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1982 BUILDING DEPARTMENT
❑BUILDING INSPECTOR
grAOSSISTANT 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 : 7,6 7 n�Qt_,Z H k! 'j ALE 4 7•~ DATE: 7— 7 " 2oZ�
/ /T 3S
PERMIT# l'I� .rNS�f( 1/u°�' ISSUED: z SECT: I• BLOCK:-2— LOT:
LOCATION: A OCCUPANCY:
❑ VIOLATION NOTED THE WORK IS... Cr ACCEPTED ❑ REJECTED/ REINSPECTION
❑ SITE INSPECTION REQUIRED
❑ FOOTING
❑ FOOTING DRAINAGE
❑ FOUNDATION
❑ UNDERGROUND PLUMBING NOTES ON INSPECTION:
❑ ROUGH PLUMBING
❑ ROUGH FRAMING
❑ INSULATION _
❑ NATURAL GAS 'Or//G J1 q) .J
❑ L.P. GAS �n�u u
iZJ► !7d �• 77
❑ FUEL TANK
❑ FIRE SPRINKLER SS(/e. I t
❑ FINAL PLUMBING
❑ CROSS CONNECTION
❑ FINAL
_.� OTHER -
BUILD TMENT
VILL OF RYE B OOK Initial Inspection Date: El Pass
5T&V�'N r6� 938 KING ST RYE BROO Ew YORK 10573 7- q - 20211 i}� Fail
BUILDING&FIRE INSPECTOR (914)9 w rook.or Re-Inspection Date: ❑ Pass
Sieve FBwSGL, v
�e +oD`C• • �9t32 •� ❑ Fail
FIRE INSPECTION REPORT', NOTICE OF VIOLATION & ORDER TO REMEDY SAME
Site Address: �2 . Zone: 06- 5 SBL: 1`1 1 - 3�',_ - Z
Occupancy: ��: State Use Classification:
Business Owner: :_.0 t = I I J t`1 Phone:
Building Owner: �: ��t "� +��� r��� k �lA 2- Phone: 2-J3 " S 0 Z 0
Emergency Contact: ,,`'N j S Phone: 2 03 3 Z 7- - y /y
Building Representative in Attendance:
------------------------------------------------------------------------------------------------------------------------------------------------------------------
Take notice that the following violations of the New Yprk State Uniform Fire Prevention&Building Code and/or the Code of the
Village of Rye Brook were found to exist at, 2 to - ,in the Village of
Rye Brook,NY on, 7 U L )� q 20 2- 1 The person o entity served with this Order to Remedy shall
immed ately commence to cQTect all listed violations and shall completely cure each violation described herein by no later than
J L�Z`{ ,which is thirty(30)days after the date of this Order to Remedy.Furthermore,
upon curing any listed violation(s),you shall immediately contact the Building Department during normal business hours to schedule a
re-inspection of the premises to confirm full compliance with all applicable codes,laws,rules®ulations.
BE ADVISED THAT YOUR FAILURE TO CORRECT ALL VIOLATIONS IS A CRIME PUNISHABLE BY FINE,IMPRISONMENT OR BOTH.
------------------------------------------------------------------------------------------------------------------------------------------------------------------
No YES N/A
1.PORTABLE FIRE EXTINGUISHERS (PFE's)
a.906.1. Are PFE's installed throughout the space&on the premises as required by code. a._ ✓
b.906.3.1.Is the maximum travel distance to a PFE 75 feet or less. b. ✓ _
c.906.5.Are PFE's conspicuously located&readily accessible. c _ ✓ _
d.906.6.Are PFE's unobstructed/unobscured from view. d.
e.906.7.Are PFE's properly mounted as per the manufacturers instructions. 0—
f.906.9.Are PFE's properly installed:<40 lbs.max.5'above floor;>401bs.max.3.5'above floor. f._ ✓
2.FIRE ALARM SYSTEM&SMOKE DETECTORS ✓
a.901.6.1.Is the fire alarm system inspected,tested&maintained in accordance with NFPA 72.
b.907.4.2.1.Are manual pull stations located within 5 feet of exits&within 200 feet of each other. b._ ✓
c.907.4.2.2.Is the height of the pull station handle located between 42&48 inches above the floor. c.
d.907.3.Is a fire alarm system provided in existing buildings as per section 907.3.1 &907.3.2.
