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BUILENT DEC - 1 2025
VIL OKVILLAGE OF RYE BROOK
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938 KIN NY 10573 BUILDING DEPARTMENT
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PLUMPBING PERMIT APPLICATION
FOR OFFICE USE ON W #: �— Ill/ PP#: .�—��.
Approval Date: 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 ADMINISTRATIVE 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, Ifl I Z 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:/ / �t /7!)IICC �� , 12 e book P SBL: I-2-)L�11;149' Zone:
2.Proposed Work: /
3.Property Owner: Address:
Phone#: Cell#: // email:
4.Master Plumber: Q 5q)tk'a r rCn Address: �/(J D /V 1n _52 ( 5— V p,,// 1
Lic.#:L Phone#: Cell#: email: '�
Company Name: Address: J (� s . 4 r U
f.
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 st Floor
2nd Floor
3'd Floor
4'h Floor
5'h Floor
Exterior
5.*List Other Equipment/Provide Details: 2 ni ne, u;L QaA,
(Notarized Signatures Required Next 2 Pages)
-1- 6/1/2024
STATE OF NEW YORK,COUNTY OF WESTCHESTER ) as:
Pai g rafe) ,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 or J )e C Q��,20)LS day ofj�(,.Qln 6eL 20 °
t
Signature of Property Owner Signature of Applicant
savj, h wmeiA's i�f Ara''
Print Name of Property Owner Pri;btaryPublic
f Applicant
Notary PublicSHARI MELILLO LI A WHALEN
jotary Public,State of New York Notary Public,State of New Ybrk
No.01ME6160063 No.01 WH6394580
Qualified in Westchester County Oualified in Westchester County
Expir2097
ommission Expires January 29,202� COmtntSS10n �July 8'
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. 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 -0
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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 NEWS �YORK,COUNTY OF WESTCHESTER ) as:
31, �G�Vc (n t "'P YLS ,residing at, lU 6JC1'1 liK 1JrtR I fyp J�op Xc_ A1`( 105?�
(Print na e) (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;
, 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.
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(Signature of Property Owner(s)
SkAk �4nS
(Print Name of Property wner(s))
Sworn to before me this 1
o ce�.�� , 20
(Notary Public)
SHARI MEULLO
Notary Public,State of New York
No.01ME6160063
Qualified in Westchester County _3_
Commission Expires January 29,202-7
6/l/2024