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BUIL TMENT 2 [Ec ,
VIL of RY aOK Al MAR 132025
938 KING ET RYE BR NY 10573
a -�
k ' ov VILLAGE OF RYE BROOK
BUILDING DEPARTMENT
INTERIOR BUILDING PERMIT APPLICATION
FOR OFFICE USE ONLY:MR 18 Z825
Approval Date: P rt#: / d 'd `7 Application Fee:$ 11 /
Approval Signature: Permit Fees:$ Cie,
Disapproved: Other:
Application dated: 3 / 3— is hereby made to the Building Inspector of the Village of Rye Brook,NY,for the issuance of Permit for the
interior alteration of an existing building,or for a change in use,as per detailed statement described below. �y
1. Job Address: _c1_�1 air"C t2.4 3e I ,Q I%' SBL: //3_5-,s�—/— ! P zone: I a-
2. Proposed Improvement.(Describe in detail):
X Al
e
3. Does the proposed improvement involve a Home-Occupation as per§250-38 of the Code of the Village of Rye Brook?
No:� s: If yes, indicate: TIER l: TIER II: TIER Ill:
4. Will the proposed project require the installation of a new,or an extension/modification to an existing,aatomatic fire
suppression system(Fire Sprinkler,ANSL System,FM-200 System,Type I Hood,etc...) :No: -! Yes:
(if yes,please submit a separate Automatic Fire Suppression System Permit application&2 sets of detailed engineered plans)
5. Occupancy;(1 fam.,2 fam.,comm.,etc,..)Prior to Construction: After Construction:
6. N.Y State Construction Classification: N.Y.State Use Classification:
7. Property Owner: Y—► )(_t pie fl k Address: /ll Elm i ,ll or-i,ue a, ne karz A/, y
Phone# _l Anp. n Cell# 6 V6- 1r9—"70 email:
8. Applicant: '411—1_4c' ra (L�j l 1 T dress: 1,. f
Phone#, 11T � yT ? (> _Cell# Y- ;27 tf— G/G D email: ��.
9. Architect: Address:
Phone# Cell# email:
10. Engineer: Address:
Phone# Cell# email:
11. General Contractor:FLJT- uV Address: "thy/
Phone#G( —4W—tl L cell# 7/V, 2)Y— 060 email: �w ), 4'4r
12. Estimated cost of construction $ o C��D
(NOTE The estimated cost shall include all labor,mattnai,scauolding,fixed equipment,professional fees.and material and labor«hich may be donated
gratis.)
13. Job Timetable: Start: Finish:
(I)
6/1/2024
BUILD DEPARTMENT
VIL f E OIL RYE B' oOK MAR 13 2025
938 DING JREET RYE BRO NY 10573
(914)939-Oti68 VILLAGE OF RYE BROOK
BUILDING DEPARTMENT
wwwx cbrooknv.goy
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:
I, L'ATH ej�i N t- tL L S+w-l ,residing at, /l FL/1'I 14I LL �5 P-/✓E, IZ7 C d-Oo e~
(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;
1 ELn'I f r LL ' K) i y c , Rye Brook,NY.
(Job 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.
(Signature of Pro O er(s))
CA7P&,2/iVr 6&-_6r9'x��
(Print Name of Property Owner(s)) r
Sworn to before me this b
day of V \C_�c\h , 20 ��
A��n� V�1�
(Notary Public)
SHARI MEULLO
Notary Public,State of New York
No.01ME6160063
Qualifled In Westchester County,
Commission Expires Jehtlary 29.20 -� (2)
6/1/2024
This application must be properly completed in its entirety and must 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:
R.TH EL+JF F >�12 I ,being duly sworn,deposes and states that he/she 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
_Ali 0,&77G 77LE F7T-i NG /n/G 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 3 ram/
day of M Cq r`C \ , 20—c9s day of �Jq 20
Signatu Owner C&Wature of Applicant
e of Property Owner Print Name of AfTlicant
Notary Public Notary Public
SWI MEULLO
Notary Public,State of New York
No.o1ME6160063
Qualified in Westchester County.� S'I'BVEN SII.YERMAN
commission Expires 3tintiary 29,20�
NOTARY PUBLIC,STATE OF NEW YORK
Registration No.01 SI6353376
Qualified in Westchester County
My Commission Expires: I 2
(4)
6/I/2024