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Westchester_Rockland Electrical Inspection Services, Inc. Phone: 914-347-3595
DO NOT WRITE HERE-FOR OFFICE USE ONLY 43 North Lawn Avernus y Fax:914-347-3596
Elmsford, NY 10523 - - .. ... a. _ BUILDING PERMIT NO.
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CITY OR VILLAGE �O(zn ZIP CCODE� TOWNSHIP' - COUNTY f _
10S
STREET AND N AD {9 POLE NUMBER
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BETWEEN WHAT TWO CROSS STREETS IS PREMISES LOCATED?W ^v SECTION -.BLOCK LOT -
OC UP NT'S NAME 'T V 11N1 BUILDING OCCUPANCY - N
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OWNER'S NAME AND ADDRESS - - - _ HO TELEPHONE NUMBER -
-SA ME M e 2 1
CURRENT SUPPLIED BY FROM THEIR OFFICE WORKIFELEPHONE NUMBER - -
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LIST BELOW ALL EQUIPMENT WHICH YOU INSTALLED
NUMBER OF OUTLETS NO.OF FIXTURES& MOTORS. HEATERS ..OFFICE USE-t
LOCATION LAMP RECEPTACLES ONLY°
SIDEWALL SWITCH INCADE FLUORE NO. H.P.EACH - NO. -. WATTS EACH
OUTSIDE ma4�;' 1; `•�. 4so. _ �n� ..:te:
. BASEMENT
If FL.
.. 2"FL.
Sao FL
REMARKS:LIST OTHER ELECTRICAL DEVICES NOT SET FORTHgBOVE
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,
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. 'i
SIZE OF SERVICE : -FEEDERS - -
2o0 /- 1
CHARACTER OF WORK NEW) "ADDITIONAL[3 EXPOSED❑ CONCEALED❑ 7NUST ENTER APPLICANTS.
4DENTIFlCATION,NUMBER
SERVICE ENTERS BUILDING OVERHEADW UNDERGROUND❑ O
- '-." AVOID DELAYS BY GIVINGFULL ANDACCURATE INFORMATION.ALL,SFACE MUST BE FILLED II ;ORi1PpLICATION;MAY BE RETURNED '
-NAME OF COMPANY DATE OF APPLICATI -
SIGNATO
.STREET ADDRESS TELEPHONE NO.
CIr1(OR POST OFFICE ZIP CODE LICENSE NO.WHEN APPLICABLE
M�1 1�120
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