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1982 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 : �n '-Yl-A-L I 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
BUILDING DEPARTMENT
VILLAGE OF RY9 BROOK Initial Inspection Date: ❑ Pass
STEVEN E.FEWS 938 KING STREET,RYE BROOK,NEW YORK 10573 .2-.1s,—aoQsl� 1-ail
BUILDING&FIRE INSPECTOR (914)939-0668 ;www.ryebrookny,goy Re-Inspection Date: U Pass
sfews n.rvebrookny_gov
I I Dail
FIRE INSPECTION REPORT, NOTICE OF VIOLATION & ORDER TO REMEDY SAME
Site Address: 3Lo <XDW k� 1,� S-' Zone: 00 P SBL: /y/, 2
Occupancy: yak I a a,. State Use Classification:
Business Owner: ur� 1.►A. QVkt. I L Phone: 9/yam F 3 7- O fG y
Building Owner: ►kJ I Aj` 1 ad.t. Qe�1,.1-�1 4.1 Ci Phone: �B O.s
Emergency Contact: Sa M & -, 4-h C-.- iMG 1, L-t Phone: 9 Lo 1 Z
Building Representative in Attendance: S"ocl 40.,_1
--------------------------------------------------------__---_---------
Take notice that the following violations of the New York State Un'form Fire Prevention&Buildin�iCode and/or the Code of the
Village of Rye Brook were found to exist at, 1 3�. SOu k Q 1 ejItG S-rLe in the Village of
Rye Brook,NY on, e- rtA C-f'N 2 s- 20 2-sr- .The person or ntity served with this Order to Remedy shall
immediately mence to correct all li violations and shall completely cure each violation described herein by no later than
�� S- Z O which is thirty(30)days after the date of this Order to Remedy.Furthermore,
upon curing any listed viol tion(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 TITA'T YOUR FAILURE TO CORRECT'ALL VIOLATIONS IS A CRIME PUNISHABLE BV FINE,IMPRISONMENT OR BOTH.
No VFs 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, V
e.906.7.Are PFE's properly mounted as per the manufacturers instructions. e,_ ✓�
f.906.9.Are PFE's properly installed:<40 lbs.max.5'above floor;>40 lbs.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. a.
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. d.
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.__ V
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._ _� _
_
e.901.6.1.Are sprinkler heads&cover plates unfinished or of factory applied finish only. e._ v _
f.901.6.3.Are records of all system inspections,tests&maintenance reports maintained on the premises. f._ ✓ _
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._ vel
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.
k.901.8.Are all fire protection systems in place and maintained untampered. k. ✓
INSPECTOR: DATE: Z Z 6- 2,0 Z T
R— f 1,1/2024
No W's 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.EXITS,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,mirrors,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. C. ✓ _
f. 1004.9.Are all spaces having an assembly occupancy posted with an approved occupant load sign. t. _
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 I.
are placed on one side of the aisle&at 44"wide where fixtures are placed on both sides. /
in. 1018.3.Are non-public/non-accessible aisles serving less than 50 people maintained at least in. V _
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. _ ✓
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. .i _
e.315.3.1.Is storage maintained 24"or more below the ceiling in nonsprinklered buildings, e. ,C _
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._ Z
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.
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. A
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._ 1� _
INSPECTOR: DATE: Z�Z,�
-2-
Revised w112024
NO VkS 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. _ _ A
b.606.3.Are approved standardized,pictorial signs posted adjacent to each elevator call station on all b.
floors reading; IN Flltl?EMF.RGF:NCV.Do NOT USE EI,F:VA'1'OR.USF.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. _ �C
e.[a]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. ✓_ _
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.[RB]122-5.13.Are grease traps provided and installed as required by Village Code. C.
f.[Pel 1003.10.[RB] 122-6.Are grease traps properly maintained as per State and Village Code. f. _ v? _
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-buming 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. ✓ _
d.[PM]603.4.Are safety controls for fuel-burning equipment maintained in effective operation. d. _ f
e.[PM]603.5.Is the fuel-burning equipment provided with adequate combustion&ventilation air. e.
11.MOTOR FUEL-DISPF,NSING FACILITIES&REPAIR GARAGES
a.2303.2.Is an approved,labeled&readily accessible emergency disconnect switch provided a. _ _ 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. _ _ r
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.
1.2.HAZARDOUS MATERIALS(IIAZ-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. _ _✓ _
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.
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. V-1
14.GENERAL HOUSOKEEPING
a.Good
b.Fair
c. Inadequate ^f 2�� ZS d.Poor INSPECTOR: DATE:�I . DATE: Z' 20
-3-
Remed 6n/2024
ITEM NUMBER REMARKS
7 c < < wAsh .L
1
1 2 �002 �17
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13A Sf ,e�l MA I-) sc,
INSPECTOR: l DATE: C- - �Sr ad L
-4-
Revised 6/1/2024
Inspection,Testing and Maintenance Form Wet Pipe Fire Sprinkler
ALL SAFE Systems
FIRE SPRINKLER SYSTEMS
INC.
This form covers the minimum requirements of NFPA•25 2017 for wet pipe fire sprinkler systems connected to water supplies without tanks or fire pumps.Seperste forms are avaliabh for fire pumps,
tanks,hose connections,and other fire protection systems.More frequent Inspecilon,testing and maintenance may be necessary depending on the conditions of the occupancy and the water supply
Property Name Data of Work
Shopping Center Bldg 2(126.150 S Ridge St and 27 Rye Ridge Plaza) 10/22/2024
Address Plsorre
24 Rye Ridge Plaza g14.701.4005
City State Zip Code Property contact
Rye Brook New Yark 10573 Alma Hakanlin
Owner Name
Win W490 Realty LLC
All responses refer to the current work performed on this date
Inspection Type
Weekly Monthly Quarterly Semiannual Annual Syear
Notes
1)All questions are to be anwered Yes,No,or Not Applicable.All'No answers are to be"piarned In Part III of this form.
