for the legal owner and is duly authorized to make and file this application.
(indicate architect,contractor,agent,attorney,ctc.)
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 Sworn to before me this
day of r�u�t�PrfLLQ , 20 2-Lk clay of , 20
-+6,LUC,
urcof pertyOwner Signature of Applicant
1 LsItMao�,AG.1W�
Print Name of Property Owner Print Name of Applicant
Notary Pub Notary Public
GREGORY M.RNERA
Notary public,State of New York
No.M R16441396
Qualified In Westchester County
Commkd"Expires September 26,
(4)
8/12/2021