3.FIRE SUPPRESSION SPRINKLER SYSTEM&FIRE HYDRANTS /
a.901.6.1.Is the sprinkler system inspected,tested&maintained in accordance with NFPA 25-13. a._ ✓ _
b.901.6.1.Are the main valves secured against tampering in the open position. b._
c.901.6.1.Are sufficient clearances maintained from fire sprinkler heads to fixtures or materials. C._ ✓
d.901.6.1.Is a supply of six spare heads&a wrench maintained on the premises. d._ Z
e.901.6.1.Are sprinkler heads&cover plates unfinished or of factory applied finish only. e._ ✓
f.901.6.3.Are records of all system inspections,tests&maintenance reports maintained on the premises. f._ Z
g.913.5.Is the fire pump inspected,tested&maintained in accordance with this section&NFPA 25. g._ ✓ _
h.507.5.2.Is the fire hydrant system properly maintained,operational,compatible w/NST&tested annually. h.
i.507.5.4.Are fire hydrants&fire protection equipment unobstructed. i._ ✓ _
j.507.5.5.Is a clear space of not less that 3 feet maintained around all hydrants. j._ ✓ _
k.901.8.Are all fire protection systems in place and maintained untampered. k._ Z _
g c�
INSPECTOR: -�' �' DATE: r / I p�C) /
--
Revised 2/1W22
No YEs N/A
4.STANDPIPE.CABINETS&FIRE DEPARTMENT CONNECTIONS
a.901.6.1.Is the standpipe system inspected,tested&maintained in accordance with NFPA 25-14. a.
b.901.6.1.Has the required flow test been performed within the past 5 years as per NFPA 25-14. b.
c.912.2.3 Are standpipe FDC threads compatible with fire department standards. C.
d.905.7.Are cabinets containing fire fighting equipment unobstructed/unobscured. d.
e.905.7.1.Are cabinets containing fire fighting equipment properly identified&labeled. e.
f.912.2.1.Are exterior FDC's fully visible&recognizable from the point of fire department access. f.
g.912.4.Are all FDC's unobstructed and available for immediate access by the fire department. g.
5.EMS,MEANS OF EGRESS&OCCUPANCY
a. 1031.2.Are exits&exit enclosures continuously maintained free from obstructions or impediments. a.
b. 1031.3.Is the means of egress free from obstructions including accumulated ice&snow. b.
c. 1031.6.Are exits maintained unobstructed by furnishings,decorations,draperies,minors,etc... C.
d. 1031.7.Are existing emergency escape&rescue openings maintained as per this section. d.
e. 1010.1.Are egress doors provided and maintained as required by this section. e.
f. 1004.9.Are all spaces having an assembly occupancy posted with an approved occupant load sign. f.
g. 1013.1.Are exits marked by a properly located,approved&readily visible exit sign. g.
h. 1013.1.Is the maximum travel distance to any exit sign in an exit access corridor 100 feet or less. h.
i. 1013.4.Are tactile exit signs complying with ICC/ANSI 117.1.provided as required by code. i.
j. 1013.3.Are all exit signs illuminated at all times. j,
k.1008.1.Are the means of egress&exit discharge illuminated at all times the building is occupied. k.
1. 1018.3.Are public aisles in group B&M occupancies maintained at least 36"wide where fixtures 1.
are placed on one side of the aisle&at 44"wide where fixtures are placed on both sides.
m. 1018.3.Are non-public/non-accessible aisles serving less than 50 people maintained at least M.
28"wide,or at least 36"wide where serving 50 or more people.
