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D Send t o El
ec
tr
ic
Department
of
Building
s
Dat
e
__
_ _
__
_ _
Vill
age
of F
re
eport
Pe
rmit
#
----
-
----
Applica tion
for
Pe
rmi
t to
Wi
re
or
Re
wire
Electr
ical Installations
Ma
ster E
le
ct
rician
__
_ _ _
___
_
__
_
__
Licen
se
No. _
__
_ _
__
_ _
__
_ _
C
ompan
y Name
- - -
----
--
-
----
--
D
esignate
d
ln
s
pecti
on Agen
cy
__
_____
_
_____________
____
_
L
ocatio
n o f
Wor
k _
__
_
__
_ _
__
_
__
_
___
_
__
_
___
_
__
_ _ _ _
Ty
pe
of
Work to Be Per
fo
rmed
(
co
mpl
e
te
bottom
section
for
all
wo
rk
involvin
g
th
e el
ec
t
ri
c s
ervice
in
te
rconne
ction)
Est.
Cost
-----
- - -
----
---
----
-
---
---
--
-
--
-
--
- -
A
ddr
ess
of
Owner _
____
___
_________
___
____
_ _ _ _ _ _
•a
• e • • • • • • • • • • • • e • • e e
•••••••a•
a••
a a a a a a a
a••
a a a a a a a a a a a a a
aw
a
a•
a a a a a a a I a a a a a a a a a a a a a I a a a a
The
under?igned hereby makes application for
an
electrical permit and does
ag
r
ee
to comply
with all
of
the provisions
of
the Village of Freeport Code.
This
app
licati
on
is to
be
accompanied by a
co
mplet
ed
application to a Freeport approved
Insp
ec
ti
on
Agency.
It
is
to
be
understood that a
ll
work is to
be
inspected and certified by a Freeport approved
Inspection Agen
cy
before being concealed. Fees for such
in
spections are not covered by the
Village Electrical Permit.
•••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••
Affidavit
of
Maste
r
Electri
cian:
_ _
__________
___
____
_
be
ing duly
swom,
deposes, and says that he
is
the master el
ectr
ician employed
by
the
abov
e named
mvner
and is duly
au
tho
ri
zed to perform the work described
St
ate
of New York )
A
ppli
c
ant
's
Sig
na
t
ur
e
Co
un
ty
)
Add
r
ess
~-------~~~-----
-
T he following section is to be co
mpl
eted
for
all
ch
a nge
of
se
rvice pe
rmit
s:
Se
rvic
e i
s:
Reside
nt
ial
Overh
ea
d
Si
ngle
Phase
New
Greater than 200 A
mps
Utility
Reconnect Required
(Must submit Inspect
ion
Cer
tificate)
Co
mm
er
ci
al
Under Ground
3
Ph
ase
Exis
ting
S
worn
to before me on
thi
s:
_
__
_ d
ay
of , 20_
Notary
Pub
lic
~----
----
·
·-
--
-·
--
-- ·-
..
@
Cer~fled
Electrlcnl
Inspections,
Inc.
188
PnrkA~cnue
•
Amityville,
NY
11701
•Tel
(631)'598
-5
610
•
A1
(631)
598
-
0541-•
www
.
ul-11y.com
.
ELECTRICAL
INSPECTION
FORM
AppllcaOon
#:
.
APPLICANT
..
..
I
OWNER/TENANT
LAST
NAME'
.
..
o
New
Slru
clure
· ·
Date
F
li
ed
Q
Reno/AddlUon
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CITY
ICITY
-·-
Bulld
l
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Permit
#
STATE
TownMUage
Appllcalfon
#
-
--
ZIP
'
COOE
=i~A
TE
·
ZIP
coot;
'
COMPANY
PHONE#
.·HOME
PHO
NE
#
Sq.
Footage
of
lnspecUon
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~
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··-
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PHONE#
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CELL
PHONE#
:
Email
Address
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..
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lnspeclor
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use
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COMPANY
F/\X
#
r
WORK.~HONE
ti'
'
·-
-·
-·
____
..
.
..
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a R
esldentrar
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Commerlca
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Rough
0
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p Q
As-Sulit
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0
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We
ll
0
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1
I 0
B•soment
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0
Bed
0
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0
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0
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of
0
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Bed
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Dining
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0
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Office
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Ha
ll
1
0
2nd
Floor
#
of
0
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0
Bed
0
Fam
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Dining
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Kitchen
0
la
u
ndry
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Office
0
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Hall
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-
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G'round
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Grou
nd 0
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Tub
0
New
Cl
Existing
·
----
·
--·----·-
--
·
---
0
3111
Phase 0
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0
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rvice
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Add/flonpl
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I
~
-
Date
; fflspector Uso
Only
. . .
