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1932 BUILDING DEPARTMENT
❑BUILDING INSPECTOR
VAsSISTANT 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 : / U IC DATE:
PERMIT# V7ruQ � -J SPPC iJ+�ISSUED: SECT:�421�-5-9 BLOCK: LOT:
LOCATION: n n,`1�n n • `—Wl� k outs OCCUPANCY:
❑ VIOLATION NOTED THE WORK IS... ❑' ACCEPTED ❑ REJECTED/ REINSPECTION
❑ SITE INSPECTION REQUIRED
❑ FOOTING
❑ FOOTING DRAINAGE
❑ FOUNDATION
❑ UNDERGROUND PLUMBING NOTES ON INSPECTION:
❑ ROUGH PLUMBING
❑ ROUGH FRAMING
❑ INSULATION p P
❑ NATURAL GAS �I (� fi�Sl �C �JJ FOLLOLi
❑ L.P. GAS
❑ FUEL TANK
❑ FIRE SPRINKLER
❑ FINAL PLUMBING /
❑ CROSS CONNECTION A r/o.�J S6KAV /L
❑ FINAL
❑ OTHER
BUILD TMENT
VILL OF R OOK Initial Inspection Date: ❑ Pass
S MV e V 1 5 938 K NG ST RYE BROO EW YORK 10573 -Z 5�- ZcJZ Fait
BUILDING&FIRE INSPECTOR (914)9 rook.or Re-Inspection Date: ❑ Pass
7• 19132 �— Z�- Z°L ❑ Fail
FIRE INSPECTION REPORT,NOTICE OF VIOLATION & ORDER TO REMEDY SAME
Site Address: 9 L7—II �J ��4 c7.) W I ' � e�. Zone: 3s- SBL: ? "/-
Occupancy: / `7-,,tlr7 d 2 2 On K C� 1,4 L State Use Classification:
Business Owner: 1�LI L �'LLA Phone:
Building Owner: PAL t .) �_ l� Q(nn� ,L C0� b Phone:
Emergency Contact: Z z U � l-t C ,^, n, U 6e t Phone: Z 03- Z S 7- D/-2 O
Building Representative in Attendance: O e 1 '�) k ► r •� S / — ���3 S - /%l
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Take notice that the following violations of the New York State U iform Fire Prevention&Building Code and/or the Code of the
Village of Rye Brook were found to exist at, DS7 A.]�.A.-,<<h N 1 LL t2 or ,in the Village of
Rye Brook,NY on, A Pk, I 1 _ 2 y 20 L_.The person or entity served with this Order to Remedy shall
immediately commence to rrect all listed violations and shall completely cure each violation described herein by no later than
2 1,4 e Z 'y 202 V ,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.
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No YES N/A
1.PORTABLE FIRE EXTINGUISHERS (PFE'1s)
a.906.1. Are PFE's installed throughout the space&on the premises as required by code. a.
b.906.3.1.Is the maximum travel distance to a PFE 75 feet or less. b.
c.906.5.Are PFE's conspicuously located&readily accessible. c._ woo'
d.906.6.Are PFE's unobstructed/unobscured from view. d._ y0o' _
e.906.7.Are PFE's properly mounted as per the manufacturers instructions. e._ ,G
f.906.9.Are PFE's properly installed:<40 lbs.max.5'above floor;>40 lbs.max.3.5'above floor. f._ Z
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.907J.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.—
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&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._
INSPECTOR: �� �� �� DATE:
-I-
RevLwd 2/10/22
�wlwww�-- .............. Ir.....
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.
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. _
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. _ 7
1. 1018.3.Are public aisles in group B&M occupancies maintained at least 36"wide where fixtures
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 M. _ ✓ _
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.✓_
d.604.3.Are electrical service equipment working spaces free from any stored materials. d. ✓ _
e.604.3.1.Are all electrical control panel room doors,panel boards&disconnects properly labeled. e._ ✓
f.604.4.Is the building free from unfused multi-plug electrical adapters. f. _ ✓
g.604.5.Are electrical extension cords being used in a safe manner as per code. g. ✓
h.604.6.Are all junction,switch&outlet boxes fitted with approved covers or plates. h. V" _
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._ 7 _
k.915.1.Are Carbon Monoxide Detectors installed&maintained as required by this section and by 1103.9. k._
INSPECTOR: �``�- �1 I'� DATE: J - Vg
2
Revised 6/11/2020
No YEs N/A
8.ELEVATORS.DUMBWAITERS&ESCALATORS
a.[PM]603.1.Are elevators properly maintained,and is the current certificate of inspection on the premises. a. _ _U./ _
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. L/ _
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.
