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Operating Permit 2024-2025
W U w LO z c z HoW o Q A w w w z a ors o az o W Wwa HoW�' a F, ow z c� M-�I � ✓ FFF`-------11{ a O Ow w � w A Q V W ° Aow w � A. A � ow ° a � z 0 CN O h• vJ n w U W U O0.4xzUaxo M� w � wx � LO p � a1zz M�+�I a `: o w o a W z a' � ►-� a� � xHw � zx � H z AO A H o � Uw ] � En CA, N +-� MCI W awG a3 z W En CS, N N N xzwwHQ w � `� W M ,� aZ- z � M ~ F+I oZ < Au< p m W z A z w �i N ^/ Haa „ oaw o H A W �Tl w O W wu U ! v w U �'' U ° w cri a c Hz A � HH A w z QyE BRC��. O� tim cu � • �9a2 BUILDING DEPARTMENT ,❑BBUILDING INSPECTOR 2/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: 210 F CG Cr,'✓• (�L✓ DATE: .J / Z0LY PERMIT# �I RlZ J..�S PP c ISSUED: SECT: i z>/ T-� BLOCK:_LOT: / LOCATION: I � CA r r- OCCUPANCY: ❑ Violation Noted THE WORK IS... PASSED ❑ FAILED REINSPECTION 12'SITE INSPECTION REQUIRED ❑ FOOTING ❑ FOOTING DRAINAGE ❑ FOUNDATION ❑ UNDERGROUND PLUMBING NOTES ON INSPECTION: ❑ ROUGH PLUMBING ❑ ROUGH FRAMING ❑ INSULATION (� ❑ Natural Gas - ` U P 7,'n 3' /� Z D L v ❑ L.P. Gas TtisP� G ��� ❑ FUEL TANK ❑ FIRE SPRINKLER r\ PJ ot if CO -�C( p L (� ❑ FINAL PLUMBING ❑ CROSS CONNECTION ❑ FINAL OTHER I BUILAD ;kT]l ENT _ VILLOOKInitial Inspection Date: ❑ Pass /CV � q.OS 938 KING STW YORK 10573 3 - //- 1 U Z y hd' Fail BUILDING&FIRE INSPECTOR (914) ook.or Re-Inspection Date: ❑ Pass PCC'Js a-)�K � S/- //- 2 U z y ❑ Fail FIRE INSPECTION REPORT,NOTICE OF VIOLATION & ORDER TO REMEDY SAME Site Address: 7 C) t l_L 1= T A 12 L V i_") Zone: SBL: 12 y, 2 ;� Occupancy: 11 State Use Classification: Business Owner: L�L_ F- M ,? � _phone: Building Owner: Phone: Emergency Contact: Phone: Building Representative in Attendance: ------------------------------------------------------------------------------------------------------------------------------------------------------------------ Take notice that the following violations of the New York State Uniform Fire Prevention&Building Code and/or the Code of the Village of Rye Brook were found to exist at, 2 cp 1�,c/1_,,4 /`A /� T2, I t/-7�, ,in the Village of Rye Brook,NY on, M A P r k I I 20_2_.,e,.1 .The person or entity served with this Order to Remedy shall immediately commence to correct all listed violations and shall completely cure each violation described herein by no later than ,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.)L _ b.906.3.1.Is the maximum travel distance to a PFE 75 feet or less. b._ 4 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._ Vol 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. 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._ _ 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 WNST&tested annually. h._ i.507.5.4.Are fire hydrants&fine protection equipment unobstructed. i._ „L j.507.5.5.Is a clear space of not less that 3 feet maintained around all hydrants. j._ k.901.8.Are all fire protection systems in place and maintained untampered. k. INSPECTOR: �s DATE: -1- Revised 2/10/22 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. 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. _ 7 _ f.912.2.1.Are exterior FDC's fully visible&recognizable from the point of fire department access. f. 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. C 110 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. h. 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. i. _ , _ 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. 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.Y d.604.3.Are electrical service equipment working spaces free from any stored materials. d.X, _ e.604.3.1.Are all electrical control panel room doors,panel boards&disconnects properly labeled. e. v _ 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. kX INSPECTOR: DATE: ! Z -2- Revised 6/11/2020 _ 8.ELEVATORS,DUMBWAITERS&ESCALATORS No YES N/A 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. 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. e. [B]3005.1.Are elevator machine room doors maintained unobstructed at all times. e. 9.COMMERCIAL KITCHENS a.906.1. Are portable Class K fire extinguishers installed within 30 feet of cooking equipment. a. 7� _ b.904.12.5.Is the fire protection equipment inspected,tested&maintained as per Section 901.6. b. 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. f.[[PC] 1003.10.[RB] 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 a. [PM]603.1.Are all heating appliances properly installed&maintained in a safe working condition. a. _ I _ b. [PM]603.2.Are all fuel-buming appliances&equipment connected to an approved chimney or vent. b. /_ _ c. [PM]603.3.Are heating appliances maintained with proper clearances from combustible material. C. 7 _ d. [Pml 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. g 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. _ v d.5003.7.1.Are proper No SMOKING 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. x d.505.1.Are approved address&building numbers properly placed&plainly visible from the street. d. 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. 7� _ 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 HOU KEEPING a.Good b.Fair c.Inadequate d.Poor INSPECTOR: �' DATE: 3 -3- Revised 9/17/21 OZOZ/11/9 POS!naa -{r :ILdQ --!'1i J ' �� y� :-dO.LD3dSNj d hq co a � ' t Sn 2ty I"v oo Z fir';a d-�;7 °K'2i o 'r m �- r) L7 �? -C)S CYI r-.!D 1 r �" 1 s v -A-) S c-,C+ 1 �351N —Crj D :;,f r )j )^a te S?12I�W -dag am wul INVOICE Emergency Sewer N Drain Inc. ersdinc@verizon.net PO Box 11 914.478.4900 Hawthorne,NY 10532 Marco Monroy Bill to Ship to Marco Monroy Marco Monroy 20 Bellefair Boulevard 20 Bellefair Boulevard Rye Brook,NY 10573 Rye Brook,NY 10573 Invoice details Invoice no.:7113 Terms:Due on receipt Invoice date:05/02/2024 Due date:05/02/2024 01 C05/0 Pr uct or service Description Qty Rate Amount 24 les Regular service:[Bellfair Kitchen] 1 $495.00 $495.00 Flushed and Jetted Service Main Line leading from two grease traps and, cleaned out grease traps. Techs:Juan/Estaban 2. 05/01/2024 Sales A 2%credit card fee will apply. 1 $9.90 $9.90 Subtotal $504.90 Sales tax $42.29 Total 4LRA%P-#-r 9 Payment -$547.19 Balance due %W 00 Paid in Full 7 Emergency Sewer N Drain Inc. I v6j'ce PO Box 11 Hawthorne, NY 10532 914.478.4900 ersdinc@verizon.net BILL TO Marco Monroy 20 Bellefair Boulevard Rye Brook, NY 10573 INVOICE t DATE TOTAL DUE DUE DATE TERMS ENCLOSED 7038 03/27/2024 $276.36 03/27/2024 Due on receipt DATE DESCRIPTION AMOUNT 03/26/2024 {Re}: Bellfair Kitchen 250.00T Snaked out grease trap and found heavy amounts of grease. 'Credit was applied' less -100 off from [$350] Technicians: Ben/Juan 03/26/2024 A 2%credit card fee will apply. 5.00T SUBTOTAL 255.00 TAX 21.36 TOTAL 276.36 BALANCE DUE $276 36 Emergency Sewer N Drain Inc. Invoice PO Box 11 Hawthorne, NY 10532 914.478.4900 ersdinc@verizon.net BILL TO Marco Monroy 20 Bellefair Boulevard Rye Brook, NY 10573 INVOICE#t DATE TOTAL DUE DUE DATE TERMS ENCLOSED 7017 03/18/2024 $547.19 03/18/2024 Due on receipt DATE DESCRIPTION AMOUNT 03/15/2024 {Re}: Bellfair Kitchen 495.00T Flushed and Jetted Service Main Line leading from two grease traps and, cleaned out grease traps. Techs: Ben/Juan/Estaban 03/15/2024 A 2%credit card fee will apply. 9.90T SUBTOTAL 504.90 TAX 42.29 TOTAL 547.19 BALANCE DUE $547-19 r Emergency Sewer N Drain Inc. I vdice PO Box 11 Hawthorne, NY 10532 914.478.4900 ersdinc@verizon.net BILL TO Marco Monroy 20 Bellefair Boulevard Rye Brook, NY 10573 INVOICE# DATE TOTAL DUE DUE DATE TERMS ENCLOSED 6878 01/04/2024 $547.08 01/04/2024 Due on receipt DATE DESCRIPTION AMOUNT 01/03/2024 {Re}: Bellfair Kitchen 495.00T Flushed and Jetted Service Main Line leading from two grease traps and, cleaned out grease traps. Techs: Ben/Juan/Estaban 01/04/2024 A 2%credit card fee will apply. 9.80T SUBTOTAL 504.80 TAX 42.28 TOTAL 547.08 BALANCE DUE $547 08 INVOICE Emergency Sewer N Drain Inc. ersdinc@verizon.net PO Box 11 914.478.4900 Hawthorne,NY 10532 Marco Monroy Bin to Ship to Marco Monroy Marco Monroy 20 Bellefair Boulevard 20 Bellefair Boulevard Rye Brook,NY 10573 Rye Brook,NY 10573 Invoice details Invoice no.:6712 Terms:Due on receipt Invoice date: 10/19/2023 Due date:10/19/2023 # Date Product or service SKU Oty Rate Amount 1. 10/18/2023 Sales $490.00 $490.00 {Re}.Bellefair-Kitchen Cleaned and snaked 2 grease traps in Kitchen.Technicians:Juan/Maney 2. 10/18/2023 Sales $9.80 A 2%credit card fee will apply. Subtotal $499.80 Sales tax $41.86 Total $541.66 Overdue 10/19/2023 Emergency SewerN Drain Inc. ]nvdCe PO Box 11 Hawthorne, NY 10532 914.478.4900 ersdinc@verizon.net BILL TO Marco Monroy 20 Bellefair Boulevard Rye Brook, NY 10573 INVOICE# DATE TOTAL DUE DUE DATE TERMS ENCLOSED 6651 09/28/2023 $547.19 09/28/2023 Due on receipt DATE DESCRIPTION AMOUNT 09/27/2023 Bellefair Kitchen 495.00T Snaked and cleaned out grease trap and, found heavy buildup of food particles. Technicians:Juan M. 09/27/2023 Includes a 2%credit card fee. 9.90T SUBTOTAL 504.90 TAX (0.08375) 42.29 TOTAL 547.19 BALANCE DUE $547-19 All Safe Fire Sprinkler Systems Invoice 375 Executive Blvd Elmsford, NV 10523 Tel: 1-888-325-5723 Date Invoice# Fax: 914-747-3983 1,25 2023 88657-SS Bill To Ship To Belle Fair Club House 24 Bellfair Blvd 20 Bell Fair Blvd Rye Brook,NY Rye Brook,NY 10573 P.O. No. Terms Project Net 30 24 Bellfair bivd Quantity Description Rate Amount 1/17/23 Sprinkler inspection 0.00 O.00T Dry Sprinkler system Inspection Testing Maintenance as per portion of NFPA 595.00 595.00T #25.System back in good service. Wet Sprinkler system Inspection Testing Maintenance as per portion of NFPA 0.00 O.00T #25.System back in good service. Please note effective January 1,2023 there will be a fee of 3.5% upon all Subtotal credit card Transaction.Thank you for your business! $595.00 Sales Tax (8.375%) $49.83 Please make checks payable to: All Safe Fire Sprinkler Svstems Total $644.83 Payments/Credits -$644.83 Balance Due $0.00 Protecting Life and Property Since 1983 SALES•SERVICE•RECHARGING•INSTALLATION•PORTABLE EXTINGUISHERS•AUTOMATIC SYSTEMS ��SAFE FIRE HOSE•CODE 96 VENTILATION SYSTEMS•SPRINKLER SERVICE•EXHAUST CLEANING•EXIT LIGHTING �0��� NN �� 5 EMERGENCY LIGHTING•BATTERY BACK UP SYSTEMS•FIRE ALARMS•BACK FLOW TESTING ��� 375 EXF,CtITIVE BLVD. ELMSFORD,NY 10523 TEL 1-(888)325-5723 FAX(914) 747-3983 Licensed in NY,CT,Ll&NJ 15852 9 Arrival Time:_ DepartureTiime: wTechnicianName Customer Name: T "PIBill To: Address: tY Address: Zip Code: __ -_- Phone #:_-___ Zip Code:- —_ Phone#:____ E-Mail: Contact Name: DATE: ANNUAL SERVICE [SEMI ANNUAL ❑ MONTHLY ❑ NEW ACCOUNT❑ EMERGENCY CALL ❑ O DESCRIPTION TOTAL SOn rl y aj I ^ SUB TOTAL VISA L] MASTERCARD ❑ TERMS.C.O.D.