HomeMy WebLinkAboutRB25-0009 VILLAGE OF RYE BROOK
Building Department-Inspections
938 King St Rye Brook,NY 10573 1 Phone:(914)939-0668 1 Fax:(914)939-5801
CERTIFICATE OF OCCUPANCY
Occupancy granted date: 12/08/2025 Permit Number: RB25-0009,Issued on 09/30/2025
Visit result: Granted and fully completed Date of inspection: 12/08/2025
Parcel number: 135.26-1-26 Municipal Address: 20 CHURCHILL RD
Legal Description:
This certificate does not in any way relieve the owners or any person or persons in possession or control of the
premises,building,or any part thereof from obtaining such other permits or licenses as may be prescribed by law for
the uses or purposes for which the building or premises is designed or intended. Furthermore,it does not relieve such
owners or persons from complying with any lawful order issued with the object of maintaining the premises or building
in a safe and lawful condition. No changes or rearrangement in the structural parts of the building or in the exit
facilities shall be made,and no enlargement,whether by extending on any side or by increasing in height shall be made,
nor shall the building be moved from one location to another until a permit to accomplish such change has been
obtained from the Building Inspector.
Additional .
Occupancy permit description:
ALL WORK COMPLETED OK TO ISSUE CERTIFICATE.POWDER ROOM COMPLETED.
Outstanding matters:
•
Robert Jackson
20 Churchill Rd,Rye Brook
+19149340114
robertjacksonsr54@gmail.com
Inspected
Alfredo(Freddy)DiVitto
Building Inspector,Village of Rye Brook
+19149390668
Syr BRC�,�.
BUILDING DEPARTMENT
❑B LDING INSPECTOR
SSISTANT BUILDING INSPECTOR VILLAGE OF RYE BROOK
❑CODE ENFORCEMENT OFFICER 938 KING STREET• RYE BROOK,NY 10573
(914)939-0668 FAx (914)939-5801
www.ryebrook.org
- - - - - - - - - - - - - - - - - - - - INSPECTION REPORT - - - - -- - - - - - - - - - - - - - -
ADDRESS• v
4_ DATE L:.Il_ ,\ rim I Q
_ _ a •
PERMIT#�� _7 ISSUED:/0-8 SECT:-/3 46 BLOCK: LOT: 2-6
LOCATION: �bCa�2� /"� _ OCCUPANCY:
❑ VIOLATION NOTED THE WORK IS... ACCEPTED ❑ REJECTED/ REINSPECTION
❑ SITE INSPECTION REQUIRED
❑ FOOTING
❑ FOOTING DRAINAGE
❑ FOUNDATION
❑ UNDERGROUND PLUMBING NOTES ON INSPECTION:
❑ ROUGH PLUMBING
❑ ROUGH FRAMING
❑ INSULATION
❑ NATURAL GAS
❑ L.P.GAS Kl
❑ FUEL TANK
❑ FIRE SPRINKLER
FINAL PLUMBING
❑ CROSS CONNECTION
❑ FINAL
❑ OTHER
BUILDING DEPARTMENT
❑ It IIIMING INMILCAOR
O/ ..[['PANT BUILDING INSPECTOR VILLAGE OF RYE BROOK
❑CODE IiNFON I MENT Orr•ICER 938 King Street • Rye Brook, NY 10573
(914) 939-0668 I"AX (914) 939-5801
www,rygb
- - - - - - - - - - - - - - - - - -
- - INSPECTION REPORT - - - - - - - - - - - - - - - - - - - -
ADDR1;SS : z'o eOa.Q.
PIIRm1,1,t Pe oZb ' /S 7 ISSUI:140-8-2,r Sliu A
I,OCATION: P06-3 LA., GO&% +
❑ Violation Noted THE WORK IS... 2/1)ASSED ❑ FAILED / REINSPECTION
❑ SITE INSPECTION REQUIRED
❑ FOOTING
❑ FOOTING DRAINAGE
❑ FOUNDATION
❑ UNDERGROUND PLUMBING NO'I'I:S ON 1NS1'pcnON:
j,YROUGIJ PLUMBING
❑ ROUGH FRAMING
❑ INSULATION
❑ Natural Gas �Q�, , 6t,�
❑ I,.R Gas c 1 �
❑ Furl.TANK 7 Q�U_
❑ FIRE SPRINKLER s/V tJ V
❑ CROSS C;ONNI:C:TION -------- /�`�i
- �y� 4Rnv�.