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.[RBI 122-5.B.Are grease traps provided and installed as required by Village Code. e. _ voo' _
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. _ L/
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-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.
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. Vol
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. _ 1 —
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. _ 0/ _
b.407.3.Are spaces and individual containers containing haz-mats properly labeled&identified. b. _ _✓ _
c.5004.2.Are stored haz-mats provided with approved secondary spill containment. C. _✓ _
d.5003.7.1.Are proper No 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. Vol
b.405.1.Are emergency evacuation drills conducted at the intervals as specified in Table 405.2. b.
c.405.5.Are records of emergency evacuation drills kept&maintained on the premises. C.
d.505.1.Are approved address&building numbers properly placed&plainly visible from the street. d. _ ✓ _
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. L I�
14.GENERAL HOUSEI EPING
a.Good
b.Fair
c. Inadequate f u
d.Poor INSPECTOR: f DATE: y- Z /- 202
-3-
Revised 9/17/21
ITEM NUMBER REMARKS
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INSPECTOR: DATE:
-4-
Revised 6/II/2020
Quality Elevator Inspection Inc.
Quality Elevator Inspection Michael A Byrnes
P.O. Box 563 QEI Inspection Supervisor
Millwood NY 10546 NAESA C-4063 & QEITF E-000283
50 Years' Experience,there is no Substitute Tel(914)924-8563 fax(914) 762-0296
Email mbgeiaaol.com
August 2,2023
Blind Brook Club
980 Anderson Hill Rd.
Purchase NY 10577
On August 2, 2023, at your request,Quality Elevator Inspection witnessed a Code required Category One
test on a Hydraulic Elevator located at Blind Brook Club, 980 Anderson Hill Rd. Purchase NY 10577.
The test was performed by ThyssenKrupp Elevator Mechanics. The test was performed in compliance
with the rules and regulations of the American Society of Mechanical Engineers,ASME A 17.1 Safety
Code for Elevators and Escalators.
Car 1,ThyssenKrupp Endura TAC 32 SN#EFL691, 3 Stop, Capacity 2100 lbs. 125 FPM
Had the following Violation
ABC Type fire extinguisher is Needed in the Lobby of Floor 1/Control Space
If you have any questions or concerns, feel free to contact me at your convenience.
Sincerely,
Michael A. Byrnes
QEI Inspection Supervisor
Pre-Engineered Restaurant Fire Suppression Systems Report
- - - - -
SERVICE COMPANY DATE OF SERVICE TIME A.M. P.M.
�v �2 Z ✓
`l �✓c% PV 0 �L�. O r ANNUAL. SEMI-AN UAL RECHARGE INS ALLATK)N RENOVATION
V LOCATION OF SYSTEM CYLINDERS UL SW
EaVI4
No
I�,.�.5 ' v - V �/Z MANUFACTURERI V`CY i O C� ❑
�� n ` MODEL NUMBER /WET RY CHEMICAL
VV hQ/v�/1 -_ ✓
��tf C NDER SIB MASTER CYLINDER SIZE SLAVE CYLINDER SIZE SLAVE
pit--L+0 0 5�e,�- �v & ---
__ _ FUSE LINKS 380°F. FUSE LINKS 460"F. FUSE UNKS 5W.F OTHElop R
CUSTOMER 1
Name �%ka ) O 0 (_ I FUEL sr+uTOFF ELECTRIC - Gas- slz�
Address O�L0 `zL,S/\ 11) R- ---
n SERIAL NUMBER LAST HYDRO TEST DATE LAST RECHARGE DATE
y }�� v r✓� '� _ _ State ZIP 2 Z.o V (,p
MANUFACTUR 5 MANUAL REFERENCE
Telephone���CA 5-14�?U Store No.
nn PAGE NUMBER: DRAWING NUMBER: DATE
Owner or Manager -_ !-1 V+r�✓1 - -. . -
COOKING APPLIANCE LOCATIONS: LEFT TO RIGHT
'�
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
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 seats intact,evidence of tampering ✓ 25. Exhaust fan in operating order lr
7. If system has been discharged,report same '� 26. All filters in place
S. Pressure gauge in proper range(If gauged) ✓ 27. Fuel shut-off in on position
9. Check cartridge weight(If applicable) 28. Manual&remote set/seals in place
10. Hydrostatic test date 7-10 P�-2dv 6 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 L/ 32. Clean cylinder&mount 4�
14. Test for proper operation from remote L/ 33. Fan warning sign on hood v
15. Check operation of micro switch t/ 34. Personnel instructed in manual operation of system +/
16. Check operation of gas valve `� 35. Proper hand portable extinguishers v
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:
On this date, this pre-engineered fire suppression system was inspected and operationally tested in accordance with the fire
ppression system requirements of NFPA17 or 17A, 96 and the manufacturer's manual with tge-results indicated above.
