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Westchester Rockland Electrical Inspection Services, Inci
_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.
TEMP# DAE
7
CITY OR VILLAGE ZIP CODE TOWNSHIP
STREET AND NO.OR ROAD
7 /-// ( ``,N<J�'C� Q \ POLE NUMBER
BETWEEN WHAT TWO CROSS STREETS IS PREMISES LOCATED? SECTIQN, ^ BLOCK ` I J LOT
OCCUPANT'S NAME L BUILDING OCCUPANCY
'=2' �3l'ICL �ti / / -1j_'7 ( �_ L
OWNER'S NAME AND ADD�� HOME TELEPHONE VIMBEFI `,�
J � Y�
CURRENT SUPPL4ED BY FROM THEIR OFFICE WORK TELEPHONE NUMBER
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.
2'^FL.
3'FL.
REMARKS:LIST OTHER ELECTRICAL DEVICES NOT SET FORTH ABOVE: // / p C �" /�S % ,}/�. e`
F I. •.e S 6 CAI M-C �14 4f 4
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
/O O /4- Z-
CHARACTER OF WORK NEW❑ ADDITIONAL❑ EXPOSE CONCEALED❑ MUST ENTER APPLICANTS
IDENTIFICATION NUMBER
SERVICE ENTERS BUILDING OVERHEAD UNDERGROUND fl /
AVOID DELAYS BY GIVING FULL AND ACCURATE INFORMATION.ALL SPACE MUST BE FILLED IN OR APPLICATION MAY BE RETURNED.
NAME 91F COMPANY DATE OF PP ICAT10 ; SIGNATUR4 OF
APPLICANT
r Y LC,,-
STREET ADDRESS TELEPHONE NO.
CRY OR POST OFFICE �./ '� ZIP CODE ti".� LICENSE NO.WHEN APPLICABLE 5 `�
• ,�E 13RC��� _
BUILD:IN1G-91ffPAItTMENT D �/
VILLAGE OF RYE 131k4OK
938 KING ET RYE BR Qom;NY 10573 FB � 1 2
(914)939', _ X(9 `939-5801
v�vctv�t.t? zoak or>; VILLAGE OF RYE csF;, OK
- -- BUILDING DEPARTMFtt T
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: � Approval Signature:
Inspection Agency: W'w Electrical Permit#: �-� O -2--
Fees: paid Kdue ( ) Building Permit#:
Application is hereby made to the Building Inspector of the Village of Rye Brook NY, for the issuance of a Permit for tli
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: a 7 A/CclpwOdcAf 43 Phone#:
Owner: /,j��cj , Address&Phone: SH"e—
Use/Occupancy: Parcel I.D.#: Zone:
Proposed Electrical Work: NS' cc�-
eSSvt /A-1- 0-r-O _je.3L'T(�--eS K
LICENSED ELECTRICIAN'S INFORMATION:
Name(Please ;:I Phone d(0 to I
Signature: Westchester County License#: 5
Company Name: v-D C4 O cc, 7n1 C-
Company Address: 13 3 eL'i r�--'e'oj J L City/Town:
State: Zip Code: kO S 7 3 Phone#:
Field Contact&Phone:
Revised 9/6/11