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BUIL , G6DE MENT
VmL ' E OF RYE OK
FrR938 KIN ` ET RYE Bltdok,NY 10573 -
0668 '
='Ar6o V.20V
PLUMBING PERMIT APPLICATION
FOR OFFICE USE ONLY HP #: PP#: 2u (� I
Approval Date: FEB 4 6 2026 Permit Fee: S
Approval Signature: �- r Disapproved:
(fees are non-refundable)
DO NOT START WORK or CONSTRUCTION UNTIL A PERMIT HAS BEEN ISSUED BY THE BUILDING
INSPECTOR. THE ADMINISTRATIVE FEE FOR WORK PROGRESSED OR COMPLETED WITHOUT A
PERMIT IS 12% OF THE TOTAL COST OF CONSTRUCTION WITH A MINIMUM FEE OF$750.00
Application dated, :2/ S 12 6 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,
I.Address: 4 W WWN6 W00b P-lb • A)Q T SBL: 0-5 3- 4'2 Zone: �� 45
2.Proposed Work: GA-5 fl Q 0 R�-:PA 4 9
3.Property Owner: 'FNVt4Q- Bftwbe:�M a7 Address: 4 W)NA1N6 WWI) )VejKM
Phone#: CelI#: cQS1 email:
� "
4.Master Plumber: 1�/lllt-�f 1 1C-.(Z- sN r.�Z ' Address: RW 11�lu�.13G�-J�-1�t/-,tom- I W
Lic.#: Phone#:-7�� `��CeII#: � 3 {0� email: HjW Fj M JPWPJ44B• M�T,r
Company Name: )H 1 �` Qom(,MRJ A)4 1 tJ C- Address: 10� C IV 1 4td "F 1
INDICATE FIXTURES & LINES TO BE INSTALLED AS PER THE FOLLOWING SCHEDULE:
Location Water Urinals Drinking Sinks Showers Bath Laundry Domestic Fire I Sanitary Natural/ Other* Total
Closets Fountains Tubs Tubs Service Service Sewer LP Gas
Basement
I st Floor
2nd Floor
3rr Floor
41 Floor
51'Floor
Exterior
5.* List Other Equipment/Provide Details:
'b w le CQeK��
(Notarized Signatures Required Next 2 Pages)
b/l/2024
STATE OF NEW YORK,COUNTY 4 WESTCHESTER ) as:
CN u&7�L_ 13A-L f i0EYW`f ,being duly sworn,deposes and states that he/she is the applicant above named,
(print name of individual signing as the appli t)
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 Wore me this Sworn to before e this
day of ,2 day of = ,20
�I �IWI l
19nature of Property O Signature of Applicant
j1IM 111111/1///�
1 s
L� �- �T�(,f f1/l/�f ,.,•'`�,,,�F' ��BF�4',' .�IIW1
Print Name of Pr ,1 t�LL •' STx1,j0vL4;' r t Name of Ap ant
�'•oFTARY p�161-IC .
- Wota tary Public l
NOTARY PU LIC STATE OF NEW YOLK „s + G /- �� �`
BRONX COUNTYs f�J
LIC.#Ol OY6258379 '"+vrrr r aala+"
COMM.EXP,03/26/2028
This application must be properly completed in its entirety and trust 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-
bn 1202a
BUILD MENT
VIL E OF RY OOK
938 KING ET RYE BR NY 10573
ov
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 YORK, COUNTY OF WESTCHESTER ) as:
1, Enver Balidemai , residing at,
(Print 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,
1 WindirQ Wood Road North, Rye Brook NY 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 stonnwater 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 Oµmer(s))
(Pant Name of Property Ovvner(s))
Sworn to before me this 5
day of ,24 C
ary blic
EDWARD OYEBISI
NOTARY PUBLIC STATE OF NEW YORK
BRONX COUNTY
LIC.#01OY$258379
COMM. EXP.03/26/2028
W 2Q24