APPLICATION FOR ELECTRICAL PERMIT
VILLAGE OF CEDARHURST
Issued Pursuant to the Provisions of the Village of Cedarhurst Ordinance &
Electrical Code, and the Building & Fire Code of the State of New York
Permit #:________________
Date Rec’d: _______________
Zone ______ Type Dwelling _________ Section _____ Block _____ Lot __________ Flood Zone: ________
Location: ________________________________________________________________________________
Owner Name: ___________________________________________ Tele: _________________________
Residential : ____________ Business: ______________ Garage: ____________ Other: _________________
General description of proposed work: _________________________________________________________
________________________________________________________________________________________
Estimated Cost of work: ____________________________________________________________________
FIXTURE OUTLETS RECEPTACLES SWITCHES FIXTURES RANGERS COOKING DECKS OVENS
INCANDESCENT FLUORESCENT MERCURY VAPOR AMT KW AMT KW AMT KW
DISH WASHERS EXHAUST FANS DRYERS FURNACE MOTORS FUTURE APPLICATION FEEDERS SPECIAL REC’PT TIME CLOCKS BELL TRANS.
AMT K W A M T H P AMT KW OIL HP GAS AMT NO AWG AMT AMP AMT AMPS
UNIT HEATERS MULTI OUTLET SYSTEMS NO. OF FEET DIMMERS SERVICE DISCONNECT NO. OF METER EQUIP.
AMT HP AMT WATTS AMT AMP TYPE
SERVICE
1/2W 1/3W 3/3W 3/4W # of CC COND. PER / A W G of C C Cond. # of Hi-Leg A W G of Hi-Leg # of Neut. A W G of Neutral
Other Apparatus:
Electricians Name: ___________________________________________ Tele. #: ________________
Address: _____________________________________________________________________________
ToH/ToNH/ToOB – License # ____________________ Exp. Date: _______________________________
Village of Cedarhurst License #: ____________________________ Exp. Date: _____________________
Workmen’s Compensation Certicate # _______________________________ Exp. Date: ____________
Electrical permit is issued to the provisions of Section 57 of the Workmen’s Compensation Law. No Work to be
started until Electrical Permit has been approved.
Owner Signature: __________________________ Electrician’s Signature: ________________________
BUILDING DEPARTMENT NOTES:
Fee:___________
Receipt#:_______ Ck. #:_____
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