❑ ABLE ueQN IPT OF INVOICE TAX CREDIT CARD 1 DEPOSIT CUSTOMER x BALANCE DUE NFSAInspection, Testing and Maintenance Form ��......,...,.._,..,._,,.,�. Wet Pipe Fire Sprinkler Systems This form covers the minimum requirements of NFPA 25-2017 for wet pipe fire sprinkler systems connected to water supplies without tanks or fire pumps.Separate forms are available for fire pumps,tanks,hose connections,and other fire protection systems More frequent inspection,testing and maintenance may be necessary depending on the conditions of the occupancy and the water supply. Owner/Owner's --- Representative Addresstp / / Ell I Phone _ /Gc l l Property Name �1�//'Q Address n/ Phone Date of Work lbw All responses refer to the current work r pverformed on this date. :��Inspection Type Weekly Monthly quarterly (� Semiannual Annual S-Year 1)All questions are to be answered Yes,No,or Not AP koble.All"No"answers are to be explained in Part 111 of this form. Notes 2)Inspection,Testing and Maintenance tasks are to be performed with water supplies(int-ludinq fire pumps)in service,unless the impairment Procedures of Chapter 15 of NFPA 25 are followed. PART I--Owilur's skctit)jj No N/A PART 2-Inspector's Section(continued) A.Is the building occupied? b.Visible sprinklers B.Has the occupancy and hazard of contents remained the same since the last inspection? 1.Proper position:Upright,pencieiit,sidewall? 2.free of leaks,corrosion,damage? C.Are all fire protection systems in service? 3.Proper clearance below sprinklers? D.Has the system remained in service without 4.Free of foreign material,including paint? modification since the last inspection? ------- 5.Liquid in all glass bulb sprinklers? E.Was the system free of actuation of devices or alarms C.Visible pipe since the last inspection? 1.In good condition/no external corrosion? Own s Replesentative(printed) 2.No mechanical damage or leaks? Sjgnat a B - 3.No external loads? �( d.Visible pipe hangers/seismic bracing not loose or damaged? e.Sprinkler wrench(es)with spare sprinklers? A,Inspections-Report any failures in Section III f.General information sign attached and legible? 1.Weekly Inspection Items g.Has internal inspection of the pipe(removing a w preventer isolation -- flushing connection and one sprinkler head near the a.Control Valves(including backflo end of a branch line)performed in the last 5 years? If valves)supervised with seals passed inspection as no,conduct internal inspection described in II.A.2.a) h.Hydraulic information sign securely attached to riser7�� b.Relief port on RPZ not discharging? and legible? _ 2.Monthly Inspection Items(in addition to above items) 5.S-Year Inspection Items(in addition to above items) a.Control valves and valves on backflow preventers _ a.Alarm valves and associated strainers,filters,and 1.In correct(open or closed)position? �/ restricted orifices passed internal inspection? 2.If not electrically supervised,locked in correct b.Check valves internally inspected,all parts operate position? _ and are in good condition? V 3.Accessible and free from visible leaks? c.Internal pipe inspection performed per II.A.4.g 4.Provided with appropriate wrenches? (/ S.Provided with appropriate identification? B.TestingReport on- p y failures In Section It/ _ res No N/A b.Alarm valve free from physical damage,trim in 1.Quarterly Testing Items correct(open or closed)position,and no leakage from a.Mechanical water flow alarm devices actuated and retarding chamber or drains? ✓ flow observed? 3 Quarterly Inspection Items(in addition to above items) b.Main drain test for system downstream of backflow a.Gauges monitoring water pressure in good condition device or pressure reducing valve? and showing normal water supply pressure? ✓ 1.System Static Pressure b.Fire department connections visible,accessible, 2.System Residual Pressure— psi psi 0 couplings and swivels not damaged,gaskets in place --- ._ and in good condition,check valve not leaking clapper 3.Was flow observed? , peer in place and operating properly,and automatic drain Are results comparable to previous tests?g properly? Of plugs or _ valve in p p lace and operating 2.Semiannual Testing Items(in addition to above items) caps are not in place,inspect for interior obstructions) ✓ a.Valve supervisory switches indicate movement? c.Control valves electrically supervised? b.Electrical waterflow alarm devices actuated and d.Alarm and supervisory devices not damaged? — alarmed? e.Pressure reducing valves in open position,not 3.Annual Inspection Items(in addition to above items) leaking,with downstream pressure per design criteria, a.Main drain test(for systems not tested quarterly) and in good condition with hand wheels not broken? ✓ 1.System Static Pressure psi 4.Annual Inspection Items(in addition to above items) 2•System Residual Pressure PSI a.Proper number and type of spare sprinklers? 3.Was flow observed? 1 List of spare sprinklers attached and legible? 4.Are results comparable to previous tests? Comments-Use the reverse side of the form or additional comments forms for additional comments. All"No'answers must be erplomed. ti2019 National Fire Sprinkles Association,514 Progress Drive,Suite A,Lnsthwum Heights,MD 21090 www nlsa.u� g coon 2SWCT vcr 2019.11 Std 2017 Page 1 01 2 r 8.Testing-f±port anfailures in Section 111 .._.-_ 2•Annual Maintenance Items On addition to above items) b.Post indicating valves opened until spring or torsion felt In the rod then closed back ya turn? ✓ a.Operating stele of all OS&Y valves lubricated, completely closed,and reopened? f✓ C.All sprinklers manufactured after 1920?-_ b.Sprinklers and spray nozzles protecting commercial d.Quick response sprinklers 20 years old or more cooking equipment and ventilating systems replaced replaced or successfully sample tested in the last 10 except for bulb-type which show no signs of grease ears? L-11_ build-up? e.Standard response sprinklers 50 years old or more replaced or successfully sample tested in the last 10 ears? PART 3-Comments f.Standard response sprinklers 75 years old or more Any"No"answers,test fuilures or other problems found with the sprinkler system must be explained here.replaced or successfully sample tested in the last 5 (As o courresy note urr a separate full,,nq y-,u erns ofrord nnything that you sow whrk ptrfarmin0 years? V, your work that is not 0 port of the NSPA 25 requirements utcldinp any recalled products that you g.Dry-type sprinklers replaced or successfully sample rw tied tonotice• tested in the last 5 years? _ too' OLD- YJII�K /�h.Sprinklers subject to harsh environment replaced or � J 6Y,11' -Successful) sample tested In the last 5 ears? KtrLI �r!-- i.Antifreeze solutions eNfic ravit 1.Correct at most remote point? 2.Correct at interface with wet system? 3.Correct at other test points over 150 gal)? ------ -- - --- --- 4.Correct typeof antifreeze? _ j.All control valves operated through full range and returned to normal position? _ k.Backflow devices passed forward flow test? I.Pressure reducingvalves passed partial flow test? -' —' 4.5-Year Inspection Items(in addition to above items .�1 - D a.Sprinklers above high tem rature tested? 1 b.Gauges checked by calibrated gauge or replaced? ( w c.Pressure reducingvalves passed full flow test? C.Maintenance ra Fzo MIA — - -- 1.Regular Maintenance Items a.If any sprinkler failed the sample testing of Part II.B.3 were all sprinklers represented by that sample replaced? -- --- ----- -- b.If sprinklers have been replaced,were they proper - -- - -- replacements? _ c.Marine systems normally having fresh water were _ drained and refilled twice if raw water got Into the _system? _- ✓ `_ d.Heat tape inspected r manufacturer's Instructions? __- e.If any of the following were discovered,was an obstruction investigation conducted?Explain reasons(s)and findings in Part tit �- -- -- 1.Defective intake screen on pump supplied from aPta sources --- -- --- - ___ 2.Obstructive material discharged durinA flow tests 3 Foreign material in dry - - --- --- ------- t*pe wives check va7ves_or pumps - 4.Foreign material in water during drain test or plugging of inspector's test c_oonection -- —' -- ----- S.Plugging of pipe ors rinklers found durir�acthlallo s or work --- - - - 6.Record of broken mains In the vklnllY— _7.Abnormalry frequent false-trl ng of drY-pipe valves 9.Failure to flush yard pping or surrotidin mares following new Inspector's Information infla0ation or repairs I state that the information on this form is correct at the time and place Only 9.System is returned to service after an emended period of tune out of inspection,and that all equipment tested at this time was left in operating service(more than one year) condition upon completion of this Inspection except as noted in Port Ill above. 