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[JAN
J ` 1rJIBULL i R MENT 2 U 2026
ViI. or Ryu OK
` 938 KIN ' i ! }°i- 13 : ,NY 10573
VILLAGE OF k�Y E BROOK
.: BUILDING DEPARTMENT
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PLUMBING PERMIT APPLICATION
FOR OFFICE USE ONLY BP#: PP#: Z e O 1
Approval Date
2 Permit Fee: S Q�
Approval Signature: Disapproved:
(fees are non-refundable)
DO NOT START WORT{or CONSTRUCTION UNTIL A PERMIT HAS BEEN ISSUED BV THE BUILDING
INSPECTOR.THE ADMINISTRATIVE FEE FOR WORK PROGRESSED OR COMPLETED WITHOUT A
PERMIT IS 2%QF THE TOIAL COST OF CONSTRUCTION cONSTRUCTION WITH MINIMUM-FEE OF S750.00
Application dated, 4t1 I 1S eUv 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 Ural Codes.
t.Address: 2 Horseshoe Lane Rye Brook NY 109573 SBL: i2a `s-1 " i " b Zone-.
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2.Proposed Work: 7e) L
3.Property owner: Jeffrey H. Fischer Address: 2 Horseshoe lane Rye Brook NY 109573
-- Phone#: 914 939 7933 �Cellll#: 914 673 3773 email: chfabi@aol.cjolm�
IX
4.Master Plumber: _ (✓•^ �?' f`�Z.t S2 — Address:
Lic.#•� Phone#: S`f' r Cell#: _ L� = �aii:_ (f-t�
Company Name: tt(.Address: '?C'-a(11
INDICATE FIXTURES& LINES TO BE IrUTALLED AS PER THE FOLLOWING SCHEDULE: 616r
Location Water Urinals Drinking Sinks Showers Bath Laundry Domestic Fire Sanitary NaturaU Other* Total
Closets Fountains Tubs Tubs Service Service Sewer LP Gas
Basement
I st Floor
Ind Floor
3td Floor
4&Floor
5"Floor
Exterior
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5.*List Other Equipment/Provide Details: + t
�. f�r�
(Notarized SLgnattur•• Required Next 2 Pages)
4- 6/1,2024
I
BUILD t MENT
VIL OF RY OOK
938 KING Q ET RVE BR ,NY 10573
-0 $ .
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*#**#**#***4***************#****#*##**#*##**tttttttttttt#####ttttt#ttttt##t#**t*##**#*###tt#tt#tttt#t##
AFFIDAVIT OF COMPLIANCE
VILLAGE CURE 6216 • 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
�rO�,+F NEW YORK, COUNTY OF WESTCHESTER ) as:
re t1. 'Fischer ,residing at,-R H(la hoe La j�" Frl.)oy , NY im-
(Piin(name) (Address where you live)
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;
L w k e .evwic 9'1 "10573 , 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.
Ca
lSigWl re a r wner(,O}
Jeffrey H. Fischer
(Print Narne of Property Owner(s))
Sworn to before me this_ •,�r ""` gT
day of � I�L1�r'1! , 20 �� �, $,
r
s + •
(Not — L + m-
w1,202,
1
STATE OF NEW YORK,COUNTY OF WESTCHESTER ) as:
being duly sworn,deposes and states that lie/she is the applicant above named,
(print name of individual signing as the applicant)
and further states that(s)he 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 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.
Sworn to before me this _ ISM Sworn to before me this 20+11
day of hu 20 9,(0 ` day of 20
S` a of P ope,rty Owner aignaturgeof Applicant
4" ti. Pl*er kvaCtA a�
Print Name of Property Owner �.90"!�E_T Jr,� Print Name of Applicant
OP�. = ,
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1 No Public
N ublic = E 1Ni� 1
' MARIA FtIZK
NOTARY PUBLIC
4•,,�w '� ��,�`" My Commission Expires Aug.31,2026
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4~wlIMi1M���M
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. 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-
6/11202a