_F�w _3
\J 6k� C,,j\ V-&, T _
SERVICE TECHNICIAN PERMIT NO. DATE: TIME: AM PM CUSTOW-WS AUTHORIZED AGENT
The above service technician certifies that the system was personally inspected and found conditions to be as indicated on this report.
CUSTOMER COPY
Remittance Section
tee:aenn°sai�: Account Number: 85111
Invoice Number: x-2845850
Work Order Number: F1994164
PO BOX 36014, Newark,NJ 07188-6014 Location: 61
Invoice Date: 05/15/2023
Return Service Requested Invoice Due Date: 06/14/2023
Total Due: $1,351.32
Amount Enclosed: $
Make checks payable to Trans-Clean
TRANS-CLEAN
BLIND BROOK CLUB PO BOX 36014
980 ANDERSON HILL RD Newark.NJ 07188-6014
RYE BROOK NY 10573
IIIIILIILII11111'IIIIIIIIIILII'llllll'IIIIIIIIIIIJIIIIIIII
Keep lower portion for your records-Please return upper portion with your payment.
Important Messages
To pay this Invoice with a credit card, complete the information below&fax a copy of the entire invoice to: 973-882-1832
MC / VISA / AMEX #
Card Holder: Expires: Sec Code:
Give us a call for all your Facility Service needs!
1(800)847-3735
Visit our brand new website! WWW.TRANS-CLEAMCOM
Customer Reflects Payment
Account Number Invoice Date Invoice Number Due Date Received Through
85111 05/15/2023 x-2845850 06/14/2023
Item Extended
Quantity Number Description of Work Unit Price Price
1 85111 HOOD CLEANING $1,095.00 $1,095.00
1 85111 LOCAL ORDINANCE SURCHARGE $3.00 $3.00
Note: Fuel Surcharge. Sub Total: $1,098.00
Please Send/Reference Invoice#x-2845850 with Payment. Fuel Surcharge: $148.89
Work Order Number: F1994164 Sales Tax: $104.43
TOTAL DUE: $1,351.32
If you have questions regarding your bill, please call us at(888)292-7463 or visit us on the web at www.tralis-clean.com
Customer Service Order
45 Mayfair Place,Stratford CT 06615(203)377-3171
Blind Brook Club MONDAY 5/15/2023
Address 980 Anderson Hill Road
city St zip Rye Brook NY 10577 Truck#46 Lead Man Luis
Contact Austin Braswell(5/23) contact2Paul Crew Juan M.
Email abraswell@blindbrookcJub.org Phone 2 Rafael Z.
Phone (914)939-1450 contact3 FW Num 85111
loblle Phone (914)498-0403 Phone 3
Main System Prep System
Hood 1 15, Hood SS Hood 1 8' Hood SS
Filters 8 Clean On Site q Plates Filters 5 Clean On Site u Plates
Duct 1 8' Hood Duct Duct 1 50' Branch Duct Access 5
Shaft 1 6' Shaft Belt Size Shaft Belt Size
Fan 1 XL Side Mounted Fan Fan
Back&Sidewall Areas/Drip Cup-Trays: Back&Sidewall Areas/Drip Cup-Trays:
1-35'Duct(5-Accesses)/Backwall area Backwall area
Equiptment to be Cleaned: Areas to be Cleaned:
-�
FA�N�r7B� LTS PLACED size - --�
Check Fan Belt(s) AWNrI L ITEMS/AREAS CLEANED.
i
TestFan(s)Before/After i HIGH PRESSURE STEAM CLEANED AND
CHEMICALLY DEGREASED TO MEET AND
Clean Work Area WITH NFPA CODE#96 11.6
—
TClean Out Sink Area
TPilot Lights Lit +Tax
Terms Net 30 Amount Due:
Floor Areas Mopped
I All Equipment Account For
TRANto NATURE DATE
Created 5/11/2023 at 11:24:20AM Page 1
FLEETWASH F1994164-A
Facility Services
ACCOUNT NAME 28 LAW DRIVE CUSTOMER SIGNATURE ROUTE;61-05
FAIRFIELD,NJ 07004 Gv+wz,Luis
BLIND BROOK CLUB 800-847-3735 ZwWw,Was!
