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-�-j�( I)R 0�-i�,, [ECIENED
BUILDING DEPARTMENT MAY 2 2 2023
VILLAGE OF RYE BROOK
938 KING STREET RYE BROOK,NY 10573 VILLAGE OF RYE BROOK
(914)939-0668 BUILDING DEPARTMENT
www_ryebrook.org
ELECTRICAL PERMIT APPLICATION
Westchester County Master Electricians License Required
FOR OFFICE USE ONLY BP#: EP
Approval Date: MAY C7Permit Fee: $ /
Approval Signature: Other:
********************* ************** *************************************************************
Application dated, S 2 Z- 23 is hereby made to the Building Inspector of the Village of Rye Brook NY, for the issuance of
a Permit to install an or reinove 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.
2
L Address: 2 7 J S. n,D4#4 S•f- SBL:,�-�''•35-o -5 1 Zone: Q S
2.Property Owner:w Q j N 1 M H Q/ q Z q Address: 2 7 r 5*. /t"CQ(j a- S -
Phone#: V-Ok& Cell#: ��Y-y�� ��b6 email:
3.Master Electrician/Licensed Installer: FV'a"k- C4S +C 1(a N o Address: SO p✓ba�W /r/�•�1 jti
Lic.#:6,f Phone#: fign 7?-7?YQ Cell#: 91q-4 t0 67ff-t email: FVAO koe�- Sao •C-cp
Company Name: C4 S fG�l H o ���t �`1 G Address: S 8 a y0 46C�.tJ a Y, l7�*ow t 0,1 �.� /Ort
4.Proposed Electrical Work/Fixture Count:
' r"�p(Q < <h G O I� mot' �O�✓c,{Ct...-1- �.X �'�.i�S
'�►C v/ �O o S t t�., r rye. S t• G l+,c•c.� e`v>h e✓f�.� t�l ��Q �l'�S
5.31 Party Electrical Inspection Agency:
STATE �ffje;//*
WORK,COUNTY OF WESTCHESTER ) as:
�✓�ti k h0,being duly swom,deposes and states that he/she is the applicant above named,and does further
(print name of individual sue' p�S as a applicant)
state that(s)he is the L'./l+G I C. # a W% for the legal owner and is duly authorized to make and file this application.
(Master Electrician/Licensed Installer)
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 a:'-) Sworn to before me this
day of\--"-US; 3 day of
Si a e of Property er I Signature of Applicant
Pri a of Property Ow r t Name of Ap 'c
�
Notary POU&I MEULLO Notary Public
Notary Public,State of New York SHARI MELILLO
No.01ME6160063 Notary Public,State of New York
Qualified In Westchester Count- No.OIME6160063
Commission Expires January 29,2 Qualified In Westchester County 3/3/2023
Comm4won born January 29,29.1
STATEWIDE •
Service Willi litlegrilY
0:0
SWIS • : APPLICATION0.
Office Use Ugff Permit#
rmit# � Utility ID#
Final Certificate#
City/Village C Zip /�S 3 Township C Eme k County Wes 4-vAe54a,-,
Address -7 Ste' �� Cross Street Section Block
t t
Owner Name/Address(If different than above) L ; ., Q�,4 24 t Cyr,ect Number q,U_ V 6/_
�r I� C i ( (o
1lasement 1st FI. 2nd Fl. 3rd FI. More Than 3 FI. Garage Attic Outside 11 Residential &Commercial
Receptacles Special Recept GFCI AFCI Switches Dimmers Smoke Alarms Carbon Monox Hood Trash Compact
Amt Amps
Range(s) Cooktop(s) Oven(s) Dishwashers Refrigerator Disposal Microwave Warm Draw
Incandescent Rvewcfierrt
d
SERVICE
Amperage Voltage 1 P I 3P #Meters rnnect Underground New Reconnect
❑Overhead ❑Change
Visual Re-Inspection Safety Re-Inspection Re-Inspection
Additional Information
nn .�(off rcS c c �.-�- ..i
O4(l au *- r-r- r i �+il o l �C _
.(� '
v(f o a S< w �r�S r t w,a..y,.w►c y 1 9
D �C [E DD
MAY 2 2 2023
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 any other Inspection company.The applicant,owner
Of authorized agent agrees to all the above terms and conditions as set forth for the application.
Inspector Date Finalized Inspector#
Company Name ke//(2 0 CC. Date S 2 Zl7 Signatures/ ,
Address c—� ��Q� w� City/State •fOh �! Zip Code
License# `7 Z Phone# Q 1 y