�m Village of Rye Brook
Q Building Department-Inspections
938 King St Rye Brook,NY 10573 1 Phone:(914)939-0668 1 Fax:(914)939-5801
INSULATION
Permit number: RB25-0009 Permit type: Residential —Remodel/Renovation— Interior
Municipal address: 20 CHURCHILL RD Legal address:
Status of inspection: Completed Issue date: 09/30/2025
Deficiencies
No deficiencies or remarks noted.
Visits
VISIT DATE INSPECTOR VISIT RESULT SITE CONDITIONS
10/22/2025,2:50 PM Alfredo(Freddy)DiVitto Passed
+19149390668
Parties
NAMEANDCOMPANY CONTACTROLES
Robert Jackson 20 Churchill Rd,Rye Brook Applicant,Homeowner/Property Owner,Property owner
+19149340114
James Farrell 66 Heatherdell Road,Ardsley General contractor
+1914-438-0250
��� [3Rnv�.
0 �m Village of Rye Brook
Building Department-Inspections
938 King St Rye Brook,NY 10573 1 Phone:(914)939-0668 1 Fax:(914)939-5801
1962
im � I
Permit number: RB25-0009 Permit type: Residential—Remodel/Renovation—Interior
Municipal address: 20 CHURCHILL RD Legal address:
Status of inspection: Completed Issue date: 09/30/2025
Deficiencies
No deficiencies or remarks noted.
Visits
VISIT DATE •• VISIT RESULT SITE CONDITIONS
10/22/2025,2:48 PM Alfredo(Freddy)DiVitto Passed REMOVED SHOWER AND ADDED CLOSET IN ROOM NEXT DOOR.
+19149390668
Parties
NAMEANDCOMPANY CONTACTROLES
Robert Jackson 20 Churchill Rd,Rye Brook Applicant,Homeowner/Property Owner,Property owner
+19149340114
James Farrell 66 Heatherdell Road,Ardsley General contractor
+1914-438-0250
VILLAGE OF RYE BROOK - BUILDING DEPARTMENT
938 KING STREET - RYE BROOK, NY
(914)939-0668 1 www.ryebrook.org
Residential / Interior (Remodel/Renovation) Permit
PERMIT #:
/_1III 17C7��'A
PARCEL ID #:
PARTIES:
NOTICE
RB25-0009
001411a119.161al14101
43-W.5=1
ISSUED: 09/30/2025 EXPIRES: 09/30/2026
Applicant, Homeowner/ Property Owner, Property ownerGeneral contractor
Robert Jackson James Farrell
20 Churchill Rd 66 Heatherdell Road
Rye Brook, NY 10573 Ardsley, NY 10502
1.THIS PERMIT MUST BE CONSPICUOUSLY POSTED ATTHE JOB SITE.
2. A COPY OF THE APPROVED PLANS MUST BE KEPT ON SITE.
Hours of Operation of Construction Equipment / Village Code §158-4: WEEKDAYS - 8:00am to 6:00pm or dusk, whichever is earlier;
SATURDAYS - 9:00am to 4:00pm; - SUNDAYS & HOLIDAYS -No Construction Activity Allowed
This permit is valid for a period not to exceed twelve (12) months from the date of issuance, and covers only that work listed above. Separate permits are required for any
electrical, plumbing, fire suppression, fire/smoke/carbon monoxide detectors/alarms, or any other work not covered under this permit. The approved plans must be kept on
the job site & be made available for review by the Building Department upon demand. Any amendments or changes to the approved plans must be designed by your
architect/engineer and submitted to the Building Department for review and approval prior to performing the work.
�1i
Steven E. Fews - Building & Fire Inspector
#R,Interior Building Permit ApplicationVillage of Rye Brook
938 King St Rye Brook, NY 10573
Phone: (914)939-0668 1 www.ryebrook.gov
Building Department
Project Information
SBL
Zone
Address Line 2
135.26-1-26 20 Church Hill Rd
R-15
20 Churchill Road
Proposed Improvement
Bathroom Renovation
Does the proposed project involve a
Home -Occupation as per §250-38 of
Village Code?
❑ Yes 0 No
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 0 No
N.Y. State Construction Classification N.Y. State Use Classification Occupancy Pre -Construction
VB R-3
1f
Occupancy Post -Construction
(1 fam., 2 fam., comm., etc...)