LOCATIONa DA SPECIAL 0
ACCOUNT t 8 5 1 1 1F1 8 1 0 5 1 5 2 3
I I
PURCHASE 71 �71 I 1 17 U I
ORDERM
Billing Address Loeatlon of Service
Name BLIND BROOK CLUB RYE BROOKIHOOD
Street 980 ANDERSON HILL RD
City RYE BROOK
State2lP NY
REFN
Deacriptlon:
Jobs)Performed Subtotal
0 1 COMPACTOR 0 11 RETRIEN CART
VAI
0 2 HVAC 0 12 SNOW PLOW
0 3 GAS STATION 0 13 SALTING 00 1 90 00 00 0 09 00
10 10 10 10 10 10 10
Q 4 CANOPY 0 14 LANDSCAPING �0 20 20 20 20 20 20
0 5 BUILDING WASH 0 15 DEB 30 30 30 30 30 30 30
0 8 GRAFFITI 0 16 LINE STRIPING
40 40 40 40 40 40 40
• 7 HOOD CLEANING 0 OIL ILL LN-
17 _UP 50 50 50 50 5® 50 50
0 8 SIDEWALKS 0 is P URE 60 60 60 60 60 60 60
— WASHING
0 9 SWEEPING 0 19 HOUSE WASHING 70 70 70 70 70 70 70
0 10 LITTER PATROL 0 20 SOLAR PANEL 80 80 80 80 80 80 80
0 11 R MA I 0 2/ MISCELLANEOUS fl0 90 90 90 11 90 BD 90
UAM spp"m ides We•ntl kni•wdwpe
Gallons of wash water recovered and taken to a FLEETWASH facility at 45 Mayfair Place,
Stratford, CT for final examination. 'This amount will only be entered if requested by our customer.This
amount is an estimate of the recovered gallons. This amount may be entered at either the wash site or at
the disposal facility Wash waste water is non-hazardous. There are no legal requirements for a manifest.
III 11111111111111111111111111111111111
W01994164
SYSTEM RECORD OF INSPECTION AND TESTING(continued)
7. NOTIFICATIONS THAT TESTING IS COM L
Time-
Monitoring organization Contact:.
Building management
Contact: Time:
Time:
Building occupants Contact: —
Authority having jurisdiction Contact: Time:
Other, if
Contact: Time:
required --- ---- —
8. SYSTEM RESTORED TQ qRM L Q Time:
j} TION J
��.% ?�( 1
Date: 4{ -- - ---
9. CE FICATION
Thi sy a as'speE erein htts been inspected estf:d according to NFPA 72, 2013 edi14,
ti n, Cha ter
1,
Print, rata
Signed:
r- ,
L�� Ti
Phone.
OrgapitatiluI:
Qualifications(refer to 10.5.3): - ---- - - - -
10. DEFECTS OR MALFUNCTIONS NOT CORRECTED AT CONCLUSION OF SYSTEM
INSPECTION,
TESTING, OR MAINTENANCE
-
10.1 Acceptance by Owner or Owner's Representative:
The undersigned accepted the test report for the system as specified herein:
Signed: &��L�_-_- _ Printed name: Date:
Organization: Title: Phone:
�ght 9 2012 Natlonal Rue lfro*Wm AsWdetlon•This form may be coped for(ndlViduai use olhat than to resale.it may not be Odpled to commercial sale or dismmAlon.
Ot il
SYSTEM RECORD OF INSPECTION AND TESTING
This form is to be comp/etedby the system inspection and lasting conlracloral the lime ofa syalem test.
ll sha/fbe permi!!ed to modify/h/s Corm as needed to prowde a more complete and/or clear mcoe
"serf N/A/n?#unused hnas I
Adach add/lions ; its data of(ea u/lions as nectessary to provide a complete
Inspection,Trst Start Dateffime: ` InsNction,Tcst Completion,QaW1,4p�!:
Supplemental Form(,)Attached: tyesntol ����
1. PROPERTY INFORMATION j
Name of pro 1 �t�{ 13a,8�11
"r
t
Address:
Description of property:
Name of property repre,entative:
Address:
Phone: Fax. E-mail:
2. TESTING AND MONITORING INFORMATION
'resting organization: Scarsdale Security Systems,Inc
Address: 132 MontgomeryAvenue, Scarsdale. NY 10583
Phone: (914)722-2200 Fax: 914)72�299 E-mail:
Monitorh organi/tgm �IC
Addrec
Phone.. ) Fax: E mail:
Accuunt number. 0(7_ 1 tonylinc : Phone line 2.
