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0 [ECIEMED
BUILDING DEPARTMENT Q
VILLAGE OF RYE BROOK JUN - 2 2025
938 KING STREET RYE BRO(}.K,NY 10573
(914)99-0668 VILLAGE OF RYE BROOK
wwwL.i rookny.gov BUILDING DEPARTMENT
PLUMBING PERMIT APPLICATION
FOR OFFICE USE ONLY BP M PP#.
Approval Date:
Permit Fee: S
Approval Signature: Disapproved:
(fees are non-refundable)
DO N04 S'lAR1 NNORK or CONSTRUCTION L)N IIL A PEWMI'l IIAS BLLN ISNL ED BY THE BUILDING
INSPECTOR THE ADMINISTRATIVE FEE FOR WORK PROGRESSED OR COMPLETED WITHOUT A
PERMIT IS 12% OF"I HE TOTAL COST OF CONSTRUCTION WITII A MINIMUM FEE OF$750.00
Application dated, (a I t ` 25 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: 1 �Yl k a �� 0 L SBL: 13 St qn)—/- 1 S Zone:,e-/
2.Proposed Work: I a4t
3.Property Owner: (y f-ecU A-h Address: ID rY)F h Pq f1Q n L n , Lie r }
Phone#: 03 cl 44 N`"�1 Cell#: email:_ -d•��h 2,04 re_Zk 4/�-l/
4.Master Plumber. Mt)MnQ Address: (:1 .,t 'P n C_
Lic.#: 11_11P1 .Phone g(4, 4A _'�O l 1 Cell#: (11. Lj n I email:
Company Name: Rr'cl-le_ Mer ha n l(.'_Ct_l Address: L1(0L) �J• (AL a r) PC
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
3'Floor
4'h Floor
5's Floor
Exterior
5.*List Other Equipment/Provide Details:
(Notarized Signatures Required Next 2 Pages)
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 ail 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 -_a Sworn to bef re me this
day of /\� -�,20 v1 day of ,2DA5 _
Signature of Property Owner Signature of Applicant
Print Name of Property Owner Print a of Applicant
Notary PublicSHARI MELILLO otary Publi�iLM r
Notary Public,State of New York 1 !
No.OIME6160063
Qualified In Westchester County +
Commission Expires January 29,20 �
This application trust be properly completed in its entirety and trust 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-
6/1/2024
BUILD DE 'ARTMENT D
VILLE OF RYE BROOK ECEME
938 KING ST ET RYE BROOK,NY 10573
(014)g39-066$_), J II N - 2 2025
�v�v�v�eliookre�s�ov
VILLAGE
�/-OIF RYE
pBROOK
at ic,t*a:isyt�•�•*sirxY:x�9;kkk�•:F:Fkksk•k:t•k*nFX:F air st is**:FiF*it Jr�k•k�:h h Yeh x,kxik i:�•:F:kk*kd:t#nF ik***A'�t ik**fY i• •ir Yc lcN.�f0.�WtMUi aYal Rf��*'k MrSY k#�'Yr�
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, ad 0 DAg4i<' , residing at, Q �" `��� Q
(Print namc) ( \Jdress 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;
L,4A n/ k , Rye Brook,NY.
(_hen Addi �,)
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.
I kJ_/1J `J vW_
(Signature of Property Owner(s)1
Herz IA'�\ �J (r,VG\�L
(Print Name of Property Owner(s)i
Sworn to beforeme this
of 20 �
(Notary Public)
SHARI MEULLO
Notary Public,State of New Yofk
No.01ME616G063
Qualified In Westchester County 1 -3-
Commission Expires Jandafy 29,20�—[
6/1/2024