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ECENE
BUIL
DING 6"TMENT I D
VILLAGE OF RYE AROOK R 2 7 2025
938 KING STREET RYF Mdi��,NY 10573 L-__a
OF RYE BROOK
NV AV ov
BUILDP4G DEPARTMENT
k
INTERIOR BUILDING PERMIT APPLICATION
FOR OFFICE USE ONLY:
Approval Date: JUN 0 2 900 Permit# ��/`3:7 Pplication Fee:$ Inn
Approval Signature: V461 4� Permit Fees:$ a'o
Disapproved: Other:
Application dated: J C)7_� is hereby made to the Building Inspector of the Village of Rye Brook,NY,for the issuance of a Permit for the
interior alteration of an existing building,or for a change in use,as per detailed statement described below.
1. Job Address:10 Z�t A VC�'I t 1�'C'P,, 1-�"p IA q -f �16 —/-41 Zone:1kY 16 SBL: /,35
2. Proposed Improvement.(Describe in detail): Rv P1 ac-'r 1. q 'EA-e- Ck e45 0 cke
-e
3. Does theproposed improvement involve a Home-Occupation as per§250-38 of the Code of the Village of Rye Brook?
No:iif Yes:— If yes,indicate: TIER 1: TIER]I: TIER III:
4. 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...)-.No: V Yes:
(if yes,please submit a separate Automatic Fire Suppression System Permit application&2 sets of detailed engineered plans)
5. Occupancy;(I fam.,2 farn.,comm.,etc...)Prior to Construction: I F(k!n, After Construction: k Foim
6. N.Y State Construction Classification:— N.Y.State Use Classification:
7. Property Owner: L-e-0 vl 4 5,4 tV k U, C UA' A �(AA`ddress:16 C_kA V tX) I�
Phone# M +- 93-4 YZ I Cell#J email: (,P_90 d l"if
3 4-'5"K�94?1 I
8. Applicant: Address:
Phone# Cell# —email:
9. Architect: Address!
Phone# Cell# ------- email:
10. Engineer: Address: ------
Phone# Cell# email:
11. General Contractor: r)-F J! ;.art 44-f74 Address:4 +6
Phone# Cell# 39-0256 email:-jnreon4e.4ofe :T P Gm4il
12. Estimated cost of construction $ (I 06, 0 C)
(NOTE The estimated cost shall include all labor,material,scaffolding,fixed equipment,professional tees,and Material and labor which may be donated
gratis.)
13. Job Timetable: Start: [CA�-C. ITL'Vl C Finish: Xu
M
6/112024
BUILDA D�PAR'� T I� '
VILLV<� E OF RYE OOK R1 MAY 2 7 2025
938 KING STREET RYE BROOK,NY 10573
i 0§6 VILLAGE OF RYE BROOK
wN i ov 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: II n ) }
,residing at, t L� C lit Ul !`'C tt'� 1 � 1�</E- f W
(Print name) (Address NNhere you h%C)
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;
r �^� f�vb"CQ
Rye Brook,NY.
(Job Addre>s)
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 of Property Owner(s))
69 I-) CG'Cc 04�1S
(Print Name of Property Owner(s))
Sworn to before me this
day of ffirt 20
7
(Not' u tic
GREGORY V.RIVERA
-��ry Public,Stale of New York
No.01 R16441398 (2)
'`tmlified In Westchester County
'urntnission Expires September 26,20�i
6!I/2024
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. 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:
, 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 V Sworn to before me this
day of� , 2 day of , 20
Signature of Property Owner Signature of Applicant
[_"'"i'l Cl cq '-I y GI
Print ame of Property Owner Print Name of Applicant
i
&J�Y� &
Notary fc Notary Public
GREGORY N.RNERA
Nel"y Public,Slate of New York
No.01 R16441398
Qualified In Westchester County Q
commission Expires September 26,20if
(4)
6/I/2024