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BUIL DEPAR,MENT JUL 17 2023
VIL ° CE OF RYE 60K
938 KING S'rr ET RYE; BROOK, NY 10573 VILLAGE OF RYE BROOK
`:�" f3668 BUILDING DEPARTMENT
www V lkook.ork
ELECTRICAL PERMIT APPLICATION
Westchester County Master Electricians License Required
FOR OFFICE USE ONLY RP#: ! EP#: c -3— 9.
Approval Date: JUL Permit Fee: $
?IV �\ ,Approval Signature: Other:
Application dated, •2023 is hereby made to the Building Inspector of the Village of Rye Brook NY, for the issuance of
a Permit to install and/or move 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.
I el
1.Address: 21 qo a NQ&o\t SBL: 'JZ ,p��� Zone:
2.Property Owner: MQjfeUA t'] ( l[ V/le ff++Addrees�is 21 � e VLOCkA 'y� 2 G Wk��os1s
Phone#: Cel #: G 11)5 W- O U3 email: M 1141.E e� aM 1 -Luy)
3.Master Electrician/Licensed Installer: CAW p 'y, �Q�, C) Address: w CAM�J!
Lic.#:�Phone l#,:��4��1(� 9-4*p Cell#:0 90232-W email:
Company Name: -5}�Cl r-,C Address:
3\��-Ct( a d_ On t !)� C }oq
4.Proposed Electrical Work/FixturcCount:� 1AQQtQ(�l(Gi4 l 70(om ou(no Gtti-Ic k
U� -No 00 l
Me
S.3"Party Electrical Inspection Agency:904C W1It l�,' (e o o J'e(o ka o oc• 1 M 01410 J�
;5 lhtt Ny• 1Z52
STATE OF
OFANEW YORK,COUNTY OF WESTCHESTER I as:
0-VI VI G `Y VQIV—o ,being duly sworn•deposes and states that he/she is the applicant above named,and does further
(prim name of indi%idual signing as!h_e applicant)
state that Whe is the lI'Y1QS. (' El Yl1Clr1 C for the legal owner and is duly authorized to make and file this application.
(Master Electrician I 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 Uu _ Sworn to beforq me this (Vk
day of 4- 20 -ga day of ~ 20 23
Signature of Property Owner Signature of Applicant
Moltmj ILeAnCkV, Joys CaW E: Wall-0
Print Name of Property O er 1Print Name vtApplica t
Notary Public Notary Public
WIL=DE6444314
IS
NOTARY PUBEW YORK
Registrati444314Qualified ir CountyCommissi /28/2026
INSPECTIONSTATEWIDE
Service With Integrity
0:0 Main Street,Fishkill, NY 12524 1 emoil:office@swisny.com
SWIS JOBAPPLICATION tel 845.202.7224 '1 fax 914.219.1062 1 SWISNY.com I SWISTraining.com
Office Use Elect. Permit# �^� � / �` Date
Bldg Permit# (f 7 Utility ID#(/
Final Certificate#
City/Village e (1p(j� zip Township County WeS, Skr-
Address `� I Cross Street Section Block Lot
l 35's> 1`1
Owner Name/Address(if differentthan above) q; fFA r•MPII 5o/WS Contact Number 9 t _�(�- �3(Q
Basement st Fi. Di-Ad FI. ❑3rd Fl. ❑More Than 3 FL ❑Garage bi Attic ❑Outside 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 Fluorescent
SERVICE
Amperage Voltage 1 P 3P #Meters #Disconnect ❑Underground ❑New ❑Reconnect
-a•pQ a Dt � I I 0-overhead Change
❑Visual Re-Inspection ❑ Safety Re-Inspection ❑ Re-Inspection
Additional Information
n c� C::S /11 L
RF B
JUL 2 7 2023
VILLAGE OF RYE BROOK
BUILDING DEPARTMENT
This application is valid for one ttl year from the date received by 5WI5.This application Is intended to cover the above listed items to be inspected,Nat any time of inspection additional items have been installed,you are
authorized to make the inspection and adjust the fee for the addtional hems inspected.The applicant declares that there is no open applications for the above address with any other Inspection company.The applicant,owner
or authorized agent agrees to all the above terms and conditions asset forth for the application.
Inspector Date Finalized Inspector#
Company Name ,141, ,1t ,, r ','VAC, Date r 13 Signature
Address C Tj S 1 City/State d �V I Zip Code l p�b
License# a-7- Phone# ��b-- �, LI,(If0