10.There is reason to believe the system contain—odlum silicate or Its - - -- - -- derivatives or highly corrosive fluxes am pipe per Inspector(print 11.Raw water was u_mped into the fire io c department connection ✓� /7(// u.Pinhole leaks Inspector Signatficene CCCiii��'lllIL4MMK 111511-C/r i- f,if conditions were found that required flushing,was flushing of system conducted? Certification or um er,if applicable g. Was a valve status test conducted after opening any closed valves? Company h.h.Adjusted,repaired,reconditioned or replaced All riliOv E 9 a ►� components had the associated tests and/or Company Address/]/ { ,YSr� __ _— inspections performed? _ _ ✓ 7l` r - Comments-use file reverse side of the form or additional comments forms for additional comments.All••No"answers must be explorned. 02019 National Fire Sprinkler Association,S14 Progress Drive,Suite A,ltnthicum Heights,MD 21090 willw lfsa or R Form 7riWFT Ver 2019.11 Std 2017 Page 2 of NFSA Inspection, Testing and Maintenance Form W, Er Imam..,,.,,.,,,,,e._,_e,,,,,,,,,,r Wet Pipe Fire Sprinkler Systems This form covers the minimum requirements of NFPA 25-2017 for wet pipe fire sprinkler systems connected to water supplies without tanks or fire pumps.Separate forms are available for fire pumps,tanks,hose connections,and other fire protection systems.More frequent inspection,testing and maintenance may be necessary depending on the conditions of the occupancy and the water supply. Owner/Owner's / Address /Vdl Phone Representative G Property Name l�l r Address Phone 100/iri IV Date of Work / r All responses refer to the current work performed on this date. Inspection Type 0 Weekly I Monthly OQuarterly Semiannual 05`nnual 5-Year 1)All questions are to be answered Yes,No,or Not Applicable.All"No"answers ore to be explained in Part III of this form. Notes 2)Inspection,Testing and Maintenance tasks are to be performed with water supplies(including fire pumps)in service,unless the impairment procedures of Chapter 15 of NFPA 25 are followed. Inspector's A.Is the building occupied? b.Visible sprinklers B.Has the occupancy and hazard of contents remained 1.Proper position:Upright,pendent,sidewall? the same since the last inspection? 2.Free of leaks,corrosion,damage? C.Are all fire protections stems in service? 3.Proper clearance below sprinklers? D.Has the system remained in service without 4.Free of foreign material,including.paint? modification since the last inspection? 5.Liquid in all glass bulb sprinklers? E.Was the system free of actuation of devices or alarms c.Visible pipe since the last inspection? 1.In good condition/no external corrosion? _ er's epres ntative p►in ed) 2.No mechanical damage or leaks? 3,No external loads? I a Vol- d.Visible pipe hangers/seismic bracing not loose or damaged? e.Sprinkler wrenches)with spare sprinklers? f.General information sign attached and legible? A.Inspections Report any failures In Section 1!! g.Has internal inspection of the pipe(removing a 1.Weekly Inspection Items flushing connection and one sprinkler head near the a.Control Valves(including backflow preventer isolation end of a branch line)performed in the last 5 years? If valves)supervised with seals passed inspection as no,conduct internal inspection described in II.A.2.a) ✓ h.Hydraulic information sign securely attached to riser b.Relief port on RPZ not discharging? and legible? 2.Monthly Inspection Items In addition to above items) 5.5-Year Inspection Items in addition to above items a.Control valves and valves on backflow preventers a.Alarm valves and associated strainers,filters,and 1.In correct(open or closed) osition7 restricted orifices passed internal inspection? 2.If not electrically supervised,locked in correct b.Check valves internally inspected,all parts operate position? and are in good condition? )/ 3.Accessible and free from visible leaks? c.Internal pipe inspection performed per II.A.4. 4.Provided with appropriate wrenches? S.Provided with appropriate identification? B.Testing—Report any failures in Section 111 Yes No N/A b.Alarm valve free from physical damage,trim in 1.Quarterly Testing Items correct(open or closed)position,and no leakage from ✓ a.Mechanical water flow alarm devices actuated and retardingchamber or drains? flow observed? 3.Quarterly Inspection Items(in addition to above items) b,Main drain test for system downstream of backflow a.Gauges monitoring water pressure in good condition device or pressure reducing valve? and showing normal water supply pressure? 1.System Static Pressure psi b.Fire department connections visible,accessible, 2.System Residual Pressure --Psi couplings and swivels not damaged,gaskets in place 3.Was flow observed? and in good condition,chock valve not leaking,clapper 4.Are results comparable to previous tests? in place and operating properly,and automatic drain 2.Semiannual TestingItems(in addition to above items) valve in place and operating properly? (If plugs or a.Valve supervisory switches indicate movement? —tti caps are not in Elace,inspectfor interior obstructions) ✓ b.Electrical waterflow alarm devices actuated and c.Control valves electrical) supervised? alarmed? d.Alarm and supervisory devices not damaged? 3.Annual Inspection Items(in addition to above items) e.Pressure reducing valves in open position,not a.Main drain test for systems not tested quarterly) leaking,with downstream pressure per design criteria, System Static Pressure and in good condition with hand wheels not broken? 1. si 4.Annual Inspection Items(in addition to above items) 2•System Residual Pressure sI a.Proper number and type of spar s rinklers? 3.Was flow observed? 1.List of spare sprinklers attached and legible? 4.Are results cam arable to previous tests? comments-use the reverse side of the form or odditlonol comments forms for additional comments.All'No'answers must be erph—rd. 02019 National Fire Sprinkler Association,S14 Progress Drive,Suite A,Lint hicum Height%,NID 21090 www nlsa.org I orm 25WCT Ve,2019.11 St,1 2017 Page 1 of 2 PART 2-Inspector's Section(continued) Yes No N/A PART 2-Inspector's Section(continued) Y yy� NIA B_Testing-Report only failures In Section Il! 2.Annual Maintenance Items(in addition to above Item b.Post indicating valves opened until spring or torsion a.Operating stem of all OS&Y valves lubricated, — felt In the rod then closed back Xturn? completely closed,and reopened? _ C.All sprinklers manufactured after 19207 _ �/ — b.Sprinklers and spray nozzles protecting commercial d.Quick response sprinklers 20 years old or more cooking equipment and ventilating systems replaced replaced or successfully sample tested in the last 10 except for bulb-type which show no signs of gt pase years? _ ✓ build-up? e.Standard response sprinklers 50 years old or more -- - - -- replaced or successfully sample tested In the last 10 years? Comments f.Standard response sprtnklers 75 years old or more �rlY"No"answers,test failures or other prablems found with the sprinkler replaced or successfully sample tested in the last 5 system must be explained here. (As a rourfery,nine rw,a srlvuate Jwrn any amcerm uMnrt anPrhnp flier yw,sow while perA......,p years? ✓ your walk(flit h nN aplift o/the NFPA)S rrgrnrr.nra. udrrp any recefhdprpducts Mat, g.Dry-type sprinklers replaced or successfully sample An pened to rwfrce. i tested in the last 5 years? I _L O(AV rn -sob_#&f h.Sprinklers subject to harsh environment replaced or /(/ r successfull sample tested in the last 5 ears? �/I.Antifreeze Antifreeze solutionspecific gravity eM 1.Correct at most remote oint? _ Lo 2"1 2.Correct at Interface with wet system? 3.Correct at other test points over 150 al)7 ✓ 4.Correct type of antifreeze? j.All control valves operated through full range and 1'' returned to normal position? ✓ - lV k.Backflow devices passed forward flow test? I.Pressure reducing valve- sLlassed_partial flow test? 4.5-Year Inspection Items(in addition to above items) lie, — - — - -- a.Sprinklers above high temperature tested? ---- b.Gau es checked by calibrated gauge or replaced? c.Pressure reducing valves passed full flow test? C.Maintenance rea No N/A ---- 1.Regular Maintenance Items -t--- __ a.If any sprinkler failed the sample testing of Part II.B.3were all sprinklers represented by that sample replaced? b.If sprinklers have been replaced,were they proper -" -- - -- - replacements? c.Marine systems normally having fresh water were drained and refilled twice if raw water got Into the system? - d.Heat tape inspected per manufacturer's Instructions? - e.If any of the following were discovered,was an obstruction investigation conducted?Explain reasons(s)and findings in Part If/ --•---- 1.Detective intake screen on pomp supplitd from sources ---- - --------------- _ _ 2.Obstructive material dlschar ed d_urins flow tests 3.Foreign material in dry pipe valves.check valves or pum s _ - -- -- - - - -- —I 4.Foreign material In water during drain test or plugging of inspector's -- .--- - -. tes_tco_nnection - - - S.Plugging of pipe or sprinklers found during activation or work 6.Record of broken mains in the viNni�__ -_ 7 APART 4-Inspector's Information D_ormahy frequent tals_e trlPWrsg of Ary pspe"N's -` -B.Facture to flush yard prang or wrrtwrtrxng mains lolbwlrtg new Installation or repairs I state that the information oil this form is correct at the time and place of Illy 9.System is returned to service aher an axtenrled porlod of lime out or inspection,and that ail equipment tested at this time was left ul operating service inure than one year) condition upon coin letion of this ir1 pection except as noted in Part I_I_I above. 30.There Is reason to believe the system c,mtarns atdlum silicate or Rs ---- derivatives or Fit hi corrosive fluxes In cop W inspector(prince 11.Raw water was pumped into the fire department connection 12.Piohole asks Inspector Signature and 1) f.If conditions were found that required flushing,was flushing of system conducted? Certification or License Numb , applicable -� g. Was a valve status test conducted after opening any closed valves? Company i / h.Adjusted,repaired,reconditioned or replaced 1 ��Q, components had the associated tests and/or ✓ Company Addrilff V l4���GGGI inspections performed? Comments•Use the reverse side of the fume at additional comments forms for additional continents. All'No"answers must be evplamed. (02019 National Fire Sprinkler Assoc au—,514 Progress t),eve.Suite A,Linthicum Heights,Mn 21040 www.ofsa ur 6 Form 25WFT Ver 2019,11 Still 2017 Page 2 of T NFSA Inspection, Testing and Maintenance Form �Q�l ( �--..n....