HomeMy WebLinkAboutAbandoned Application s�
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VILLAGE OF RYE BROOK
MAYOR 938 King Street,Rye Brook,N.Y. 10573 ADMINISTRATOR
Jason A.Klein (914)939-0668 Christopher J.Bradbury
wwwayebrook.org
TRUSTEES BUILDING&FIRE INSPECTOR
Susan R.Epstein Michael J.Izzo
Stephanie J. Fischer
David M.Heiser
Salvatore W.Morlino
NOTICE OF DISAPPROVAL
Application # 22-035 November 29, 2022
Atefeh Carpenter&Ashley Carpenter
25 Churchill Road
Rye Brook, New York 10573
PLEASE TAKE NOTICE that your revised application for building permit dated,September 30,2022, for the
premises located at 25 Churchill Road, Parcel ID# 135.26-1-10, has been disapproved because of non-
compliance with the following section(s) of the Code of the Village of Rye Brook:
§250-6.G. (3) The minimum required rear yard setback is 40 feet. The proposed one-story
addition will result in a rear yard setback of 34.88 feet.
§250-37.B The maximum allowable main building coverage is 16%. The proposed one-story
addition will result in a main building coverage of 17.2%.
§250-6.G. (1) (d) [21 Unenclosed off-street parking shall not be developed within
25 feet of a front lot line. The proposed driveway expansion at
the Winding Wood Road elevation will result in unenclosed
off-street parking within 6 feet of the front lot line.
Please revise your plans to fully comply with the applicable section(s) of Village Code,or an appeal to this decision
may be brought before the Village Zoning Board of Appeals (ZBA) in accordance with §250-13 and §250-40 of
the Code of the Village of Rye Brook. Applications to appear before the ZBA are available at the Building
Department or online at www.ryebroQk.org.
Sincerely,
Michael J. Izzo
Building& Fire Inspector
mizzo&ryebrook.org
BR
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19
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404 ClmthiewaW
VILLAGE OF RYE BROOK
MAYOR 938 King Street,Rye Brook,N.Y. 10573 ADMINISTRATOR
Jason A.Klein (914)939-0668 Christopher J.Bradbury
www.ryebrook.org
TRUSTEES BUILDING&FIRE INSPECTOR
Susan R.Epstein Michael J.Izzo
Stephanie J.Fischer
David M.Heiser
Salvatore W.Morlino
NOTICE OF DISAPPROVAL
Application # 22-035 October 4, 2022
Atefeh Carpenter&Ashley Carpenter
25 Churchill Road
Rye Brook, New York 10573
PLEASE TAKE NOTICE that your revised application for building permit dated,September 30,2022, for the
premises located at 25 Churchill Road, Parcel ID# 135.26-1-10, has been disapproved because of non-
compliance with the following section(s) of the Code of the Village of Rye Brook:
§250-37.B The maximum allowable main building coverage is 16%. The proposed one-story
addition will result in a main building coverage of 17.2%.
5250-6.G. (1) (d) [21 Unenclosed off-street parking shall not be developed within
25 feet of a front lot line. The proposed driveway expansion at
the winding wood Road elevation will result in unenclosed
off-street parking within 5 feet of the front lot line.
Please revise your plans to fully comply with the applicable section(s)of Village Code,or an appeal to this decision
may be brought before the Village Zoning Board of Appeals (ZBA) in accordance with §250-13 and §250-40 of
the Code of the Village of Rye Brook. Applications to appear before the ZBA are available at the Building
Department or online at www.tyebroQk.org.
Sincerely,
Michael J. Izzo
Building& Fire Inspector
mizzo Uebrook.org
Building Permit Check List&Zoning Analysis
Address: t__ SBL:
Zone: Use o Const.Type: -�, Other. CDC-,- t 9 .
r
Submittal Date: _Sj 74 I-Z-Z- Revisions Submittal Dates: S ZZ-` (0 ZZ ��' ZO Z Z
Applicant: C►,2�F 1 C( �o Z L r 11 1 \
Nature of Work: C�t_.� f Z r!)
