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R
ECEN
BUILDING DEPARTMENT
VILLAGE OF RYE BROOK AUK 2 2 2025
938 KING STREET RYE BROOK,NY 10573 VILLAGE OF RYE BROOK
(914) 9-0608 BUILDING DEPARTMENT
wwWAak(jo#ny.gov
PLUMBING PERMIT APPLICATION
- '3 4
FOR OFFICE USE ONLY BI'#: PP#: c� /''
Approval Date: CS - Z.7 2 O Permit Fee: $ VlJ
Approval Signature: �Cu' 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 2 is hereby made to the Building Inspector of the Village of Rye Brook NY,for the issuance of
a Permit to install and/or re ove 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: SBL: 1a9 � l
Zone:-k—J-5
2.Proposed Work: '�I 1D F'r2pt,►-k `f 4% ►'v1 �K ¢ �MiE
��lSTlet CbWN Tio'�'� � `_
3.Property Owner:44
L!&ON3 Rmem l "S Oa Rt�iv ddress:
Phone#: Cell#: email:Z�l(N�rl�h 6 °1 W��
4.Master Plumber: -1-T t�JAZ Nr[) 2�r'1 N(,I(2�t Address:
Lic.#:1 K 1 o Phone#: Cell#: email: ,J
Company Nama2441 N 4Mk-flu I~IBI N �N CAT 1 N(,y Address: 7 e) ���S 12ae 0 019 r (OP
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 pot
2nd Floor
Yd Floor
41 Floor
5'Floor
Exterior
5.*List Other Equipment/Provide Details: rs`%&-e card gmo aQ 'k -C-j)F (1) gomea Co ST&Va
(Notarized Signatures Required Next 2 Pages)
-1- 6/1/2024
BUILDING MPAR MENT LS C E O VL�
VIL AGE OF RYE OOK
938 KING ET RYE BROOK,NY 10573 AUG 2 2 2025
-0668 _
ov 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:
residing at,
(Print name) (Address where you lip e)
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;
b r r ( Gi /I 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.
.........
------
(Signature of Protp }, ne
(Print Name of Property Owner(s))
Sworn to before me this
dav of '�S's , 20�S
(Notary Public)
SHARI MELILLO
Notary Public,State of New York
No,01ME6160063
Qualified in Westchester County 7 -3-
Commission Expires January 29,20 z
6/1/2024
STATE OF N
5KV YORt COUNTY OF WESTCHESTER ) as:
1114g duly sworn,deposes and states that he/she is the applicant above named.
(print name of tndtviduai signing as the applicant)
and further states that(s)he is ttic N laster 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 1 '/� Sworn to before me this a
day of U 5 ,20 D 57 day of .20
Sign re of Pr perry Owner Sig ature of Applicant
� 1 r �
Print Name of Property Owner P ' t Name of Applicant
'A'�v N-
I MrULL
Notar u c,State of New York NotanB MlgIcMEULLO
Notary Public,State of New York
No.01ME6160063
063
Qualified In Westchester County No.OWestch 0ter
Commission Expires January 29,202? �ualifled In Westchester County?
Con nisslon Expires January 29,2;L7
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 ill be
returned to the applicant.
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