HomeMy WebLinkAboutPP25-143 . _
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QETRYE
BUIMI VIL OK938 KIN NY 10573
SEP - 3 2025
ov
VILLAGE OF R'(f: I:FtOOK
PLUMBING PERMIT APPLICATIO
FOR OFFICE USE ONLY BP#: PP 4 05
Approval Date: SEP 0 3 2025
PP Permit Fee: $ Yhl
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, q L-L 2 S 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: nn
l /1 �� S�� Tye SBL: 144 1 , q �j Zone:
2.Proposed Work: W P W 1 ft G i vt C SEWPcic E�PQ,4o c Nm r (cQpde II� I l)
3.Property Owner:J (n C, /6 rctgo Address: +
Phone#: _ I`1 " l �1 Cell#: email
4.Master Plumber: ke. l �RA f►I Address: Ip0 Q5s I cn j 5,,10 0j, IFIA-O knj N y
Lic. #: Phone#: ���(���� 2SQO Cell#: email IN04ktl •CSA I_j(4b VLAeC4fn►✓t(I ell
Company Name: I C'Cl�'1P�S� Address: (0o GinY(G11A5 Q.pG,d, E(rk5f0r NY
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`d Floor
4"Floor
5`h Floor
Exterior
5.* List Other Equipment/Provide Details:
(Notarized Signatures Required Next 2 Pages)
-I t' 1 ,W1
STATE OF +QNEWYORK, COUNTY OF WESTCHESTER ) as:
kC V' ,cuy)1 ,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.
S nm to before me th" Q Sworn to before me t 's
d y of 20� day of 20
;con
a re of pe Owner ignature of Applicant
G 15 r'
Print Name of Prope4 Owner Print Name of Applicant
LOA ota ublic ry Public
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.
NOTARY B I BARON-pgNIEL
Registctttion NO
OF NEVV YORK
DEOUNA BARON-DAMEL o 01Bq�3
NOTARY PUBLIC,STATE OF NEW PORK My Commission
to Westchester County
�
Registration No.01 BA0032946 omission Expires
Qualified in Westchester unt
My Commission Expires "
6/I/2024
BUILDINEfiI✓kRTMENT �_. : t F;
VILLAGE OF RY"ROOK
938 KINGJET RYE BR* ,Mi" NY10573 SEP - 32025
4 -0
ANT
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:
ji, —To l In CCf P 14rCA r-1 , residing at, 3On 5 dAl Et'me S rreelf'
(Print name) (Address where you li 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;
snn &DAn U` c Ske'o'f , , 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.
L
(Signature of Property ON er(s))
p15�CG Ill D
(Print Name of Property Owner(s))
Sworn to before me this
day of , 202,,S _
FNOTARYPUBLIC,
EOUNA BARON-DANIEL
STATE OF NEW YORK
( otary Public) Registration No.01BA0032946
Qualified in Westch Countymmission Expires
-3-
6/1/2024