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HomeMy WebLinkAboutEP21-303 s s ' _ � e = O n N � N 00 a s e O U en � 064 = a _ A Poo Q Uo U = O [.� E� ��.1, z 1 a W o a sW t�t�� w V W (� 0 Z tl1 aji V e _ e, M U O F Ul u 9 A p � © a W < a � yE BRC�u� IE BUIL E. MENT IrFklnxl E � 1./f E V of RYE OK ED 938 KIN ETRY B ,NY 10573 i 1 7 2021 (914}9 ' 939-5801 VILLAGE OF RYE BROOK or I BUILDING DEPARTMENT ELECTRICAL PERMIT APPLICATION -- Westchester County Master Electricians License Required FOR OFFICE USE ONLY BP#: EP#: Approval Date: NOV I 9 .2W Permit Fee: S Approval Signature: Other• Gt_ 0�( Disapproved: . (fees are non-refundable) Application dated, i i I t I 1 4y 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, wiring, fixtures,or to perform other high or low voltage electrical work as per the detailed statement described below. The applicant & property owner, by signing this document agree that all electrical work performed q4will be in conformance with all applicable Federal, State,County and Local Codes. 1.Addrel 3- - C -7� - 3 C1► ✓ SBL: .3 5. 7s — Zone: y 2.Property Owner: t Address: Phone#: Cell#: email: h 3.Master Electrician: .Jr��.r ��1`,1c� Address: I S S)oLth 6j Yi SA Qs; L 10f11 I Lic.#: E I� Phone#: - Cell#:c� )�4 j j(nO. L40ZL) email: k Company Name: I-a-6eJA 0— F_`�r-1rL e Address: N 1057-3 4.Proposed Electrical Work/Fixture Count: i STATE OF NEW 1YORK, COUNTY OF WESTCHESTER ) as: ry`I ' e c<_ ,being duly sworn,deposes and states that he/she is the applicant above named,and does further (print name o individual signing as the applicant)state that(s)he is the legal owner of the property to which this application pertains,or that(s)he is the C1 .f 1ryk 6?L' Cr for the legal owner and is duly authorized to make and file this application. (indicate architect,contractor,agent,attorney,etc,) The undersigned further states 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 4pproved 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 efore me this��-111 Sworn to before me this j l'.h day of 20 � day of f el 20-a 1 Signature of Property Owner r e o Applicant Print ame o, rope Owner Prin ame Appl' t of Public o Publ LiSA DiC1t'CC40 �qf�A 0I0I0MIA AlotarY Public. - to x Yor!1 1VO�Publ • $MIS !#NOW YQ11t Ne 48— N6 4@16��0 Cert'fTjc,_.to File it r Eil® iN W4 IvFF3teV r Gomm; _ 7/, /p�L�vt Qomrl�latiwon ExAlres+ �I�; � 7n/17 Westchester Rockland Electrical Inspection Services, Inc. Phone: 91 34 J8595 DO NOT WRITE HERE-FOR OFFICE USE ONLY 43 North Lawn Avenue fa : 14-347-3596 Elmsford NY 10523 � BUILDING PERMIT NO. TEMP ll DATE r/I CITY OR VILLAGE ZIP CODE TOWNSHIP COUNTY rao� 05 3 - ' S EET AND NO.OR RO POLE NUMBER 77� BETWEEN WHAT TWO cAoss STREETS IS PR IS t LOCATED? SECTION BLOCK LOT OCCUPANT'S NAME ING OCCU ANCY 1 OW R'S NAME. O ESS HOME TELEPHONE NUMBER 0 n IVL. CURRENI SUPPLIED BY j 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 FLUORE NO. H.P.EACH NO. WATTS EACH INSPECTION OUTSIDE BASEMENT 1"FL. 11111 2-FL P- 3' ILLAGE E -_N DEPA il TMEN REMARKS:LIST OTHER ELECTRICAL DEVICES NOT SET FORTH ABOVE; ~ cz, V W-2 THIS APPLICATION IS INTENDED TO COVER THE ABOVE LISTED ITEMS TO BE INSPECTED.IF AT ANY TIME OF INSPECTION AD MONAL 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 L] EXPOSED❑ CONCEALED Ci MUST ENTER APPLICANTS IDENTIFICATION NUMBER SERVICE ENTERS BUILDING OVERHEAD LI UNDERGROUND L] () 0 1 _ ^ AVOID DELAYS BY GIVING FULLAND ACCURATE INFORMATION.ALL SPACE MUST BE FILLED IN OR APPLICATION MAY BE RETURNED. NAME O�gMPANY DATE OF APPLI ATIO SIGN RE OF APPLICANT De�lr� r '. I I ►1 2 STREET ADORE S$ TELEPHONE NO. 1 ILI 5 �, e :E51- D5b OTP03 'OF ICE 1- Z1,C®F� L6CENSE NO.WHEN APPLICABLE I AFFIDAVIT IN SUPPORT OF FEE WAIVER RELATED TO HURRICANE IDA STATE OF 1 K COUNTY OF L9 C A e- �es QJ- J-Q-ff Lcc -Wc— (insert name), being duly sworn, deposes and says 1. I am the applicant fora Building Permit/Certificate of Occupancy /Demolition Permit Electrical Permit/Plumbing Permit/Fence & Wall Permit Mechanical Permit/Pod Permit(circle all that apply) 2. 1 am the legal owner of property located ate �' Rye Brook,New York (insert street address) OR I am the (Architec Contracto Engineer/Attorney) (circle one) for the legal owner of property located at4 LA-3 (o 1 E 1S -4A'U �O°n CArc-� Rye Brook, New York and I am duly authorized by property owner ( �uy le to make and file the accompanying application. 3. The following is a description of(1) the work to be performed under the permit for which I am applying; and (2) how the work arose as a direct result of Hurricane Ida: 0 U �'1-t tie_ PaAeAh �0 C1 lJ.: ' ��C- es --b c - 4. The work described herein arose as a direct result of Hurricane Ida and does not include Work which was not caused by Hurricane Ida. Sworn to before me this 17 'h Day of Dgewjje , 20a� Notary Public LISA 000CC10Do Notary Public • 3'ate of New York No te10c30 L 17 2021 c6R1$Crte File in 'N, t ^.c s sr:curd Commiaaiun Expires: ��3.� �a' VILLAGE of RYE BROOK BUILDING DEPARTMENT