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BUILD"-DEPARTMENT LS(CIE Q 1W E
VILI{ AGeOF RYE BROOK
938 KING rREET RYE BROt ' NY 10573 APR 2 9 2025
(914)939-0668
ww 6 ov VILLAGE OF RYE BROOKBUILDING DEPARTMENT
ADMINISTRATIVE EXTERIOR BUILDING PERMIT APPLICATION
FOR EXTERIOR WORK WHICH DOES NOT REQUIRE VILLAGE ARCHITECTURAL REVIEW BOARD APPROVAL
FOR OFFICE USE ONLY: 6�'6'�-09A"PPLICATIONFEE-
APPROVAL APPROVAL DATE: MAY 0 p RaI #'SIGNATURE: PERMIT FEES:
H.O.A.APPROVAL: DATE:
DISAPPROVED: OTHER:
Application dated: is hereby made to the Building Inspectorofthe Village of Rye Brook,NY,for the issuance ofa Permit for the
construction of buildings,structures,additions,alterations ftor for a change in use,as per detailed statement described below.
1. Job Address: 42,
2. Parcel ID#: SfLC (1j),35 BLC�K- lO1` '-1 I{ Zone: Iz- 1P
3. Proposed Improvement(Describe in detail): 0-j'd r ng J�_0.GCAQ QA(-'2p to O kAke-n
4. Property Owner: e_nr-1Q;r_> [ 1 C]L- tfll
Address:
Phone# 914 Cell# q/y-760-ZyiG e-mail dAn iSCt_.QA'tt &Pft&4�_CBm
List All Other Properties Owned in Rye Brook: N A
Applicant:
Address.
Phone# Cell# e-mail
Architect:
Address:
Phone# Cell# e-mail
Engineer:
Address:
Phone# Cell# e-mail
General Contractor:
Address:
Phone# Cell# e-mail
(1)
6/1/2024
5. Occupancy;(I-Fam.,2-Fam.,Commercial.,etc...)Pre-construction: Post-construction:
6. Area of lot: Square feet: Acres:
7. Dimensions from proposed building or structure to lot lines: front yard: rear yard:
right side yard: left side yard: other:
8. If building is located on a corner lot,which street does it front on:
9. Area of proposed building in square feet: Basement: P,fl: 2"d fl: 3rd fl:
10, Total Square Footage of the proposed new construction:
11. For additions,total square footage added:Basement: P,fl: 2"d fl: 31d fl:
12. Total Square Footage of the proposed renovation to the existing structure:
13. N.Y.State Construction Classification: N.Y.State Use Classification:
14. Construction Type&Location:()Typical Western Lumber Frame;()Timber Frame[TC];()Wood Truss[TT];
()Pre-engineered wood[PW];Located;()Floor Framing[F];()Roof Framing[R];()Floor&Roof Framing[FR];Other:
15. Number of stories: Overall Height: Median Height:
16. Basement to be full,or partial: finished or unfinished:
17. What material is the exterior finish:
18. Roof style:peaked,hip,mansard,shed,etc: Roofing material:
19. What system of heating:
20. If private sewage disposal is necessary,approval by the Westchester County Health Department must be submitted with this
application.
21. Will the proposed project require the installation of a new,or an extension/modification to an existing automatic fire
suppression system?(Fire Sprinkler,ANSL System,FM-200 System,Type I Hood,etc...)Yes: No: _
(if yes,applicant must submit a separate Automatic Fire Suppression System Permit application&2 sets of detailed engineered plans)
22. Will the proposed project disturb 400 sq.ft.or more of land,or create 400 sq.ft.or more of impervious coverage requiring a
Stormwater Management Control Permit as per§217 of Village Code? Yes: No: Area:
23. Will the proposed project require a Site Plan Review by the Village Planning Board as per§209 of Village Code?
Yes: No: (if ves,applicant must submit a Site Plan Application,&provide detailed drawings)
24. Will the proposed project require a Steep Slopes Permit as per§213 of Village Code Yes: No:
(if yes,you must submit a Site Plan Application,&provide a detailed topographical survey)
25. Is the lot located within 100 ft.of a Wetland as per§245 of Village Code? Yes: No:
(if yes, the area ofwetland and the wetland buffer zone must be properly depicted on the survey&site plan)
26. Is the lot or any portion thereof located in a Flood Plane as per the FIRM Map dated 9/28/07? Yes: No:
(if yes, the area and elevations ofthe flood plane must be properly depicted on the survey&site plan)
27. Will the proposed project require a Tree Removal Permit as per§235 of Village Code?Yes: No:
(if yes,applicant must submit a Tree Removal Permit Application)
28. Does the proposed project involve a Home-Occupation as per§250-38 of Village Code? Yes: No:
Indicate:TIER 1: TIER IL TIER I IL (if yes,a Home Occupation Permit Application is required)
29. What is the total estimated cost of construction: $ :!V. 000 Note:estimated cost shall include
ail site improvements, labor,material,scaffolding,fixed equipment,professional fees,including any material and labor which may be
donatedgrads.If the final cost exceeds the estimated cost,an additional fee will be requiredprior to issuance of the CIO.
30. Estimated date of completion:
(2)
6/1/2024
BUIL�OF
TMENT
v)<L OOK APR 2 9 2025
938 KING fiREET RYE BRo NY 10573
(9I4�939-066$_� VILLAGE OF RYE BROOK
�r��w, ov BUILDING DFEPARTMFrO
_6 _�_ _ �v
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:
residing at, 942 kocz rP4e /-�,�ca2• l�cfe 2 V
(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;
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.
a4l_ _
(Signature of Property Owner(s))
-�FN2 I C0 AeA'2 I Al
(Print Name of Property Owner(s))
Sworn to before me this «f tf--
day of v 20_7_�
hS� G
(Notary Public)
DONALD A. CASSONE
Notary Pubic, State of New York
No. 01CA6061097
Qualified in Westchester County (3)
Commission Expires July 9, 2031-�
b/1/2024
This application must be properly completed in its entirety by a N.Y. State Registered
Architect or N.Y. State Licensed Professional Engineer & signed by those professionals where
indicated. It must also 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:
k&iA1/L 1 W IVA-*1 n11 _ , 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
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.
Sworn to before me this Sworn to before me this
day of fH '12!L , 20 a SJ day of , 20
Signature of Property Owner Signature of Applicant
€ fQI c0� +f 4-,.I AJr
Print Name of Property Owner Print Name of Applicant
Notary Public Notary Public
DONALD A. CASSONE
Notary Pubic, State of New Yodt
No. 01 CA606'1097
Quelified in Westchester County
Commission Expires duly 9, 20-11
(4)
6/I/2p24