�.....,.�.,a Dry Pipe Fire Sprinkler Systems This form covers the minimum requirements of NFPA 25-2017 for dry pipe fire sprinkler systems connected to water supplies without tanks or fire pumps.Separate forms are available for fire pumps,tanks,hose connections,and other fire protection systems.More frequent inspection,testing and maintenance may be necessary depending on the conditions of the occupancy and the water supply. Owner/Owner's --- Representative t- Address tT. �� - --- t I'CI; cc, t��- Phone Property Name 1 Tom'`G Address -- �1 � Phone Uate of Work -7 r / / All responses refer to the current work performed on this dote. Inspection Type ❑ Monthly ❑ --- Quarterly ❑ Semiannual ❑Annual n 3-Year 1)All questions are to be answered yes,No,or Not Applicable.All"No"answers are to be explained in Part Ill of this form. ❑ 5 year I Notes 2)Inspection, Testing and Maintenance tasks are to be performed with water supplies(including_--procedures of Chapter 15 of NFPA 25 ore followed 9 fire pumps)in service,unless the impairment A 1_the building occupied? t B.Has the occupancy and hazard of conten7re-amedc.Fire department connections visible,accessible, the same since the last inspection? couplings and swivels not damaged,gaskets in place C.Are all fire protection systems in service? and in good condition,check valve not leaking,clapper in place and operating properly,and automatic drainD.Has the system remained in service with modification since the last inspection? valve in place and operating properly? (!fplugs or L Was the system free of actuation of deviccaps are not in place,inspect or interior obstructions) d.Control valves electrically supervised? since the last inspection? -- r Oer s RAresentatly� printede� e.Alarm and supervisory devices not damaged? � �/ f.Pressure reducing valves in open position,not leaking, 1� Signature agiiDate—_ —r with downstream pressure per design criteria,and in good condition with hand wheels not broken? 4.Annual Inspection Items(in addition to above items) a.Proper number and type of spare sprinklers? A.Inspections--Report an 1.List of spare sprinklers attached and legible? FP y/oilItem/n Section 111 b.Visible sprinklers C and Weekly Inspection Items —' ol valves(including backflow preventer isolation 1.Proper Position:Upright,pendent,sidewall? )supervised with seals passed inspection as 2.Free of leaks,corrosion,dama e? bed in 11 A.2.a) 3.Proper clearance below sprinklers? ipe valve enclosures maintaining min.40'F reeof foreign material,including paint?s on systems without low pressure alarms in 5 Liquid in all glass bulb sprinklers? ondition showing normal air and waterc.Visible pipere? 1.In good conditip�no E is trial�o.o. �— d Retie/port on av2 not dischargf�g? ------- 2.No mechanical damage or leaks? e.For freezer systems,gauge near the compressor 3.No external loads? readnng the same as the gauge on the dr d.Visible pipe hangers/seismic bracing not loose or — Pipe valve. r2.Monthly Inspection Items(in addition to above items) damaged? a.Control valves and valves on backflow preventers -e.Dry-pipe valve passed internal inspection? 1.In correct or closed)position? It.Low temperature alarms look okay? 2.If not electrically supervised,locked in correct / g.Pipe through freezers free of ice blockage? Posh--tion?_ /� h.Sprinkler wrenches)with spare sprinklers? `3.Accessible and free from visible leak I.General information sign attached and legible? 4 Provided with appop�iate wrenches? - j Has internal in of the i S.Provided with a Pin (removing a appropriate idenuflcation7 flushing connection and one sprinkler head near the b.Dry-pipe valve free from physical damage,trim in end et a branch line performed in the last S years? If / correct(open or closed)position,and no leakage from no,conduct internal inspection X �..intermediate chamber or drains? k.Hydraulic information sign securely attached to riser cundition Gauges on syses with low pressure alarms in good ana legible?showing normal water and air pressure? 1.Low air pressure signal passed test?.Gauges monitoring au or nitrogen(not connected to S.5-Year Inspection Items(in addition to above items) a constantly attended location)in good condition a.Alarm valves and associated strainers,filters,and showing normal pressure? _ estricted orifices passed internal inspection? 3.Quarterly Insp---eCtiOn hems(in addition to above items- -- b.Check valves internal) ins I a.Gauges monitoring water pressure in good condition y peened,all parts operate T and are in go conditions x and showm normal water s_�pply pressure? c.Internal pipe inspection perfot med per ILA.4.j b.Gauges monitoring air or nitrogen(connected to a-t�I — conttanttyattended i / +— g•Testin �-- ocation)showing fn good .1 I B-Re ort on o!/ores in Sect/on/// condition and normal r 1•Quarterly TP.Sting,tems '�F No NJq� L—•— p essure. _ — "— a.Mechanical waver flow alarm Vices and flow observed?_ Comments'Use rh"i'vVie side o/the/or.n a ond:r.onar<ommMn Ormt b.Prlmlrlg IeVPI CUrreCl? ---_�— C2G19 Mauonai Fire Sprinkler Association,S1a Progress Drive,Suite A.ttnthicum Heights,MU n ors / for Oddrrionol conunm4 .411"Nu'answers must be rsploinen. 90 www.nrse.org Form 25"Ay --- _--_—V --- --- vet 2019.11 Std 201J rage to(i C.Quick open_- i`vicepassed test? Q d.Main dram test for system devicedr in testss re r reducing of backflow e.Iran y of the following were discovered,was an I.System_ Static Pressur------�_ obstruction Investigation conducted? reason O ndin Explain 2.S ste ----- ----- sin Part!ll Y m Residual Pressure psi 1 0e/ecme smoke seen on 3.Was flow observed? - °n supplied 1 o A 2 Obstructive mi aI dacha ^$ourcN 4.Are results co 3 /ore.n material In dry pi iged during/- Ip=tests comparable to previous tests? M valves,check ,i r,°, 2.Semiannual T a Forego material in water during drain test or p1u pumps Testing Items In test connection 8grng of ins a.Valve Supervisory ( addition to above Items) -- Dtr'pr s pervisory switches indi S.Plu m of pipe or sprinklers f - b.Electrical cote movement? 6 Record of broken m found dur�^B�cti-v-,,,or work waterflow alarm devices �^t n the viumty alarmed? actuated and - ?Abrwrmally frequent fals t„ 8.Failure to Rush yard pip,n Vin of dr PIP e valve-i 3.Annual Inspection It ---- '-,elation 8 or surrounding mains lollowing new - ems(in addition to above Items or rep...., / a.Main drain test(fors stems ) 9.system is returned Ip l X Y not tested quarterly) service(mote ce alter an extended period o/time out of 1.System Static Pressure _-_( o e roan one earl 2.System Residual ---- 10.There s reason to believe to pressureenwt.v_of or h.hly currosrve/lu System in °turns sodium silicate or its 3-Was flow — Sisl observed? L� 11.R•w water was Pumped Into the fire department Woe 4.Are r Psi 12.Plnhol wrtment coon esults co - a leaks connection mparable to previous tests? 13.A soxmcrea:-e,n,ime fit, the b.Post indicating vale requirement for wale/to,cache original system acceptance test es opened until spring felt in the rod then closed back%turd? g or torsion f.((conditions were found hatsrequired tea gushing, c.All sprinklers manufactured after 1920? flushing of system conducted flushing,was d-Quick response sprinklers 20 Years old or more g• Was a valve status test conducted after opening any replaced or successfully sample tested in the last 10 -- closed valves? - -f years? / h.Adjusted,repaired,reconditionedreplaced e.Standard response sprinklers SO -- r components had the associated tesstsand/or - replaced or successfully sample years old or more inspections performed? years? P e tested in the last 10 2.Annual Maintenance Items(in addition to above items) f.Standard responses sprinklers 75 a•Operating stem 0f all 1V ,(valves lubri replaced r p Years old or more P o successfully sample tested in the last S completely closed,and reopened? cared, years? b.Interior g.Dry-type sprinklers replaced or successfully sample y Pepe valves cleaned? C.SONi Points drained prior to freezin tested in the last 5 yearS?_ weather? h.Sprinklers sub-ect to harsh environment replaced or d Sprinklers and spray norrles rotectin cookin P B commercial g equipment and ventilating systems replaced successfully sample tested in the last 5 Years? except for bulb-type which show no signs of grease Aerated through f build-up? j returned to normal g full range and s� Position I.Low temperat-`-ur_alarms passed test? It.Dry-Pipe valve a •,• s • P rtial(low trip test(unless full trip A^Y"No"answers,feftJailutef°,Other r test done) hero,us•additional comments forms, D o-ems found wRh the 1.Initial as, ure --_ out sprinkler system must be erp/." -_`--w pressure �_ r�^Yrhmp"I You Sow while pe/o m nsOry !Af o courtesy,note on O seporore JOrm pay r0^re/its 2 Initial water onY/era/led 9 Your work that a Or a 3.Valve tripped ps; Vro rs rho,you ho coed to norrcr Purr o/the NFPA pp-ed air pressure 25 reWgremtnh a.valve tnVVrd . um�- _ 5 Results p comarable to prey"tons tests? —'-- psi 9 1 V r ack ---� 1.Automatic air mainten—maintenance devices passed? In C_ cc' r 1 �^GC � 1 M.Bflow devices passed forward flow test? N yl t n.Pressure reJu—cing 9 valves passed partial flow test? 4,3 Inspection Items W,addition to above items) C / t 1 - a.Dry Pipe valve full flow trip test � t.1.Initial air pressure - ---_ 2.Initial water pressure --_--- ------ 3.Valve IriDped air weswre —~-- --�---- _ 4.Vaive tripped time u _ (NFPA 25 does nor require 60 sec water delsvrry Gmel m;s 6`Results comparable to m s -�� trslsl b.Air leakage test passed? ----- S`5-Year Inspection Items(in addition to above items) as Sprinklers above high tern -- - - b.Gauges checked b perature tested? _ Y calibrated edu C.Pressure r '—'�-gauge or replaced? •' ' ,cing_valves passed full flow test? I state that the inform otion on this form is correct of r equipment I., OI this hme wa,left in ht time and C.Maintenance ------------- of noted In Po J operol;np condition,,an�.,11 onY pJ Ipti 14 and the,elpr .