2)Inspection,Testing,and Maintenance tasks are to be performed with water supplies(including fire pumps)In service,unless the impairment procedures of Chapter 15 of NFPA 25 we followed.
PART 1-Owner's Section
A.Is the building occupied? 8.Hn the oaupanq and hatSrd of earRutts renamed the same anee the tat Impaction?
Yes Yee ---- `�
C.Are ae fin protection systems In servics? D.Has the system remained In service without modification since 0a lest inspeeuon7
YH y,.
E Was the system free of sedation of devices and alarms since this hat Inspection?
Yes
Owne(s Representative i&aaCL Dale
j 10/22/2024
Signature
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PART 2-Inspector's Section
A.Inspections-Report any failures In Seetlon III
1.Weekly Inspection Items
a.Control Valves(including bsckfbw preventer Isolation valves)supervised with tools passed b.Relief port on RPZ not discharging
Inspection as described In".A.2.a) WA
Yes
2.Monthly Inspection items On addition above Items)
a.Control Valves and Valves on backflow preventera
1.In correct(open or dosed)position? 2.It not electrically supervised,locked In coned position?
Yea
WA
3.Aconsible and free from visible Wake? 4.ProWded with appropriate wrenches?
Yes Yes
5.Prwlded wvnh appropriate Idenillicabon?
Yes
b.Alarm vave free from physical damage,trim In correct(open or dosed)position,and no leekaga from retarding chamber or drabs?
WA
3.Quarterly Inspection Items On addition to above items)
Iof4
a.Gauges monitoring Ovate,wessure in good condition and showing normal water supply b.Fire department connections visible,accessible,couplings,and swivels not damaged,
pressure gaskets In piece and in good condition,check valve not leaking,clapper In place and operating
Yes- --- - — property,and operating drain valve In place and operating properfy.(if plugs or caps are not In
---- - - -—�place,Inspect for Interior obstruetlora)
c.Control valves electrically supervised d.Alarm and supervisory devices not damaged?
Lyes Yea --_
e.Pressure reducing valve In open position,not leaking,with downstream pressure per design
criteria and in good condition with hand wheals not broken?
N/A ----
4.Annual Inspection(In addition to above items)
a.Proper number and type of spare sprinklers? 1.List of spare sprinklere sttadtad and legible
Les
b.Visible Sprinklers
1.Proper position:Upright,pendent,s1dewa117 2 Free of leeks,corrosion,damage?
Yes Yea
3.Proper clearance below sprinklers? 4.Free of foreign material Including paint'
Yea Yea I
S.Liquid In sit gas bulb sprkWers?
Yes
c.Visible Pipe
1.In good condition/no external corrosion? 2.No meeMnkel damage or,WsW
F(Yes l
3.No external bads J id.Visible pipe hangars/seismic bracing not loose or damaged?
l
Yea --- ----- I 1 Yes
e.Sprinkler wrench(es)wkh spare sprinkiers f Genveal Information sign attached and legible
Yes , Yea
g.Has the internal Inspection of pipe removing a flushing connection and one sprinkler head h.Hydraulic Information sign securely attached to riser and legible?
near the end of a branch taro)performed In the last 5 years If no,conduct Internal Inspection N/A
S.5-Year Inspection Items(in addition to above Items)
a.Alarm valves and associated strainers,filters,and restricted orifices passed Internal b.Chack valves Internally Inspected,all parts operate and arc In good condition
Inspection? ----_---.-_ --- WA
N/A -- —
c.Internal pipe inspection performed per II.A.4.g
NIA
B.Testing-Report any failures In Section III
1.Quarterly Testing Items
a.Mechanical water flow alarm devices actuated and flow observed? b.Main drain test for system downstream of backnow device or pressuring reducing valve?
NlA — �- —
— Veer - -- _ -----------—
1.System startle pressure(psi} 2.System residual pressure(psi)
70 SS
3.was flow observed? 4.Are results comparable to previous tests?
2.Semiannual Testing Items(in addition to above Items)
a.Valve supervisory switches Indicate movement? b.Electrical water flow alarm devices actuated and claimed?
I Yes
3.Annual Inspection items On addition to above Items)
a.Main drain test(for system not tested quarterly)
1.System static pressure(pso 2.System residual pressure(pal)
(70
3,Was flow observed? 4.Are results comparable to previous tees?
Yes � Yea
b.Post Indicating valves opened until spring or torsion felt In the rod then closed back 114 c.Ali Sprinklers manufactured after 19207
tum-7 --- ----
Yes
----
�N/A
2of4
d.Quick response sprinklers 20 years old or more replaced or successfully sample tested in e.Standard response sprinklers 50 years old or more replaced or successfully sample tested In
the last 10 yesrs7 the last 10 years?
NIA -- N/A --- -- - J
— - —— —J L---- - --
Jr.Standard response sprinklers 75 years or more replaced or successfully sample tested In the g.Dry•type sprinklers replaced or successfully sample tesisd in this Ito 5 yam?
Iasi 5 ytars7 NIA I
h.Sprinklers subject to harsh environment replaced or successfully sample tested In the last 5
years?