1f
What is the total estimated cost of construction:
(NOTE: The estimated cost shall include all labor, material,
20000 USD
scaffolding, fixed equipment, professional fees, and material
and labor which may be donated gratis.)
Interior Building Permit Application, page 1 / 1
�yE 6Rnv� VILLAGE OF RYE BROOK
F
2m 938 King St Rye Brook, NY 10573
W
Phone: (914)939-0668 1 vmmw.ryebrook.gov
>�• �O� Building Department
1962 '
Residential / Interior (Remodel/Renovation) Permit
Permit Set 20 CHURCHILL RD P# RB25-0009 R# 135.26-1-26
PERMIT INFORMATION
Address Permit number Date issued
20 CHURCHILL RD RB25-0009 09/30/2025
REVIEWED BY
If you have any questions regarding the review of these drawings please contact:
Application in general
Steven Fews
stevefews@ryebrook.org
INSTRUCTION ANDATTENTION
It is the responsibility of the Applicant to print full size the entire approved permit package and provide at the time of inspection.
TABLE OF CONTENTS
Cover page 1
Building Permit 2
Required Inspections 3
Interior Building Permit Application 4
Building Department. 938 King St Rye Brook, NY 10573 / Phone: (914)939-0668
VILLAGE OF RYE BROOK
938 King St Rye Brook, NY 10573
Phone: (914)939-0668 1 w ..ryebrook.gov
Building Department
INSTRUCTIONS
THE PERMIT HOLDER AND/OR PROPERTY OWNER IS RESPONSIBLE FOR ENSURING THAT ALL REQUIRED/APPLICABLE INSPECTIONS ARE SCHEDULED AND THAT
THE PERMIT IS COMPLETE
REQUIRED INSPECTIONS
Name
Rough plumbing
Rough Electric
Description
Installation of all plumbing including drains, waste, vents and water supply lines. A test for this portion is
required including a 100 psi test on all water supply lines.
Rough Electric
Insulation Installation of the insulating material and vapour barrier. Blown -in insulation can be installed after the ceiling
drywall is applied and confirmed at the Occupancy inspection.
Certificate of Occupancy Completion of ALL Work, All fees Paid and Final Survey in if required)
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L�(_QR(�v� VILLAGE OF RYE BROOK
938 King St Rye Brook,NY 10573
W �
QPhone:(914)939-06681 www.ryebrook.gov
19p2 '��O Building Department
INSTRUCTIONS
THE PERMIT HOLDER AND/OR PROPERTY OWNER IS RESPONSIBLE FOR ENSURING THAT ALL REQUIRED/APPLICABLE INSPECTIONS ARE SCHEDULED AND THAT
THE PERMIT IS COMPLETE
a �
REQUIRED INSPECTIONS
Name Description
Rough plumbing Installation of all plumbing including drains,waste,vents and water supply lines.A test for this portion is
required including a 100 psi test on all water supply lines.
Rough Electric Rough Electric
Insulation Installation of the insulating material and vapour barrier.Blown-in insulation can be installed after the ceiling
drywall is applied and confirmed at the Occupancy inspection.
Certificate of Occupancy Completion of ALL Work,All fees Paid and Final Survey in if required)
Interior Building Permit Application
® Village of Rye Brook
938 King St Rye Brook, NY 10573
Phone: (914)939-0668 1 www.ryebrook.gov
Building Department
Project Information
SBL Zone Address Line 2
135.26-1-26 20 Church Hill Rd R-15 20 Churchill Road
Proposed Improvement
Bathroom Renovation
Does the proposed project involve a
Home-Occupation as per§250-38 of
Village Code?
❑ Yes 0 No
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 F No
N.Y. State Construction Classification N.Y. State Use Classification Occupancy Pre-Construction
VB R-3 1f
Occupancy Post-Construction (1 fam., 2 fam., comm., etc...)
1f
What is the total estimated cost of construction: (NOTE: The estimated cost shall include all labor, material,
20000 USD scaffolding,fixed equipment, professional fees, and material
and labor which may be donated gratis.)
Interior Building Permit Application,page 1/1
�kE 4Rnv� VILLAGE OF RYE BROOK
938 King St Rye Brook,NY 10573
Q Y Phone:(914)939-06681 www.ryebrook.gov
>>/� �9b2 ' Building Department ❑
Residential/Interior(Remodel/Renovation) Permit
Permit Set 20 CHURCHILL RD P#RB25-0009 R#135.26-1-26
PERMIT INFORMATION
Address Permit number Date issued
20 CHURCHILL RD RB25-0009 09/30/2025
REVIEWED BY
If you have any questions regarding the review of these drawings please contact:
Application in general
Steven Fews
stevefews@ryebrook.org
INSTRUCTION AND ATTENTION
It is the responsibility of the Applicant to print full size the entire approved permit package and provide at the time of inspection.