Reviews:ZBa MAY 2 6 2022 pB: BOT: Other.
hMW OK
( ( ) FEES:Filing: 74 BP: C/O: Flood Plane: Legalization:
( ) (a/ APP: Dated: ✓ Notarized: ✓ SBL ✓ Truss I.D. Cross Connection: ✓ H.O.A.:
(� ( ) Scenic Roads: Steep Slopes: Wetlands: Storm Water Review: Street Opening.
( ) ( ) ENVIRO:Long. Short: Fees: N/A:
( ) ( ) SITE PLAN:Topo: Site Protection S/W Mgmt.: Tree Plan: Other.
( ) ( ) SURVEY:Dated: Current: Archival: Sealed Unacceptable:
( ) (✓� PLANS:Date Stm-Te� Seale& ✓ Copies: Z Electronic: •" Other.
(� ( ) License: Workers Comp: Liability Comp.Waiver. Other.
(� O CODE 753#: Dated. N/A:
(� ( ) HIGH-VOLTAGE ELECTRICAL:Plans: Permit: N/A: Other.
( ) ( ) LOW-VOLTAGE ELECTRICAL:Plans: Permit: N/A: Other.
FIRE ALARM/SMOKE DETECTORS:Plans: Permit: H.W.I.C.:_Battery:_Other.
( ) ( ) PLUMBING Plans: Permit: Natty Gas: LP Gas: N/A/: Other.
( ) ( ) FIRE SUPPRESSION:Plans: Permit: N/A: Other.
(✓f ( ) H V.A.C.: Plans: Permit: N/A Other.
( ) ( ) FUEL TANK:Plans: Permit: Fuel Type: Other.
O O 2020 NY State ECCQ N/A: Other.
(� ( ) Final Survey Final Topo: RA/PE Sign-off Letter. As-Built Plans: Other.
(� ( ) BP DENIAL LETTER: C/O DENIAL LETTER: Other.
Other.
mtg.date: approval:- notes:
( ZBA mtg.date: approval• notes:
( )PB mtg.date: approval: notes:
REQUIRED EXISTING PROPOSED NOTFS
t S is /<OtZ - 07-
Circle; t o"J
'k � ,
Front: 3$;l �-1 l • G
Sides: tS 40
13 o -7r.� • C, 3 - �' l Z S 13 U An-
Main Cov !(� 13 6__ t? Z Z�'� 3 • S3 'Z v
Accs.Cov
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3
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Parlang: Z S G -�c, t Z _ l V AA- -L L ,r
HHght/Stories
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Residential Building Permit Fee Work Sheet
Permit#: Date Issued: SBL: Zone:
Address:
Property Owner&Contact Info:
Job Description:
For all new dwellings and for additions measuring 800 sq. ft. or more made to existing
dwellings, the following fee schedule shall apply: (plus any alteration fees)
Total Sq. Ft. (excluding basements) x $225.00 x $I 5.00/$I,000.00
Basement Sq. Ft. x $65.00 x $I5.00/$I,000.00
--------------------------------------------------------------------------------------------------------------------
New Construction Sq.Ft. • New Construction Cost • Building Permit Fee
Basement= sq. ft. x$65.00 = $ x $I5.00/$1'000.00= $
Attached Garage= sq.ft.x$225.00= $ x$I5.00/$I,000.00= $
1'1 Fl. = sq. ft.x $225.00= $ x $I5.00/$I,000.00 = $
2nd Fl. = sq. ft. x$225.00 = $ x$I5.001$I,000.00 = $
3rd Fl. = sq. ft.x $225.00= $ x$I5.00/$I,000.00= $
41,Fl. = sq. ft.x$225.00= $ x$I5.00/$I,000.00 = $
Total Sq.Ft. = sq. ft. Total Cost= $ Total B.P.Fee= $
Total Amount Paid= $
Total Amount Due= $
Date: Signed:
p
BUILD MENTID
VILE o R : ooK MAY 2 4 2022
938 KING "JT33ft ,NY 10573
VILLAGE OF RYE BROOK
;i iii kkk iitti ilt#kki}l;ik kltR}iitii}}ttk}!•tt}lktii}}t4ttlf}!i ltki!}li tiiY}!!##;iiitt i�kl R�Nr;.QEP}PRTMENT
ARCHITECTURAL REVIEW BOARD CHECK LIST FOR APPLICANTS
This form must be completed and signed by the applicant of record and a copy shall be
submitted to the Building Department prior to attending the ARB meeting.Applicants
failing to submit a copy of this check list will be removed from the ARB agenda.