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..
Rou
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· ·
...
TemP.
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Closed
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lnspf:Ofors Notes:
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Toll
Free
:
(888)
238
~
1338
•
Froc
(631)
598-05
41
Electrical Inspection Service, Inc.
Date:
375
Dunton
Avenue,
East
Patchogue,
NY
11772
Tel: (63
1)
286-6642 Fax: (631) 2866683
INollcsheet
Co
ntractor
i . JHomeowner
Village:
Town
: (Hegslrom)
Map
: I Grid:
N
umber
:
(Botwoen) Cross St:
(County) Map:
(Owner) Na
me
:
Street:
(Owner Add
ro
ss) Number:
Residential
Comm
ercial
Section:
Street:
Indoor
Outdoor
Renovation
Tel:
1st Floor
2nd Floor
Addition
Zip:
Po
le:
----
(And)
Cross St.:
I
Block:
Lot
--1
(Contr)
Tel
2:
Attic/3rd
Basement
Out
Bldg.
C/S/Z:
Pool
HotTub
1 Survey
No Visual
Defect
CSST Bond
New
Bld
g.
Service Only
Plastic Pipe
Service is:
Overhead
New
Service
Underground
Change
Re-Connect
Meters
Amps Phase
Temp
Issued
Switches
Receptacles Fixtures GFl's
Fans
Sm
oke Detect. CO/Combo CAC
Furnace Oil Gas
Circ.
Heaters
Range/Amps Oven/Amps Dishwas
h/
Amps Wash/Amps
Drye
r/
Amps Microwave/Amps HydroTub/Amps
Other E
qu
ipment
Installed
By.
Addres
s:
C/
SfZ
:
Insp
ec
ti
ons:
First.
Second·
Photovo
lt
aics
Panels
Inverters
# Size
# Size
System
Size
Receptacles:
Switches:
Fixtures:
GFl's
Fan's
2
3
SD
Comme
nts
Violations
Li
e. #.
Phone.
Email
Third: Re-Inspect:
CO/Comb
L Inspection
Co
mp
le
te
Fee:
' Pe
rmit#
.
1
Fax
·
Final:
-1
Ins
pect
ors
Signature
Date Printed 5(
29
/2014
Contract
ors
Signature Homeowners Slgnatue
..
r
...
.
...........
.
...
.
...
.........
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.....
..
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..
..........
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_
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..
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......
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"'
!
•oFFICE
U
SE
ONLY•
Appointment
Day:
Date: Tim
e:
Inspector: i
t
...
......
..
.......
.
...
..
..
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......
.
....
.
.....
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- •• -
••
• i
Long
Island
Electrical
Inspecto
rs,
Inc
21
Third
Avenue
Bay
Shore
,
NY
11706
Requested
Bv:
Tele: 631-647-7447
Fax: 631-647-7445
. Website:
www
.lieinspect
or
s.com
Email:
Va
lerieliei@optimum.net
i ~
-
-
---
-
-
--
---
..
~
-------
-
·-
-·
: Sent
to:
i
! •office U
se
Only' :
--
--
-----
..
--
---
----
-·--·
---·
Date:
CompanyName:~-------
~
~---~---
---~-~~~
License
No
:
Address:
~~~~~~---------~~--~--~~-~-~-
Phon
e
#:
~~----~-----~--~~-----~~-~~~~
Fax # I E-mail:
~
---~----~~~--~--~~~--~~~~~
Job
Is:
0
Residential
0
Commercial
0
Industrial
Job
Location:
Nam
e:
Address:
Cross
Street:
Ph
one#:
Pe
rm
i
t#
:
Tax
Map
Section:
---
Lot:
---
.
