HomeMy WebLinkAboutPP25-172 i
�lE, B RC��
BULL En
MENT
VIL OF RYE OOK DEC 2025
938 KIN ET RYE B NY 10573
(914)9 939-5801
.or
PLUMBING PERMIT APPLICATION
FOR OFFICE USE ON Y BP#: PP#:
Approval Date: Permit Fee: $
Approval Signature:. Other:
Disapproved:
(fees are non-refundable)
Application dated, is hereby made to the Building Inspector of the Village of Aye 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 he in conformance with all applicable Federal,State,County and Local Codes.
1.Address: SBL: i _�.�u f1_ J _ L pone:
14
2.Proposed Work:
3.Property Owner: Address-- Du}U !E�5 --9 Cj j C4-0 U C ,
Phone#: email:
4.Master Plumber: Address:
Lic.#: P e#: Cell email:
Company Name: Address:
INDICATE F TURES& ES 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 2.
1st Floor +j
2nd Floor ,
3 Floor
4 Floor
511 Floor
Exterior
5.*List Other Equipment/Provide Details:
(Notarized Signatures Required Next 2 Pages)
i
3/21/19
ST T-OOI NEW YORK,COUNTY OF W'ESTCHESTER ) as:
being duly sworn,deposes and states that he/she is the applicant above named,
(p ' t name of i dual si 'ng as the applicant)
rther s to 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 snake and file this application.
(in ' tchitect,contractor,agent,attorney,etc.)
That all tents 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.
Swom to before me this Swom to before me this
day of U/ M6 jC 20 day of V�V ,20
%nilture of Property Owner SUa�'!��i A lic
Z,
Print Name f Property Owner Print Nafte o Applicant
—ZL &Z��
Notary P c NtWERA
y c
��i y M. ERA
Mate of New York ary public,State of New York
011RIG441396 No,01RiS441398
rig In Westchester County dual Pied In Westchester County
'Ftia Fi a'r tS4lt i� dW perly completed in its entirety and m VIi4 a9"!'6IhM�Z ec�ss Z re(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-
3/21/l4
BUILD MENT
V1 E OF RYI BROOK
938 KrNG ET RYE 13RQUtc,NY 10573
(914)9 9 39-5801
w
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 YOM COUNTY OF WESTCHESTER ) as:1, A�� LV , residing at, 57 1 6,.Z
XILI
i Prinf name) (Address tic here vou1hc
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;
7 5 -�l� Pt✓ , Rye Brook, NY.
I lob 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 Property Owncr(s))
k40�� Lei inol
{Print Name of Pro(eny Owncr(s))
Sworn to before me this
day of �. ( { p , 2Q
(No ta�, )71 ,ii,
GREGORY M.RIVERA
Netny Public,State of New York
No,U1R16441399
Qualified In Westchester County }
Commission Expires September 26,20
3/21/19