Job Address: 25 CHURCHILL ROAD Date of Submission:
Parcel ID#:
135.26-1-10 Zone: R-15
Proposed Improvement(Describe in detail):
ADDITION/ALTERATION TO EX.FAMILY ROOM 8 SUNROOM, APPLICANT CHECK LIST:
MUST BE COMPLETED BY THE APPLICANT
EXTEND FRONT ROOF GABLE.ADD HALF DORMER,NEW SIDING The following items must be submitted to the Building
8 ROOFING TO MATCH EXISTING,EXTEND EX.REAR PATIO,
Department by the applicant-no exceptions.
r•XPAND FXMINn DRIVEWAY Tn MATCH FXISTINr:
Property Owner: ATEFEH CARPENTER 1. Completed Application
2. Two(2)sets of sealed plans. (one full size(maximum
Address: 25 CHURCHILL ROAD,RYE BROOK,NY 10573 allowable plan size=36"x 42")and one I 1"x 17")
3. ( )Two(2)copies of the property survey.
Phone# 4. ( 1Two(2)copies of the proposed site plan.
Applicant appearing before the Board: 5. 4 One electronic/disc copy of the complete
MICHIEL A.BOENDER application materials.
6. ( Filing Fee.
Address: 109 WILLETT AVENUE,PORT CHESTER,NY 10573 7. ( )Any supporting documentation.
914-937-4226 8. ( VOA approval letter. applicable/
Phone# 9. (V P In
Photographs.
Architect/Engineer.
ARCHITECT 10.( )Samples of finishes/color chart.(a sample board or
model maybe presented the night oJrhe meeting)
Phone# 914-937-4226
By signature below, the owner/applicant acknowledges that he/she has read the complete Building Permit
Instructions&Procedures,and that their application is complete in all respects. The Board of Review reserves
the right to refuse to hear any application not meeting the requirements contained herein, (J
/-1
Sworn to before me this �` '-"+ SSwornto before me this n o 1
day of a!c j 20 2-2 day of 20 OD
anature of Prope ;Owner ature pplicant
ATEFEH CARPENTER
Print Name of Property Owner P' ame of Applicant
t 1
to Public Notary Pub c `
111 SHARI MELILLO
CAROLYN MARIE CANNI Notary Public,State of New York
Notary Public-Stale of Neww Yoi*York No.01CA6177080 No.01ME6160063
Qualified in Westchester County Qualified In Westchester County
My Commission Expires Nov.5,2023 1 .
Commission Expires January 2;
BUILD R,,, MENT
REVISED SEP 2 .0 MZ' vIL lE o 3 ootc
938 KIN NY 10573
APPLICATIOIIIEP 3 0 2022 MAY 2 4 2022
u � r
I D
DATED: VILLAGE OF RYE BROOK
liltitititftt+iililtiiitttt++fitiitit+ftitiliififki iitiik+i!!filitt#+tti iti ttttf ..1�t tiOIal '(� rl!YEIDAR_TMENT
FOR OFFICE USE ONLY:
Approval Date: Permit# Application#
Approval Signature: ARCHITECTURAL REVIEW BOARD:
Disapproved: Date:
BOT Approval Date: Case# Chairman:
PB Approval Date: Case# Secretary:
ZBA Approval Date: Case
Other:
r
Application Fee ermit Fees:
iit+l4iftii}Fi F4Fiitttitiy■ittiitktt}tiii Rttt ilitit■itti tiii}tigftiltiktitttif it ttitiii tttitit#iii if!l t+it!
