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1962 BUILDING DEPARTMENT
❑BUILDING INSPECTOR
ASSISTANT BUILDING INSPECTOR VILLAGE OF RYE BROOK
❑CODE ENFORCEMENT OFFICER 938 KING STREET • RYE BROOK,NY 10573
(914) 939-0668 FAx (914) 939-5801
www.ryebrook.org
- - - - - - - - - - - - - - - - - - - - INSPECTION REPORT - - - - - - - - - - - - - - - - - - - -
ADDRESS : DATE:
PERMIT# ISSUED: SECT: BLOCK: LOT: —
LOCATION: 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
❑ NATURAL GAS
❑ L.P. GAS
❑ FUEL TANK
❑ FIRE SPRINKLER
❑ FINAL PLUMBING
❑ CROSS CONNECTION
❑ FINAL
❑ OTHER
p EC ENE
BUILD MENT JUN 2 12024
VII,� OI;`I . OK VILLAGE OF RYE BROOK
938 KING�\ � 'T.�t �ti` � NY 10573 BUILDING DEPARTMENT
FIRE INSPECTION / OPERATING PERMIT APPLICATION?
FOR OFFICE n J S ONLY: % ' o,,4A
Fee Paid: $ �. Inspection Date&Time: /�'ll[��c9_C�1 4o v)",/
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
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Application,dated: L-0 I oZ I I a%4 ,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.
1. Address: 1 Rose Lane, Rye Brook, NY 10573 SBL: 129.25-1-1.122 Zone: PUD
2. Business/Occupancy Name: Kingfield Lot Owners Association NYS Use Class:
3. Property Owner: Kingfield Lot Owners Association Address:
Phone#203-653-6542 Cell# email: ebaidwin@plazarealtymgmt.eom
5. Business Owner: Address:
Phone# Cell# email:
6. Emergency Contact: Courtney Baldwin Address: 1010 Hope Street 2nd Floor, Stamford, CT 069C
Phone# 203-653-6542 Cell# email: ebaidwin@plazarealtymgmt.com
7. Inspection Escort: Title:
Phone#: Cell#: email:
8. Provide a brief description outlining the current and`or intended use of the property:
Outdoor Pool & Spa
9. List all Hazardous Materials:
10. Occupant Load:Existing: Proposed: Other:
11. Date&Disposition of Previous Fire Inspection: 5/10/2023 Pass [] Fail
8/)2/2021
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 >
COUNTY OF WESTCHEISTER ) as:
being duly sworn,deposes and states that he/she is the applicant above named,
(print name of IndhLIdual signing eppfka;i—W)
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 a(!tj1eoVbus1sQss 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 of Q.t ,20 z�? day of 1110C4,20
EVE MARIE ALTIERI I EVE MARIE ALTIEF
y NOTARY PusLic NOTARY Pusue
State of Connecticut Y- State of Connectleu
No ary Public My Commission Expires Notary Public �� y Commission Explr
June 30,2026 June 30,2028
Signature of Property Owner Sign�icant -
t
Print Name of perty Owner Print Name of Appikant
2
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