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BUILIa)(1�G DEPARTMENT ��� ��_�
VILj,AGE OF RYE OK
VILLAGE OFF,YE BROOK938 KINO'kOET RYE B1 QX NY 10573 BUILDIPfCi D1I'Ja,RTMFNT
(914)�-056 ---. _
www.tyeblook.org
ELECTRICAL PERMIT APPLICATION
Westchester County Master Electricians License Required
FOR OFFICE USE ONLY BP#: � EP#:AUG
2lqApproval Date: Permit Fee:$ c c
Approval Signature: V Other:
fy
rtrtrtApplication dated, —�_� is herade to the Building Inspector of the Village of Rye Brook NY, for the issuancert 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. By signing this document, the applicant & property owner agree that all electrical work
performed will be in conformance with all applicable Federal,State,County and Local Codes, L / /}
1.Address: /7 Ss ✓l H P- 1 -e rj'TR E T SBL: �j'36'c�'7 u' Zone:(_
2.Property Owner: f/r7 A." dC&neg Address: ok n,
Phone#: Cell#: —7 3-5_S 3/U email: 1eL 3n;�•�z
3.Master Electrician: . Address;
Lic #: Phone#:Y/!�7T� Cell#: q'/4e -&C- T7 r' email:T 'y�.B���t.g,C, r>,..,C�,.I
z z-y
Company ame: ,e y� eC' .ry.� L C'vi..,i Address: �/ St= w�.iF1c C
4.Proposed Electrical Work/Fixture Count: A/`�' O�)i/ / S
5.3"'Party Electrical Inspection Agency: 1
STATE OF NEW YORK,COUNTY OF WESTCHESTER ) as:
,being duly swom,deposes and states that he/she is the applicant above named,and does fiuther
(print name of individual signing n the applicant)
state that(s)he is the legal owner of the property to which this application pertains,or that(s)he is the
for the legal owner and is drily authorized to make and file this application. (indicate architect,contnetor,agent,artlemy,etc.)
The undersigned further states that all statements contained heroin are true to the beat 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 wed as in accordance with the New York State Uniform Fire
Prevention&Building Code,the Codj of the Village of Rye Brook and all other applicable laws,ordinances,and regulations.
Sworn to efo me is Sworn to before me this
day o 20 day of
opery Owner s
gnature of Applicant
Prop O r _ Name of Applica
N
Notary RI
SBA,WILLQ
titre "•. MARIA ROSA MARTINEZ
�:. Notary Public,Stara of New York
Notary Public•State of Florida No.o1ME6160063
tM Commission run HH 68250 �(�
or rti°F My Comm.Expires Jan 19,2025 Qualified In Westchester 29 Zo_ 6123Ro22
Bonded through National Notary Assn. Commission Expires 18nuary
INSPECTIONSTATEWIDE
Service With lutegril-v
0:0
SWIS JOBAPPLICATION • 0.
Office Use Elect. Permit# Date
Bldg Permit# Utility ID#
Final Certificate#
City l Village C I �� Zip 0 —7 `Township Court ��T� .`5 L-
,r �
Ad ss .7 { , Cross Street Section Block Lot
Owner Name/Address iff different than above) Contact Number
❑Basement st FI. ❑ 2nd FI ❑3rd FL ❑More Than 3 FI_ [:]Garage 0 Attic E]-6vtside ❑Residential ❑Commercial
Receptacles Special Recept GFCI Al Switches Dimmers Smoke Alarms Carbon Monox Hood Trash Compact
Amt Amps
Range(s) Cooktop(s) Oven(s) Dishwashers Refrigerator Disposal Microwave Warm Draw
Incandescent Fluorescent
SERVICE
Amperage Voltage 1 P 3P #Meters #Disconnect ❑Underground ❑New ❑Reconnect
IE]Overhead ❑Change
❑Visual Re-Inspection ❑ Safety Re-Inspection ❑ Re-Inspection
Additional Information }� ,gyp
//�S-7&AALA �s?�
Z C fr/t7 �A5 ✓'T�)DE �y ✓� ��cc/Z�� '
1tL; I
AUG 2022 L
VILLAGE CAN l BROOK
BUILDING DEPARTMENT
Thn application is valid for one(1)year from the date received by SWiS.This application is intended to cover the above listed Gems to be inspected,H at arty timed Inspection additional items have been installed.you are
authorized to make the inspection and adjust the fee for the additional items inspected.The applicant declares that there is no open applications for the above address vMh any other inspection company.The applicant,owner
or authorized agent agrees to all the above terms and conditions as set forth for the application.
Inspector Date Finalized Inspector#
Company Name �/� l � �� L Date z Si
Address f � City t ,�� 1.01, Zip C
License If 1 ,� f Phone#
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