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BUIL MENT
VIL E'0 � E: OK
938 KING T, Y ,NY 10573 MAY 2 0 2025
� ov
VILLAGE OF RYE BROOK
_ BUILDINdG DF''A.I??-VRQT
FOR OFFICE USE ONLY:
onx�Approval Date: 00,
AUG mi �c Application# AjfflQ!!i_ W
Approval Signature: ARCHITECTURAL REVIEW BOARD:
Disapproved: : Date: 8I zo l -5
BOT Approval Date: Case# Chairman:
A4
PB Approval Date: Case# Secretary
ZBA Approval Date: Case#
Other: ! J
Application Fee: Permit Fees:
EXTERIOR BUILDING PERMIT APPLICATION
Application dated: ereby made to the Building Inspector of the Village of Rye Brook,NY,for the issuance of a Permit for the
construction of building ,structure ,additions,alterations or for a change in use,as per detailed statement described below.
1. JobAddress: /�z
2. Parcel ID#: /05-f 2_/9 Zone: Z_/�
3. Proposed Improvement(Describe in detail): 3 k e d o4u) /Leie lQ P Q y!
�SQ�u�P S�-Z2 �•
a �h_d S
4. Property Owner: 1011-taa 6A_,6 n 6('6t_, — /-i
Address: /a2 �a /0,0-'o /c?p2 L, L
Phone# 9/ L/ - V6 2 -tW Cell# e-mail q S l( /Z ep eAe�l
List All Other Properties Owned in Rye Brook:
Applicant:
Address:
Phone# Cell# e-mail
Architect:
Address:
Phone# Cell# e-mail
Engineer:
Address:
Phone# `Cell# e-mail
General Contractor:
Address:
Phone#_ Cell# e-mail
(I)
6/1/2024
5. Occupancy;(1-Fam.,2-Fam.,Commercial.,etc...)Pre-construction: Post-construction:
6. Area of lot: Square feet: Acres:
7. Dimensions from proposed building or structure to lot lines: front yard: rear yard:
right side yard: left side yard: other:
8. If building is located on a corner lot,which street does it front on:
9. Area of proposed building in square feet: Basement: 11,fl: 2"d fl: 3`d fl:
10. Total Square Footage of the proposed new construction:
11. For additions,total square footage added:Basement: 11 fl: 2nd fl: 3`d fl:
12. Total Square Footage of the proposed renovation to the existing structure:
13. N.Y. State Construction Classification: N.Y. State Use Classification:
14. Number of stories: Overall Height: Median Height:
15. Basement to be full,or partial: finished or unfinished:
16. What material is the exterior finish:
17. Roof style;peaked,hip,mansard,shed,etc: Roofing material:
18. What system of heating:
19. If private sewage disposal is necessary,approval by the Westchester County Health Department must be submitted with this
application.
20. 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: No:
(if yes,applicant must submit a separate Automatic Fire Suppression System Permit application&2 sets of detailed engineered plans)
21. Will the proposed project disturb 400 sq.ft.or more of land,or create 400 sq.ft.or more of impervious coverage requiring a
Stormwater Management Control Permit as per§217 of Village Code? Yes: No: Area:
22. Will the proposed project require a Site Plan Review by the Village Planning Board as per§209 of Village Code?
Yes: No: (if yes,applicant must submit a Site Plan Application,&provide detailed drawings)
23. Will the proposed project require a Steep Slopes Permit as per§213 of Village Code Yes: No:
(if yes,you must submit a Site Plan Application,&provide a detailed topographical survey)
24. Is the lot located within 100 ft.of a Wetland as per§245 of Village Code? Yes: No:
(tf yes, the area of wetland and the wetland buffer zone must be properly depicted on the survey&site plan)
25. Is the lot or any portion thereof located in a Flood Plane as per the FIRM Map dated 9/28/07? Yes: No:
(tf yes,the area and elevations of the flood plane must be properly depicted on the survey&site plan)
26. Will the proposed project require a Tree Removal Permit as per§235 of Village Code? Yes: No:
(if yes,applicant must submit a Tree Removal Permit Application)
27. Does the proposed project involve a Home-Occupation as per§250-38 of Village Code? Yes: No:
Indicate: TIER I: TIER II: TIER III: (f yes,a Home Occupation Permit Application is required)
28. List all zoning variances granted or denied for the subject property:
29. What is the total estimated cost of construction: $ / 1-5,290 Note:The estimated cost
shall include all site improvements,labor,material,scaffolding,fixed equipment,professional fees, including any material and labor which
may be donated gratis.Ifthe final cost exceeds the estimated cost,an additional fee will be required prior to issuance of the C/O.
30. Estimated date of completion:
(2)
6/1/2024
BUILDZMENT �C F � UvVIL OK
938 KING NY 10573MAY 2 0(9 VILLAGE OF RYE BROOK
BU!LDIN(7, nEPgpTNIPNIT
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, �' U Olt !��U/� ,residing at, /� �a��0 A Xo/
(Print name) (Address where you live) 61
being duly sworn,deposes and states that(s)he is the applicant above named, and further states that(s)he is the i,;sJ=
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.
h , e
APV�
(Si ature of operty er(s))
(Print Name of POCrty,Owner(s))
Sworn to before me this
day of iwc\\
(Nofary Public)
SHARI MELILLO
Notary Public,state of New York
No.OIM E6160063
QtMdifled In Westchester County.
Commission Expires January 29,20 2- 7 (6)
6/1/2024
This application must be properly completed in its entirety by a N.Y. State Registered
Architect or N.Y. State Licensed Professional Engineer & signed by those professionals where
indicated. It must also 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 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 legal owner of the property to which this application pertains, or that (s)he is the
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. By signing this application, the property owner further declares that he/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 stormwater or
groundwater connections or sources of infiltration into the sanitary sewer system on or from the subject property.
Sworn to before me this a�/i/ Sworn to before me this
day of /7 , 20 day of , 20
�i
Si ature Prop6rty Owner Signature of Applicant
u 6KoF6 'e _
Print Name 41roperty Owner Print Name of Applicant
Notary Public SHARI MEULLO Notary Public
Notary Public,State of New York
No.01ME6160063
Qualified In Westchester County
Commission Expires January 29,20Z�
(g)
6/1/2024