N/(------- --- i
I.Antifreeze solution specific gravfty
1.Correct at most remote point? 2.Correet at interface with war system?
N/A (WA
3.Correct at other test points(over 150 gal) 4.Correa type of antifreeze?
N/A N/A - ---- j
J.All control valves operated through full range and returned to normal position? k Bacidlow devices passed forward flow lest?
Yts � N/A - - ----�
I.Pressure reducing valves passed partial flow last?
N/A
4.5-Year Inspection Items(in addition to above Items)
a.Sprinklers above high temperature tested? b.Gouges checked ug by calibrated gouge or repiaced7
j N/A NIA
c.Pressure reducing valves passed full flow tes17
NIA
C.Maintenance
1.Regular maintenance items
a.If any sprinkler failed the sample testing of Pon 11.8.3 were all sprinklers represented by that b.If sprinkler has been replaced,were they proper replacements?
sample rtplactd7 -
--
N/A ---------- —
c.Marine systems normally having fresh water were drained and refilled twice if raw water got d.Neat tape Inspected per manufacturers instructlone?
into the system? N/A
i N/A -- - j
a.if any of the following were discovered,was an obstruction investigation conducted?Explain reason(s)and findings in Part III
1.Defective Intake screen on pump supplied from sources_ 2,Obstnctfw material discharged during flow test
WA -- 1 WA
- J
!.Foreign materW In dry pipe valves,ettadt valve at pumps_ 4.Foreign material In water during drain test or plugging of Inspectors test Connection
t WA J NIA
S.PhggYq of pipe or sprfnlders fmw dwI g activatlon or work 6.Reead of broken mains In vicinity
WA ------- ------] N/A
7.Ali ncenialy frol"M fNNddppkg of dry-pipe valves a.Failure to flush yard piping or surrounding mains following new InsW lotion or repairs
FWA
9.EysteM to returned to service after an extended period of time out of service(more then one 10,There is Nissan to below the system contains sodium silicate or Its darlvstlans or highly
7OK)7 corrosive fluxes In copper pipe
NU I N/A )
11.Rex ureter was ptattpod Ielia the fire department connections --J 12,Pinhole looks ---
WA
f.if conditions were found that required flushing,was flushing of system conduetad7 g.Was a Volvo status test connected after opening any closed valves?
WA N/A
h.Adjusted,repaired,reconditioned or replaced components had the associated tests and/or
Inspections perfomxd
N/A -- -- - - -�
2.Annual Maintenance items(in addition to above items)
a.Operating stem of all OUY valves lubricated,completely closed,and reopened? Is.Sprinklers and spray nozzles protecting commercial cooking equipment and ventilating
lWe system replaced except for bulb-typt which shows no signs of grease buf d-W?
NIA
PART 3-Comnmfta
30f4
Any'No answers,test failures or other problems found wilh the sprinkler system must be explained here.(As a courtesy,note on a separate form arty concems about anything that you saw while
perfoAng your work that is not a part of the NFPA 25 requirements including any recalled products that you happened to notice)
Comments
PART 4•Inspeotoes Information
I state that the Information on this is form correct at the time and place of my inspection,and that all equipment tested at this lime was left in operating condition upon completion of this Inspection
except as noted In Part III above.
Company Company Address
AB Safe Flre SprlNcler Systems,Inc 37 ExeovtNe Blvd Elmsford,NY 10523 ---
Inspector Date Certification or License Number,If applicable
SFAN BROWN i(10/=024
Inspector Signature
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� 1
------------------------------
i
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i
t t
Inspection performed In accordance wlrh NFSA Standard for the Inspection,Testing,and Maintenance of Water-eased Fire Protection Systems,2017 edition.
4of4
SYSTEM RECORD OF INSPECTION AND TESTING
This loan rs to bo wmple/ed by/he system inspeCAon and iesAng-ni actor at/he t me of a system test
It shalt be permitted/o mod1fy lhrs/orm as needed to Fvovede a more canp/eta and or Uear rpcerd.
/nserr/YJA ,n a.'/unused Ines.
Attach addition/sheets,data.or Gz(cu/scions as nae essary to provido a comp/eto record
Insrwction Test Sian Dale"I imc: 6/24/2024 Inslxcuutr lb l l umplchun I)afc'Ilmc 6/24/2024
Suppleniental Fonnrsl Auachcd: _ i)es:nol
1. PROPERTY INFORMATION
.Name or pmpertc: Rye Ridge Shopping Center- Bldg. 2
Addre.s: 126-150 S. Ridge Street and 27. Rye Ridge Plaza Rye Brook, NY 10573
De,criplion of pro[wri): Retail Stores & Restaurants
Name of propert) rcpresencinsc: Win Ridge Realty - Al�Hakanjin
Address: 24 Rye Ridge Plaza
Phone: 914-701-4005 Fa-,: I -:1il ahakanjin@winridge.cpm
2. TESTING AND MONITORING INFORMATION
resung organization: Scarsdale Security Systems, Inc
.Address: 132 Montgomery Avenue,Scarsdale, NY 10583
Phone: (914)722-2200 Fa.: (914)722-2299 L mail: seryice@scarsdalesecurity.com
.Monitoring organization: Scarsdale Security Systems Inc.
Addrevv 132 Montgomery Avenue Scarsdale, NY 10583
Phone: 914-722-2222 Fay: F inail:
Account number: 541306 I'hune line I' Ph+nac fine'.