6.COMBUSTIBLE STORAGE&WASTE MATERIALS
a.304.1.Is the building(s)and premises maintained free from accumulated combustible waste material. a.
b.304.1.2.Is property free from weeds,grass,vines or other growth capable of being ignited. b. _ ,G
c.304.2.Is combustible rubbish stored so as not to create a nuisance or hazard to the public. C.
d.315.3.Are combustible materials properly stored&separated from ignition sources. d. _ ,L
e.315.3.1.Is storage maintained 24"or more below the ceiling in nonsprinklered buildings, e.
and 18"or more below sprinkler head deflectors in sprinklered buildings.
f.315.3.2.Are exits&exit enclosures maintained free from stored combustible materials. f.
g.315.3.3.Are boiler,mechanical&electrical rooms maintained free from stored combustible material. g.
h.313.1.Is building maintained free from stored fueled equipment. (motorcycles,mopeds,mowers,etc...) h.
7.ELECTRICAL
a.604.1.Is the building free from modified/damaged wiring,devices,appliances,equipment a.
and maintained free from electrical hazards.
b.604.2.Are electrical service equipment areas properly illuminated. b.
c.604.3.Are proper working space clearances provided&maintained for electrical service equipment. C._ ,C
d.604.3.Are electrical service equipment working spaces free from any stored materials. d.
e.604.3.1.Are all electrical control panel room doors,panel boards&disconnects properly labeled. e.
f.604.4.Is the building free from unfused multi-plug electrical adapters. f.
g.604.5.Are electrical extension cords being used in a safe manner as per code. g.
h.604.6.Are all junction,switch&outlet boxes fitted with approved covers or plates. h._X_
i.604.6.Is the building free from open-wiring spliced electrical connections. i.
j.604.8.Are electrical motors maintained free from accumulated oil,dirt&debris. j.
k.915.1.Are Carbon Monoxide Detectors installed&maintained as required by this section and by 1103.9. k._
INSPECTOR: DATE: % OG
-2-
Revised 6/11/2020
No YEs N/A
8.ELEVATORS,DUMBWAITERS&ESCALATORS
a.[PM]603.1.Are elevators properly maintained,and is the current certificate of inspection on the premises. a. _ _ ✓
b.606.3.Are approved standardized,pictorial signs posted adjacent to each elevator call station on all b. _ _ ✓
floors reading; IN FIRE EMERGENCY,DO NOT USE ELEVATOR,USE EXIT STAIRS
c.606.7.Are keys for elevator car doors&fire department service kept in an approved location. C. _ _ ✓
d.315.3.3.Are elevator machine rooms maintained free from stored combustible material. d.
e. [B]3005.1.Are elevator machine room doors maintained unobstructed at all times. e.
9.COMMERCIAL KITCHENS
a.906.1. Are portable Class K fire extinguishers installed within 30 feet of cooking equipment. a. _ _V/ _
b.904.12.5.Is the fire protection equipment inspected,tested&maintained as per Section 901.6. b.
c.904.12.5.2.Are automatic fire extinguishing systems serviced at least every 6 months. C.
d.904.12.5.3.Are fusible links&automatic sprinkler heads replaced annually. d. _
e.[RBI 122-5.13.Are grease traps provided and installed as required by Village Code. e.
f.[[PC]1003.10. [RBI 122-6.Are grease traps properly maintained as per State and Village Code. f.
g.[RB] 122-6.C., 122-9.Are all service,maintenance,&repair records for grease traps and related
plumbing maintained on the premises as required by Village Code. g.
10.HEATING SYSTEMS
a. [PM]603.1.Are all heating appliances properly installed&maintained in a safe working condition. a.
b. [PM]603.2.Are all fuel-burning appliances&equipment connected to an approved chimney or vent. b.
c.[PM]603.3.Are heating appliances maintained with proper clearances from combustible material. C. _ I,/
d. [PM]603.4.Are safety controls for fuel-burning equipment maintained in effective operation. d.
e. [PM]603.5.Is the fuel-burning equipment provided with adequate combustion&ventilation air. e.
