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H O U
BUILDING DEPARTMENT
VILLAGE OF RYE BROOK OCT - 2 2025
938 KING STREET RYE BROOK,NY 10573
(914)939-0668
www.!yebrookny.jzov
FOR OFFICE USE ONLY:
Approval Date: i+d Application#
Approval Signature: ARCHITECTURAL REVIEW BOARD:
Disapproved: Date:
BOT Approval Date: Case# Chairman:
PB Approval Date: Case# : Secretary:
ZBA Approval Date: Case#
Other: ;
Application Fee: Permit Fees: 201
ROOF PERMIT APPLICATION
Application dated: is hereby made to the Building Inspector of the Village of Rye Brook,NY,for the issuance of a Permit to
Re-Roof an Existing Building,as per^nde''tail'eed statement describedbelow. �j
1. Job Address: +� - '\� It"�ti BL: 1135' 75'�—F/ Zone: #412--7
Property Owner: I Address: 3
Phone#: fir+ I Cell#: email: "�S`1/•^(��I DQ-1'lAl t i a�{3( 9' '�
2. Applicant:�1 U�`� Address:4C t NItA4Q SI- I� �rt��� W6 1-3►y Phone#: ,'p S- C13q I ff,, Cell#: email:
3. Roofing Contractor: ►Y1.CyuAr1 `(t_D(1(I(lUi AddressAS 4 cP2 Yam(,NT I(12�8
Phone#: Cell#: email:
4. Job Description,list all Methods&Materials: �1(9.�
5. Estimated Cost of Job:S 3, (NOTE:The estimated cost shall include all site
improvements,labor,material,scaffolding,fixed equipment,professional fees,and material and labor which may be donated gratis.)
6. If corner property,indicate str t frontage:
7. Construction Type: RECU6 NYS Construction Class:
8. Number of stories: Height:
9. Is garage being re-roofed:No:( )•Yes:X)Attached No:( )•Yes: ( )Number of Cars:
10. Is roof peaked,hip,mansard,flat,etc: hm--X .C�
11. Estimated date of completion:
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Please note that this application must include the notarized signature(s) of the
legal owner(s) of the above-mentioned property, in the space provided below.
Any application not bearing the legal property owner's notarized signature(s)
shall be deemed null and void, and will be returned to the applicant.
STAJOF YORK, UNTY OF WESTCHESTER ) as:
"��c1� 6 t' 4 �1� v�► ,being duly sworn,deposes and states that he/she is the applicant above named,
(print name of individual sigdng as the applicant)
and further states that (s)he is the ler of the property to which this application pertains, or that (s)he is the
�f 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.
Sworn to before me this 2 Sworn to before me this
day of Q , 20 day of �� , Nil'
Signature of Property er Signature of Applicant ^�
14�LAo / `4J`+i, R4 A(\"�
Print Name of ProrArty Owner Print Name of Ap licant
Notary Public Notary Public
CHRISTOPHER J.BRADBURY CHRISTOPHER J.BRADBURY
Notary Public,State of New York Notary Public, State
of r ON York
No.01 Bk6159985 Pao.01 Lab 159y85
Qualified in Westchester County r� Qu2lified in Westchester County
Commission Expires January 29,20 Commission Expires January 29,20
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