Stcam of tnnsmission: Digital
Entity to sshich alanns are rciransmiticd: Phone'.
3. DOCUMENTATION
On-site location of the required record documents and site-specirac software:
4. DESCRIPTION OF SYSTEM OR SERVICE
4,1 Control Unit
%lanufacturcr. Silent Knight 'slodel nund,cr 5820
4.2 Software and Firmware
Firntwate rcrision numtxr.
43 System Power
43.1 Priman•(Main)Power
Nominal cottage. 120 Anips: 15 Lccauon: Electrical Closet
Ocercurrcni prnteceion i)pe: Amps: Disconnecting means location.
CoprngtM O 2012 Natrol Fire ftocson A uodLw.Tr"form m&y be C coma tar Y,O vo ai use other thin to reset.n entry rot De o09aed for oorrrnergei rise Or*$VbAloft
1 a'
SYSTEM RECORD OF INSPECTION AND TESTING(continued)
4. DESCRIPTION OF SYSTEM OR SERVICE (continued)
4 1.2 Secondary Power
I.pc: Battery Electrical Closet^
Itanen qIs 1i1 ahplicahle): Lead Acid
Calculated capacity of Ninerics to drive the.csrenr
In standhN,m(xle fhottf.j. 24 In alanu male umnutc.c 10
S. NOTIFICATIONS MADE PRIOR TO TESTING
monittrring orgamt:ruon tbnfact: Scarsdale Security Systems Inc. I lint:
Building management tlmtact: Time:
Building occupants Ck'JIU.'t: rime:
Authority having jurisdiction Conwo: I on.:
Other. If Contact; I imc:
required
6. TESTING RESULTS
6.1 Control Unit and Related Equipment
Visual
In Functional
Description s ction Test Comments
Control unit i Pass
Lam s/LEDs/LCDs ' Nf Pass
Fuses ❑ _ ❑
Trouble signals 31" Pass
Disconnect switches 01 Pass
Ground-fault monitoring1 1� i Pass
Supervision CJ Pass
Local annunciator t➢f a Pass
Remote annunciators P1 Pass
Remote power panels 16 61t Pass
❑ Pass
61 Secondary Power
Visual Functional
Description Inspection Test Comments
Battery condition Id 12( Pass
Load voltage Id 51" t pass
Discharge test 0 ❑ I
Charger test ❑ ❑ M
Remote panel batteries ❑ ❑
eoorrynt C 2012!utonaf Foe Proccton Alsaoaf on INS form mar be eetva0!a oN W usi use outer bra..for reaue it mar n.N be coD•70 for wv%� ",sale or O1171bul•on
SYSTEM RECORD OF INSPECTION AND TESTING(continued)
6. TESTING RESULTS(continued)
63 Alarm and Supervisory Alarm Initiating Device
Attach supplementary device test sheets for all initiating devices.
6A Notification Appliances
Attach supplementary appliance test sheets for all notification appliances.
6.5Interface Equipment
Attach supplementary interface component test sheets for all interface components.
Circuit Interface/Signaling Line Circuit Interface/Fire Alarm Control Interface
6.6 Supervising Station Monitoring
Description Yes No Time Comments
Alarm signal 12( ❑ 15:00 Pass
Alarm restoration ❑ 15:10 I Pass
Trouble signal ❑ 15:00 Pass
Trouble restoration b�1 ❑ 15:10 Pass
Supervisory signal Pf ❑ 12:00 Pass
Supervisory restoration N p 15:10 Pass
6.7 Public Emergency Alarm Reporting System
Description Yes No Time Comments
Alarm signal F-f ❑
Alarm restoration ❑
Trouble signal ❑
Trouble restoration ❑
Supervisory signal Ef ❑
Su erviso restoration Ed ❑
CoWi ht 0 2012 N bonal Fee PlOWCWn Anodnpn.Tho form entry De tr pteA la rcmaL al toe wwr iron 1pc res".f(may not be copw tQ cprtrnermal sale tv*%zbw w
SYSTEM RECORD OF INSPECTION AND TESTING (continued)
7. NOTIFICATIONS THAT TESTING IS COMPLETE
Monitoring organization Contact: Scarsdale Security Time: 10:00am
Building management Contact: Time:
Building occupants Contact: Time:
Authority having jurisdiction Contact: Time:
Other, if Contact: Time:
required
8. SYSTEM RESTORED TO NORMAL OPERATION
Date: 6/25/2024 Time: 10 00am
9. CERTIFICATION
This system as specified herein has been inspected and tested according to NFPA 72, 2013 edition,Chapter
14.
Signed: �,j �pB,� ,� Printed name: John Fleischman Datc: 06/25/2024
Qrgahir�ti n' Scarsdale Security Services title: Fire Inspector Phone: 914-722.2308
Qualifications(refer to 10.5 1)•
10. DEFECTS OR MALFUNCTIONS NOT CORRECTED AT CONCLUSION OF SYSTEM
INSPECTION,
TESTING, OR MAINTENANCE
Inspection Completed 6/25/2024
Rye Ridge Deli-Front Horn Strobe not working
Deficiency Ticket- Technician Onsite 7/10/2024-Horn Strobe that is not working is not part of Win Ridge System,
They do have connection to ring shopping center if deli system goesw into alarm alarm
7/10/2024 Technician onisite, System online and operations normal.
10.1 Acceptance by Owner or Owner's Representative:
The underslcined accepted the test report for the system as�specified herein:
Signcd: ���,, p-y� ` Printed name: /'l.l IIjY1 "rlh i����I�` Date:
Organization: WYIV VG IZ{Slitr(ir l�� Phune.
