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YOU ARE HEREBY REQUESTED TO
INSPECT AND ISSUE CERTIFICATES
FOR THE FOLLOWING ELECTRICAL
EQUIPMENT TO BE INSTALLED BY
THE UNDERSIGNED
TEMP.I! DATE
CITY ILLAGE TOWNSHIP COUNTY.
STREET ND NO.O OAD •-�� - POLE RUMBER
BETNEEN WHAT TWO C OSS STREETS IS PREMISES LOCATED" SECTION BLOCK LOT
OCCUPANT'S NAME - / � B LDING OCCUPANCY
1 t/
OWNER'fINAME ANDADDAIL HOME( PH N MBER
LA
CURRENT SUPPLIED BY FROM THEIR OFFICE WORK TELEPHONE NUM ER ` 1
BUILDING IS
NEW❑ OLD WORK IS NEW❑ ADDITIONAL DEFECTS P'EMOVED❑
LIST BELOW ALL EQUIPMENT WHICH YOU INSTALLED _
NUMBER OF OUTLETS No.of Fixtures& MOTORS HEATERS BRANCH OFFICE USE
Loca- Lamp Receptacles CIRCUITS ONLY
tion Side Attach't H. Watts A.W.G.
Ceiling wall Recep'Is Switch Pendant Bracket No. Type Each NO Each NO Gauge INSPECTION
OUT-
SIDE
SUB-
BASE
BASE-
MENT
ist
FL
2nd
FL.
3rd
FL.
REMARKS:LIST OTHER ELECTRICAL DEVICES NOT'ET FORTH ABOVE:
THIS APPLICATION IS INTENDED TO COVER THE ABOVE-LISTED EQUIPMENT TO BE INSPECTED,BUT IF AT TIME OF INSPECTION,THERE IS
FOUND ADDITIONAL_EQUIPMENT NOT ABOVE LISTED,YOU ARE AUTHORIZED TO MAKE THE INSPECTION AND ADJUST THE FEE TO COVER
THE ADDITIONAL EQUIPMENT,AS PROVIDED BY THE APPLICANT.
SIZE OF MAINS FEEDERS ELECTRIC SIGNS/LAMPS TOTAL WATTS
CHAR ER OF WMr ❑ EXPOSED GAS TUBE SIGN/TRANSFORMERS OF VA
❑ CONCEALED
DATE WORK TO BE STARTED DATE COMPLETED SIZE OF SIGN(NUMBER) CAPACITY
SERVICE ENTERS BUILDING MANUFACTURER OF SIGN
❑ OVERHEAD ❑ UNDERGROUND
DATE INSPECTION REQUESTED ON( R AS EAR AS POSSIBLE) MUST ENTER APPLICANTS _
�. IDENTIFICATION NUMBER
AVOID DELAYS BY GIVING FOLL AND ACCURATE INFORMATION.ALL SPACES MUST BE FILLED IN OR APPLICATION MAY BE RETTJANED.
PRINT NAME AND ADDRESS
NAME OF APPLICANT DATE O APP IC\A�TIQ SIGNATURE OF APPLICANT
STREET S TELEPHONE NO.
\ ;
CITY OR POST, FICE ---�,.. \ ZIP CODE LIC NS NO.WHE APPLICABLE
t
❑ 85 Jahn Street ❑ 41 State Street ❑ 584 Delaware Avenue ❑ 217 Lake Avenue ❑ 202 Arterial Road
NEW YORK, NY 10038 I ALBANY,NY 12207 I BUFFALO, NY 14202 ROCHESTER,NY 14608 SYRACUSE,NY 13106
— . .—. . � --.1 — I A r-%9-% nr rIIr"%r 1 1A IMF--P9%A/Ir'11TrnC%
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10 PEARL STR EETT
PORT QfESTER,NEW YORK
APPLICATION FOR ELECTRICAL PERM
711LAGE OF RYX CATICV IS HEREBY made to the Building Inspector of the
]PUILDINGf LWr the approval of the detailed statement herewith submitted
�1ation of the electrical work herein described, and for a
permit to install such electrical work.
It is agreed that if such permission be granted that said
installation and equipment will be installed in conformity with this
application, as approved, and that all State laws, by-laws and ordinances
of the Town of Rye, and rules, regulations and orders of any board, body
or department so far asothe same may be pertinent, including the National
Board of Fire Underwriters, will be complied with.
The applicant further agrees to furnish such additional information,
plans or statements as may be required by the Building Inspector.
PER41T NO.
eledtrician license Jo %
hereby applies to the Building Inspector of theVGIC OR &0€ '
permit for XTILDING DEPARTMENT
at
Type of Building '
for owner.
owner.
Alteration
Addition iX (Signed)
New
-lec rician
Address
Fee: \C�nS�\-�
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