TABLE OF CONTENTS
Cover page 1
Building Permit 2
Required Inspections 3
Interior Building Permit Application 4
Building Department.938 King St Rye Brook,NY 10573/Phone:(914)939-0668
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VILLAGE OF RYE BROOK
P 938 King St Rye Brook,NY 10573Ki
%ffll
Phone:(914)939-06681 www.ryebrook.gov
Building Department
Electrical/New Fixtures And Wiring(Remodel) Permit
Permit Set 20 CHURCHILL RD P#RB25-0090 R#135.26-1-26
PERMIT INFORMATION
Address Permit number Date issued
20 CHURCHILL RD RB25-0090 10/29/2025
REVIEWED BY
If you have any questions regarding the review of these drawings please contact:
Application in general
Alfredo(Freddy)DiVitto
adivitto@ryebrook.org
INSTRUCTION AND ATTENTION
It is the responsibility of the Applicant to print full size the entire approved permit package and provide at the time of inspection.
TABLE OF CONTENTS
Cover page 1
Building Permit 2
Required Inspections 3
Application Materials 4
3rd Party Electrical Inspection Form 5
Electrical License-Photo-Westchester County 6
Electrical Permit Application 7
Building Department.938 King St Rye Brook,NY 10573/Phone:(914)939-0668
BRnuk VILLAGE OF RYE BROOK
O� 938 King St Rye Brook,NY 10573
W �
Q Phone:(914)939-0668 1 www.ryebrook.gov
> �O
��• 02 • i Building Department
INSTRUCTIONS
THE PERMIT HOLDER AND/OR PROPERTY OWNER IS RESPONSIBLE FOR ENSURING THAT ALL REQUIRED/APPLICABLE INSPECTIONS ARE SCHEDULED AND THAT
THE PERMIT IS COMPLETE
rol
REQUIRED INSPECTIONS
Name Description
Final Inspection Completion of all required items under the permit including the site grading and the surveyor's final grading
certificate.
Certificate of Occupancy Completion of ALL Work,All fees Paid and Final Survey in if required)
t� I
EC�EWE
BUIL�'ING DEPARTMENT
VILLAGE OF RYE BROOK OCT 2 1 2025
3D
938 KIN(;STn'i,I RYu,BR(oif,NY 10573
(914)19-0668 VILLAGE OF RYE BROOK
%9%%\.rVthfookn"1Q)Y BUILDING DEPARTMENT
ELECTRICAL PERMIT APPLICATION
Westchester County Master Electricians License Required
FOR OFFICE USE ONLY BP tt: EP 0:
Approval Date: Permit Fee: S '
Approval Signature: Other:
##fff##f####fk#ffff##ff!!!#!#f4k#k!!!!f!!4####4t##fk#!#!!!4!!!!#!!!!#!t!#!!!k##f##fkf##k#k4f#f####
DO N07 s 1.%RT N%ORK or CONSTRI CTION UNTIL A PERNIII HAS BEEN ISM E:D Bl"THE BUILDING INSPEX I OR.
THE ADMIN IS I R IilVE FEE FOR %CORK PROGRESSED OR C'ONIPLLI E:D N I I ROUT A PERMIT IS 12°4.01 I IIE
TOT,%I.COST OF C'ONSI RI ( TION R'ITII ► \I IN I N11 \I FEE OF$750.00
Application dated, 10 is hereby made to the Building Inspector of the Village of Rye Brook NY,for the issuance of
a Permit to install and4r rembive electrical equipment,wiring, fixtures,or to perform other high or low voltage electrical work as per
the detailed statement described below. By signing this document, the applicant & propem owner agree that all electrical work
performed will be in conformance with all applicable Federal,State,Count) and Local Codes.
