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BUILD Nc I EP'ARTMENT
VIL�A,f iF OF RYE 'OOlc ID
938 KINc,,'SS'v'RYE B ,NY 10573 JAN 0 1 2026
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wwt,-.i-yehl-� ny. roov RUIU)ING DEPARTMENT
PLUMBING PERMIT APPLICATION
FOR OFFICE USE O7<I,Y BP#: PP#: 2j,C j
Approval Date: JAN -PIA)
026 Permit Fee: $ 2nC-) '
Approval Signature: _ Disapproved:
(fees are non-refundable)
DO NOT START WORK or CONSTRUCTION UNTIL A PERMIT IIAS BEEN ISSUED H) THE BL111 DING
IN.sPECTOR, THE AC3�[INISTRATIVE FEE FOR WORK PROGRESSED OR C()\IPLLTED WITIIO[ I A
PI RMIT IS 12%OF THE TOTAL COST OF COISSTRUCTIOV 4�ITH A lIl itiIt NI FEE OF S750.00
Application dated, 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.
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1.Address: ! 1 ,�'�ri 1�CC�L CX l� '_ ? o�;(: SBL: !>-S Zone:
.Proposed Work: twja, e If I`C.i
VV� fU�f}
3.Property Owner: r .i? KJ r", kc t-j Z _ Address: y 1! 1{lY ,►�
Phone#: �`�+.` r' l ;` `�f Cell 4: q IH 7 , w i email: �' I Q. -
4.Master Plumber:,f?t},A h_; fr (`Al c. Address: f c i7
Lic.#: t ``f+ Phone#:fiqJ Cell-#: email: .4 v, �< I„���uti= 't�;• -Company Name: (_r,`S; a.a �1,..;,::, _c�ti.c;. Address: ' ��% h ._•.��c 5•= r.� + ! ;
INDICATE FIXTURES& LINES TO BE INSTALLED AS PER THE FOLLOWING SCHEDULE:
Location Water Urinals Drinking Sink., Showers Bath Laundry Domestic hire Sanitary Natural/ Other* Total
Closets Fountains -Cubs Tuhs Service Service Sewer LP Gas
Basement ✓
I st Floor
2nd Floor
3"Floor
4`h Floor
5'h Floor
Exterior
5.* List Other EquipmentTrovide Details:
(Notarized Signatures Required Next 2 Pages)
STATE OF NEW YORK, COUNTY OF WEST(:[-ESFER ) as:
,b;;mg duty sworn.deposes and states that he she is the applicant above:named.
(print name of individual siting as the applicant)
and further states that{sWhe 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 hisiher knowledge and belief,and that any work perfonned.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 Rve Brook and all other applicable laws, ordinances and regulations.
Sworn to before me this Sworn to before inc this
day of ,20 day of CaA, eta a 4
Signature of Property 61ner Signature of Applicant
Lile Kvirikadze '` asnkthu
Print Name of Property Ow ivi Ainlamc of Applicant
Notary PuhjLEWtSA A GRISTINA Nolar*FOWA GRISTI^'
NOTARY PUBLIC-STATE OF NEW YORK,, ,40TARY PUBLIC-STATE O'
No.01 GR6438779 No.01GR6435'
Qualified in Putnam County Qualified in Putn
'illy Commission Expires 08-22-2026
Ally Commission Exp►:*s .«-cul�a
'Phis application uiwa be properly e onipleted in its entirely and must include the notarized slgnature(%) of
the legal owncr(sl ol'the stibJecl property. and the applicant orrecord in the spaces provided. Applications
not properly completed in its entirety and/or not properl , -signed shall be do enik:d hull and void and -, ill be
returned to the applicant.
2-
6 t^_02a
BUILD xwrMENT
VIL00i OF RYk OOK
938 KING ur RYE BR '`, NY 10573
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lr7r+air*'t!#,t,ki,rw*#Ir,t+Y*+k#�Wr t*,Mit*tifFiF tk#irP.4*******ie+r Yr rY+Y,t***,r 9r,t it t,F�i949rw,t*,tit**,Y4frhr�w,rFirfR*,F**#te ik,R#Yt*it#1�r#Urt*#
AFFIDAVIT OF COMPLIANCE
VILLAGE CODE §216 • STORM SEWERS AND SANITARY SEWERS
THIS AFFIDAVIT MUST BEAR THE NCTARIZED SIGNATURE OF THE LFdG L PROPERTY OMER AND BE SUBMITTED
ALONG WITH ANY BUILDING OR PLUMBING PERMIT APPLICATION . ANY BUILDING OR PLUMING PERMIT
APPLICATION SUBMITTED WITHOUT THIS COMPLETED AND NOTARIZED FORM WILL BE A,ETUANED TO THE APPLICANT .
STATE OF NEW YORK, COUNTY OF WESTCHESTER ) as:
Lile kvirikadze , residing at,
�� ►
Jdr:"S lk hcre;un live)
being duly sworn, deposals 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 ofCompl imce pertains at;
�14 i✓Amgaar L , Rye Brook, NY.
(14,:i01JI"-!
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.
He kvirikadze
Sworn to before me this �]` 1—
day o
\..i jry Pubho
TERESA A GRISTINA
^TARY PUBLIC-STATE OF NEW YORK
No.01 GR6438779
"'fed in Putnam County -3
�n Expires 08-22-2026
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BUILDING DEPARTMENT
❑BJ111.UING INSPECTOR
ASSISTANT BUILUI\b INSPECTOR VILLAGE OF RYE BROOK
❑COIIE ENFORCEMENT OFFICER 938 KING STREET- RYE BROOK, NY 10573
(914)939-0668 FA..c (914) 939-5801
www.ryebrook.org,
- - - - - - - - - - - - - - - - - - - - INSPECTION REPORT - -- - - - - - - - - - - - - - - - - -
ADDRESS : `I --7,oqN q- % z o l - l - Z 02
--- DATE:
PERMIT# Z ISSUED:L7- L(. SEC.,-: }W• 5' BLOCK: 3 LOT: S
LOCATION: Z p 5£mt
---- --- _- OCCUPANCY:
❑ VIOLATION NOTIiI) THL WORK IS... Otl ACCEPTED ❑ REJECTED/ REINSPECTION
❑ SITE INSPECTION REQUIRED
❑ FOOTING
❑ FOOTING DRAINAGE
❑JOUNDATION
UNDERGROUND PLUMBING NOTES ON INSPECTION:
❑ ROUGH PLUMBING
❑ ROUGH FRAMING
❑ INSULATION
❑ NATURAL GAS
❑ L.P. GAS 2�u nt ►ti
1 O
❑ FUEL TANK 'J . V. C .
❑ FIRE SPRINKLER
❑ FINAL PLUMBING ' -1
El CROSS CONNECTION /1w��'� Aj
C1..'� L
❑ FINAL (!wi/l. ✓Qv b�,� �� - (aVCc.. �lR�
❑ OTHER
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