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BUILDING DEPARTMENT
VILLAGE OF RYE BROOK APR 2 9 2022
938 KING STREET RYE BROOK,NY 10573
(914) 939=-3668
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ELECTRICAL PERMIT APPLICATION
Westchester County Master Electricians License Required
FOR OFFICE USE ONLY BP#: EP#: C_;o -�
- 4 2022 '—
Approval Date: MAY Permit Fee: $ J ��
Approval Signature: 1,/L Other-
Disapproved:
(fees are non-refundable)
Application dated, 14—a9—=-)--�-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 will be in conformance with all applicable Federal,State,County and Local Codes.
I.Address: 100.E K:Jtj St SBL: 10.y3 l d- Zone: 1Z 2-0
2.Property Owner: S C h ue 1f of Address: I 0bd2 k:
Phone#: 911j -30-- �O696 S Cell#: email: e), kk► KA 16C) +1 e5 rL &u Z t(041
3.Master Electrician:CgP1X4t roff-0 w, Address: I 'gr01.JNca U ?I0&e I76,174 CA{n(f r-
Lic.#: E_ yq Phone#: q1 j-&1jf-Zy67Ce11#: 9j -qS8 -11IS email:( -Afacfi(tc)Ylnrep-e fectr;C.cow,
Company Name: oqo E(ectc.e corp Address: 7Q1 Aipr44 13c r y r4tw �MotmaooyieelC
4.Proposed Electrical Work/Fixture Count: rLe-n((;fit ma . h e fee tc:e j;)cu n e lM e`►j'I r PAri ,
II i
ay..,A t'ra"AS-per 5w ,tf 1t
STATE OF NEW YORK,COUNTY OF WESTCHESTER ) as:
Nt K k1 SC R u6I1 W ,being duly sworn,deposes and states that he/she is the applicant above named,and does further
(print name of 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 N h*
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 approved 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 before me this Aji Sworn to before me this o7 U
day of Aprl--L, 20 day of o
LAN
S LANDSMAN ignature of Applicant
Si ature of PropertyOwner Notary Public of New York
l r/ 1 �+C11��((p/�. REGISTRATION#01LA6428985 �(J
�1 i"� J YL I t•Wy COMMISSION EXPIRES 02/0?2026
Print Name of Property Owner rint Name of pplicant
.T a g,r-tw) - — VA&P
N ary Public Notary Public
AUDREY T.COTRONA
Notary Public,State of New York
No.01 C04909694
Qualified in Westchester County �/ Z"L
Commission Expires At$rit,t qv Loll
si t vznz t
Westchester Rockland Electrical Inspection Services Inc. a� "14-34p , MILDING
Phone: 95
DO,VOT WRITE HERE-FOR OFFICE USE ONLY P Q. Box 208 '2596
Carmel, NY 10512
' RM 'NO.TEMP# DAT
CITY OR VILLA ✓�GE ZIP CODE TOWNSHIP COUNTY
STREET AND ST NO.OR ROAD
POLE NUMBER
BETWEEN WHAT TWO CROSS IS PREMISESION
LOCATEDT SECT BLOCK LOT
c,
OCCUPAW'fNAME BUILDING OCCUPANCY
r
OWNER'S NAME ANDAdDhft
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 FI_UORE NO. H.P.EACH NO. WATTS EACH INSPECTION
OUTSIDE
BASEMENT ".._`
t `
1� FL l
2-FL
1 CS.
REMARKS:LIST OTHER ELECTRICAL DEVICES NOT SET FORTH ABOVE:
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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,
MATERWS 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 l FEEDERS
JS
CHARACTER OF WORK NEW❑ ADDITIONAL❑ EXPOSED CONCEALED❑ MUST ENTER APPLICANTS
IDENTIFICATION NUMBER
SERVICE ENTERS BUILDING OVERHEAD UNDERGROUND❑ rr��
1 L/
AVOID DELAYS BY GIVING FULL AND ACCURATE INFORMATION.ALL SPACE MUST BE FILLED IN OR APPLICATION MAY BE RETURNED.
NAME OF COMPANY DATE OF APPLICATION r
ATURE OF APPLICANT
STREET ADDRESS TELEPHONE NO.
101 Df ik 1 n t-rr / - f Fqc, 7
CRY OR POST OFFICE MP CODE LICENSE NO.WHEN APPLICABLE
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