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E A, MENT D IE C E U V E
BUILD1) P
VILLT�COF RYE �OK
938 KING 91 ET RYE BR ; NY 10573 "3
(914)93 939-5801
wwvtt ®' .or VILLAGE OF RYE BROOK
BUILDING DEPARTMENT
ELECTRICAL PERMIT APPLICATION
This application must be filed in person at the Building Department by the Licensed Electrician of
Record and must be accompanied by the completed Electrical Inspection Agency application form.
Office Use Onl :
Date: 15LIzi -- j�� ___— Approval Signature: — —
Inspection Agency: ' " 'C�
J --- Electrical Permit#: —_ 5 L _
Fees: _ — paid ( )due( Building Permit#:—
Application is hereby made to the Building Inspector of the Village of Rye Brook NY, for the issuance of a Permit for the
installation/removal/repair of Electrical Equipment as per detailed statement described below,and in accordance with the
Code of the Villageof Rye Brook,NYSUFP&BC,NEC,NFPA and all other applicable State,,County
/,and
l�Local Laws.
Address: 7 3o �1�✓G s1. Phone#: 3 . 6/ �y
Owner: t 1 (AG4- O¢ k( 9AV U1'f—' Address&Phone:
Use/Occupancy: Parcel I.D.#: Zone:
Proposed Electrical Work: fjcan e'C1' C.M<-C-?
//1-.-_ (Vi11*1
LICENSED ELECTRICIAN'S INFORMATION:
Name(Please;Print • J C"{� � C Phone#
Signature: Westchester County License#: z2—
Company Name: ffe tec-vl( C.) n
Company Address: 0 cJ 2r City/Town:
State: Zip Code: to3 3, Phone#:�zjVb
Field Contact&Phone:q/�y2V .
Revised 9/6/11
WestchlBster Rockland Electrical Inspection Services, Inc. Phone: 914-347-3595
DO NOT WRITE HERE-FOR OFFICE USE ONLY 43 North Lawn Avenue Fax: 914-347-3596
BUILDING PERMIT NO.
TEMP 8 DATE
�x!
CITY OR VILLAGE J ZIP CODE TOWNSHIP COUNTY
STREET AND NO.OR ROAD 1 POLE NUMBER
BETWEEN WHAT TWO CROSS STREETS IS PREMISES LOCATED? SECTION BLOCK LOT
OCCUPANTS NAME /, j/ ILDING OCCUPANCY BU
OWNER'S NAME AND ADDRESS HOME TELEPHONE NUMBER
CURRENT SUPPLIED BY FROM THEIR OFFICE WORK TELEPHONE NUMBER
LIST BELOW ALL EQUIPMENT WHICH YOU INSTALLED
NUMBER OF OUTLETS NO.OF FIXTURES& MOTORS HEATERS OFFICE USE
LOCATION LAMP RECEPTACLES ONLY
SIDEWALL SWITCH INCADE GFLUORE NO. H.R.EACH NO, WATTS EACH INSPECTION
OUTSIDE V
BASEMENT
,IT FL.
2ND FL.
3RD FL.
REMARKS:LIST OTHER ELECTRICAL DEICE RTH
THIS APPLICATION IS INTENDED TO COVER THE ABOVE LISTED ITEMS TO BE INSPECTED. IF AT ANY TIME OF INSPECTION ADDITIONAL ITEMS HAVE BEEN INSTALLED,YOU ARE
AUTHORIZED TO MAKE THE INSPECTION AND ADJUST THE FEE FOR THE ADDITIONAL ITEMS INSPECTED AS PROVIDED BY THE APPLICANT.THE APPLICANT DECLARES THAT THERE IS
NO OPEN APPLICATIONS FOR THE ABOVE WITH ANY OTHER INSPECTION COMPANY. WREIS, INC. IS NOT LISTING, LABELING, UNDERWRITING OR CERTIFYING ANY EQUIPMENT,
MATERIALS OR DEVICES WHICH ARE PERFORMED BY OTHER CERTIFIED TESTING AGENCIES OR INSPECTION COMPANIES.THE APPLICANT,OWNER.OR AUTHORIZED AGENT AGREES TO
ALL THE ABOVE TERMS AND CONDITIONS AS SET FORTH FOR THE APPLICATION.
SIZE OF SERVICE FEEDERS
CHARACTER OF WORK NEW❑ ADDITIONAL❑ EXPOSED❑ CONCEALED❑ MUST ENTER APPLICANTS
IUENTIFICATpN NUMBER
SERVICE ENTERS BUILDING OVERHEAD❑ UNDERGROUND❑
AVOID DELAYS BY GIVING FULL AND ACCURATE INFORMATION.ALL SPACE MUST BE FILLED IN OR APPLICATION MAY BE RETURNED.
SIGNATURE OF APPLICANT
NAME OF COMPANY, � � DATE OF APPLICATI(?N
STREET ADDRESS TELEPHONE NO.
CITY OR POST OFFICE Q� ZIP CODE -7^� LICENSE NO.WHEN APPLICABLE