-_-"-.----�-.- -----rt lie above. .an 1.Regular Maintenance Ise yf Ho Nfn Inspector(grin d _ —� a.If asprinkler failed the sample testing of Part II.B.3 I/�`---� - were all sprinklers represented b Inspector Signature and Date replaced? Y that sample ,� b.((sprinklers have been re I Certification or License Number,If replacements) Paced,were they Proper aPPlicable c-Dry_pipe system= °ndlt -n dr - _ Company d.Nave auxiliary drains been efnlpn? plied. Company Address F "'✓ 'c-U Comments.Use the reverse r, r `'� 0i019 National FireSpinkler A„O�apJno,r'^ bm- Jam,forpddr(ranal<Ommrntf All^NO^ l.• ^V j"SIC Pro gress Drwq Suite A,lmthrcum Neghts,MD 21090 omwers mus t be eaplomtd www.nfsa.org Form 2SDRY vex 2o19.11 Sld 2017 Page 2 or 2 Inspection, Testing and Maintenance enance Form p Sprinkler Dry Pipe Fire S p Systems DG3V This form covers the minimum requirements of NFPA 25-2017 for dry pipe fire sprinkler systems connected to water supplies without tanks or fire pumps.Separate forms are available for fire pumps•tanks,hose connections,and other fire protection systems.More frequent inspection,testing and maintenance may be necessary depending on the conditions of the occupancy and the water supply, Owner/Owner's — Representative tquestylon Address LProperty Nameu Phone Address ' ,`� �Date of Work Phone All responses refer to the current work performed on this date. Inspection Type ❑ Quarterly ❑ Semiannual ❑Annual ❑ 3•Year S-Yer s ore to be answered Yes,Na,or Not Applicable.All"No"answers are to be explained in Port 111 of this form. Notes 2)lnspection, Testing and Maintenance tasks ore to be performed with water supplies(including fire pumps)in service,unless the impairment Procedures oJChapter 15 of NFPA 25 are followed. A.Is the building occupied?_ B.Has the occupancy and hazard of contents remained c.Fire department connections visible•-accessible, _the same since the last inspection_? couplings and swivels not damaged,gaskets in place C.Are all fire protection systems service? - I and in good condition,check valve not leaking,clapper n place and operating pper D.Has the system remained in service without -- g Properly,and automatic drain modification since the last inspection? valve in place and operating properly? (If plugs or E.Was the system free of actuation of devices or alarms caps are not in place,inspect for interior,obstructions) _since the last inspection? d.Control valves electrically supervised? O ers Re,Presentative(printed)` e.Alarm and supervisory devices not dama ed� ? r f.Pressure reducing valves in open position,not leaktng, S. LIgn5UW&eFd0aTe _- _ with downstream pressure per design criteria,and in I __flood condition with hand wheels not broken? n a.Pr4.Annual Inspection Items(in addition to above items) oper number and type - YPe of spares rinkIli A.Inspections-Report any failures/n_Sect/on//1 1.List of spare sprinklers attached and legible? 1.Daily and Weekly Inspection Items b.Visible sprinkler-- — a.Control Valves(including backflow preventer isolation _1_Proper_ position:Upright,pendent,sidewalI? valves)supervised with seals passed inspection as �� 2.free of leaks,corrosion,damage? described in II.A.2.a) 3•Proper clearance below sprinklers? b.Dry-pipe valve enclosures maintaining min 40'F - 4.Free of foreign material,including------- g paint? C. Gauges on systems without low pressure alarms in 5•L' uid in all glass bulb sprinklers? good condition showing normal air and water yl :.Visible pipe Pressure? --od con - X' -- In ood_con_ditio_n/no .twmaf,a..o,;,, ? -d.Relief port on RP2 of dischar to + -- --O g g; �Z No mechanical damage or leaks? e.For freezer systems,gauge near the Compressor 3•No external loads? reading the same as the gauge on the dry-pipe ? d.Visible pipe hangers/seismic bracing not loose or the valve. 2.Monthly Inspection items(in addition to above items) damaged? ` a.Control valves and valves on backflow preventers e.Dr --- X ✓'pipe valve passed internal inspection? 1.Incorrect_ (open or closed)position?- - f•Low temperature alarms look okay? 2.If not electrically supervised,locked in correct Pipe through freezers free of i - position? �/ I — ice blockages ---____- h.SPI inkler wrenches)with spare sprinklers? 3.Accessible and free from visible leaks? - i.General information sign attached and legible? _ 4 Provided with appropriate wrenches) j.Has internal inspec the pier(removing a S_Provided with appropriate identification? flushing connection and onr sprinkler head near the b.Dry-pipe valve free from physical damage,trim n end of a branch line correct(open or closed )performed in the last 5 years? If position,ar,d no leakage frorn _no,conduct internal inspection _intermediate chamber or drains? , k.Hydraulic information sign securely attached to riser C.Gauges on systems with low pressure alarms in good and legible? / condition showing normal water and air presswe? � -- /� d.Gauges monitoring air or nitrogen(not connected to I_Low air pressure signal passed test? *o f- 5.5-Year ins -- --- _L_ a constantly attended location)in good condition pection Items(in addition to above items) /! a.Alarm va es and associated strainers,filters,and showing normal pressure? \ re.tricted orifices passed internal in, 7 I 3.Quarterly Inspection Items(in additio—n to above items) -'- __pection. b.Check valves internally inspected, all parts operate i a.Gauges monitoring water pressure in good condition T and are in good Land tion�_ and showing normal water su I T ----___ P y pressure? c.Inte•nal pipe inspection performed A b.Gauges monitoring —� --- _ _ -- per air or nitrogen(connected to a --- I constrntly attended location I B.Testing-BrPort ony fppuret in section r!r --i showing in good res Ne N/n i condition and n-nor-- pressure? I.Quarterly TeS n�Items -- ----------�. -•.� a Mechanical Hater flew alai - "—" --- m devices actuated and �J -flow ubservy�d. Cnmmems.use;he rew/re;i0e o/rhe%rm o+eye,r.w,o,sornmrn ei fonilc JOr OQypiunof commwr, oe019 National A$Socla onal Fire 5 ton, L---, --8 ---- '-_J-y ;14 Progress Da mMt,ve,Suite A.Lmlhicu Heights,M 21090 Ali.Nu-onsuen mots be svww.nlsa.or� Ver 2019.11 Sid 2017 Page 1 of 2 1 C.Quick opening a a a device passed test? d.Main drain test for system downstream of backflow �. r a a a device orPressure re`g�atve? e.If any of the followin B were discovered,was an obstruction investigation conducted?Expfoin 1.System Static Pressure , rC05On5(5)and findin sin Part ll! 2.System Residual Pressure--- p51 1 Defeclive intake screen on pure L.su hed from 3.Was flow observed? C • Si 2.Obslruc[Ive material dischargetl durlo�l_�tO tourcas 4.Are results com 3 .ore,n material in d a ow lest parable to r V ry pipe vol es.check valves or pumps p e sous tests? a rare gn material In water dun ng 2.Semiannual Testing Items in a test connection dra'^Ir'1°r PIv6s a or ins -- f ddition to above items) per tors a.Valve supervisory switches indicate movement? S.Plu not or pipe or sprinklers ement? 6 Record of r found during aruvation o wort b.Electrical waterflow alarm devices actuated and _ b oken mains in the vicinity 7.Abnormally,Ireguent falseg,, ;n 1 alarmed? / __` so d,yp,pevaroes -- T 8.failure to flush yard piping or surrpvndl-n 3.Ann ual Inspection Items(in addltlon to above Items) installation pr repairs B mains following new a.Main drain test f 9.System it rgtumod to <r filer an extended ef;od as time out o! (or systems not tested u ) serv,cc(more than one year) 1.System Static Pressure q arterl -/� 10.There is reason to believe the system conbmt sodwm s;hcate or Its +-• 2.System Residual Pr - sl d.r .lives of h,hi - eSSUfP y CUrrOfwe fluxes in co pit,p,0e /1 was flow Observed? -- - ,I1.Raw water w 4.Are results co psi 12 Pinho. as pumped into the lire department connection parable in ests? leaks to previous t _ 13 A s°x'^ere„e,n hme..amine b.Post indicatin requirement for water to reach the nspeuor's les<conneaioa t g valves opened until spring or torsion f.If conditions were found[hat required flushing,was felt in the rod then closed back%turn? t.All sprinklers manufactured aher 19Z07 - flushing of system conducted? d.Quick response sprinklers 20 years old or more g Was a valve status test conducted afte,opening any replaced or successfully- uccessfully sample close_ d=alves7 Years? P e tested in the last 10 h.Adjusted,repaired,reconditioned or replaced e.Standard response sprinklers SO /` components had the associated tests and/or replaced or successfull Years old or more inspectlons performed? y sample tested in the last 10 2.Annual in Items(in addition to above items) years? f.Standard response sprinklers 75 a.Operating stem of all OS&Y valves lubricated, replaced or successfully sample tested in the las or t Completely closed,and reopened? years? 