11.MOTOR FUEL-DISPENSING FACILITIES&REPAIR GARAGES
a.2303.2.Is an approved,labeled&readily accessible emergency disconnect switch provided a. _ _ ✓
in an approved location within 100' of,but not less than 20'from fuel dispensers.
b.2304.3.4.Are dispenser operating instructions conspicuously posted on every fuel dispenser. b. _ ✓
c.2304.2.4.Are fuel-dispensers unobstructed&in clear view of the attendant at all times. C.
d.2305.5.Are approved portable fire extinguishers complying with Section 906 with a minimum rating of d. _ _ ✓
2-A:20-B:C provided&located not more than 75' from pumps,dispensers&fill-pipe openings.
e.2305.6.Are warning signs provided&posted within sight of each dispenser as per this section. e.
f.2305.7.Are weeds and other combustible materials kept at least 10' from fuel-handling equipment. f. _
g.2306.4.Are above-ground tanks provided with vehicle impact protection. g.
h.2306.5.Are above-ground tanks provided with secondary spill containment. h.
12.HAZARDOUS MATERIALS(HAZ-MATS)
a.407.2.Are S.D.S. Sheets for all haz-mats readily available on the premises. a.
b.407.3.Are spaces and individual containers containing haz-mats properly labeled&identified. b.
c.5004.2.Are stored haz-mats provided with approved secondary spill containment. C.
d.5003.7.1.Are proper NO SMOKING signs provided as per this section. d.
13.MISCELLANEOUS
a.403.1. Is an approved fire safety&evacuation plan prepared&maintained for the building/occupancy. a. }� _
b.405.1.Are emergency evacuation drills conducted at the intervals as specified in Table 405.2. b.
c.405.5.Are records of emergency evacuation drills kept&maintained on the premises. C. X
d.505.1.Are approved address&building numbers properly placed&plainly visible from the street. d.
e.506.1.Are approved key boxes(knox boxes)provided,properly located&equipped with the proper keys. e. -9—
f.703.1.Is all required fire-resistance rated construction properly maintained as per code. f.
g.703.1.Are openings through fire-resistance rated assemblies properly protected&maintained. g.
h.5303.5.Are compressed gas cylinders&systems secured&safeguarded against damage&access. h._ —
i.5303.6.1.Are compressed gas cylinder caps or collars in place at all times except when tanks are in use. i.
45
14.GENERAL HOUSEKEEPING
a.Good _yl
b.Fair
c. Inadequate
d.Poor INSPECTOR: C \ DATE:
-3-
Revised 9/17/21
ITEM NUMBER REMARKS
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INSPECTOR: DATE: �- 9 Z 0 2
-4-
Revised 6/11/2020
Inspection/Test Start Date/Time:
Inspection/Test Completion Date/Time:
I- PROPERTY INFORMATION
Name of property: Q,�kX to,
Address:
Description of property: S i-
tpz,
Name of property representative:
4 _rn r JO 4--f
Address: ;�P
Phone: 0Z 3 Fax:
E-mail:
2. TESTING AND MONITORING INFORMATION
Testing Organization:
V t C 1-,-A
Address:
W_t-;-T
Phone: It; D4. a
Fax: E-mail:
Monitoring organization: tj r.
Address: TOAF,.
Phone: Fax:
----------------
Account number- (C) Phone line 1:
Phone line 2: 5
Means of transmission:
Entity to which alarms are retransmitted:
Phone:
3. DOCUMENTATION
On-site location of the required record documents and site-specific software: -(,j4C J'9
4. DESCRIPTION OF SYSTEM OR SERVICE
4.1 Control Unit
Manufacturer: Model number: it" �
4.2 Software and Firmware
Firmware revision number.
4.3 System Power
4.3.1 Primary(Main)Power
Nominal voltage: A
-------------- Location: :1�4�
Overcurrent protection type. e,6 Amps:ffMjk,. .
Amps: Disconnecting means location:
Copynght®2018 Automatic Fire Alarm Associabon Phone:844438-2322 F—16T13 www.aW.org
of 4
4. DESCRIPTION OF SYSTEM OR SERVICE (continued)
43.2 Secondary Power
Location:
Type.