EXTERIOR BUILDING PERMIT APPLICATION
Application dated: 5-2-2022 is hereby made to the Building Inspector of the Village of Rye Brook,NY,for the issuance of a Permit for the
construction of buildings.structures.additions.alterations or for a change in use,as per detailed statement described belom.
1. lobAddress: 25 CHURCHILL ROAD
2. ParcelID#: 135.26-1-10 Zone: R-15
3. Proposed Improvement(Describe in detail): ADDITIONIALTERATION TO FIRST FLOOR DEN/FAMILY ROOM AND SUNROOM,
EXTEND FRONT GABLE ROOF FASCIA,ADD HALF DORMER,EXTEND BACK PATIO
AND EXPAND DRIVEWAY
ATEFEH AND ASHLEY CARPENTER
4. Property Owner:
Address: 25 CHURCHILL ROAD,RYE BROOK,NY 10573
Phone# Cell a e-mail atefah@hotmail.com
List All Other Properties Owned in Rye Brook:
Applicant:
Address:
Phone# Cella e-mail
Architect: MICHIEL A.BOENDER
Address: 109 WILLETT AVENUE,PORT CHESTER,NY 10573
Phone# 914-937.4226 Cella e-mail michiel@edgewterarchitects.com
Engineer:
Address:
Phone a Cell a e-mail
General Contractor:
Address:
Phone# Cell# e-mail
(1)
sn 21202I
5. Occupancy;(1-Fam.,2-Fam.,Commercial.,etc...)Pre-construction: 1-FAMILY Post-construction: 1-FAMILY
6. Area of lot: Square feet:
15,012 SF Acres: 0.34 ACRES
41.6' 35.5'
7. Dimensions from proposed building or structure to lot lines: front yard: rear yard:
right side yard: 25' left side yard: 34'.9 other:
8. if building is located on a corner lot,which street does it front on:
CHURCHILL ROAD
9. Area of proposed building in square feet: Basement: NA i"fl: NA 2nd fl: NA 3"fl: NA
552 SF
10. Total Square Footage of the proposed new construction;
11. For additions,total square footage added:Basement:
NA i»fl: 552 SF 2nd fl: NA 3"fl: NA
12. Total Square Footage of the proposed renovation to the existing structure:
129 SF
13. N.Y.State Construction Classification:
VB N.Y.State Use Classification: R-3
14. Number of stories: 1 Overall Height: NA Median Height: NA
15. Basement to be full,or partial:
NA , finished or unfinished: NA
16. What material is the exterior finish: WHITE CLAPBOARD SIDING&BRICK VENEER
GABLE Roofing material: ASPHALT
17. Roof style;peaked,hip,mansard,shed,etc: g
18. What system of heating: HOT-WATER HEATING AND CENTRAL AIR-COOLING
19. If private sewage disposal is necessary,approval by the Westchester County Health Department must be submitted with this
application.
20. Will the proposed project require the installation of a new,or an extension/modification to an existing automatic re
suppression system?(Fire Sprinkler,ANSL System,FM-200 System,Type I Hood,etc...) Yes: No:
(ifyes,applicant must submit a separate Automatic Fire Suppression System Permit application&2 sets of detailed engineered plans)
21. Will the proposed project disturb 400 sq.ft.or more of land,or create 400 sq.ft.or of impervious coverage requiring a
Stormwater Management Control Permit as per§217 of Village Code? Yes:Z No: Area: e00 SF
22. Will the proposed projec require a Site Plan Review by the Village Planning Board as per§209 of Village Code?
Yes: No: (if yes,applicant Hurst submit a Site Plan Application,&provide detailed drmvings)
23. Will the proposed project require a Steep Slopes Permit as per§213 of Village Code Yes: No:
(if yes,you must submit a Site Plan Application,&provide a detailed topographical survey)
24. Is the lot located within 100 ft.of a Wetland as per§245 of Village Code? Yes: No:
(f yes,the area of wetland and the wetland buffer zone must be properly depicted on the survey,&site plan)
25. Is the lot or any portion thereof located in a Flood Plane as per the FIRM Map dated 9/28/07? Yes : No:
(if yes,the area and elevations of the_Jlood plane must be properly depicted on the survey&site plan)
26. Will the proposed project require a Tree Removal Permit as per§235 of Village Code? Yes: No:
(if yes,applicant must submit a Tree Removal Permit Application)
27. Does the proposed project involve a Home-Occupation as per§250-38 of Village Code? Yes: No:
Indicate: TIER I: TIER iI: TIER iIi: (ifyes,a Home Occupation Permit Application is required)
28. List all zoning variances granted or denied for the subject property:
29. What is the total estimated cost of construction: S Note:The estimated cost
shall include all site improvements,labor,material,scaffolding,fazed equipment,professional fees, including any material and labor 1vhich
may be donated gratis.lfthe final cost exceeds the estimated cost,an additional fee will be required prior to issuance of the C'O.