1.Address: SBL: 3 cS-•06 71 Zone:
2.Property Owner: CO isC Q—r A Oj Address: S 411 E
Phone#: Cell#: email:
3.Master Electrician/Licensed Installer: Address:
Lic.#: 13AP Phone#: —Z Yf Cell#: Nly mail: 9!-A ELft-TRIC 7
Company Name: 9 TA_ E—Z-E—T/Z0L Address: 4,42 89AE W 3TAM500 L? "603
4.Proposed Electrical Work/Fixture Count: WIAA AA-21"M'100M 61y A%O
Tb Wci ul9E _ 3 rArj ND_ 4W 6N T
5,3"'Party Electrical Inspection Agency:
M STATE OFWYORK,COUNTY OF WESTCHESTER ) as:
1 r I44A4!L I R0 I� .being duly sworn.deposes and states that he/she is the applicant atxwe named,and does further
i print name of irAn tdual,tgntn the appltcant)
state that Whe is the r/3-/- EL�'C• for the legal owner and is duly authorized to make and file this application.
�tasr4r taectrict ut Licensed installer
she undersigned further states that all statements contained herein are true to the best of his/her know ledge 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 ac in accordance with the New York State L'nifinrtt Fire
Prevouttion&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 be or me this
day of 20 day of .20
_ r
Signature of Property Owner S' nature of Appli
Print Name of Property Owner Prin ame of Appl'•ant!,
Notary Public <E RA
►vetary Public,State of New York b-121)24
No 01Ri6441398
Qualified in Vhslchesler County ,�
Corrtmi-sicn Expires September 26,20
STATE WIDE INSPECTION SERVICES, INC.
Service 0ith Integrity
0:0 • •
iswis JOB APPLICATION0. •
Office v, Elect.Permit a Date
/�
Bldg Permit # R Il�S_ C Sq Ft
Plumbing Permit s V
Final Certificate z
City/Village O Zip/0 S 7 j Bu ldmo Dept. Q�L Q��K County 5�
Address r QO Cross Street �\ eSecttiion �,' Block / Lot
Owner Name/Address(U oAfe ent than above) '` 66
oe Contact Number
❑ �Basement st Fl. ❑2nd FI. ❑3rd FI. ❑More✓Than 3 FL ❑Garage ❑Attic ❑Outside CWesidential ❑Commercial
Receptacles Special Recept GFCI AFCI Switches Dimmers Smoke Alarms C/O Detector Hood Trash Compact
Amt Amps /
Range�s Cooktop' Oven(s) Dishwashers Refrigerator Disposal Microwave Luminaires Generator Transfer Switch
SERVICE
Amperage #Panels :P 3P Mett, » Disconnect []Underground ❑ Nev, ❑ Reconnect ❑Repair
❑Overhead ❑Upgrade ❑ Disconnect
Utility ID# ❑Con Ed ❑ '. SEi; ❑Central Hudson ❑ Orange/Rockland
PHOTOVOLTAIC SYSTEM
PV Modules Inverters AC Disconnect Junction Box Combiner Box Load Center PV Monitor Energy Storage System DC Disconnect
❑Legalization ❑ Safety Inspectior ❑Consultation
WIRE BATH 2vof"1 ►REn�vJAT v/j
D �OMI�
�C T 2 1 2025
VILLAGc Gi- RYE 3RCOK
6UILDING DEPrARTMEW
This appiK~is valid for one 0I year from the date recewed tsy SW15.The ap~fon is mended to tour the above listed items to be inspected,of at any htme of trnpwifon additional items have teen installed,you are
aulhorulad to make the Inspection and adjust the fee for the additional Urns it"mcted.The applicant dadams that there a no open applicabons for the ebove adds with any other nspe<twn<.-pan,The appitcaot.
owrer or authorized&gem agrees to as the above tans and conditions as set fonh rot the apphtattom
Email Address A A FLETetc Name f
License a 96.0 Date Signature �
Address 79 Q tA RA 1 City/State (,+/ Zip Code 0
CompanyA.—rL�T2i Phone /N 87 8 'g
�< Electrical Permit Application Village of Rye Brook
938 King St Rye Brook, NY 10573
Phone: (914)939-0668 1 www.ryebrook.gov
Building Department
Project Information
SBL Zone
135.26-1-26
Proposed Electrical Work/Fixture Count 3rd Party Electrical Inspection Agency
Wire Bathroom Reno SWISS
Master Electrician/Licensed Installer Information
Name Lic# Address email Phone#
Michael Troy 1386 796riar Brae Road Stamford CT 06903 ataelectric@optonline.net 914 879 8487
Cell# Company Name Company Address
914 879 8487 ATA Electric
Address of Work?