Battery type(i
f a licable):
PP
Calculated capacity of batteries to drive the system:
In alarm mode(minutes):
In standby mode(hours):
5. NOTIFICATIONS MADE PRIOR TO TESTING Time:
Contact: �
Monitoring organization Time:
Contact: = r
Building management y Time:
Contact:
Building occupants Time:
Contact:
Authority having jurisdiction Time:
Contact:
Other,if
j required
1 6. TESTING RESULTS
6.1 Control Unit and Related Equipment
Visual Functional comments
� Description
Ins ection Test
11 0° Cl
Control unit ❑
Lams LEDs LCDs 0 ❑ ___ --
Fuses ❑
Trouble si 3nals ❑ ❑ ---------
Disconnect switches ❑ _____----
Ground-fault monitorin ❑
! ❑
Supervision. ❑
❑
Local annunciator ❑
i
Remote annunciators ❑
Remote power panels ❑
1I ❑
l
6.2 Secondary Power
Visual Functional Comments
Ins ection Test
Description
Battery condition ❑ ❑ `
I Load volta e El
Discha a test ❑
11
Char er test ❑
Remote panel batteries ❑
i
www.ataa.org
1 phone_844•i38-2322
copyright*2018 Automatic Fire Alarm Association
)f 4
6. TESTING RESULTS (continue
6.3 Alarm and Supervisory Alarm Initiating Device r
Attach supplementary device test sheets for all initiating devices.
6.4 Notification Appliances
Attach supplementary appliance test sheets for all notification appliances.
6.5 Interface Equipment
Attach supplementary interface component test sheets for all interface components.
f Circuit Interface/Signaling Line Circuit Interface/Fire Alarm Control Interface
6.6 Supervising Station Monitoring
Description Yes No Time
r Comments
i Alarm signal
❑ `
Alarm restoration ❑ ❑
Trouble signal ❑ ❑ 1
Trouble restoration E
❑
Supervisory sig2nal ❑
Supervisory restoration ❑ El
6.7 Public Emergency Alarm Reporting System
F
Description Yes No Time
Comments
Alarm signal ❑ ❑
I
Alarm restoration ❑ ❑
Trouble signal ❑ ❑
Trouble restoration ❑ Eli Supervisory signal ❑ El Supervisoryrestoration ❑ ❑
1
i
1
Copyright®2018 Automatic Fire Alarm Association Phone:844-438.2322
www.afaa.org
i 3
i
7. NOTIFICATIONS THAT TESTING IS COMPLETE
Monitoring organization Contact: Time: qz
c Building management Contact: /V 4 tf Time:
Building occupants Contact: Al Time:
_ Authority having jurisdiction Contact: Time:
Other,if Contact: Time:
required
8. SYSTEM RESTORED TO NORMAL OPERATION
Date: ` "
�..� G�.3` � - Time:
9. CERTIFICATION
This system as specified herein has been inspected and tested according to NFPA 72,2013 edition,Chapter 14.
Signed: - -'6 �. -� Printed name: �!41,jue-j. t.r 1,14 Date:
Organization:(9�•f.k a Y fry. i,ew-u t r r" Title: >W \0-•7t.+1 C i�� >g�'�it i f.,•,f,e Phone: /' - rCi
Qualifications(refer to 10.53):
10. DEFECTS OR MALFUNCTIONS NOT CORRECTED AT CONCLUSION OF SYSTEM INSPECTION,
TESTING, OR MAINTENANCE
10.1 Acceptance by Owner or Owner's Representative:
The undersigned accepted the teat report for the system as specified herein:
Signed: Printed name: l Ctrt) r ��, C✓Yl(�/IG �`�j `ta 3-?.1�
Organization: "?i iv x tC r A- Title: Phone:
:
31
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Copyright O 2018 Automatic Fire Alarm Assoaabon Phone:844438-2322
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Encore FI re Pmtedl on
70 Briton Street
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FIRE PROTECTION
Bill To
Dunion Dohs
375 East Puthen Avenue hMs i www encoreffeprotsom(;oml
Cos Cob.CT 06W7 If you h-e any WWII"or cattcams please reach us at
.can
Invoice No. 12737495 serviceLocrwn DWW Donuts-267 South Ridge street
Invoice For Inspection Job llt31644910 io5wrm4) 257 Salt Rage Sled
Rye BrocK NY 10573
TransactionDs1e i 5/d12024
Due Dee ; 501QO24(plls Upon Receipt)
Notes
Completed-05.31 24
'n snection of the Portabie F-6inpYeMts Servoed a Tagged Fir WP/41Q(41
Noted Please see Se,M a Trade for drtrineies found.Ouote to follow
OF UrAllildes Aft
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Terms 3 Conditions
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Subject: Fwd: Invoice #12737495 from Encore Fire Protection
• for Inspection Job #34604910 at Dunkin Donuts - 267
South Ridge Street
Date: May 31, 2024 at 9:00:18 AM
To-- Chris Pedicini cpedicini312@gmaii.com
f Begin forwarded message:
From: Phyllis Bauer <servicetrade-
noreply+6t9@servicetrade.com>
Subject: Invoice #12737495 from Encore Fire
Protection for Inspection Job #34604910 at
Dunkin Donuts - 267 South Ridge Street
Date: May 31, 2024 at 8:43:39 AM EDT
To: tournasmgmt(@aol.com
Reply-To: pbauer@encorefireprotection.com
encore
FIRE PROTECTION
Encore Fire Protection Sent You an
Invoice
Encore Fire Protection shared Invoice#12737495 for Inspection Job
#34604910 at Dunkin Donuts - 267 South Ridge Street with you.
