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Westchester Rockland Electrical Inspection Services, In Phone: 914-347-3595
DO NOT WRITE HERE-FOR OFFICE USE ONLY 43 North Lawn Avenue Fax: 914-347-3596
Elmsford, NY 10523 BUILDING PERMIT NO.
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TEMP# DATE
CITY OR VILLAG ZIP CODE._ TOWNSHIP COU TY
l< � c7 A-)5 % GUeS KAeSTe�,�_
STREET AND NO.OR ROAD POLE NUMBER
2 14l u r w '+c t /?0,4 -� ,
BETWEEN WHAT TWO CROSS STREETS IS PREMISES LOCATED? SECIQ�N�J• BLOCK O
t
OCCUPANT'S NAME_ BUILDING OCCUPANCY
OWNER'S NAME AND ADDRESS HOME TELEPHONE NUM�E
;/ �z-2
CURRENT SUPP4IED BY r FROM THEIR OFFICE WORK TELEPHONE NUMBER
(�G v /G
LIST BELOW ALL EQUIPMENT WHICH YOU INSTALLED
NUMBER OF OUTLETS NO.OF FIXTURES& MOTORS HEATERS OFFICE USE
LOCATION LAMP RECEPTACLES ONLY
SIDEWALL SWITCH INCADE FLUORE NO. H.P.EACH NO. WATTS EACH INSPECTION
OUTSIDE
BASEMENT
1 FL.
2H'FL.
3-FL.
REMARKS:LIST OTHER ELECTRICAL DEVICES NOT SET FORTH ABOVE: Y(C.i / t
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.
SIZE OF SERVICE FEEDERS
CHARACTER OF WORK NEW f 1 ADDITIONAL❑ EXPOSE CONCEALED Cl MUST ENTER APPLICANTS
IDENTIFICATION NUMBER
SERVICE ENTERS BUILDING OVERHEAD_f UNDERGROUND[]
AVOID DELAYS BY GIVING FULL AND ACCURATE INFORMATION.ALL SPACE MUST BE FILLED IN OR APPLICATION MAY BE RETURNED.
SIGNATURE OF NAME OF COMPANY / DATE OF APPLICATION APPLICANT
STREET ADDRESS TELEPHONE NO.
CRY OR ST OFFICE / /�` A I / ZIP 0DS�Z LICENSE NO.WHEN APPLICABLE
BUILDING DEPARTMENT
VILLAGE OF RYE BROOK — 2M
938 KING T12TET RYE BRooK,NY 10573 FM
(914)939 066810' took.o' rg
X(914)`939-5801 VILLAGE OF RYE BROOK
wWW.rBUILDING DEPARTMENT
ELECTRICAL PERMIT APPLICATION
This application must be filed in person at the Building Department by the Licensed Electrician of
Record and must be accompanied by the completed Electrical Inspection Agency application form.
Office Use Only:Date: C�l/
/II3 Approval Signature:
Inspection Agency: w Electrical Permit#: C'
Fees: if 8L paid ((due ( ) Building Permit#:
Application is hereby made to the Building Inspector of the Village of Rye Brook NY, for the issuance of a Permit for the
installation/removal/repair of Electrical Equipment as per detailed statement described below,and in accordance with the
Code of the Village of Rye Brook,NYSUFP&BC,NEC,NFPA and all other applicable State, County and Local Laws.
Address: - /f(CC,n!0PW'- &IR:J Phone#: 9l Y
Owner: Address& Phone:
Use/Occupancy: Parcel I.D.#: f '7 GYM Ilk Zone: �75
Proposed Electrical Work: deeel'�/1L_ Sc'_n__y'(Cam_ D.11 D4--,4 s
LICENSED ELECTRICIAN'S INFORMATION:
Name(P ase V C-c- Phone# T75(k— d(0 1
Signatur Westchester County License#: 5 `�
Company Name: o'j o, 71n1 L
Company Address: l3 City/Town: R,v�- ��e4-c_
State: �3 Zip Code: �O`; 7 3 Phone#:
Field Contact&Phone: 5�•�
Revised 9/6/1 1
Westchester County Electrical Licensing Board
Westchester County Clerk's Office
"Vaster Eiec?rician License 2013
Thomas J Carlucci
D.O.B: 09/10/1954
f� Company:
Maywood Electrical Co Inc
13 Bent Avenue
Port Chester,NY 10573
License No. 565 - -
Expires on:12/31/2013 Peter Borducci