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HomeMy WebLinkAboutEP17-032 _ i L /�,t i •\ i O a 16 � o N � M r. ti oTOWZI Q ,,, o z d; r�l A rn © p � oT i as W x F ..0.4 w Qo A a i a BUILDING DEPARTMENT VILLAGF.OF RYE BROOK 938 ICING STREET RYE BROOK,NY 10573 0 (914)939-0668 FAX(914)939-5801 Q 0� 2017 ELECTRICAL PERMIT APPLICATION NG©�A' Ook Westchester County Master Electricians License Required 'ANT L- 1 Cl t►ppro►al Date: FEB_ I] Application Fee: $ Approval Signature: Permit Fee: S Disapproved: Other: (Teen are non-refundable) Application dated, is hereby made to the Building inspector of the Village of Rye Brook NY, for the issuance of a Permit to install and/or remove electrical equipment,wiring, fixtures,or to rwrform other high or low voltage electrical work as per the detailed statement described below. The applicant & property owner, by signing this document agree that all electrical work performed will be in conformance with all applicable Federal, State,County and Local Odes. 1.Address:_ O f A L t'"v +�D _ SB1.: Zone: 2.Property Owner: D P yr/,e y N jE l,4 Al Address: � 'slr�C E 77 / Phase#: /�/` — 7' Cell#: IAI- `]C6 3�1.)-S --_email: /I/7/S".Master Electrician: r.ai v—i Fc v-4 Address: S Qt a7>/ r no O t5�v r- } 1., °� ! 0 - ail: T)?o1 4 , / S Ca►`r # #: Cell#; -�1!G em ��a�,,, Ltc. Phone / � - fly- ,b,�g � � Company Name: A6.4F,�i De&T;a.✓ S-nc �2;'7 Address; © o,c O ►�r �* ty r e-Q1 /�7/ 4.Proposed Electrical Work/Fixture Count: ...Q ,, LA r►t .� /P.yti 4e,f .a r3o4' v ;9 D i vQ tt tittttttttttt#tools titttttt ttttttt tt titttttttttttttie.F tlrefl�,►aF#iaF�tN fFw1aMltk vtr eie+rRierA,t fr F it*iN,t*!*Y vk�r it fk&aYk st Yrik STATE OF NEW YORK,COUNTY OF WESTCHESTER ) as: .being duly swots,depc}ses and states that he/she is the applic;artt above nanx:d.and does lunher state that(s)he is the legal owner of the property to which this application pertains.or that(s)he is the for the legal owner and is duly authorized to make and file this applic,atioe. The undersigned further states that all statements contained herein are true to the best of his/her know ledge and belief.and that am work performed,or use cmducted at the above captioned propert% will he in cont'onnanee 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 Sworn to before me this day of'�'�%Acl `�S ,20 day of A0 1� Signature of Property Owner Sign of Appli tt Print Name of Property Owner Name of Applic:tut�� ' Notary Public - Notary Publ*BARI MEULLO Notary .lublic,State of New York No.01 MES160063 Cualltled in Westchester County 0 Commission Exoires January 29.20�_` 1 MF7 ' 17 ti .� Westchester Rockland Electrical Inspection Services, Inc. y Phone: 914-347-3595 DO NOT WRITE HERE-FOR OFFICE USE ONLY 43 North Lawn Avenue � � :, Fax: 914-347-3596 Elmsford, NY 10523 r [ Y M MI•N07 TEMP A OA.'E 7 U-'� CITY OR VILLAGE yr' y ` ZIP CODE TOWN '"- & 6F l"p� Lis a COUNTY STREET AND NO.OR OAD S'c -r4 L e-0 777- POLE NUMBER BETWEEN WHAT TWO CROSS STREETS IS PREMISES LOCATED? SECTION BLOCK LOT OCCUPANT'S NAMED BUILDING OCCUPANCY OWNER'S NAME AND ADDRESS // HOME TELEPHONE NUMBER r1ri- e-pT� 77 CURRENT SUPPLED BY FROM THEIR OFFICE WORK TELEPHONE NUMBER LIST BELOW ALL EQUIPMENT WHICH YOU INSTALLEO NUMBER OF OUTLETS NO._OF FIXTURES& MOTORS HEATERS OFFICE USE LOCATION LAMP RECEPTACLES ONLY SIDEWALL SWITCH INCADE FLUOR€ NO. H_P EACH NO. WATTS EACH INSPECTION OUTSIDE BASEMENT I'FL 2' FL a`°-FL REMARKS:LIST OTHER ELECTRICAL DEVICES NOT SET FORTH ABOVE: Svrt�je, 2 fjo itJ 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 WREI%INC.IS NOT LISTING.LABELING.UNDERWRITING OR CERTIFYING ANY EQUIPMENT. MATERIALS DR 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❑ ADDITIONAL L7 EXPOSED L] CONCEALED❑ MUST ENTER APPLICANTS IDENTIFICATION NUMBER SERVICE ENTERS BUILDING OVERHEAD Q UNDERGROUND AVOID DELAYS BY GIVING FULL AND ACCURATE INFORMATION.ALL SPACE MUST BE FILLED IN OR APPLICATION MAY BE RETURNED. NAME OF COMPANY DATE OF AppUCATpPI SIGNAT RE I. AP IFFY-"-- Q*7 I T�T;nIV' -/a-l X STREET ADDRESS TELEPHONE NO. CITY Pq$'f OFFICE Z1P LICENSE NO.WHEN APPLICABLE i►�L 21 1 I