Means of transmission: 7,
Entity to which alarms are retransmitted: Ph<�n
3. DOCUMENTATION
On-site location of the required record do cumenLs and site-specitic,oftware:
4. DESCRIPTION OF SYST SERVI E
4.1 Control Unit
Model number:
Manufacturer.
4.2 Software and Firmware
Firmware revision number:
43 System Power /
43.1 Primary(Main]Power
Nominal voltage: _— Amps: �� Location:
Overcurrent protection type: Amps: Disconnecting means location:
Copyright r.2012 National Fire PMWC60n Asaoastlon.This form may be coded for individual use other ftn for resale.it may not be coped for oommerdal sale or dktrladion.
'u. 1 of 4)
SYSTEM RECORD OF INSPECTION AND TESTING (continued)
4. DESCRIPTION OF SYSTEM OR SERVICE(continued)
4 1.2 Seconda Power
Type: 1 -- -- — L ton: —
Bancry type(if applicable): �J
Calculated capacity of batteries to driNe the sy. n �\
In btandby mode(hours). In alarm mode(minutes): v
5. NOTIFICATIONS MADE PRIOR TO TESTI
Monitoring organization Cont.:ct. �C�i�t✓ Time:
Building management Contact: Time:
Building occupants c untact: Time:
Authority having jurisdiction Contact: Time:
Other, if Contact: Time:
required
6. TESTING RESULTS
6.1 Control Unit and Related Equipment
Visual Functional
Description Insyect•o_n_ Te / 1 Comments
Control unit T /
Lam s/LEDs/LCDs I � `
Fuses ❑ ❑ _
Trouble signals _
Disconnect switches ❑
Ground-fault monitoring
Supervision
Local annunciator 1�
Remote annunciators
Remote rower panels
61 Secondary Power
Visual Functional
Description Ins ect on _ Test Comments
Battery condition o
Load voltage -_ 6 _
Discharge test ❑ ❑
Charger test ❑ ❑
Remote panel batteries ❑ ❑
Copyrght C 2012 Natlonal Fire ProoMm Association.This form maybe copied far IndiVWuai uee otrW than for resale.tt may not be copied tor oo mnerciai seb or disMb Ven.
(p.r 4)
SYSTEM RECORD OF INSPECTION AND TESTING(continued)
6. TESTING RESULTS(continued)
63 Alarm and Supervisory Alarm Initiating Device
Attach supplementary device test sheets for all initiating devices.
6A Notification Appliances
Attach supplementary appliance test sheets for all notification appliances.
65 Interface Equipment
Attach supplementary interface component test sheets for all interface components.
Circuit Interface/Signaling Line Circuit Interface/Fire Alarm Control Interface
6.6 Supervising Station Monitoring
Description Yes No Time I_ Comments
Alarm signal ❑
Alarm restoration t ❑ Uv ��
Trouble signal I ❑ ,O
Trouble restoration Q O t'i (�
Ir
Supervisory signal 0 �S
Supervisory restoration C3
6.7 Public Emergency Alarm Reporting System
Descrl tion _ Yes No Time Comments
Alarm signal ❑ ❑
Alarm restoration ❑ ❑
Trouble signal ❑ ❑
Trouble restoration ❑ ❑
Supervisory signal ❑ ❑
Supervisory restoration ❑ ❑
Copyright&2012 National Fire Protection Association This form may be copied for inaivldual use other then for resale.It may not be copied for commercial seta or dlstnlwtion.
INITIATING DEVI E d
SUPPLEMENTARY RECORD OF INSPECTION AND TESTING (conaft"od)
2. INITIATING DEVICE TEST RESULTS(continued)
_09vice Type Address Locatlon Test Results
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See main System Record of Inspection and Testing for additional information,certifications,and approvals.