Cogrgte C 2012 NaborW Fre F*�Assoaaton Tlts Corm may be copb0 for rndmouw use 0VW VW lot resale It may rot be coped tar OWWWCW saw a dr3'1r0voen
Date WORK ORDER SUMMARY 2024
To
Fortina Rye Ridge LLC
4 MacDonald Ave, Ste 5
Armonk, NY 10504
Service Location: Fortina Rye, 136 South Ridge St, Rye Brook NY 10573
Telephone
914-510-2032
Email
lilian@fortinapizza.com
DATE DESCRIPTION OF SERVICE NOTES PAID
1/9/24 Grease Trap Cleaning &Oil Collection Brown Yes
2/13/24 Grease Trap Cleaning & Oil Collection Brown Yes
3/12/24 Grease Trap Cleaning & Oil Collection Brown Yes
4/16/24 Grease Trap Cleaning & Oil Collection Brown Yes
5/14/24 Grease Trap Cleaning & Oil Collection Brown Yes
6/11/24 Grease Trap Cleaning & Oil Collection Brown Yes
7/16/24 Grease Trap Cleaning & Oil Collection Brown Yes
8/13/24 Grease Trap Cleaning & Oil Collection Brown Yes
9/10/24 Grease Trap Cleaning & Oil Collection Brown Yes
10/8/24 Grease Trap Cleaning & Oil Collection Brown Yes
11/12/24 Grease Trap Cleaning & Oil Collection Brown Yes
12/10/24 Grease Trap Cleaning & Oil Collection Brown Yes
Thank you for your businessl
VELVET ROPE MANAGEMENT LLC
PO BOX 69 tt
ARMONK NY 10504 '`
_ Hudson Valley Fire.Inc.
136 Washington Street
Peekskill,N.Y. 10566
914 788-6654/FAX 914 788-4654
February 6,2025
Forting Rye Ridge
136 South Ridge Street.
Rye Brook,New York 10573
Please allow this letter to serve as notification that Fortina Rye Ridge
maintains a service contract with Hudson Valley Fire for the inspection of their
fire protection equipment. Please find below the services included in the
contract.
• Annual.inspection Exit& Emergency Lights Inspection (9)
Last service date 2/4/2025 Next service due date 2/2026
• Semi-annual inspection of the fire suppression system and the
replacement of fusible links
Last service date 10/15/2024 Next service due date 4/2025
• Semi-annual Hood cleaning
Last service date 10/17/2024 Next service due date 4/2025
Thank You for your attention to this matter. If you require any other
information please feel free to contact my office.
Sincerer,
14 .4
Karen Mazno
Accounts receivable manager
Hudson Valley Fire
Pre-Engineered Restaurant Fire Suppression Systems Report
Hudson Valley Fire Inc. Business Name Customer Information
136 Washington Street Address
Peekskill, NY 10566 City State Zip Code
Telephone Store No.
914-e88-6654 Fax Email
Owner/Manager/Authorized Agent
Date of Service Time In Time Out
Annual Semi Annual Installation InspeRion/Maintenance Recharge Renovation
System Information System Information
Manufacturer: Fusible Links(Quantity of Each): 165° 21Y_280°
System Name/Model: 36o° 450°_ 50c°
Thermal Heat Detectors 135° 190°_ 225°
Manufacturer Manual Reference: (Quantity of Ea(h): 325° 456'_600°
System Type: ❑Wet Chemical ❑Dry Chemical Fuel Shut Off
System Meets UL 3oo Requirements: ❑Yes El No Type; ❑Electric Mechanical
Serial Number: Fuel Shut Off Size(s): Fuel Shut Off(1) Fuel Shut Off(2)
Fuel Shut Off
CylinderSize(s): Main Secondary(1) Secondary(2) _ SerialNumber(s): Fuel Shut Off(1) Fuel Shut Off(2)_
Secondary(3) Secondary(4) Secondary(5) Last Hydrostatic Test Date:
Cylinder Location(s): Last Recharge Date:
System Checks Yes No* N/A System Checks Yes No* N/A
1• All appliances properly covered w/correct nozzles ❑ ❑ ❑ 18. Travel of cable nuts/S-hooks checked ❑ ❑ ❑
2.Duct and plenum covered w/correct nozzles ❑ ❑ ❑ 19. Piping&conduit securely bracketed and clear of debris ❑ ❑ ❑
3.Positioning of all nozzles checked ❑ ❑ ❑ 20. Proper separation between fryers and flame ❑ ❑ ❑
4.System installed in accordance w/MFG UL listing ❑ ❑ ❑ 21. Proper clearance:flame to filters ❑ ❑ ❑
5.Hood/duct penetrations sealed w/weld or UL device ❑ ❑ ❑ 22. Exhaust fan in operating order ❑ ❑ ❑
6.Checked for intact seals,evidence of tampering ❑ ❑ ❑ 23. All filters replaced ❑ ❑ ❑
7.Has system has been discharged?report same ❑ ❑ ❑ 24. Fuel shut-off in on position ❑ ❑ ❑
8.Pressure gauge in proper range ❑ ❑ ❑ 25. Manual&remote set/seals in place ❑ ❑ ❑
9.Cartridge weight checked ❑ ❑ ❑ 26. Systems covers replaced ❑ ❑ ❑
1o.Cylinder and mount inspected ❑ ❑ ❑ 27. System operational&seals in place ❑ ❑ ❑
11.Operated system from terminal fusible link ❑ ❑ ❑ 28. Slave system operational ❑ ❑ ❑
12.Tested for proper operation from manual remote pull ❑ ❑ ❑ 29. Cylinder&mount cleaned ❑ ❑ ❑
13.Operation of micro switch checked ❑ ❑ ❑ 3o. Fan warning sign on hood ❑ ❑ ❑
14.Operation of fuel shut-off checked ❑ ❑ ❑ 31. Personnel instructed in manual operation of system ❑ ❑ ❑
15.Nozzles clean and clear of debris ❑ ❑ ❑ 32. Proper hand portable extinguishers in place ❑ ❑ ❑
16.Proper nozzle covers in place ❑ ❑ ❑ 33. Portable extinguishers properly serviced ❑ ❑ ❑
17. Replaced fusible links ❑ ❑ ❑ 34. Service&Certification tag on system ❑ ❑ ❑
NOTE DISCREPANCIES OR DEFICIENCIES
Cooking Appliance Locations:Left To Right
-
The service technician certifies that the system was inspected and found conditions to be as indicated on this report.