30. Estimated date of completion:
(?) �SED
PLANS SEP 3 0 2022
i F) TED:
'
BUILDING DEPARTMEN
VILLAGE OF RYE BROOK REVISED
938 KING STREET RYE BROOK,NY 10FI /A NS SEP 3 0 2022
(914)939-0668 DATED:
RESIDENTIAL LOT AREA COVERAGE
Address: 25 CHURCHILL ROAD Section: 135.26 Block: 1 Lot: 10
PERMITTED COVERAGE RATIOS IN RESIDENTIAL DISTRICTS (Local Law 3-88)
YOUR ZONE AREA IN MAIN ACCESS. DECK
ZONE DISTRICT SQ. FEET BLDG. BLDG. MAX.
CHECK MAX.
R-35 35,000 14% 4% 5%
R-25 25,000 14% 3.5% 4%
R-20 20,000 14% 3.5% 4%
R-15 15,000 16% 3.5% 4%
R-15A 15,000 12% 3.5% 4%
R-12 12,500 17% 4% 4%
R-10 10,000 20% 4.5% 3.5%
R-7 7,500 23% 4.5% 3.5%
R-5 5,000 30% 5% 3.5%
R-2F 5,000 30% 5% 3.5%
Existing: Proposed:
1. AREA OF LOT 15,012 Sq. Ft. 15,012 Sq. Ft.
2. AREA OF HOUSE
a. Coverage of Main Building
(Including Attached Garage or Accessory Building) 2,043.0 Sq. Ft. 2,584.0 Sq. Ft.
b.Area of 11 Floor Divided By Area of Lot x 100 13.6 % 17.2 % `Z-i!A
3. AREA OF ACCESSORY BUILDING
(Includes Detached Garages,Tool Shed, Playhouses) NA Sq. Ft. NA Sq. Ft.
a. Coverage of Accessory Building
Area of Accessory Building Divided By Area of Lot x 100 NA % NA %
4. AREA OF DECK NA Sq. Ft. NA Sq. Ft.
a. Coverage of Deck
Area of Deck Divided By Area of Lot x 100 NA % NA %
I attest to the best of my knowledge and belief,the above information is correct.
MICHIEL A. D4 lyugn MKHIELA.B EWER
DN:=*L K"NDEK PMk ou,
BOENDER D.."n �1:12
DMe:2022D9.21 11:1102
Architect's Signature
(3)
8/1=021
BUILDING DEPARTMENT PLANS SEP 3 0 2022
VILLAGE OF RYE BROOK DATEED'
938 KING STREET RYE BROOK,NY 10573
(914) 939-0668
IMPERVIOUS COVERAGE RATIOS RESIDENTIAL DISTRICTS
Address: 25 CHURCHILL ROAD Section: 135.26 Block: 1 Lot: 10 Zone: R-15
IMPERVIOUS SURFACES (Definition): All buildings, as defined herein, and all areas on the ground or elevated above
the ground which are comprised of materials through which water cannot readily flow, including, but not limited to
asphalt, concrete, masonry, wood, gravel and clay, and which consist of elements including, but not limited to, court
yards, sports courts, swimming pools,patios,sidewalks,ramps, terraces and driveways.
