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BUIL ENT F,-,G 2 8 2025 €
VIL E C1 .RX. OOK _ _
NY 10573 VILL�C ,;nt
938KING .Q. ,FT,RYa•BCt `,
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INTERIOR BUILDING PERMIT APPLICATION
1
j FOR OFFICE USE ONLY:
'kP 2 3 Z 5 Permit � .� A licatioti Fee:$ 5
Approval Date: pp
Approval Signature: Permit Fees:$
Disapproved Other:
Application dated: is hereby made to the Building lnspectorof the Village of Rye Brook,NY,for the issuance ofa Permit for the
interior alteration of an existing building,or for a change in use,as per detailed statement described/below.1. Job Address: SBL: �'?, ? / '� /C�
Zone:
2. Proposed Improvement.(Describe in detail):
3. Does thg proposed improvement involve a Home-Occupation as per§250-38 of the Code of the Village of Rye Brook?
No:X. Yes: If yes,indicate: TIER I: TIER II: TIER III:
4. 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 Mood,etc...):No: Yes:
(If yes,please submit a separate Automatic Fire Suppression System Permit application&2 sets of detailed engineered plans)
S. Occupancy;(1 tam.,2 fam.,comtn.,etc...)Prior to Construction: wic9— After Construction: 0-pa C.Q._
6. MY State Construction Classification: N.Y.State Use Classification:
7. Property Owner. ima n ,.M h9,4C.A. Address:
Phone#mot � w j��"'Cell# emailf^Qt�" {�l�.C.f�C/1P.rc5 '�
8. Applicant: Address:
Phone# Cell# email:
9. Architect: Address:
Phone# Cell# email:
10. Engineer: Address:
Phone# Cell# email:
11. General Contractor: � IngAddress: lag
Phone 411 b Cell# email: 1SL?�.-Q2Z_t�C+t�D�•L' 'l
12. Estimated cost of construction $ 3001DOa
(NOTE:The coitnaled cost shall include all labor,material,scaffolding,fixed equipment,professional fees,and material and labor which may be donated
gratis.)
13. Job Timetable:Start: Finish:
(1)
6/1/2024
BUILD MENT AUG 2 8 2025
VIL 1+,o OOK
938 KING ! R $lt ,NY 10573 vl L L;.,c i
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AFFIDAVIT OF COMPLIANCE
VILLAGE CODE §216 • STORM SEWERS AND SANITARY SEWERS
THIS AFFIDAVIT MUST B$AR THR NOTARISED SIGNATURE OF THE LEGAL PROPERTY OWNER AND BZ SUBMITTZD
ALONG WITH ANY BUILDING OR PLUMBING PERMIT APPLICATION. ANY BUILDING OR PLUMBING PERMIT
APPLICATION SUHMITTED WITHOUT THIS COMPLETED AND NOTARISED TORN WILL BZ RZTURNRD TO THS APPLICANT.
STATE OF NEW YORK,COUNTY OF WESTCHESTER ) as:
residing at, Ia
(Print name) (Address where you live)
being duly sworn,deposes and states that(s)he is the applicant above named,and fiirther states that(s)he is the
legal owner of the property to which this Affidavit of Compliance pertains at;
go �h �Op < C,.P_Q_ " ,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.
i
(Signature of ncr(s))
7r Al _
(Print Kim of Idperty Owinr(s).)n
Sworn to before me this d
day + ,20-2-5
E
L SORBARA
(Nata Pub ic) ,STATE OF NEW YORK
SOg421792
ESTCHESTER COUNTY
PIRES SEPTEMBER T,2029
(2)
611/2024
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. Any application not properly completed in its entirety and/or not properly
signed shall be deemed null and void and will be returned to the applicant.
Please note that application fees are non-refundable.
STATE OF NEW YO K,COUNTY OF WESTCHESTER ) as:
_ 7 z o--- being duly sworn,deposes and states that he/she is the applicant above named,
(print i m ofal signing as the applicant)
and further states tha (s)he is the legal owner of the property to which this application pertains, or that Whe is the
/ 21'e__ for the legal owner and is duly authorized to make and file this application.
in scale 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 conforniance 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 lie/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 storniwater or groundwater
connections or sources of infiltration into the sanitary sewer system on or from the subject property.
Sworn to before me this Sworn to before the this w
day of t, 4— , 20 R 5 day of , 20
Signatu of LLoptifyOwner Signantr pp is
tNary
me o roperty O� er�1.] �_. Print Na o pltcant
Public Notary 1 tbii
CASEY L.SORBARA
NOTARY PUBLIC,STATE OF NEW YORK JOI IN n G0 ANRf Lrp
N0.Ol SO6421792 Nolary Yt+bile,�t:dh'It Now Ytuk
OUAUFIED IN WESTCHESTER COUNTY a70�1
MY COMMISSION EXPIRES SEPTEMBER 7,2029 C)U.ttiliEtcl in V/estClu ster f`tyin(y
<'ornmisslon t'xptres JU1y31,2t'l�
(4)
6/t/2024