Homeowner Information
20 Churchill Rd Rye Brook, NY 10573 Robert Jackson
Electrical Permit Application,page 1/1
State Wide Inspection Services
DE,C rLc--`� I (�V 1080 Main Street
Fishkill, NY 12524
845 202-7224 Phone
�E� - 2 2�25 914-24-21919-1062 Fax
STATF WIC>E INSPECTION SERVICES Email: off ice^(swisny.com
VILLAGE OF RYE BROOK Website: www.swisny.com
Se—ce warn /ntegr;ty BUILDING DEPARTMENT
BY THIS CERTIFICATE OF COMPLIANCE STATE WIDE INSPECTION SERVICES
CERTIFIES THAT:
Upon the application of: Upon Premises Owned by:
ATA Electric, LLC Robert Jackson
79 Briar Brae Road 20 Churchill Road
Stamford,CT 06903 Rye Brook, NY 10573
Located at:20 Churchill Road,Rye Brook, NY 10573
Section: Block: Lot: Electrical Permit Number:
135.26 1 26
Certificate Number: 2025-7620 Building Permit Number: RB25-0009
A visual inspection of the electrical system was conducted at the Residential occupancy described
below.The electrical system consisting of electrical devices and wiring is located in/on the premises
at:20 Churchill Road, Rye Brook,NY 10573
The First Floor Bathroom was inspected in accordance with the NYS and NFPA 70-2017 and the detail
of the installation, as set forth below,was found to be in compliance on the 1st day of December
2025.
Name Quantity Rating Circuit Type
GFCI 01
Switches 03
Luminaires 04
Fan 01
Officer: Frank J. Farina
This certificate may not be altered in any way and is validated only by the presence of a seal at the location
indicated.This certificate is valid for work performed on the date of inspection only.
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BUIL Et
ME OCT - $ 2025
VIL E OF RYEK
938 KIN ET RYE BY 10573 ----- ---
VILLAGE OF RYE BROOK
BUILDING DC PARTMENT
W "-.
PLUMBING PERMIT APPLICAATION j
FOR OFFICE USE ONLY B C,�
P#: R '51,J �./ —1 PP#: � �'� / 5 —7
Approval Date: \ Permit Fee: $ / ( 5Dd-
T
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 TH E TOTAL COST OF CONSTRUCTION WITH A MINIMUM FEE OF$750.00
Application dated, /0 2:5� 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: 20 C,#We /LL �o�D SBL: /� • �62o Zone: f/5-
2.Proposed Work: B.9- U00j &_Voymyv
3.Property Owner: OBdlz _k- ae5cJ Address: 26
Phone#: // —U(/ Cell# / -U9U email - -Tkol mSi254<_C0,9dXA/L,04
4.Master Plumber: h9rn+yc 1rG-1. 1LOA rf Address:/LT6-,F/►¢4� L f" fl a." 06k
Lic.#:�Phone#: Cell#:4/1 YO 3 6_7 O email:17 f O 0,2
Company Name: Q[ng e3 it l •./e Address:
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
Ist Floor r
2nd Floor J
3rd Floor
4°i Floor
5'Floor
Exterior
5.* List Other Equipment/Provide Details: ' O'w Ls- Roo en 2 Ff�(" !�-
(Notarized Signatures Required Next 2 Pages)
1- 6/1/2024
s
STATE OF NEW YORK,COUNTY OF WESTCHESTER ) as:
,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
day of ,20 day of ,�20
tgnature o r erty Owner S ature of AppK
—Fa 0-�i
Print Name of Property Owner Print Name o Applicant
&651 OJ&4�1.
No ary tc otary is
GREGORY M.RIVERA GREGORY M.RIVERA
Newry Public,State of New York Ndary public,State of New York
No.01 R16441396 No.01 R16441398
Qualified In
nn Westchester County Qualified in Westchester County
C0I"issappliCationePiLMNe6Pro ly completed in its entirety and mtQcml�t t�t��9�c rs ina e(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.
-2-
6/l/2024
r n Il
BUILDM_ MLOV
MENT
VIL OOK I ULI - & 2025
938 KING ,NY 10573 VILLAGE OF RYE BROOK
BUILDING DEPARTMENT
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:
31, , residing at,
(Print nanm) (Address where you lie)
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;
, 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 Prop is wner(s))
(Print Name of Property Owners;u
Sworn to before me this 71
day f ,20
GREGORY M.RIVERA
Notary Public,State of New York
No.01 RI6441398 -3-
Qualified In Westchester County
Commission Expires September 26,20
6/1/2024