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yE DROt R
BUIL E MENT
VIT. E OF RYE OK AUG 15 2022
938 KIN ET RYE B ,NY 10573 VILLAGE OF RYE BROOK
BUILDING DEPARTMENT
or _ __.._ .--
ELECTRICAL PERMIT APPLICATION
Westchester County Master Electricians License Required {
FOR OFFICE USE ONLY /- ,A"G
9': FP #: QQ`f7
Approval Date: Permit Fee: $ 'DIN
Approval Signature: Other:
Application dated, S c� 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. 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. 4
1.Address: SBL: 115.-39 — 1 — 2.3 Zone:
2.Property Owner: 7 Q 0 Address:
Phone#:q(!( -7 f 6-`3 0-M Cell#: email:
3.Master Electrician:_ Address:
Lic.#: Phone#: 19 IcA_ Cell#: ly'-qZ -BIUO email: I(I ,e-V k �Ca c -c>t.CC:yh
Company Name: Address: IDS�y
4.Proposed Electrical Work/Fixture Count: t GO o o /.A,-0
5.31 Party Electrical Inspection Agency: ���e-Lk) 4 ti
STATE OF NEW YOM COUNTY OF WESTCHESTER ) as:
_&hl ,being duly sworn,deposes and states that he/she is the applicant above named,and does further
(print name of individ l signing as the applicant) _
state that(s)hc is the legal owner of the property to which this application pertains,or that(s)he is the Cc �i-r�r x-: c
for the legal owner and is duly authorized to make and file this application. (indicate archoc,, ontractor,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 I I I" Sworn to b ore me this $ I vl
day of ,20 � day
Si a e oof7Property Owner Signature of Applicant
N 01AA
Print Name of Property wner Print Name of App i nt
Notary Public Totary Pub
DAf�UNCy ALDANA
Notary Public-State of New York
No.01AL6425946
Qualified in Westchester County
y Commission Expires 11/29/202 6/23/2022
STATEWIDE INSPECTION
Service With Integrity
SWIS0:0 Main Street,Fishkill, NY 12524 1 emoill:. •
JOBAPPLICATION0.
Office Use Elect.Permit# 7 Date
Bldg Permit# Utility ID# //ems►«�
Final Certificate#
City/Village Zip Los---7-3 Township County
Address Y Cross Street S tion L Block ` Lot
Owner Name/Address(if different than above) ` �-1, v Contact Number
❑Basement ❑ 1st FI. ❑2nd Fi. ❑3rd FI_ ❑More Than 3 FI. [:]Garage ❑Attic ❑Outside ❑Residential [:]Commercial
Receptacles Special Recept GFCI AFCI Switches Dimmers Smoke Alarms Carbon Monox Wood Trash Compact
Amt Amps
Range(s) Cooktop(s) Oven(s) Dishwashers Refrigerator Disposal Microwave Warm Draw
Incandescent Fluorescent
SERVICE
Amperage Voltage 1P 3P #Meters #Disconnect Underground ❑New ❑Reconnect
CA /;La/;ya L _:L ❑Overhead ®Change
❑Visual Re-Inspection ❑ Safety Re-Inspection Re-inspection
Additional Information
Gv 72�'
AUG 15 2022 3
VILLAGE OF RYE BROOK
BUILDING DEPARTMENT
This application is valid for one(1)year from the date received by SWIS.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.The applicant declares that there is no open applications for the above address with arty other inspection company,The appiicam,owner
or authorized agent agrees to all the above terms and conditions as set forth for the application.
Inspector Date Finalized Inspector#
'12 Company Name Date Z Signature
Address Ir�C. City/State Zip Code l �
Phone# q — 1