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BUIL E RTMENT APR _ 4 2025
VIL � E OF RYE BROOD
938 KIN ET RYE BROOK,NY 10573 VILLAGE OF RYE BROOK
l �� -0668 BUILDING DEPARTMENT
. ehrookny.gov
PLUMBING PERMIT APPLICATION
FOR OFFICE USE ON1,Y l�� PP#: r� �
Approval Date: Permit Fee: $ / 1 /0 — N
Approval Signature: APR Disapproved:
(fees are non-refundable)
DO NO1'START %NORk or CQNS7'RLC"1ION LN'1ILA PER,MI'I HAS BELN ISSULD 131 THE BUILDING
INSPECTOR THE ADMINISTRATIVE FEE FOR WORK PROGRESSED OR COMPLETED WITHOUT A
PERMIT IS 12% OF THE TOTAL COST OF CONSTRUCTION WITH A MINIMUM FEE OF$750.00
Application dated, �� is hereby made to the Building Inspector of the Village of Rye Brook NY,for the issuance of
a Permit to install and/or remove Plumbing as per detailed statement described below.The applicant&property owner,by signing this
document agree that said plumbing work r 4 will be in conformance with all applicable Federal,State,County and Local Codes.
1.Address: (l✓AFL 4 t� l� 1 I3,eo'ov_ SBL: 7/-7 ei — — Zone:
2.Proposed Work: f 4.—
3.Property Owner: IVA"i- /d Address: t L Le ra /5
AC
Phone#: 203 56I' Cell#: . 6 � /N � C
email: N.�i BEAN G
4.Master Plumber: fj W A 49- '4fb f A VD Address: Y6® /y/*AI'V 64.%,--ee N
Lie.#: 1 Phone#: __'? //3O�CeII#: email: q
Company Name:_ R e�I� A djA^'I G�.� Address: fl /� /��� � ev
INDICATE FIXTURES&LINES TO BE INSTALLED AS PER THE FOLLOWING SCHEDULE:
Location Water Urinals Drinking Sinks Showers Bath Laundry Domestic Fire Sanitary Natural/ Other* Total
Closets Fountains Tubs Tubs Service Service Sewer LP Gas
Basement
1st Floor
2nd Floor
31d Floor
4a'Floor
56,Floor
Exterior
5.*List Other EquipmenVProvide Details:
(Notarized Signatures Required Next 2 Pages)
-1- 6/1/2024
STATE OF NEW YORK,COUNTY OF WESTCHESTER ) as:
,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 Master Plumber for the legal owner and is duly authorized to make and file this application.
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.
Sworn to before me this / Sworn to fore me this
day of C\ ,20 day o
t7V�
Signa rop rty Ow1r er Signature of Applicant
km_ Nimp��A yi�- ArM6
PrintName of Applicant
7c: u��
Notary Public o ary ub is LINA WHALEN
SHARI MEULLO Navy Pur`,C,State of NewYbrk
Notary Public,State of New York No.OIWH63945W
No.01ME6160063 Oualfr.,,in Westchester County
Qualified In Westchester County Q nr-m ai0n Exom July 8,
Commission Expires January 29,20Ll
This application must he 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. Applications
not properly completed in its entirety and/or not properly signed shall be deemed null and void and will be
returned to the applicant.
-2-
6/1 f2024
BUILDIN *i�XRTMENT R, N ECE E
VILLAGE OF RYE-BROOK APR - 4 2025 -DID
938 KING STREET RYE BROOK,NY 10573
(914) 9-06b8 VILLAGE OF RYE BROOK
www,rle olkny.gov BUILDING DEPARTMENT
AFFIDAVIT OF COMPLIANCE
VILLAGE CODE §216 - STORM SEWERS AND SANITARY SEWERS
`PHIS 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:
olOfrp ,residing at, LE 1 UM IV� " K13
(Print name) (Address where you lire)
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;
S Pr ME , Rye Brook,NY.
(!ob 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 ' opetty Own i
r(s))
ham f4gi �OEPC�
(Print Name of Property Owner(s))
Sworn to before me this
dfivof \ , 20 �
(Notary Public)
SHARI MELILLO
Notary Public,State of New York
No.01ME6160063
(Qualified In westcriester County �r}
Commission Expires JanUary 29.20� / -3-
6/1/2024