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BUIZET
�'MENT
VIMLF RYE ROOK DEC 16 2025
938 KINGRYE BR",NY 10573
INTERIOR BUILDING PERMIT APPLICATION
FOR OFFICE USE ONLY:
Approval Date: DEC YL P t 2 - �`f -Application Fee:$ C
J
Approval Signature: Permit Fees: $_
Disapproved:______
Other:
Application dated: is hereby made to the Building Inspector of the Village of Rye Brook,NY,for the issuance of Permit for the
interior alteration of an existing building,or for a change in use,as per detailed statement described below.
1. Job Address: SBL: 12y 7 —/—1e., Zone: _
2. Proposed Improvement.(Describe in detail): F1 NISt,1SA7 F2�1� 'r
3. Does the proposed improvement involve a Home-Occupation as per§250-38 of the Code of the Village of Rye Brook?
No: '!�C Yes: If yes,indicate: TIER 1: TIER II: TIER III:
4. 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...) :No: Yes: �)C
(I--yes,please submit a separate Automatic Fire Suppression System Permit application&2 sets of detailed engineered plans)
5. Occupancy;(I fam.,2 fam.,comm.,etc...)Prior to Construction:?L—E�,M)L� After Construction: 1 �r1LY
6. N.Y State Construction Classification: N.Y.State Use Classification:
7. Property Owner:_ Lr:_: { )SMA Pam! Address: �- J HL�H TV l NT �l Ply
Phone# Cell# 217`37VZ email:�_N 4Y.VA15-'MA + i C04
8. Applicant: FEZ Address:
Phone# Cell# email:
9. Architect: I __Address:
c�77
Phone# Cell#q)4-IeLS7 -671!(o
10. Engineer: Address:
Phone# Cell# email:
11. General Contractor: Ctw _ MC, Address: 17 LYL4:� RD/1T 64' 64,14
Phone# Cell# I I- AEJ email:'EZQ m RAL.C.4;i.17PA--G7l W"_0 64 M41L
12. Estimated cost of construction $ 2
(NOTE The estimated cost shall include all labor,material,scaffolding,fixed equipment,professional fees,and material and labor which maybe donated
gratis)
13. Job Timetable: Start: Finish:
(1)
6/l/2424
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. 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.
STA�OF NEW ORK,COUNTY OF WESTCHESTER ) as:
_ "r, a r Jg, S�+ a V_\_ ,being duly sworn,deposes and states that he/she is the applicant above named,
(print name of individual sigttiag 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 htslher 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.
Swom to before me this Sworn to before me this W
day of DeGt'yn . 20 4 day of
Signature of Ptnperty Owner + ! Signature of Applicant
U'2 t I ,n•�
Pri of Property Otvnc Print. f Applicant
Public
Notary Public
N
SILVIA BOWRON
NOTARY PUBLIC
Sta*^of Connecticut
My C .emission Ex eS
October 31.20
(4)
6/112024
BUILyj=�
]APARTMENT
VILF RYV*OOK I I �� G' , -I j ,
938 KING SYE BROU'FC.NY 1OS73 ( 16 2Q�5
( ,a)93 -W1� DEC
wwV�.rVehnum,goV Vi'Lr ~OF `v };�
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AFFIDAVIT OF COMPLIANCE
VILLAGE CODE §216 • STORM SEWERS AND SAMTARY SEWERS
THIS AFFIDAVIT MOST 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,CO 7 OF WESTCHESTER )�}as:L
I, ✓\,residing at,
(Print name) {AddrGs-� ti sere you Iive)
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.
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.
{Sisttaatitrc of Proper
(Print`.tnsc {FI'I'rt lr_Y4� flu n�rt,,:
Sworn to before me this
day o ekx,/Yn 20
*�ait:ry P�tl+n�>
SILVIA SOWRON
tJOTARY PUBLIC
Sta;^of Connecticut
My C mission Ex es
October 31,209 (2)
Ail`tty-+awaac t 6/1/2024
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