here to review the invoic_.
Job: Inspection Job#34604910
Date: 05/31/2024
Address: 267 South Ridge Street, Rye Brook, NY 10573
iew Invoice Detail
Encore Fire Protection
35 Philmack Drive
Middletown,CT 06457
L5-SUSer,�ice@er,.corefireprotection.com
https'f/vtww.encorefireprotection.Corr'
ff you have any questions or concerns please reach us at
service1ocaUcjn5 encereiireproiecuon.ccn
Powered by SERVICE OTRADE
BELTS
ANTIO 'OR W ORKING
CHECK AND CLEAN HOODS: /
CLEAN HOODS FRONT D BACK ROOM
WASH FILTERS
CLEANED BY:
'.NECKED BY: Ncl i G� ✓1 C
DATE:
CHECK OIi4 THE ROOF:
- BELTS
- MOTOR WORKING
CHECK AND CLEAN HOODS:
- CLEAN HOODS FRONT-AND BACK ROOM
- WASH FILTERS
CLEANED BY:
CHECKED BY:
FIRE EVACUATIONS DRILLS
DUNKIN DONUTS: 267 SOUTH RIDGE STREET
PROPER PROCEDURE IN THE EVENT OF AN ACTUAL FIRE
1. HAVE KNOWLEGDE OF THE STORE TOOLS SUCH AS FIRE DETECTORS, FIRE ALARMS AND FIRE
EXTINGUISHERS.
2. IF A FIRE STARTS IN THE STORE,ACTIVATE THE ALARM IMMEDIATELY.
3. IDENTIFY IF THE FIRE IS IN THE FRONT OR IN THE BACK AREA OF THE STORE.
4. LEAVE FROM THE BACK DOOR OR FRONT DOOR IN THE OPPOSITE DIRECTION OF THE FIRE,
ACCORDING TO THE FIRE EVACUATION ROUTE MAP.
5. EVACUATE EVERYBODY THROUGH THE PARKING LOT,TO THE SIDE GARDEN OF WELLS
FARGO BANK.
EMPLOYEE SIGNATURES:
NAME SIGNATURE DATE
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FIRE EVACUATIONS DRILLS
DUNKIN DONUTS: 267 SOUTH RIDGE STREET
PROPER PROCEDURE IN THE EVENT OF AN ACTUAL FIRE
1. HAVE KNOWLEGDE OF THE STORE TOOLS SUCH AS FIRE DETECTORS, FIRE ALARMS AND FIRE
EXTINGUISHERS.
2. IF A FIRE STARTS IN THE STORE,ACTIVATE THE ALARM IMMEDIATELY.
3. IDENTIFY IF THE FIRE IS IN THE FRONT OR IN THE BACK AREA OF THE STORE.
4. LEAVE FROM THE BACK DOOR OR FRONT DOOR IN THE OPPOSITE DIRECTION OF THE FIRE,
ACCORDING TO THE FIRE EVACUATION ROUTE MAP.