TOTAL MAXIMUM PERMITTED MAX. PERMITTED
COVERAGE Zoning IMPERVIOUS
LOT AREA BY IMPERVIOUS SURFACES District COVERAGE IN FRONT
(sq.ft.) For Base Lot For Lot Area Y`RD
Area(sq.ft.)* Over Base R-35 15
Lot Area % R-25 20
0 to 4,000 0 55 R-20 30
4,001 to 6,000 2,200 35
6,001 to 12,000 2,900 27 R-15 35
12,001 to 16,000 4,520 26 R-15A 35
16,001 to 20,000 5,560 25 R-12 40
20,001 to 30,000 6,560 24
30,001 to 40,000 8,960 23 R-10 45
40,001 &larger 11,260 22 R-7 40
R-5 30
R2-F 30
*"Base Lot Area"is the minimum end of the lot size
range in the"Lot Area"column
Area of lot: 15,012 sq.ft. Existing Allowe Proposed
Total impervious coverage = 3,992.0 S .ft. 5_� S . ft. 4,939.5 S .ft.
Front impervious coverage = 4.0 % 35 % 4.03 % r�A
I attest to the best of my knowledge and belief,the above information is correct.
Ogif 4sig—I by MKH LA.SOENDER
MICHIEL A.BOENDER�-K„K;�W;"h."^� IA
NW-M21.09.I1 I I:I 1I8 M W
Architect's Signature
(4)
8/12/2021
BUILDING DEPARTMENT I^'iEVIZ'*")EDPLANS
VILLAGE OF RYE BROOK SPP 3 0 2022
938 KING STREET RYE BROOK,NY 1057 DATED.
(914)939-0668 -
BULK REGULATIONS IN RESIDENTIAL DISTRICTS
Address: 25 CHURCHILL ROAD Section. 135.26 Block: 1 Lot. 10
MAXIMUM GROSS FLOOR AREA
USE FORMULA: Maximum Gross Floor Area = 4,000 + [ (Lot Area —21,780) x 0.11478421 ]:
a. Allowed = 3,223.140 Sq. Feet
b. Existing = 2,088.6 SF Sq. Feet
c. Proposed = 2,514.8 SF Sq. Feet
HEIGHT/SETBACK RATIOS FOR RESIDENTIAL DISTRICTS
DEFINITION: A standard designed to regulate the height of a building in relation to the average grade of the corresponding portion of
the lot line from which it is set back. The ratio modifies the maximum permitted Height of Building by forming an inclined plane
beginning at the average grade along the portion of the lot line from which the setback is measured and rising toward the building at the
specified ratio above which no part of any building, other than minor architectural features such as chimneys, skylights and dormer
windows not covering more than 10% of the entire roof area, shall be permitted to extend. Height and Setback shall be calculated using
the formula; Height/Setback = X, where X is the required side or front yard ratio for the zoning district in which a property is located
as specified in Article VIII of Chapter 250. A complete elevation view for the proposed improvement must be included on the drawings.
FILL IN YOUR RATIOS:
ZONE EM77NO PROPOSED REQUIRED
FRONT: FRONT: FRONT: .44
"S SIDE: SIDE: SIDE: 1.20
FRONT: FRONT: FRONT: .48
IR25 SIDE: SIDE: SIDE: 1.30
FRONT: FRONT: FRONT: .60
0,20 SIDE: SIDE: SIDE: 1.60
FRONT: 0.445 FRONT: 0.445 FRONT: .60
RLIS SIDE: 0.52 SIDE: 0.76 SIDE: 1.60
FRONT: FRONT: FRONT: .80
R ISA SIDE: SIDE: SIDE: 2.40
FRONT: FRONT: FRONT: .69
RL12 SIDE: SIDE: SIDE: 1.60
FRONT: FRONT: FRONT: .80
/CIO SIDE: SIDE: SIDE: 2.40
FRONT: FRONT: FRONT: .96
RL7 SIDE. SIDE: SIDE: 3.00
FRONT: FRONT: FRONT: 1.20
Rd SIDE: SIDE: SIDE: 4.00
FRONT: FRONT: FRONT: 1.20
R-2F SIDE: SIDE: SIDE: 4.00
1 attest to the best of my knowledge and belief, the above information is correct.