1 b.Interior of dry-Pipe valves cleaned? —� c.Low points drained prior to freezin weather? B•Dry-type sprinklers replaced or successfully sample tested in the last 5 mercial years? d.Sprinklers and spray nozzles protecting h.Sprinklers subject to harsh environment replaced or cooking equipment and ventilating systems replaced successfully sample tested in the last 5 years2 except for P bulb typewhich show no signs of grease I.All control valves operated through full range and buildup? returned to normal position? kLow temperature alarms passed test? / .Dry-PiPe valve partial flow tripAny"No"answers•tesr/oilures prof test(unless full trip here,use additional rommrnls/arm her problems/ound with the sprinkler test done) /necrsso sWrem must be erp7oirsed 1.Initial am a about dnythrnp fhof you sow while rY /As o courtesy,note on o sepworr arm an —W scut! -- tncluct pnJarm,nv Your worts fhot,s notop.rrro the NFPA 5r Vrorlrerns ].Initial water pressure n onY rrc- u-lied products that J 7 epurrements �_____ psi vnrr hopp.ned to notice f 3.Valve(ripped a_=,� ` a.Viive vo Os,S.Rewhs comparable to previous[lsts? -- I.Automatic air maintenance devices passed? m.Backflow devices passed forward fr ---- _ ow test? - ----- _n.Pressure.!doling valves Passed partial flow test?4. —a.DYear Inspection -ems(in addition to above items) a.Dry-Pipe valve full flow trip test — - -------- 1.initial air - --------._ Dressure 2.Inrtui water pairressure 3.Valvepped tri __ s - --- ----- pressure ---- a.Valve tripped time 5.Water delivery time si (NFPA 75 does riot.epode 60 see wore.dehve ms -- ry hme) ma --�- 6.Results comparable to wev,ous teas) ---------__�__-- b.Air leakage test passed?S.5-Year Inspection Items(in addition to above items) a.Sprinklers above high_ _temperature tested? b.Gauges checked by calibrated gauge or replaced? c.Pressure reducing vas�ves passed full flow test? store rhorrhrinJam Orion onthis wmr, equrpnienl testedol this time wos le r in rorrecf of the rime and poor.of Ins ---- oA noted in P / opnabnp rondrhon„port com , Y Ihn ion, ,tinnd eR e.Maintenance - —_ err N+—above plefion oI this Inspection e.cept 1.Regular Mai__ate^a^ce Items r•s Inspector(printed —- ---- No N/A a.If any sprinkler tailed the sample testinSignature-andr s were all sprinklers represented by that amp art II.B.3 Inspector Date replaced? A__ �� / -']_ \ b.If sp-- prink�ers have Certification or License Number,if applicable / `I been replaced,were they proper I _ n C.Dry-pipe systems kept in dry condition? Company d.Have auxiliary drains been emptied?o `� — company Address t-'^•2 comment'.Usr mr �. 11 l C 02019 National fire$ 1e t,A,�fAe�ern o additional Co-, /ormf/Or oddrhonol<ommMfi All_ l v p.inkler Atsa<iatwn,91a Prog.ess Drive,Suite A,cmlh,cum M No-answers must aghts,MD 21090 be eaPlomed. www.nfsa.org corm 25DRY vet 2019.11 Sid 2017 Page 2 of 2 All Safe Fire Protection & Mechanical 375 Executive Blvd. Invoice Elmsford,NY 10523 Tel: 888-325-5723 Date Invoice# Fax: 914-747-3983 4/16/2024 60833-PM Bill To Ship To Bellefair Meeting House Belle Fair Kitchen Bellefair Deli&Market 24 Bellefair Blvd. Rye Brook,NY 10573 P.O. No. Terms Project Due on receipt Quantity Description Rate Amount 4-10-24 Quarterly Hood Cleaning 650.00 650.00T 1 -Hood cleaning(Degreased hood,duct,fan,and filters) 0.00 O.00T 6 -Filters cleaned/degreased 0.00 O.00T Please make checks payable to: All Safe Fire Protection & Mechanical Subtotal $650.00 Thank you for your business! 3%Service Fee will be assessed for credit cards Sales Tax (8.375%) $54.44 Please note our change of address effective immediately: Total $704.44 All Safe Fire Protection & Mechanical Payments/Credits $0.00 375 Executive Blvd. Elmsford, NY 10523 Balance Due $704.44 Protecting Life and Property since 1983 Pre-Engineered Restaurant Fire Suppression Systems Report SERVICE COMPANY DATE OF SERVIC TIME y AM PM. ANNUAL SEMI-ANNUAL RECHARGE INSTALLATION RENOVATION X Ce C �- " r > ' V LOCATION OF SYSTEM CVYL/INDERS UL 300 `� CCa(4 p�/iG(�I ❑YES NO MANUFACTURER MODEL NUMBER WET DRY CHEMICAL CYLINDER SIZE MASTER CYLINDER SIZE SLAVE CYLINDER SIZE SLAVE .)�c l y6U CUSTOMER FUSE LINKS 360'F. FUSE LINKS 450°F. FUSE LINKS 500 F. OTHER , �� Name mac% /�OA I% t 5 1,. FUEL SHUT-OFF ELECTRIC GAS SIZE Address �� '��" �r1V�. SERIAL NUMBER LAST HYDRO TEST DATE LAST RECHARGE DATE City Z�i�= C'.>U� State Y ZIP ' ;GA::7_ MANUFACTURER'S MANUAL REFERENCE Telephone Store No. PAGE NUMBER: DRAWING NUMBER: DATE Owner or Manager �IC-oLAS �EQOy A COOKING APPLIANCE LOCATIONS: LEFT TO RIGHT r �� l�rnu,)J 1kez� �hU/- 461r// 1. All appliances properly covered w/correct nozzles 20. Replaced fuse links 2. Duct and plenum covered w/correct nozzles �_ 21. Check travel of cable nuts/S-hooks 3. Check positioning of all nozzles. 22. Piping&conduit securely bracketed 4. System installed in accordance w/MFG UL listing _ 23. Proper separation between fryers&flame 5. Hood/duct penetrations sealed w/weld or UL device _ 24. Proper clearance-flame to filters 6. Check if seals intact, evidence of tampering �_ 25. Exhaust fan in operating order 7. If system has been discharged, report same 26, All filters in place 8. Pressure gauge in proper range (if gauged) _� 27. Fuel shut-off in on position _L. 9. Check cartridge weight(If applicable) ., 28. Manual & remote set/seals in place 10. Hydrostatic test date 29. Replace systems covers 11. 6 year maintenance date 30. System operational&seals in place _ 12. Inspect cylinder and mount 31. Slave system operational _ 13. Operate system from terminal link __7L_ 32. Clean cylinder&mount �- 14. Test for proper operation from remote 33. Fan warning sign on hood 15. Check operation of micro switch 34. Personnel instructed in manual operation of system T 16. Check operation of gas valve 35. Proper hand portable extinguishers _ 17. Clean nozzles _ 36. Portable extinguishers properly serviced 18. Proper nozzle covers in place _ 37. Service& Certification tag on system 19. Check fuse links and clean NOTE DISCREPANICES OR DEFICIENCIES BELOW COMMENTS:*4�_711 :.n'd, Drops NLL 7ce 44 _�� aYe o f- cr/' -,� w r f�+ 2 yr .�c� � �' 2 I� 4?4 6-,(,4 A (c ;5 ;� 4x�r��f --- 51-A e - ,jlo2Z.IG5 4. ae (uce -Po f- 7-9) .St c,,, ►L `LuY-Ier(1 L k3 y- it e 1 H �`it I H -- d dk- -- _ - On this date, this pre-engineered fire suppression system was inspected and operationally tested in accordance with the fire suppression system requirements of NFPA17 or 17A, 96 and the manufacturer's manual with the r sul s indicated above. / SERVICE CHNICIAN PERMIT NO. DATE: TIME: AM PM CUS PSAUTHORIZED AGENT The above service technician certifies that the system was personally inspected and found conditions to be as indicated on this report CUSTOMER COPY LLATION-PORTABLE EXTINGUISHERS AUT CODE 96 ALL SAFE SPRINKLER ROSERT SERVICE SYSTEMS EXHAUST CLEANING A EXIT LIGHTING-TMOERG EMERGENCY LIGHTING BATTERY BACK UP SYSTEMS FIRE ALARMS•BACK FLOW TESTING IFUM ® 375 Executive Blvd. • Elmsford, NY - 10523 • TEL 1-(888) 325-5723 • FAX (914) 747-3983 KAMCAJL INCLicensed in NY, CT, Ll & NJ www.allsafefireprotection.com N O 167091 Customer Name: /el Fa i r k e lw 7 r-ke Arrival Time: - — Departure Time: •' � �"-- Address: 2`-f 34- /e-f-ct - r t__-_�I✓ Bill To: N/Town, r�rb o k Address: v State: lU 7 Zip. r06 3 Phone #: • Zip Code: Phone #: E-Mail: Contact Name: Ill l(.A IDS DATE: 4 ANNUAL SERVICE❑ SEMI-ANNUAL❑ MONTHLY❑ NEW ACCOUNT❑ EMERGENCY CALL❑ CITY. EXTINGUISHER LOCATION RE- SERV. Hydro T TAKEN NEW RETURN REPL. 6 YR. AMOUNT CHARGED eCh9 EXT.LFT. MAINT. 2.5 ABC 2.5 ABC oe 5 ABC %� �,�� c ��+✓SG Zo S 10 ABC Aejow Se- / Z L O 10 ABC 20 ABC FIRE SYSTEM I'OCG�e C1126 ERE -STEM Z CLASS k�'�GG, CLASS K J Z EMG.LIGHTS Z ff-e Y s OV ze lI/ PW hb d o 's l f a c Z3 2 WHEELED UNIT 9E FIRE HOSE S Ab AOA 24 COVERS Aw- 'q4 S A) Z j 74, e CABINETS � &a.(. YO ( ) , �(1 ZZ I c. l z . C�( Pulleys gfI- E,Ht I PAR (Zp OL)kI/ IH�)c BULBS BATTERY,S HOOD JARS LINKS CARTRIDGES CAPS STRAPS WIRE LEADS S/S DIVIDERS VALVE STEMS PINS O RINGS SAFETY DISKS BRACKETS SIGNS GAUGES DETECTION AMT. TEES CONDUIT CARTRIDGE IN OUT NOZZLES AMT. O GUAGE PIPE TAGE YES NO NO GAS VALVE TYPE CART WT MANUAL PULL HOOD AND YES NO DUCT PIN (IN)0(OUT) MICRO-SWITCH REMOTE PULL 0 GEXCESS REASE YES NO 0 I AGREE THAT THE ABOVE INSPECTION PROCEDURES ` ❑ ® ❑ TERMS:C.O.D. ❑ PAYABLE UPON RECEIPT OF INVOICE❑ HAVE BEEN COMPLETEDIDELIVERED. ❑PARTIAL ORDER ❑ ORDERED 1COOMPLETE CREDIT CARD TECNICIAN SIGNATURE and l-cxZ4oZ CUSTOMER: PRINT NAME _ ^ _'6 PRINT NAME HOOD CLEANING REPORT Job Name: Llk4 1 'bQ�E -,�, —On Al-(—� Tech: ��L I do Start Time: Complete Time: 1p Date: hez 2 Pre-Cleaning Checklist All Exhaust Fans Operating and in Good Condition Yes �❑ NN * All Areas Accessible: ❑ Yes 1 No* Overall Grease Condition P,1<ornjal ❑ Heavy* Hood Lights Operating: 11,Xs ❑ No* Cracked Globes: ❑ Yes o* *Explain: Authorized Signature: Services Performed Mainline—Backline—Oven—Wok—Grill—Fryer—Pizza—Wood Hoods Cleaned Total Number Ducts Cleaned: Yes Qty: Z ❑ NN Fans Cleaned: ❑ Yes Qty: o* Filters Cleaned: es Qty: ❑ No* Misc.Cleaned: q,,xs Qty: �Q❑ No* *Explain: i I( 1 O ��- Post Cleaning Checks Fans Operating and Left Running for 24 Hours: ges ❑ No* Wiring Correct Length: �❑ /Yes ❑ No* Gas Line Reconnected: ❑ No* Wiring Waterproof: (�,,�V/ Yes ❑ No* Fans Hinged Properly: ❑ No* Wiring:No Bare Wire �es ❑ No* Floor Cleaned: Les ❑ No* Appliances Reconnected: 8' Yes ❑ No* Filters Proper Quantity and Type: es ❑ No* Access Panels Installed Properly: ❑ Yes ❑ No* Exhaust System Water Leaks: o ❑ Yes* Pilot Light Relit: Yes ❑ No* Spark Arrestors for Woods: !s ❑ No* Need Additional Access Panels: Cl No ❑ Yes* Fan Maintenance Needed: "ts ❑ Yes* If needed Size Qty Grease Collector Box: ❑ ❑ No* *Explain: Fire System Service Date: By whom: Additional Comments: lkthroug : ❑ �es ❑ No *Explain: I re w rk and ate if yo a sa ' e r'ob e Yes ❑ No *Explain: ho Z Authorized Customer Signature Date 20120710 CUSTOM, 0 Copyright 2012 Heiser Logistics �y B JUSTICE COURT OF THE TOWN OF RYE STATE OF NEW YORK: COUNTY OF WESTCHESTER ----------------------------------------------------------------------------- X >��• t9 PEOPLE OF THE STATE OF NEW YORK, -against- N o. 1380 Defendant. --------------------------------------------- X Be it known that 1, -\�'�e -p er ,the complainant herein and duly authorized C de E}�rceme Officer of e,Village of Rye Brgc ,do hereby accuse the defendant(s)n'a med above,residing at Cie ��7t `` tC'� who is the, c�,JCtCSA f the property at which the following offences were committe ,at, G 1� \ � ,in the Village of Rye Brook,State of New York,on the,��_day of, c C� 20� at or about 15 '? o'clock. COUNT ONE: thew ` c( Y- ^" t ` c C- Cy�Q `o n TO WIT: 1 `J ` o_I Yl \ \V (Q C %rC, C�QS- COUNT TWO: c C C »L IA C) TO WIT: a v V NeO c!J `l�2 COUNT THREE 00 TO WIT: k / `l�� \ \ 'UV VV' ) IC- I1`l• '�` 1. 