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MENT
VILOK O 'E� V =
938 KiN ,NY 1050
. ov SEP 1 1 202�
PLUMBING PERMIT APPLICATI XA1 aAGE pF RYE BROOK
BUILDING DEPARTMENT
FOR OFFICE USE ONLY BP #:
Approval Date: `��` 2 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 ADINIINISTRATIVE 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, 913 05 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: SBL: JJ'• —!/'S one: o�
2.Proposed Work:
3.Property Owner: ( Q Ee.L �JF4 Imo' Address: 10 J(V h.K6 n�f 1
Phone#:—703. q5(a' dLl 71 Cell#: email:
4.Master Plumber: �Q� Ilrlbr G�(1Z7 Address:__q(on r\ Sp. G
Lic.#: Phone#:G 14, q 314,S 3b 1 Cell#: email: I
Company Name: A U'C41 C 1 y yok)0 n j u j Address:�p )�, P,1 n S"-. P.0
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 1
1 st Floor 1
2nd Floor
3`d Floor
41 Floor
5'Floor
Exterior
5.*List Other Equipment/Provide Details:
(Notarized Signatures Required Next 2 Pages)
6/1/2024
SATE OF NEW YORK,COUNTY OF WESTCHESTER ) as:
('J (Y Ld-Ol f-7 ,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 3rd
day of ,20 `j day of
Signature of Property Owner Signature of Applicant
Print Name of Pro rty Owner Print Name of Applicant
No bli
LORI LOCKE
LORI LOCKE NOTARY PUBLIC,STATE OF NEW YORK
NOTARY PUBLIC,STATE OF NEW YORK NO.01 L00039106
NO.01 L00039106 QUALIFIED IN WESTCHESTER COUNTY
QUALIFIED IN WESTCHESTER COUNTY MY COMMISSION EXPIRES JULY 3,2029
leted in its entirety and must include the notarized signatures) 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 MENT
VIL OF RY OOK
938 KING ET RYE BR ,NY 10573
4 9 -0 -c
w ov
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:
� YhP f Pd d-m /3a ra-K ,residing at, red hPi a.,7 (�• Z°�i I h1W/1 I(/`T
(Print name) (Address 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;
Q c' J'a- , 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 Property Owner(s))
mtrf_1 i 4 $G_ra- I!
(Print Name of Property Owner(s))
Sworn to before me this 844--
day of , 20 2`! —
LORILOCKE
NOTARY PUBLIC,STATE OF NEW YORK
NO. 01 L00039106
(Not ubli ) fQUALIFIED IN WESTCHESTER COUNTY
MY COMMISSION EXPIRES JULY 3,2029
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