X X
Service Technician Signature Date Owner/Manager/Authorized Agent Signature
Print Service Technician Name Permit No. Print Owner/Manager/Authorized Agent Name
WHITE-CUSTOMER YELLOW-DISTRIBUTOR PINK-AUTHORITY HAVING JURISDICTION
P/N SER100C 0 2023 Heiser Logistics
HUDSON VALLEY FIRE, INC.
136 WASHINGTON STREET. PEEKSKILL, NY 10566 Date:
N 914-788-FIRE •914-788-6654
ALLEY FAX:914-788-4654 Tech ID:
FIRE.INC EMAIL:BFIREPROCa)AOL.COM
33484
Bill To: Ship To:
Quantity Description Unit Price Amount
FIRE EXTINGUISHER(S) SERVICED
FIRE EXTINGUISHER(S) RECHARGED
FIRE EXTINGUISHER(S) HYDROSTATIC TESTED
AUTOMATIC FIRE SUPPRESSION SYSTEM(S)
SERVICED
FUSIBLE LINKS FURNISHED AND INSTALLED. TEMP:
KITCHEN EXHAUST VENTILATION SYSTEM DECREASED
GREASE FILTERS, SIZE:
WET FIRE SPRINKLER(S) SERVICED
DRY FIRE SPRINKLER(S) SERVICED
EXIT LIGHT(S) SERVICED
EMERGENCY LIGHT(S) SERVICED .
WET FIRE STANDPIPE SYSTEM(S) SERVICED
BACKFLOW PREVENTION DEVICE SERVICED
Customer acknowledges services rendered. Sub Total
Customer Signature Tax
Total
Print Name
LE EXTINGUISHERS
AUT
MATIC
COD
INSTALLATION ES SYSTEMS VENTILATION
SYSTEMS
6�Upm SPRIINKLR SERVICE EXHAUST CLEANING EXIT MERGENCYLIGHT NC
pp pp BATTERY BACK UP SYSTEMS•FIRE ALARMS•BACK FLOW TESTING
➢ a 1, S f0� � a, ! R 1 �Qk I i
O O 375 Executive Blvd. • Elmsford, ICY - 10523 • TEL 1-(888) 325-5723 - FAX (914) 747-3983
` , a 1 '> Licensed in NY, CT, LI 8t NJ
>rnrw.ullsatefireprotf�ctian.com V; 1 98
Customer Name: _ Arrival Time: Departure Time:
Address: Bill To:
City/Town: rr
Address:
State: Zip:
Phone #: Zip Code: Phone #:
E-Mail: Contact Name:
DATE: ANNUAL SERVICE❑` SEMI-ANNUAL❑ MONTHLY❑ NEW ACCOUNT❑ EMERGENCY CALL❑
CITY. EXTINGUISHER LOCATION RE- SERV. Hydro T TAKEN NEW RETURN REPL. 6 YR. AMOUNT
CHARGED ReChg EXT. LFT. MAINT.
2.5 ABC
2.5 ABC
5 ABC
5 ABC
10 ABC I
r 10 ABC
10 ABC
20 ABC
20 ABC
20 ABC
FIRE SYSTEM
FIRE SYSTEM
CLASS K _' a
CLASS K
EMG.LIGHTS
PW
CO2
WHEELED UNIT
FIRE HOSE
COVERS
CABINETS
PARTS
BULBS REG / FLORESCENT BATTERY'S HOOD JARS LINKS
CARTRIDGES CAPS STRAPS WIRE LEADS S/S DIVIDERS
VALVE STEMS PINS O RINGS , SAFETY DISKS BRACKETS SIGNS GAUGES
DETECTION O AMT. TEES CONDUIT CARTRIDGE IN OUT
NOZZLES AMT. 0 GUAGE PIPE 0 TAGE 0 YES 0 NO 0 NO
GAS VALVE TYPE CART.WT. 0 MANUAL PULL O HOOD AND YES 0 NO
DUCT
PIN (IN)0(OUT) MICRO-SWITCH REMOTE PULL 0 GEXCESS REASE YES NO
0
I AGREE FIIAI I HE AHOVL INSPECTION PIIUCL UUi t ❑ ❑ TERMS:C O.D. ❑ PAYABLE UPON RECEIPT OF INVOICE❑
HAVE BEEN COMPLETELVDELIVERED.
PARTIAL OWIF-F1 I- I ORD�RF1)COMPLF I F CREDIT CARD N
'1 r
tSIGNAIUFIE ECNICIAN 1 ��---. ..-'!,'
".
