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BV[LDITMENT �� �� (J V L�
L 4 OJ Y OOK
938 KING ET RYE BR ,NY 10573
14)939- S E P - 3 2025 DD
ov
VILLAGE OF RYEBROOK
BUILDING DEPARTMENT
ADMINISTRATIVE EXTERIOR BUILDING PERMIT APPLICATION
FORFOR EXTERIMI NVORK WHICH DOE_s NOT REQUIRE VILLAGE ARCHITECTi RRAL REVIEW BOARD APPROVAL
FOR OFFICE.US.F_.ON Y: p _
APPROVAL DATE: IT#: �/ c ` I APPLICATION FEE:
APPROVAL SIGNATURE: IN PERMIT FEES:
H.O.A.APPROVAL: - DATE:
DISAPPROVED:_ OTHER:
Application dated:_08/26/2025 is hereby made to the Building Inspector ofthe Village of Rye Brook.NY,for the issuance of a Permit for the
construction of buildings.structures,additions,alterations or for a change in use.as per detailed statement described below.
I. rob Address: 12 Birch Lane, dd)9_, NY 10573
2. Parcel]D#: 135.43-1-5.40 Zone:
3. Proposed Improvement(Describe in detail):
Installation of ( 1 ) replacement Andersen 200 Series Narroline_Gliding patio Door into existing
openings with no structural alterations.
4. Property Owner:
Melissa Shaw
Address: 12 Birch Lane, Port Chester, NY 10573
Phone# (917)922-1231 Cell# _ e-mail mshawdd@gmail.com
List All Other Properties Owned in Rye Brook:
Applicant: LINDSAY LOSON
Address: 2261 Market Street STE 10301, San Francisco, CA 94114
Phone#_ 315-335-8730 —_Cell # - _e-mail lindsay@permitflow.eom
Architect:
Address:
Phone#_ Cell# — -._e-mail
Engineer: —_
Address:
Phone#_ Cell# _e-mail
General Contractor: Brian MacDonald --
Address: 421 West Ave, Building 1, Stamford, CT 06902
Phone#_ 203-406.0545 ><: Cell# 4"1'5-441-8425 e-mail PERMITS@RBAWestchester.com
(1)
6/12024
5. Occupancy;(I-Fam..2-Fam..Commercial.,etc...)Pre-construction: Post-construction: N/A
6. Area of lot: Square feet: Acres: N/A
7. Dimensions from proposed building or structure to lot lines: front yard: _ram yam: N/A
right side yard: left side yard: other: — N/A
8. If building is located on a corner lot,which street does it front on: N/A
9. Area of proposed building in square feet: Basement: 1 11 fl: 2nd fl: 3rd fl: N/A
10. Total Square Footage of the proposed new construction:^ N/A
It. For additions,total square footage added:Basement: _I"fl: 2nd;l: 3rd fl: N/A
12. Total Square Footage of the proposed renovation to the existing structure: N/A
13. N.Y.State Construction Classification: N.Y.State Use Classification: N/A
14. Construction Type&Location:O Typical Western Lumber Frame;O Timber Frame[TC];O Wood Truss[TT];
()Pre-engineered wood[PW];Located;()Floor Framing[F]:( )Roof Framing[R];()Floor&Roof Framing[FR],Other:
N/A
15. Number of stories: Overall Height:_ Median Height: i N/A
16. Basement to be full,or partial: finished or unfinished: N/A
17. What material is the exterior finis]•.: N/A
18. Roof style:peaked,hip,mansard shed,etc: Roofing material: N/A
19. What system of heating: N/A
20. If private sewage disposal is necessary,approval by the Westchester County Health Department must be submitted with this
application.
21. 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...)Yes: No:_ WA
(if ves,applicant must submit a separate Automatic Fire Suppression System Permit application&1 sets of detailed engineered plans)
22. Will the proposed project disturb 400 sq.ft.or more of land.or create 400 sq.ft.or more of impervious coverage requiring a
Stormwater Management Control Permit as per§217 of Village Code? Yes: No: Area: N/A
