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BUILDING DEPARTMENT
VILLAGE OF RYE BROOK fIL OCT 2 8 2021 1 ID
938 KINf;STRF.F.T RYF.13 om NY 10573
(914)939-0668
VILLAGE OF RYE BROOK
� BUILJiNG �EI'A.RTMENT
EA.ECTRICAL PERMIT APPLICATION .. ._ __._.___" _.
N1•c%tchc%terCo aster Electricians License Rquiredl
FOR OFFICE USE ONLN F'.I'u: Q —� S
OCT 2 8 102 /�O
Approval Date: Permit Fee: S
Approval Signature: Other:
Disapproved:
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Application dated. 'O► 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 electrical equipment.%tiring. futures.or to perform other high or lo%% voltage electrical work as per
the detailed statement described below. The applicant R propem• owner, by signing this document agree that all electrical %%ork
performed will be in conformance with all
applicable Federal.State.Count%and Local Codes.
I.Address: "4 TA Lk 11 �Zs'1 F` 2 h24,14, SBL: /S5J 15 7_/_j/ Zone: 4e—Ic
2.Property Owner: TA Q�Q CQ& R±jj2d& Address: —
Phone 91if—U—Usel Cell 917 -(hL—X.S1 emailTA�s 6irl l.C►�s
3.Master Electrician: 1 TY_ y_ =o Address: - � Fo&V G1V4 ,Ao1( it"'
Lic. A'112,?. Phone-: Cell u:9Lfft-07-9 email:
Compam Name: as S1 — ��(.E:>� Address: , 6w6613 .,V (ttf W
4.Proposed Electrical Work Fixture Count:
i,4R4�Ar*4o..*rRR*a**aiaar/a*Ra*iaaa*aaaY*aia*a*a*Ir****a*+*****A*******RR*RR*******RRRRRRRRR**Ra*RRRaRRRaR
S fA Tf_OFF NEW YORK.COUNTY OF WESTCHESTER ) as:
S-1151AL �-+ t � being dub s%%om.deposes and%we%that lit:she is the applicant abo%c named.and does further
state that(%the i%the legal o%%iter of the property to which 06%application pertains.or that i%)he is the -' Cell.-A '
fix the legal owner and is Juh authorised to make and rile This application _- ura.1,r..4c11L at,•n1,.-CtL
Ilse undersigned funher states that all statements contained herein are true to the hest of his her kno%%ledge and beliel:and that any cork
perti+rmcd.or use conducted at the abo%c captioned property%%ill be in conformance%%ith the detail>as set fimh and contained in this
applicatiOn and in an% accompanying appro%cd plans and specifications.as%%ell as in accordance%%ith the Nc%% York State Uniform fire
Pre%ention 1e Building Code.the(.'rkle ofthe Village of Rye llr%x)k and all other applicable la%%s.ordinances and n gulations.
Sit=to Nforc me this 16 Sworn to be(o e to this at
day of .20 1 �day of Q 20
Signature of PropertyOwner Sign of Applicant
�(140 0 oN�1 2� � 134 5r� Cos evu
Print Name of Property Owner r' 'ante of Applicant
Notary Pub Notan Pu,*ARI MELILLO
ttbhw el lama Notary Public,State of New York
Nosy PltbNc.State of N.Y. No. 01 ME6160063
No.01 LA6=42 n,talified in Westchester County
Qoattfed In westlres Feb.2S ly
20 L Commission Exoires January 29,20 _c i
ComrnfGdnn Exnhr3s Feb.25.
'c-O—A6
Westbhester Rockland Electrical Inspection Services, Inc. Pnome 914-347-3595
$60 NOT WRITE HERE-FOR OFFICE USE ONLY 43 North Lawn Avenue Fax: 91 7-3596
Elmsford, NY 10523 BUILDING PERMIT NO.
TEMP# DAT
CITY OR VILLAGE -• ZIP CODE TOWNSHIP -
I C 4 ���uk 3Xj4CS
STREET AND NO.OR ROAD `
"TA
T LC OTV- JZ�_ POLE NUMBER
BETWEEN WHAT TWO CROSS STREETS IS PREMISES LOCATED? SECTION BLOCK LOT
OCCUPANT'S NAME XffAW�� BUNG OCCUPANCY
�.�/
I V
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 INCfA-DDE H.
- FLUORE NO. P EACH NO. WATTS EACH INSPECTION
OUTSIDE 4
BASEMENT
JU I t u n
I
1"FL.
2"FL.
3' FL. I VILLAGE OF RYE RRO(W
B JILDINq DEPARTMENT
REMARKS:LIST OTHER ELECTRICAL DEVICES NOT SET FORTH ABOVE:
c '
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 APPUCATIONS 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
-zoo FEEDERS
CHARACTER OF WORK NEW CI ADDITIONAL❑ EXPOSED❑ CONCEALED O MUST ENTER APPLICANTS
IDENTIFICATION 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.
NAME OF COM Y DATE OF APPLIC TION r's
IGNATURE OF AP P JCANT
V- GX-CC-T to 210i-4
STREET ADDRESS TELEPHONE NO. f
- - 1
CITY OR POST OFFICE �1 ZIP COPF
W LICENSE NO.WHEN APPLICABLE