PRINT NAME - _ _ PRIN F NAML
SAFE FIRE HOSE•CODE 96 VENTILATION SYSTEMS•SPRINKLER SERVICE•EXHAUST CLEANING•EXIT LIGHTING N U
EMERGENCY LIGHTING•BATTERY BACK UP SYSTEMS•FIRE ALARMS•BACK FLOW TESTING
r' 375 EXECUTIVE BLVD. ELMSFORD,NY 10523 TEL 1-(888)325-5723 FAX(914) 747-3983
Licensed in NY.CT,LI&NJ
www.allsafefireprotection.coni
Arrival Time: Departure Time: Technician Name:
Customer Name: Bill To:
Address: Address:
Zip Code: Phone#: Zip Code: Phone#:
E-Mail: Contact Name:
DATE: ANNUAL SERVICE ❑ SEMI-ANNUAL ❑ MONTHLY ❑ NEW ACCOUNT❑ EMERGENCY CALL ❑
QTY. DESCRIPTION TOTAL
SUB TOTAL
VISA ❑ MASTERCARD ❑ TERMS:C.O.D.❑ PAYABLE UPON RECEIPT OF INVOICE❑ TAX
DEPOSIT
CREDIT CARD N
BALANCE DUE
LE EXTINGUISHERS
AUT
MATIC
HOSE
CODE
�� � ���❑ INSTALLATION S SYSTEMS E VENTILATION
SERVICE EXHAUST CLEANING EXIT LGHTG-EMERGENCY SYSTEMS
N(
BATTERY BACK UP SYSTEMS•FIRE ALARMS•BACK FLOW TESTING
375 Executive Blvd. • Elmsford, NY - 10523 • TEL 1-(888) 325-5723 FAX (914) 7+7-3983
Licensed in NY, CT, LI & NJ
i,��bu.tllls�ticiilcl�I�+l�:(:Iiun.I.�:n� _ �.
kip
Customer Name: Arrival Time: Departure Time: ._
Address:
Bill To:
City/Town:
Address:
State: Zip:
Phone #: Zip Code: Phone #:
E-Mail: Contact Name:
DATE: ANNUAL SERVICE❑' SEMI-ANNUAL❑ MONTHLY❑ NEW ACCOUNT❑ EMERGENCY CALL❑
QTY. EXTINGUISHER LOCATION RE- SERV. Hydro T TAKEN NEW RETURN REPL. 6 YR. AMOUNT
CHARGED ReChg EXT LFT. MAINT.
2.5 ABC
2.5 ABC
5 ABC
5 ABC
10 ABC
i 10 ABC
10 ABC
20 ABC
20 ABC:
20 ABC:
FIRE SYSTEM
FIRE SYSTEM
CLASS K
CLASS K
EMG.LIGHTS
PW
CO2
WHEELED UNIT
FIRE HOSE
COVERS
CABINETS
PARTS
BULBS REG / FLORESCENT BATTERY'S HOOD JARS LINKS
CARTRIDGES CAPS STRAPS WIRE LEADS S/S DIVIDERS
VALVE STEMS PINS 0 RINGS SAFETY DISKS BRACKETS SIGNS GAUGES
DETECTION O AMT. TEES CONDUIT CARTRIDGE IN OUT
NOZZLES AMT. O O GUAGE PIPE O TAGE YES NO 0 NO
GAS VALVE O O TYPE CART.WT. MANUAL PULL HOOD AND YES NO
DUCT
PIN O(IN)O(OUT) MICRO-SWITCH REMOTE PULL GEXCESS REASE YES NO
0
I(kGREE 111,11 I HE AM 1 1L.II-PE.0 HUN PHUCI.UUi ❑ ❑ TERMS:C O.D. ❑ PAYABLE UPON RECEIPT OF INVOICE❑
HAVE BEEN COMPLETED/DELIVERED.
J PARTIAI (x1[E;H Ij ORD�HFIr C(IMPI E I i CREDIT CARD 1L
TECNICIANSp'MAII�I2E
PRINT NAME
SALES•SERVICE•RECHARGING•INSTALLATION•PORTABLE EXTINGUISHERS•AUTOMATIC SYSTEMS
SAFE FIRE HOSE•CODE 96 VENTILATION SYSTEMS•SPRINKLER SERVICE•EXHAUST CLEANING•EXIT LIGHTING
EMERGENCY LIGHTING•BATTERY BACK UP SYSTEMS•FIRE ALARMS•BACK FLOW TESTING
375 EXECUTIVE BLVD. ELMSFORD,NY 10523 TEL 1-(888) 325-5723 (914)747-3983
Licensed in NY,CT,LI&NJ
- www alisafefireproiekIn.00m -, F 18927
Arrival Time: Departure Time: _ Technician Name:
i
Customer Name: Bill To:
Address: S Address:
Zip Code: Phone #: Zip Code: Phone#:
E-Mail: Contact Name:
DATE: r 11 L ANNUAL SERVICE ❑ SEMI-ANNUAL ❑ MONTHLY ❑ NEW ACCOUNT❑ EMERGENCY CALL ❑
OTY.. DESCRIPTION TOTAL
SUB TOTAL
VISA ❑ MASTERCARD ❑ TERMS:C.O.D.❑ PAYABLE UPON RECEIPT OF INVOICE❑ TAX
DEPOSIT
CREDIT CARD#
BALANCE DUE
AUTOMATIC
S-FIRE HOSE
CODE
INSTALLATION PORTABLEEXTINGUISHERS
L VENTILATION
SAFE SPRINKLER SERVICE EXHAUST CLEANING EXIT LIGHTING MERGENCY LIGHTING
BATTERY BACK UP SYSTEMS•FIRE ALARMS•BACK FLOW TESTING
6 FM ^PRO C T I O N� -- - - - - -- - --
375 Executive Blvd. • Elmsford, NY - 10523 •TEL 14888) 325-5723 • FAX (914) 747-3983
f& MWRAYNICA4 I N C. Licensed in NY, CT, LI & NJ
www.allsafefireprotection.com 169198
Customer Name: �� 7 _ Arrival Time: Departure Time:
Address: S •� y' �{
Bill To:
City/Town,;' 6
Address:
State:.L Zip I
Phone #: Zip Code: Phone #:
c
E-Mail: �J Contact Name:
DATE: ANNUAL SERVICE E" SEMI-ANNUAL❑ MONTHLY❑ NEW ACCOUNT❑ EMERGENCY CALL❑
CITY EXTINGUISHER LOCATION RE- SERV. Hydro T TAKEN NEW RETURN REPL. 6 YR. AMOUNT
CHARGED eChg EXT LFT. MAINT.