CopyripAt O 2012 National Fire Prvbcdon Association.This form may be copies for i dtvUwl use o0w than for resale.It mey not be copied for cbrr uwcial sale or de0autlom
(P. --Of--` )
INITIATING DEVIC
SUPPLEMENTARY RECORD OF INSPECTION AND TESTING (conawmed/
2. INITIATING DEVICE TEST RESULTS(continued)
De Ice Type Address tlo Teat Its
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See main System Record of Inspection and Testing for additional Information,certifications,and approvals.
CopyrigW®2012 National Fire Protection Assocadw.TM form may be copied for e4imusi tw direr than for resale.It may not be copied for corrmneraiel sale or dietrib son•
(P.__of_ )
INITIATING DEVICE
SUPPLEMENTARY RECORD OF INSPECTION AND TESTING (conanuad)
2. INITIATING DEVICE TEST RESULTS(continued)
Device Type Address tiod clest Results
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See main System Record of Inspection and Testing for additional information,certifications,and approvals.
Copyrght&2012 National Fire Protection Association.This form may be copied for individual use other than for rosals.It may not be copied to commercial sale or distribuwn.
INITIATING DEVICE
SUPPLEMENTAR RECORD OF INSPECTION AND TESTING (cowInosd/
2. INITIATING DEVICE TEST RESULTS(continued)
Device Type Address Lowon Test Results
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See main System Record of Inspection and Testing for additional information,certifications,and approvals.
Copyright o 2012 Nadwd Fie Prow N, Aawdadw.This form maybe copied for individual use other than for resale.It may not be copied for commercial sWe or dbtrbullon.
(P. _—of --)
D CC EME
BUILD dii)RTMENT
VIL��P� E OF RYE*OOK MAR — 7 2024 ] 3D
938 KING ET RYE BR T NY 10573 VILLAGE OF RYE BROOK
BUILDING DEPARTMENT
FIRE INSPECTION / OPERATING PERMIT APPLICATION
FOR OFFICE USE ONLY: n 7` 30,444
Fee Paid: $ �� /`"� Inspection Date&Time: ����
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: -�-a 7 ay is hereby made to the Building Inspector of the Village of Rye Brook NY,requesting
that a Fire Inspection be conducted at the building and premises listed below for the purpose of issuing a Permit to Operate the business,
private school and/or place of public assembly in conformance with the Code of the Village of Rye Brook,the New York State Uniform
Fire Prevention & Building Code, Title 19 NYCRR Part 1201, and all other applicable local, County, State & Federal laws, rules &
regulations,as per detailed statement described below. c
1. Address: 980 Anderson Hill Road SBL: /O�/•S�'f'- Zone:
2. Business/Occupancy Name: The Blind Brook Club NYS Use Class:
3. Property Owner: The Blind Brook Club Inc. Address: 980 Anderson Hill Road
Phone# 914-939-1450 Cell # email:
5. Business Owner: Address:
Phone# Cell# email:
6. Emergency Contact: Bruce Campbell Address: 73 Haverhill Rd, Trumbull, CT
Phone# 203-452-0937 Cell# 203-257-0170 email:bcam bell@blindbrookclub.org
7. Inspection Escort: Title: okler4/JS"h 6rU0)L-
Phone#: Cell#: email:
8. Provide a brief description outlining the current and/or intended use of the property:
Private Gold Club & Clubhouse
9. List all Hazardous Materials:
10. Occupant Load: Existing. 110 Proposed: Other:
11. Date& Disposition of Previous Fire Inspection: March 31, 2023 JR Pass ❑ Fail
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This application must include the notarized signature(s) of the legal owner(s) of
the above mentioned property, in the space provided below. Any application not
bearing the legal property owner's notarized signature(s) shall be deemed null
and void, and will be returned to the applicant.
**********************************************************************************************************
STATE OF NEW YORK >
COUNTY OF WESTCHESTER as:
Bruce L. Campbell ,being duly sworn,deposes and states that he/she is the applicant above named,
(print name of individual signing application)
and further states that he/she is the legal owner of the property to which this application pertains, or that he/she is the
General Manager ,for the legal owner and is duly authorized to make and file this application. That all
(indicate architect,business owner,attorney,agent,etc.)
statements contained herein are true to the best of his/her knowledge and belief,and that any work 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 9 Sworn to before me this
day of QU'G\N , 20 day of 20
Notary Public / nn Notary Public
Signature of Property Ow r Signature of Applicant
D ri tUc-Z, L • Ca v1,,n
Print Name of Property O ner Print Name of Applicant
SHARI MELILLO
Notary Public,State of New York
No.01ME6160063
Qualified In Westchester County
Commission Expires January 29,20__Ll 1
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