1UC0 -O All of the above is contrary to the provisions of the statute in such case made and provided.The above allegations of fact are made by the complainant herein on rect knowledge (an upon inf rmatio and elief),the sources of which being an inspection(s)on, -�(� �n. and �.� -I �U - Any false sta ements made herein are punishable as a Class"A"Misdemeanor to the N l iDated Code Enforcement Officer APPEARANCE TICKET You are hereby directed to appear before the Rye Town Justice Court,350 North Main Street,Port Chester,New York 10573 (Phone#914-939-3305)at 9a.m.on the 1 W^ —day of in connection with your alleged commission of the above described offense. NOTE: UPON FAILURE TO APPEAR A WARRANT MAY BE ISSUEQ FOR YOURARREST V2 1 Z Dated Code Enfo ement Officer �yE 6RC�v� Certified Mail ❑ BUILDING DEPARTMENT Hand Delivered ❑ VILLAGE OF RYE BROOK 1982 ' 938 KING STREET • RYE BROOK,NY 10573 (914) 939-0668 FAx (914) 939-5801 www.ryebrook.org NOTICE OF VIOLATION AND ORDER TO REMEDY SAME OWNER: Violation#: 2 011 NOTICE #: The following violations of the Code of the Village of Rye Brook, and/or the New York State Uniform Fire Prevention & Building Code (NYSUFP&BC) were found to exist at. . . parcel I.D. # located in an, zone, in the County of Westchester, Village of Rye Brook, NY on, 20 at o'clock AM / PM ; CODE SECTION TITLE/DESCRIPTION ---- -------------- ---- 1— -- ------ ------- ------------- - 1 - --- --- --- t <� e ---- -------------' ------- 1_�° -------- v -------------------------------------------------- � -' --` -----------------------------------------------------------------------�1fc c� ---C-Q_,,)�A---------------- -- ----------------------------------------------------------------------------------------------------------------------------------- ----------------------------------------------------------------------------------------------------------------------------------- ----�r�+,� ----.�-`1�---------\-`-----------------,-;Y�-----,f-.-------f{---- ------------ Notes : You are hereby directed to contact the Building Department, obtain all necessary permits and commence to correct the above captioned violation(s) immediately. Violations of the NYSUFP&BC must completely be remedied by, ► 1 \ l which is thirty (30) days after the date of this notice and are returnable at the rate of $1,000.00/day for each day of the continued violation, or imprisonment not exceeding one year, or both. A RE-INSPECTION OF THE PREm&ws IS REQUIRED BY LAW TO CONFORM COMPLIANCE wrof I'HI,NOTICE&ALL APPLICABLE CODES. FAILURE TO COMPLY WITH THIS NOTICE IS A CRIME PUNISHABLE BY I PRISO ENT OR BOTH. ❑ BUILDING INSPECTOR ❑ ASSISTANT BUILDING INSPECTOR ❑ CODE ENFORCEMENT OFFICER VILLAGE OF JKYE BROOK BUILDING DEPARTMENT / SAFE,DOUSING TASK FORCE 938 KING STREET,RYE BROOK,NEW YORK 10573 (914)939-W8- X(9A4)939-5801 www.rysbit©k.org Michael J. Izzo Steven E. Fews Building& Fire Inspector Assistant Building Inspector mizzo(&Kyebrook.org stevefewsa,!yebrook.org REFERRAL FORM To: P.C.F.D. /R.B.F.D. From: Michael Izzo In our ongoing efforts to promote public safety throughout Rye Brook, should any unsafe or questionable condition be observed during your regular tour of duty, please notify the Building Department using this referral form. Please provide a brief description of the conditions, the location, date & time observed, and forward this form to the Rye Brook Building Department for further investigation and corrective action. Some typical conditions may include: )0- Unsafe or non-permitted construction activity; unsafe or improper storage/use of construction materials or equipment; unsafe storage of flammable liquids or combustible materials. ➢ Possible residential overcrowding; all rooms converted to bedrooms; questionable basement or attic apartments; multiple kitchens; multiple mailboxes, excessive cars parked on property. ➢ Unsafe or unsanitary conditions; unsafe electrical or mechanical equipment; leaky plumbing; inadequate/inoperable sanitary facilities; excess mold/mildew condition; rodent/insect infestation. ➢ Inadequate fire protection systems; fire alarms & strobes do not sound or flash; missing or damaged smoke detectors; fire sprinkler, standpipe, hose cabinets, ANSI, or other fire protection system damaged or disabled; missing, outdated or discharged portable fire extinguishers. ➢ Exits & exit stairways blocked; exit doors locked; combustible material stored in exit or exit stairway; exit signs not illuminated; inadequate emergency lighting; accumulated snow or ice in exit discharge. -------------------------------------------------------------------------------------------------------------------------------------- Address: 20 Bellfaire Blvd . Date: 1/ 13. 1/14/2022 Time: 22:14hrs, 06:48hrs Numerous housekeeping issues including combustible storage stored against heating units, open electrical wires from light fixtures in prep room, appliances daisy chained together, emergengy egress blocked with garbage and waste oil from fryers, ongoing issue with alarm system regards to placement of smokehead between two air vents which keeps activating Submitted By: Christopher D Calamari Badge #3 Revised 4/19/10 A 0 O= CL a • m \—i • e o a 8 & � 2 a `rn `rn C pp rn o ti ;m ia 0 • ❑❑❑❑❑d m" 1 1 T'7A 1 N > ® O O Q C rn Ci 70 o n� ❑ ❑ wf� UVD is gaDi a,ci mw� Q O o F, o�rn�¢ u E 3 a`¢Era' n E EC O N Z N C • w �� ? N Z 2 mm > o N _ d N c ¢ N � N U 9 Y Q N > N N � � N N Q > a a > .. moi tV > u ~ C C��C O m U a)- U _ N (n N= Z+.« •- N to Q m O �Qmqq..��000C O C-5 11 110 f� a> o Ir c N � i_- 0-' c (a � O O a d .� N I Ir c E 1( • a) i (U c C 2 Y v O O C _ r ri ° Y � ' 7 a o m F n 'o= a \\ : O ro ro C a) WU L 4 - n (aw o N c _ • U U U m m r a i E c ro o u �__ o c� a` 0Qoa a Li r;X1 N a U3 LILI) U ox 0 od 0 co Q) Z U)co o CO (L) c LL 0-:D a. 'IT + a- N -0 ce) C: m LO 0 z (D LLJ 0 - 2 .j� sY CU- ly 00 -1: E Lli M CL �o FLU w D 0 LLJ z 4a co ru (2) En m _q co Ln IL ca Lij L: _0 L m U) L) m m -0 ru W ED to Ir CD cn co Ir, Ln (j) 0 CL Qy� BRnv� V 190 C�at� ye vy y� O� VILLAGE OF RYE BROOK MAYOR 938 King Street, Rye Brook,N.Y. 10573 ADMINISTRATOR Jason A. Klein (914) 939-0668 Christopher). Bradbury www.ryebrook.org TRUSTEES BUILDING & FIRE INSPECTOR Susan R.Epstein Steven E. Fews Stephanie J. Fischer David M.Heiser Salvatore W.Morlino December 14,2023 Via Pt Class Certified Mail BelleFair Kitchen C/o Mr.Marco Monroy 20 BelleFair Boulevard Rye Brook,New York 10573 Re: BelleFair Kitchen,20 BelleFair Boulevard,Rye Brook,New York 10573 Dear Mr.Marco Monroy, It has come to the attention of the Building Department that it has been over one year since you applied to renew your Operating Permit for the subject Place of Public Assembly,and as such your Operating Permit is now expired.Please note that the Code of the Village of Rye Brook requires that your Place of Public Assembly hold an Operating Permit,and that such permit be renewed by you annually.Please note that in order to renew your Operating Permit,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 twelve (12) 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 annual Fire Inspection with the Building Department by no later than, January 14,2024,which is thirty(30)days after the date of this notice.Please note that the property owners notarized signature,as well as the business owners notarized signature must appear on the application form in the appropriate spaces. Upon successful completion of the Fire Inspection,you will be issued a renewed Operating Permit valid for one year. Please remember that you must renew your Operating Permit every year 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 Operating Permit. Thank you. Steven E. Fews Building&Fire Inspector stevefewsQyebrook.org cc:Laura Petersen,Office Assistant cc:Alfredo DiVitto,Assistant Building&Fire Inspector /to BUILDING DEPARTMENT E� �D ( ��n VILLAGE OF RYE BROOK I v ED 938 KING STREET RYE BROOK,NY 10573 JAN 16 2024 (914)939-0668 www.ryebr_ ook ory VILLAGE OF RYE BROOK BUILDING FIRE INSPECTION / OPERATING PERMIT APPLICATIONM__ FOR OFFICE USE ONLY: / +30PA4 Fee Paid: S `� Inspection Date&Time: 0'Xj'7N 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: / /1- is hereby made to the Building Inspector ofthe Village of Rye Brook NY,requesting that a Fire Inspection a cond cted 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. .v y/os33 1. Address: ga &Z.e.cC..4lL 4010 t=&'46BL: a'y -73 — —6/ Zone: l/v 2. Business/Occupancy Name: ,Q ,/�/TCv-2 NYS Use Class: 3. Property Owner: f f'AiLo / a(Uf pWV /41SAddress: eTAL_-, 1P_ &0,0 Phone# /'y oe Cell # email: 4F"c/_ e i 05?3 5. BusinessOwne : `C;Q/Y6") 6(,YJAL&1' X -C Address: Phone# �s��Fi� y/y �o Cell# `71, ypy 3y Sz email:(dtddy�,o�Qllirec�c v 'y �l sob' 3 6. Emergency Co tact: ��yi� /�foy,�r(� -Address: .J� Phone# /al ©o email: '7- Cell# GT o�-EP 7. Inspection Escort: Title: Phone#: Cell #: email: 8. Provide a brief description outlining the current and /or intended use of the property: 9. List all Hazardous Materials: 10. Occupant Load: Existing: Proposed: Other: 11. Date& Disposition of Previous Fire Inspection: 2 Zv 2 ❑ Pass [�<Fail i 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. ********************************************************************************************************** STATE OF NEW YORK ) /—(print UNTY OF WESTCHESTER ) as: being duly sworn, deposes and states that he/she is the applicant above named,name o individual signing application) and further states that he/she is the legal owner of the property to which this application pertains,or that he/she is the 5f �jC 8 for the legal owner and is duly authorized to make and file this application. That all (indicate itect,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. Sworn to before me this Sworn to before me this day oft , 20 day of 120 ,a, Notary Public ota Publi Signature o erty Owner nt o tK, o4 (-f(-e.