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BUILDING DEPARTMENT MAY 16 2025
ID
VILLAGE OF RYE BROOK
938 KING ST RvE B K. NY 10573 VILLAGE OF RYE BROOK
E RYE � BUILDING DEPARTMENT
et�r=#n Y.aov
PLUMBING PERMIT APPL CATION
FOR OFFICE USE ONLY BP#: PP#: C:D
Approval Date: MAY 2 0 025 Permit Fee: $
Approval Signature: BisaPproved
(fees are non-refundable)
DO NOT START W ORK or CONSTRUCTION UNTIL A PERMIT HAS BEEN ISSUED BY THE BLILDING
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$750.00
Application dated,' _ l b-_'W�:_ is hereby made to the Building Inspector of the Village of Rye Brook NY,for the issuance of
a Permit to install and/or remove Plumbing as per detailed statement described below.The applicant&property owner,by signing this
document agree that said plumbing work will be in conformance with all applicable Federal, State,County and Local Codes.
1.Address: M E CT SBL:/3s 66 —1-7 4 Zone.,/0
2.Proposed Work:
3.Property Owner: Address: �� CT ems.,
Phone#: Cell#: �l4)g�4 ^$B� email: LkS 0 Y r"5 Q
(N "Kk%..�C-W
4.Master Plumber: U,/« IAW_r11�{ ' Address: d'l g M�� �T UTAZ
Lic.#: � Phone#: 3� ()09 Cell#:
Company Name: t MT T Address:
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
31 Floor
0'Floor
511 Floor
Exterior
5.*List Other Equipment/Provide Details:
(Notarized Signatures Required Next 2 Pages)
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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 rY Sworn to before me this A001
day of 2,/ ,20 26- day of l ,20 L(�
Signature of Property Owner Sign re of Appltcant
MI R stk
Print Name of Property Owner Print Name of Applicant
9ZOZ'ti 7�EM-3N
OISSININOa AN gZOZ'Y'po S381dX3 NOISSINNoo'kn
Not PuVa!sNo Publio,3S2GrM3.10N Onand k:3U :"V-LQ
dViON� p EplH Bullaa
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. 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.
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6/WO24
BUILD, P*&TMENT L
VIL E OF RYE BROOK MAY 16 2025
938 KING ET RYE BROOK,NY 10573
`( 4) 9-0665 VILLAGE OF RYE BROOK
www. bokn .( BUILDING DEPARTMENT
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:
x, VA t V-A S 1Y_ �a►4N6� , residing at, � "fh"� CfT
(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;
CT_ , 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 pump's, 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 of Property O%vner(s))
(Print Name ol'Property Owner(s))
Sworn to before me this
day of "1 a CL 20
(Notary Poh1"0iARI MELILLO
Notary Public,State of New York
No.UME6MO63
Qualified in Westchester County
Commission Expires Jentlary 29,20,Z�
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6/1/2024