2.5 ABC
2.5 ABC
5 ABC
5 ABC
10 ABC 6 !
/ 10 ABC
10 ABC
20 ABC
20 ABC
20 ABC
FIRE SYSTEM
FIRE SYSTEM
J CLASS K ✓ i r
CLASS K
EMG.LIGHTS
PW
CO2
WHEELED UNIT
FIRE HOSE
COVERS
CABINETS
PARTS
BULBS REG / FLORESCENT BATTERY'S HOOD JARS LINKS
CARTRIDGES CAPS STRAPS WIRE LEADS S/S DIVIDERS _
VALVE STEMS PINS 0 RINGS/ SAFETY DISKS BRACKETS SIGNS GAUGES
DETECTION 0 AMT. TEES 0 CONDUIT CARTRIDGE IN OUT
NOZZLES AMT. GUAGE PIPE TAGE YES NO C NO
GAS VALVE TYPE CART.WT. MANUAL PULL HOOD AND YES NO
DUCT
PIN (IN)0(OUT) MICRO-SWITCH REMOTE PULL 0 GEXCESS REASE
YES NO
I AGREE THAT THE ABOVE INSPECTION PROCEDURE" ❑ ❑ TERMS:CO.D. ❑ PAYABLE UPON RECEIPT OF INVOICE❑
HAVE BEEN COMPLETEDIDELIVERED.
U PARTIAL ORDER ORD ED COMPEER CREDIT CARD 2_
rECNICIAN SIGNATURE 4l02 _ _ CUSTOMER _, ,
PRINT NAME __- ____ _ _ _____ PRINrNANIE
BUILD MENT
VI E Of', OK
938 KING FT Rf AR NY 10573
JAN - 3 7',j25
ov
FIRE INSPECTION / OPERATING PERMIT APPLICATION
FOR OFFICE USE ONLY: C) 3OA"
Fee Paid: $ ��� (�r Inspection Date& Time: E'5��7 y
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: ,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: 13to St &A T1idole St �ye U�Dnk SBL: j 4 j.2,1 — I Zone:C I -P
2. Business/Occupancy Name: Fnr�-ina. NYS Use Class:
3. Property Owner: in'—Ri clae'_Re A L L C Address: 24JRM e Ti c,Af 1 A2,Ct'
Phone# (a1 01- y 005 Cell # email: anaYNcknivne Win ri Cla e. M
5. Business Owner: LL-C Address: macbongu Ave STE 5 Qrmon K
10100tv
Phone# (ql 4)510'2 032 Cell# email:
ql
6. Emergency Contact: So,1�nA+,o, Me1iSi. Address: 5
Phone#(0114)510-2032 Cell# email: sp,rrrr a l� tt� CAM
7. Inspection Escort: Sar MbAba M21i si, Title ire cAmc O t btra�;ong
Phone#: (q N) 5, 1 b-2 D 32 Cell#: email: Sam►,��g�tUr�►rno��n^�
8. Provide a brief description outlining the current and/or intended use of the property:
F l 1, JGrvi cc " Ees aurnnk
9. List all Hazardous Materials: N I A
10. Occupant Load: Existing: 13 k Proposed: 1 3\ Other:
11. Date& Disposition of Previous Fire Inspection:�71Une 2.a?! - ❑ Pass ❑ Fail
6/1/2024
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 WEESST--CHESTER
.pa%4 t"ai 11a being duly sworn, deposes and states that he/she is the applicant above named,
(print name of Indhrldual 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
4ent , for the legal owner and is duly authorized to make and file this application. That all
(Indicate archltdct,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.
Swam to before me this Sworn to before me this
day of 0 m8�� ,20� day of k)PGe.Y,loer ,20
h
N tic Notary Public
ignature oPProp' t VMW earure0fApplicad`t1
1A 40AI !
Print Name at Property OWMrr- Print Name of Applicant
I
RICHARD A.YARMY II LHian Medo
NOTARY PUBLIC,STATE OF NEW YORK NOTARY PUBLIC,STATE OF NEW YORK
Registration No.OIYA0013323 R.yrso-nInWeilc ingmCaeu
awlHledln WAslcheHerCouny
Qualified in Westchester County ComMsOonEx0e3 F•brunry01.2M5
Commission Expires September 08,2027
2
NI/2024
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