23. Will the proposed project require a Site Plan Review by the Village Planning Board as per§209 of Village Code?
Yes: —No: (if yes,applicant must submit a Site Plan.4pplication,&provide detailed drawings)
24. Will the proposed project require a Steep Slopes Permit as per§213 of Village Code 1'es: No: N/A,
(V'yes,you must submit a Site Plan Application,&provide a detailed topographical survey)
25. Is the lot located within 100 ft.of a Wetland as per§245 of Village Code? Yes: No: N/A
(ifyes,the area ofwedand and the wet,and beer zone must be properly depicted on the survey&site plan) N/A
26. Is the lot or any portion thereof located in a Flood Plane as p,.-r the FIRM Map dated 9,128/07? Yes:—No:
(if yes,the area and elevations ofthe f ovel plane must be properly depicted on the survey&site plan)
27. Will the proposed project require a Tree Removal Permit as per§235 of Village Code"Yes: No: N/A
(if yes,applicant must submit a Tree Removal Permit,4pplication)
28. Does the proposed project involve it Home-Occupation as § g , N/A
P P J p per 250-38 of Village Code: Yes: No:
Indicate:TIER 1: TIER II:--TIER III: (ifyes,a Home Occupation Permit. pplication is required)
10,378
29. What is the total estimated cost of construction: $ _ Note:estimated cost shall include
all site improvements,labor,material..scc ffolding,freed equipment,professional fees,including any material and labor which may be
donated gratis.If the final cost exceeds the estimated cost,an additional fee will be required prier to issuance of the C'O.
30. Estimated date of completion: N/A
Q)
6/t/2024
BUILD MENT
VIL, E OF RY OOK
538 KING ET RYE BR ,NY 10573
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AFFIDAVIT OF COMPLIANCE
VILLAGE CODE §216 • STORM SEWERS AND SANITARY SEWERS
THIS AFE':_DAVIT MUST BEAR TM: NOTARIZED SIGNATURE OF THE LEGAL PROPERTY OWNER AND BE SUBMITTED
ALONG WITH ANY BUILDING OR PLUMBING PERMIT APPLICATION. ANY EV-11,DING OR PLUMBING PERMIT
APPLICATIaN SUMITTED WITHOUT THISS COMPLETED AND FC)TARIZED FORM WILT, BE RETURNED TO T1t:3 APPLICANT.
STATE OF NEW YORK, COUNTY OF WESTCHESnrER ) as:
L MELISSA SHAW residing at, 12 Birch Lane, Port Chester, NY 10573
1116111 nam`) (Address%%here)'ou 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;
12 Birch Lane, Port Chester, NY 10573
(Job Addre•s ) Rye Brook,NY.
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.
(SignatureoRro;crty O%Nncr(s1
MELISSA SHAW
(Print Name of Prop• n,, Owner(s)) - --
Sworn to before me this �9A
-� FRANKLI11 E. BARAHONA
day of &00&T , 20_ .ZS- Notary Public, State of Connecticut
My Commission Expires Dec 31, 2027
(Nolan Publio)
(3
6nl202d
This application must be properly complete-d in its entirety by a N.Y. State Registered
Architect or N.Y. State Licensed Professional Engineer & signed kay those professionals where
indicated. 14: must also include the notarized signature(s) of the I,3gal owner(s) of fine subject
property;: and the applicant. of record in the spaces provided. Any application not properly
completed In Its entirety and,lor not properly signed shall be deemed null and void, and will be
returned to the applicant. Please note that application fee::; are non-refundable.
it tr r.ix it,Fx�Nir i:xii it i;is:Fie*ixzirk*Y•,'e;'t;c;r,}***k******************1r d:t4:4*****************&:kkr.is to iexr.it,k it,i it i<it it ix,kK;; r i;„•;; ,si�.r iexir
STATE OF NEB`YORK,COUNTY OF WESTCHESTER ) as:
LINDSAY LOSON _ 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
AGENT 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 san tar) sewer system on or from the subject property.
Sworn to before me this Sworn to before me this 26th
day of S, , 20 ?.5' day(if AuguSt _ ..,0 25
�cnc�3a.� o('oJon.
Signature of Properly owner Signature of Applicant
MELISSA SHAM LINDSAY LOSON
Print Name of Property Owner Print]Jame of Applicant
=PUbllc,
BARAHONA
Notary Public - te of Connecticut Notary Public
res Dec 31, 2027
nW Aloxandar El— IR
REGMTRATION NUMBER
COP MISSION E%PRES
�s�/i,.y� hIy I1.lOQ7
Notarized remotely online using communication technology via Proof.
(4)
6/l/2024