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198'2 BUILDING DEPARTMENT
V❑ ILDING INSPECTOR
ASSISTANT 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 : 111 A Q DATE: I,Z.• (yLf
PERMIT# �U T�S�E1 J ISSUED: SECT:fyl.27 BLOCK:/Lo-:_ 7
LOCATION: Ste► O OCCUPANCY:
❑ VIOLATION NOTED THE WORK IS... Lf ACCEPTED ❑ REJECTED/ REINSPECTION
❑ SITE INSPECTION REQUIRED
❑ FOOTING
❑ FOOTING DRAINAGE
❑ FOUNDATION
❑ UNDERGROUND PLUMBING NOTES ON INSPECTION:
❑ ROUGH PLUMBING
❑ ROUGH FRAMING
❑ INSULATION ,( /
❑ NATURAL GAS TN SP✓C_ j ��I /-0 /O
❑ L.P. GAS
❑ FUEL TANK
❑ FIRE SPRINKLER
❑ FINAL PLUMBING
❑ CROSS CONNECTION
❑ FINAL
OTHER ��
BUILDING DEPARTMENT p CE C IE ME
VILLAGE OF RYE BROOK
938 KING STPJ.r,T RYE BROOK, NY 10573 SEP - 3 2019
(914)93 �i 9 39-5801
VILLAGE OF RYE BROOK
BUILDING DEPARTMENT
FIRE INSPECTION / OPERATING PERMIT APPLICATI0�1
FOR OFFICE USE ONLY:
Fee Paid: $ JAI J(.J , Inspection Date& Time: N
FEE SCHEDULE: Re-inspection Date&Time:
Triennial& Private School Annual Inspection: =$450.00
Public Assembly Annual Inspection: <100 People=S500.00/>100 People=S750.00
Application,dated: 2 D ►1 is hereby made to the Building Inspector of the Village of Rye Brook NY,requesting that a
Fire Inspection be conduct4d at the building and premises listed below for the purpose of issuing a Permit to Operate the business,private
school and/or place of public assembly in conformance with the Code of the Village of Rye Brook,the New York State Uniform Fire Prevention
&Building Code,Title 19 NYCRR Part 1201,and all other applicable local,County,State&Federal laws,rules®ulations,as perdetailed
statement described below.
1. Address: ,o Rw e e P%..T 1, S �.vt. ►0 1 SBL: Iq/. 6� 7- 7 Zone: C'/-p
2. Business/Occupancy Name: pr%. cortAIS Use Class:
w e 3. Property (Owner: W� kA� ?,eP (,TV, i Address: L+ (Na � PLA-2 6-
Phone# q t*_ 101-4a5- Cell# email:AMKM'� C�UMI cl1r►'
5. Business Owner:t r&A &Wt f hO h dWA 69j4`J�Address:
Phone 11'7 111 7t" Cell# ,►7 '&IN► 11-NI email: �►•r e � �►. ref-k
6. Emergency Contact: Afte &We dress:
Phone# Cell# email:
7. Inspection Escort: 1> A k 'SN b.\ Title: P%! e M %'6 t C 0 t�l Le o Et {�—�—
Phone#: 111 - 112 - 7 T l u Cell#: 9 0- 1'1 a - '7-JL 1 t4 email: . ..k M a ► o rVj
8. Provide a brief description outlining the current and/or intended use of the property:
o
9. List all Hazardous Materials:
Qf 10. Occupant Load: Existing: Proposed: Other:
11. Date& Disposition of Previous Fire Inspection: ❑ Pass ❑ Fail
1
6118
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.
STATE OF NEW YORK
COUNTY OF WEST�C.,H�ES,TER > as:
WWI A C*- CS being duly sworn,deposes and states that he/she is the applicant above named,
(print name of individual signing application)
and further states that he/she is the legal owner of the property to which this application pertains,or that he/she is the
UsiN�5 U4 ,for the legal owner and is duly authorized to make and file this application. That all
(indicate architect,business owner,attorney,agent,etc.)
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.
�f I�
Sworn to before me this v ) Swan to before me this 2 }�
day of '� , 20 161 day of IA v�v �- 20 (�
Ir� V
Notary Public N tart'Public
-*uA- ��t4-,
Signature of Property Qvmow 4WVr.j�W R jff�—. &hjyjAk ature of Applicant
14NA 4*41VT rv-s C 4-CA.- Ir 1)11
Print Name of Property Owxern/r�i iJ qub U I aL Print Name of Applicant
SUSIE BRUNELLI
NOTARY PUBLIC.STATE OF NEW YORK SUSIE BRUNELLI
Registration No.01 BR6146106 NOTARY PUBLIC,STATE OF NEW YORK
Qualified in Westchester County Registration No.01 BR6146106
Commission Expires May 15,2022 Qualified in Westchester County
Commission Expires May 15.2022
2
6/1/18