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2 ECENE
BUIL ' NG DEPARTMENT
V][L 'E OF RYE BROOK SUN 1 1E2025
938 KrN ET RYE BROOK,NY 10573
-068 VILLAGE OF RYE BROOK
w �qnyaov BUILDING DEPARTMENT
PLUMBING PERMIT APPLICATION
FOR OFFICE USE ONLY B1'#: PP#: C�)'!S_� (91?U
Approval Date: f - I I - Z C7 Permit Fee: $
Approval Signature: Disapproved:
(fees are non-refundable)
DO NOT START WORK or CONSTRUCTION UNTIL A PERMIT HAS BEEN ISSUED BY 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 will be in conformance with all applicAbl F deral,State,County and Local Codes.KZA
Q
1.Address: �.. ~L. r-5 X /'3 P &,.I A e SBL: I> t�?�i 7 —J'/ Zone:
2.Proposed Work: w f P 1 p'e, 0 'PS I
3.Property Owner: 14/7 C16 Address:
Phone#: 6?i+ 1 L-A l 111I^- email:
4.Master Plumber: & rub / -GC_J'j#e-v Address:Pe �0 V 7 579 P of
Lic.#: / Z11- Phone#: Wc l;o 74 0 8-M#: email:
Company Name: kVV6 4 11C y ay P/vr-P'lL t Address:
INDICATE FIXTURES& LINES TO BE INSTALLED AS PER THE FOLLOWING SCHEDULE:
Location Water Urinals Drinking Sinks Showers Bath Laundry Domestic Fire Sanitary Naturau Other* Total
Closets Fountains Tubs Tubs Service Service Sewer LP Gas
Basement
1st Floor
2nd Floor
3`d Floor
4d°Floor
5d'Floor
Exterior
5.*List Other Equipment/Provide Details: f)t4 r T� 1 1'4 h Ae t{/e j
(Notarized Signatures Required Next 2 Pages)
.11- W 11202a
STATE OF NEW YORK,COUNTY OF WESTCHESTER ) as:
C r a i� _ ?ems e- ,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 before me this
r � n\
day of 1 nc ,20 day of ,20 dS
Signs re of Property Owner'*' Signature of Applicant
!? /✓,X/dam h V4)c / G Pq5 M64
Print Name of Property Owner Print Name of Applicant
Notary REGORY M.RNERA NotajXKpkULL0
Notary Public,State of New York Notary Public,State of New York
No.0't R16441398 No.O1MEGi00083
Qualified to Westchester County Qualified In Westchester County
t:0MMtsslon Expires January 29,260
CoWf$sion Egires_5eptember 26,206
1 hnls 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.
-2-
6/I2024
F R�JUN
10
BUILD DEPARTMENT
VIL OF RYE OOK 1 1 2025
938 KING 4 ET R, E BRO � NY 10573
4X:ini-.gov
668`', VILLAGE OF RYE BROOK
` 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:
3, 4,f t� d-� /l , residing at, a
(hint name) (Address 4here 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.
1
(Sign tore of Property Owners)
(Print Narne of Property OWneT(S))
Sworn to before me this 16
day of l az , 20
(.rvota�, it ic)
GREGORY M.RIVERA
Notary Public,State of New York
No.01 RI6441398 '''
Qualified In Westchester County
Commission Expires September 26,20
6/1 t2024
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O� tim
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BUILDING DEPARTMENT
❑B ILDING INSPECTORASSISTANT BUILDING INSPECTOR VILLAGE OF RYE BROOK
❑CODE ENFORCEMENT OFFICER 938 KING STREET - RYE BROOK,NY 10573
(914) 939-0668 FAX (914) 939-5801
www Uebrook.org
- - - - - - - - - - - - - - - - - - - - INSPECTION REPORT - - - - - - - - - - - - - - - - - - - -
ADDRESS : _ z s 2r'Xl DATE: t. ZO" Z02 r�
PERMIT#—T _2._S_� Del O_ �.J ISSUED: SECT: 3S.IV.3 BLOCK:_LOT:�L
LOCATION: +�LG./�. .�t7 M/� I'1.OLQ OCCUPANCY:
❑ VIOLATION NOTED THE WORK IS... ge ACCEPTED ❑ REJECTED/REINSPECTION
❑ SITE INSPECTION REQUIRED
❑ FOOTING
❑ FOOTING DRAINAGE
❑ FOUNDATION
UNDERGROUND PLUMBING NOTES ON INSPECTION:
❑ ROUGH PLUMBING
❑ ROUGH FRAMING
❑ INSULATION
❑ NATURAL GAS RP P A,1 A- e(4 Pal. -
❑ L.P. GAS
❑ FUEL TANK
❑ FIRE SPRINKLER
,' FINAL PLUMBING
❑ CROSS CONNECTION
❑ FINAL
-0 OTHER
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