5. EVACUATE EVERYBODY THROUGH THE PARKING LOT,TO THE SIDE GARDEN OF WELLS
FARGO BANK.
EMPLOYEE SIGNATURES:
NAME SIGNATURE DATE
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FIRE EVACUATIONS DRILLS
DUNKIN DONUTS: 267 SOUTH RIDGE STREET
PROPER PROCEDURE IN THE EVENT OF AN ACTUAL FIRE
1. HAVE KNOWLEGDE OF THE STORE TOOLS SUCH AS FIRE DETECTORS, FIRE ALARMS AND FIRE
EXTINGUISHERS-
2. IF A FIRE STARTS IN THE STORE,ACTIVATE THE ALARM IMMEDIATELY.
-. IDENTIFY IF THE FIRE IS IN THE FRONT OR IN THE BACK AREA OF THE STORE.
4. LEAVE FROM THE BACK DOOR OR FRONT DOOR IN THE OPPOSITE DIRECTION OF THE FIRE,
ACCORDING TO THE FIRE EVACUATION ROUTE MAP.
5. EVACUATE EVERYBODY THROUGH THE PARKING LOT,TO THE SIDE GARDEN OF WELLS
FARGO BANK.
EMPLOYEE SIGNATURES:
NAME SIGNATURE DATE
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DATE: 3
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CLEANED BY: /s'`O'ti
CHECKED BY:
DATE: !.' a Ll
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CLEANED BY:
CHECKED BY:
DATE:
CYAN
CLEANED BY:
Ci4ECKED BY:
DATE:
- CLEAN
CLEANED BY:
CHECKED BY:
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BUILD MENT
VI E OF RY OK APR 1 2024] 3D
938 KING ET RYE BR NY 10573
a
VILLAGE OF RYE BROOK 4 -0 BUILDING DEPARTMENT
FIRE INSPECTION / OPERATING PERMIT APPLICATION
FOR OFFICE USE ONLY:
Fee Paid:$ Inspection Date&Time:
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
Application,dated: a Z ,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.
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1. Address: o?/n7 Somb, RR Ay S�; Rme Uroek_NY SBL:f ,_�s—a—5/ Zone:
2. Business/Occupancy Name: &E ,f 0JonGA InL_ A,1_NnKtrJ NYS Use Class:
3. Property Owner: W0S1tujjiZ)r-) Park P ia2Q Assoc.L- C_Address: HI t{Pw 1_jf- _4VQ �/b��►',I/f'. �/ Ia 7Dg
Phone# Cell# ,41lq—`09-314_. email: ►�ctftti�o`7og7�ge/Cr rn
5. Business Owner: tt,na,, Address: ly47-))e0,
Phone# c) Cell .2C email: Toll KAJA ' M C� o k -C6lvl
6. Emergency Contact: CknnIS T LArr1CkS Address: -)to-7 S- ki Ay_ { eaolL M y
Phone# Cell# _Q03- 5 -g02_0 email:T LAgNA,,SMGMTR AOL•Co M
7. Inspection Escort: Title:
Phone#: Cell#: email:
8. Provide a brief description outlining the current and/or intended use of the property:
N,wiK1rl Anj Service .�fpL "Sbrr►e -)f
9. List all Hazardous Materials:
10. Occupant Load: Existing: Proposed: Other:
11. Date&Disposition of Previous Fire Inspection: �a3 I9 Pass ❑ Fail
1
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.
STATE OF NEW YORK )
COUNTY OFF WESTCHESTER ) as:
73W klie�I/y , 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
/« f 1,,VV/Auro X&F
AJi—, 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 before me this < Sworn to before me this
day of day of n r , 202-1�—
Notary P lic Notary Public
/ig/ate of Property w er Signature o Applicant
/rlWi` 4 ✓y, /��9ir/r��'i D�nni� Tour>7� _
Print Name of Property Owner Print Name of Applicant
SHAHANA KAISAR
MARGARET A. HANSEN 01A I
Notvy Public,stste of Conneckul
Notary Public,State of New York My Commission EQires August 31,2028
No. 01 HA5018310
Qualified in Westchester County
Commission Expires September 27,20
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