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BUILDING DEPARTMENT APR - 7 2025
VILLAGE OF RYE BROOK
938 KiNc STREET RYE BROOK,NY 10573 VILLAGE OF RYE BROOK
(914)939-0668 BUILDING DEPARTMENT
www.rVebrookny.gov
INTERIOR BUILDING PERMIT APPLICATION
FOR OFFICE USE ONLY:
Approval Date: APR 8 Application Fee:$ �
Approval Signature: Permit Fees: $ _
Disapproved: Other:
Application dated. ,` is hereby made to the Building Inspector of the Village of Rye Brook,NY,for the issuance of a Permit for the
interior alteration of istin building,or for a change in use,as per detailed statement described below.1. Job Address: 7 9-7 k/i✓G S j/2 FC T SBL: V�Q• - l-^�
e 130 Zone:
2. Proposed Improvement.(Describe in detail): _ ('4/L//V� 7-/L:Gr r', TTaLI¢C.0
3. Does the proposed improvement involve a Home-Occupation as per§250-38 of the Code of the Village of Rye Brook?
No:__JL Yes: If yes,indicate: TIER I: TIER II: TIER III:
4. Will the proposed project require the installation of a new,or an extension/modification to an existin automatic fire
suppression system(Fire Sprinkler,ANSL System,FM-2.00 System,Type I Hood,etc...) No: Yes:
(If yes,please submit a separate Automatic Fire Suppression System ,Pe/rrti't application&2 sets of detailed engineered plans)
5. Occupancy;(1 fam.,2 fam.,comm.,etc...)Prior to Construction: / A_ After Construction:
6. N.Y State Construction Classification: N.Y.State Use Classification:
7. Property Owner:_,J b�4AU ,0 4r4 r(J Address: 7�5 7 //l T��
Phone# 3 0 t7 Cell# email: /U//p i-G11 fir, STt f e- J �Yt�
8. Applicant: L/ tom_(Ai/L/U �� Address:
Phone# Cell# email: //Lc,Z 61 e-f'id)IC i/!�Z
9. Architect: Address: ' Co
Phone# Cell# email:
10. Engineer: Address:
Phone# Cell# email:
A 11. General Contractor.__'Q0 Address:
Phone# Cell#� -� 3f-�7�� erneeil: NzhH�s1�4�4 �a�ln
4 12. Estimated cost of construction $—/ S— a on
(NOTE:The estimated cost shall include all labor,material,'scaffolding,fixed equipment,professional fees,and material and labor which may be donated
gratis.)
13. Job Timetable: Start: Finish: //h-
f
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6/t/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.
cot-smer'Tico-r fAiq_F%E\p
STATE. OF N ,COUNTY OF WAR ) as: 6ze- JLS k Cq
J DC3- - C9_ ,being duly sworn, deposes and states that he/she is the applicant above named,
(print name of individual signing as ty applicant)
and further states that s)he_i the legal owner of the property to which this application pertains, or that (s)he is the
L t l S Ui t i r-e'' for the legal owner and is duly authorized to make and file this application.
(indicate architect,kontractor,agent,attorney,etc.)
That all statements ntained 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.
P �
Sworn to before rme this Sworn to before meJ this
A A
day of APR, l , 20 2_� day of .�-t�2� f _ , 20
Sign e o ropcAy Owner Signature of Applicant
04,1 L.,o&c�,a
Print Name of Property Owner Print Name of Appl' an
Notary Public V 0 Notary Public
SHAUN GA SHAUH GA M Y
NOTARY PUBLIC
NOTARY PUBLIC
State of Connecticut
State of Connecticut Commission Expires Feb.28,2027
14 Commission Expires Feb.28,2027
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