HomeMy WebLinkAboutFire Inspection Application 2023 BUIL R MENT D ECEOM(�
VI E OF`R OK �/ I�
938 KING ET Rl> BR NY 1057 - $ :-
MAY VILLAGE OF RYE BROOK
BUILDING DEPARTMENT
FIRE INSPECTION / OPERATING PERMIT APPLICAT
FOR OFFICE USE ONLY:
Fee Paid: $ Inspection Date & Time:
FEE SCHEDULE: e-inspection Date & Time:
Triennial & Private School Annual Inspection: $45
Public Assembly Annual In pection: <100 People _ 5.00 / 00 People= $775.00
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Application,dated: > is hereby made to the Building Inspector of the Village of Rye Brook NY,requesting
that a Fire Inspection be cbndLkted 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: % SBL: �, (o��� �� Zone: 1 L�b
2. Business/Occupancy Name: NYS Use Class:
3. Property Owner: Q L,—o 6 �4 e(,_e- Address: 6
Phone# Cell # 9l�� 7��-�(OD� email '] `` -
5. Business Owner: Address:
Phone# Cell# email:
6. Emergency Contact:--no�(�-") ra 0A vL14r:�, Address:
Phone# Cell # (q -722-- (LO email: OW
7. Inspection Escort: Title:
Phone#: Cell#: email:
8. Provide a brief description outlining the current and/or intended use of the property:
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9. List all Hazardous Materials:
10. Occupant Load: Existing: Proposed: Other:
11. Date & Disposition of Previous Fire Inspection: ass ❑ Fail
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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.
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STATE OF NEW YORK
COUNTY OF WESTCHESTER > a
WS••ILc��i ,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
�� , 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 befo e me this Sworn to before me this
day of , 20 day of , 20
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Notary Pub • / ' t � Notary 4Pbldt
Signature orfroperty Owner Signature-of Applicant
Print Name of Property Ow her Print Name of Applicant
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8/12/2021