MICHIEL A.BOENDER
Architect's Signature (5)
8/12/2021
BUILD \MENT
VIA x ROOK MAY 2 4 2022
938 KING iy ,NY 10573
VILLAGE OF RYE BROOK
" BUILDING DEPARTMENT
AFFIDAVIT OF COMPLIANCE
VILLAGE CODE�216• STORM SEWERS AND SANITARY SEWERS
THIS AFFIDAVIT MUST BEAR THE NOTARIZED SIGNATURE OF THE LEGAL PROPERTY OWNER AND BE SUBMITTED
ALONG WITH ANY BUILDING OR PLUMBING PERMIT APPLICATION. ANY BUILDING OR PLUMBING PERMIT
APPLICATION SUBMITTED WITHOUT THIS COMPLETED AND NOTARIZED FORM WILL BE RETURNED TO THE APPLICANT.
STATE OF NEW YORK,COUNTY OF WESTCHESTER ) as:
ATEFEH CARPENTER residing at, 25 CHURCHILL ROAD,RYE BROOK,NY 10573
(Print name) (Address where you live)
being duly sworn,deposes and states that(s)he is the applicant above named,and further states that(s)he is the
legal owner of the property to which this Affidavit of Compliance pertains at;
25 CHURCHILL ROAD ,Rve Brook,NY.
(lob Address)
Further that all statements contained herein are true,and that to the best of his/her knowledge and belief,that
there are no known illegal cross-connections concerning either the storm sewer or sanitary sewer,and further
that there are no roof drains,sump pumps,or other prohibited stormwater or groundwater connections or sources
of inflow or infiltration of any kind into the sanitary sewer from the subject property in accordance with all State,
County and Village Codes.
�Pmpeny
gnature o (s))
(Print Name of Property Owners))
Sworn to before me this CAROLYN MARIE CANNISTRAR:
Notary Public-State of New Yur6
day of 20 IQ No.01CA6177080
Qualified in Westchester County
My Commission Expires Nov.5.2022
tary Public)
(6)
8/12/2021
This application must be properly completed in its entirety by a N.Y.State Registered
Architect or N.Y.State Licensed Professional Engineer&signed by those professionals where
indicated. It must also include the notarized signature(s)of the legal owner(s) of the subject
property,and the applicant of record in the spaces provided.Any application not properly
completed in its entirety and/or not properly signed shall be deemed null and void,and will be
returned to the applicant. Please note that application fees are non-refundable.
STATE OF NEW YORK,COUNTY OF WESTCHESTER ) as:
MICHIEL A.BOENDER ,being duly sworn,deposes and states that he/s K-is the applicant above named,
(print name of individual signing as the applicant)
and further states that (s)he is the legal owner of the property to which this application pertains, or that (s)he is the
ARCHITECT for the legal owner and is duly authorized to make and file this
application.
(indicate architect,contractor,agent,attorney,etc.)
That all statements contained herein are true to the best of his/her knowledge and belief,and that any work performed,or
use conducted at the above captioned property will be in conformance with the details as set forth and contained in this
application and in any accompanying approved plans and specifications,as well as in accordance with the New York State
Uniform Fire Prevention&Building Code,the Code of the Village of Rye Brook and all other applicable laws,ordinances
and regulations. By signing this application, the property owner further declares that he/she has inspected the subject
property,and that to the best of his/her knowledge there are no roof drains,sump pumps or other prohibited stormwater or
groundwater connections or�sources of infiltration into the sanitary sewer system on or from the subject property.
Swom to before /
me this � ( � Sworn to before me this
day of ,20 .Z Z day of 20
tgnature of Propem Owner Signature of Applicant
Print Name of Properly OHmer Print Name of Applicant
7
Notary Public Notary Public
CAROLYN MARIE CANNISTRARC
Notary Public-Stale of New York
No.OICA6177080
Qualified in Westchester County
My Commission Expires Nov.5.2023
CAROLYN MARIE CANNISTRARr,
Notary Public-State of New Yori,
No.01 CA6177080
Qualified in Westchester County
My Commission Expires Nov.5.2623 (gl
�� 8/12/1021
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