-S Print Name of Property Owner Pr nt N e of Apph nt �A4 Maanr� 1 8 lz'zozi BUILD :Ry TMENT VILL O OOKInitial Inspection Date: ❑ Pass MICHAEL J.IZZO 938 KING S R EW YORK 10573 2 U\�9Z Fail BUILDING&FIRE INSPECTOR (914)93 - 4) 39-5801 Re-In section Date: ❑ Pass mizzoCo)rvebrook.org �117 `�— ❑ Fail FIRE INSPECTION REPORT, NOTICE OF V/IIOLnATION & ORDER TO REMEDY SAME` Site Address: C) Qp)�Cjr, `��\'' / ` �neC SBL: Occupancy. Cl k (- t TC State Use Classification: Business Owner: n- n Phone: t �� �� t c �� S 1\ Phone: Z— Building Owner: Emergency Contact: ). Phone: 1rN'r C U Building Representative in Attendance: CY _ -------------------------------------------------------------------------------------------------------------------------------------------------------------- Take notice that the following violations of4e New York State Uniform Fire Pjjventio uilding Code and/or the Code of the Village of Rye rook were found to exist at, �� _ e��. Va` +.5 y ,in the Village of Rye Brook,NY on, 20 Thgperspn or entity served with this Order to Remedy must completely cure each .> i� Z��2--Z___ ,which is thirty(30)days after the date of this Order to violation described in this Order to Remedy by Remedy.You are further directed to 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._ k 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._ v 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.907.4.1 Are manual pull stations located within 5 feet of exits&within 200 feet of each other. b. c.907.4.2 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. 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.z- d.901.6.1 Is a supply of six spare heads&a wrench maintained on the premises. e.901.6.1 Are sprinkler heads&cover plates unfinished or of factory applied finish only. f.901.6.2 Are records of all system inspections,tests&maintenance reports maintained on the premises. f 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._ -1Z _ 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. k.901.8 Are all fire protection systems in place and maintained untampered. k._ ✓ — / a INSPECTOR: `✓ DATE: 4- Revised 1014/17 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. _ v� b. 901.6.1.Has the required flow test been performed within the past 5 years as per NFPA 25-14. b. _ L.- 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. _ L� _ f.912.2.1.Are exterior FDC's fully visible&recognizable from the point of fire department access. f _ 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.X 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. eX f. 1004.3.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. h. 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. i__� 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. X_ 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. _ 1/ 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. and 18"or more below sprinkler head deflectors in sprinklered buildings. f. 315.2.2.Are exits&exit enclosures maintained free from stored combustible materials. f. g. 315.2.3.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.Are emergency&standby power systems properly maintained. a. b.605.1.Is the building free from modified/damaged wiring,devices,appliances,equipment and b. _ maintained free from electrical hazards. c.605.2. Are electrical service equipment areas properly illuminated. C. _ ✓ d.605.3.Are proper working space clearances provided&maintained for electrical service equipment. d. _ !/ e.605.3.Are electrical service equipment working spaces free from any stored materials. e. f. 605.3.1.Are all electrical control panel room doors,panel boards&disconnects properly labeled. f. g.605.4.Is the building free from unfiised multi-plug electrical adapters. 9;E h.605.5.Are electrical extension cords being used in a safe manner as per code. h.,:�% _ i. 605.6.Are all junction, switch&outlet boxes fitted with approved covers or plates. i. Xt _ j. 605.6.Is the building free from open-wiring spliced electrical connections. j. k.605.8.Are electrical motors maintained free from accumulated oil,dirt&debris. k. 1. 915.1.Are Carbon Monoxide Detecto talled&maintained as required by this section and by 1103.9. 1. IN DATE: �� \ 1 Rcvised 10/4/17 -2- No YES N/A 8.ELEVATORS.DUMBWAITERS&ESCALATORS a. [PM]606.1.Are elevators properly maintained,and is the current certificate of inspection on the premises.a. _ _ b. 607.3.Are approved standardized,pictorial signs posted adjacent to each elevator call station on all b. _ _ floors reading; IN FIRE EMERGENCY,Do No-i'USE ELEVATOR,USE EXIT STAIRS c. 607.7.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. e. [B]3005.1.Are elevator machine room doors maintained unobstructed at all times. e. _ _ 9.COMMERCIAL KITCHENS a.904.12.5.Are portable Class K fire extinguishers within 30 feet of cooking equipment. a. _ b.904.12.6.Is the fire protection equipment inspected,tested&maintained as per Section 901.6. b. _ c. 904.12.6.2.Are automatic fire extinguishing systems serviced at least every 6 months&after system C. activation,and is the certificate of inspection forwarded to the code enforcement official. d.904.12.6.3. Are fusible links&automatic sprinkler heads replaced annually. d. _ _ 10.HEATING SYSTEMS a.[PM]603.1.Are all heating appliances properly installed&maintained in a safe working condition. a. _ _ b. [PM]603.2.Are all fuel-burning appliances&equipment connected to an approved chimney or vent. b. _ 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 combustible materials kept at least 10' from fuel-handling equipment. f. _ g.2306.4.Are above-ground tanks provided with vehicle impact protection. g. h.2306.5.Are above-ground tanks provided with secondary spill containment. h. _ _ 12.HAZARDOUS MATERIALS(HAZ-MATS) c. 407.2.Are M.S.D.S. for all haz-mats readily available on the premises. a. _ d. 407.3. Are spaces and individual containers containing haz-mats properly labeled&identified. b. _ e. 5004.2.Are stored haz-mats provided with approved secondary spill containment. C. d.5003.7.1.Are proper No SMOKING 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. ,V 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. _ 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. _ _✓ 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 HOUSEKEEPING a.Good b.Fair c. Inadequate d.Poor INSPECTOR: DATE: teMxd ta4m -3- ITEM NUMBER REMARKS S �PC j lco N �� ��_ rr S �-0� h pc vVIP (� Q C7 c to u c e— f, G y ou c k— C ci cc-y X.tG CA S2 c L' r1 VA cU c�;� f-�JQQ- _a SO 04 Qs �( � I M ASS' C` C f � %;: , i C� ( C1 r-c. INSPECTOR: +_ V �' DATE: Revised 10/4/17 -4- D LEE, ; EE_-, BUILDS H*PARTMENTjD VILLAGE OZ~.'RYE13PLOOK FEB - 1 2022 938 KING$T> RytBRoib» NY 10573 4�_9 flb8. VILLAGE OF RYE BROOK w�w:ryebr-ookcor� BUILDING DEPARTMENT FIRE INSPECTION / OPERATING PERMIT APPLICATION FOR OFFICE USE ONLY: / - 3014pif Fee Paid: $ Inspection Date&Time:-7;�llrS(Y//-y )ce aDaa FEE SCHEDULE: Re-inspection Date&Time: Triennial &Private School Annual inspection: =$450.00 Public Assembly Annual Ins ction: <100 People=$525.00/>100 People=$775.00 *********************Application,dated: Z / ,is hereby made to the Building Inspector of the Village of Rye Brook NY,requesting that a Fire Inspection be&nducted 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. 1. Address: ,� Q XIZj"Ite 400 F � I�SBL: I-PY,7.3 --c)-IOJ Zone: 2. Business/Occupancy Name: - wrt"A t2 NYS Use Class: 3. Property O�wner: ,U.FFn/e n0,'OWVrc5 A SSoC' Address: �i q k—/� le- 4✓o 9'��� Phone# c//y 6W /3 Cell# email:,2A-Ar/- /7 4'S c 5 "60 c/�M 5. Business Owner: f�`C',LMQ,y �o(J �'T � Address: ��'��l /�' �� .l3ZT = ? Phone#Tl/ l .739 23 70 Cell# 9/�S/�Y9V39 5Z email: 6. Emergency Contact:T Ail f/o 'Vl1,()f1_0 V Address: �� �8 F 4 N �fa-�gy A�� e7 Phone# Cell# email: �ry�►50� C��yJ�/•� . c oyJ 7. Inspection Escort: Title: Phone#: Cell#: email: 8. Provide a brief description outlining the current and/or intended use of the property: f e AW •4 Tz 5 S r..C� 9. List all Hazardous Materials: ) 10. Occupant Load: Existing: Proposed: Other: 11. Date&Disposition of Previous Fire Inspection: Q Z c' Tl-- ❑ Fail s/tv2o21 r 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 ) CO OF WESTC ESTER ) as. 1,0ev 11r(Af'c jcrJ ga-t&e- I �:cy z S Caw• t e(/Ic�✓w� , i�s being duly sworn,deposes anWL d states at he/she is the applicant above named, trint name of indiv' ual signing a lication) d further statesthat he/she is the legal om7r of the ropertXV which this application pertains,,or that he/she is the ,!i t//,c-r-4� Y- Ffd�v;�,.�.e.�t f.f0c'i c: �/c ' (.r! the legal owner and is duly authorized to make and file this application. That all (indicate architect,business owner,attorn ,agen etc.) statements contained herein are true a 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 S Sworn to before me this S day of Fe-hr(,", ,20-'A day of � '�` �.� 20 2 )�,(, 'Notary Public Notary c 1J g aTure of Property Owner o ppli t 94^ /k s Print Name of Prof e O er C �v ��� � 'nt Name o Ap licant � /7 00 a4ZL MICHAEL A. MICMAIL&NAl�O Notary Pwft Notary PubNq>�� Reg. IrO. Rep. No. a Qualified b Oualflied M Wee1dON "(;ourMl Commissfofl M '!: 3 Commission Expires March IS.2 ' 2 S/12=1 • � J W � �� `G� O `G - WN OG O O o I rs'►o z`a � -- XX I '�b r X Won = a g S d 3 Qo YIOOp 511ELVE5 o oAYI@Ma M01 _ I �1 yQD i I r X to fl {r I11 {L 9-z at r----' Imo--_-- - II It _ ------� wit — II II 11 II fV oz; Ow N m h C� N N nrR ,ids I L.[1r m ©v, w z Lai � J_ m