Distr
i
ct:
-
--
Block:
__
_
Brief
Descripti
on
Of
Job:
{Please Circle
All
That
Apply)
Is
jo
b ready
for
Inspection:
Yes I
No
Rough
Insp
ect
ion
Fina I
Do
you
need a Temp
Certificate
: Yes I
No
Temp
Informat
ion:
Service
Siz
e:
Phase: 1 3 Other:_
Amps
:
100 150
2
00
300 3
50
400
Ot
her:
__
New
Se
rvice
Re
-
con
ne
ct Underground
Fax to
PS
E&G Fax
to
Electrician
Change of Service
Ove
rh
ead
Und
erground
Nu
mb
er
of
Me
te
rs
: _
Fax
to
PSE&G
and
Electrician Email to E
le
ctrici
an
ALLIANCE
ELECTRICAL
INSPECTIONS
LTD
PHONE:
516-280-9494 / 516·280-9495 I
FAX:~~l
·S3Ct
·
l.t.'5.!i
APPLICA
TIO
NS
ALSO
AVAILABLE
ONLINE@
AL
l/A
NCE
E/l.COMI
I Today's
Date:___}___}_
I
JOB
INFORMATION
Permit
Nu
mber:
-
---
--
Section I
Bl
ock
I Lot:
___
_,
Address:
----
--
---------
--
-------
MAIN
OFFICE:
584AROSlEY
BLV
D,
SUITE
2.02
GAR
DE
N
CITY
S,
NY
11530
City:
_____________
_
State:
___
_
Zip
C
od
e:
--
------
Owner
N
ame:~
------
·~---
---
Owner Contact:
....._
_
_._
__
_____
_
Pl
ea
se
mark
all
th
at apply:
Residential 0 Commercial 0
As
Built 0
Survey
0 R
ou
gh
O Final O
Specific
are
as
to
be
inspected (
1s
t floor kitchen, etc):
----
-
----
--
----
--~
Ready
now: 0 Not yet, will
not
ify
off
ice
: 0
Schedule with: ( Applicant: 0 /
Ow
n
er
0 )
...._
__________________
_
_____________________
_j
APPLICANT
INFORMATION
Company:
_______
_
__
_
__
_
li
c
ense
d Electrician:
----
-
-----
Address:------------
-
------------
Apt/Suite:
-----
Ci
ty:
_____________
_
S
tat
e:
___
_
Zip
Code:------
- -
Con
ta
ct:_{
__
~)
_______
_
License
Number: _ _ _
__
_
-Tow
n
of
____
_
TEMP
CERTIFICATE
(IF
NEEDED)
Service
Size:
__
_ Amp
Ov
·
erh
e
ad
0
Un
derground 0 Note:
____
__
_ _
OTHER
Other details of
Inspection:-------------------------
SIGNATURE
OF
LICENSED
ELECTRICIAN:-------------------
-
All
app
lic
ations
MUST
be approved and signed
by
the licensed elect
rlc
lan
who
completed the elect
ric
al
wo
rk.
Please refer to
sp
aclfie
to
wns
and
vlllege
s
for
perm
it
needs
an
d requirements.
If
an application
ls
missi
ng
a perm
it
numb
er, there
may
be
a delay
In
processing
yo
ur
application
and certificates.
www.a
lll
ance
e
ll.com
300
EAST
MEADO
W AVENUE
EAST
MEAD
OW, NEW
YO
RK
11
554
OFF
IC
E
516.794.0400
600
JOHNSON
AV
E
NUE
,
STE
. D2
BOHEMIA,
NEW
YOHK
11716
OFFICE:
631
.650.0200
FAX:
516
.79
4.5854
lnfo
(!)>e
i
iny.
com
W
eb
Si
t
es:www
.eiiny.co m
llE
W
YORK
BOARD
OF
F
IR
E
Ull
DE
RYI
RITE
RS
ww
w.nybfu.com
Electrical Inspectors, Inc.
INSPECTION
ORDER
FORM
THIS
IS
NOT
AN
ELECTRICAL
CER
TIFI
CATE
0 RESIDENTIAL
::J
COMMERCIAL
0 H/
OWIRE
O
#
_____
_ _
Q NE\'/WORK
[j
RENOVA
TION
Q
SUllVEY
E.
XISTING
APP
LI
CANT
:
(P
erson Requestinq
Inspection)
OWNER/T
EN
ANT
: (Location
to
be
Inspected)
Nll/.IE
/\CCOUllT
tlAl.\
E
NAME OBA
AD
D
RESS
I
LICENSE
•
ADDRESS
CITY
ST
llTE
ZIP
CITY
STATE
ZIP
PttONE
I CELL
H
OME
CELL
REQUESTED
INSPECTIOtl DATE I EMAIL
OR
FAX
NE
AR
ES
T
CROSS
STREET
TO
IVNSHIPNILLAOEICITY
(MUtll(
I
PA
llTY)
0
SATURDAY
OOHI
A
VA
IL
Alll £
I COllTACT
PERSO
N
SECTION
BLOCK
LOT
BUILDING
PER
MIT•
0 SAME
DAY
SERV
IC
E
AT
A0011
IONAl
COSTS
SPECIAL INSTRUCTI
ONS:--
--
---
----
---
--------
----------
--------
------
AREA
TO
BE
INS
PECTED
!ON
LY
CHECK
BOXES
OF
AREAS
TO
OE
I
NSPECTED
)
AlitAS
10
6(
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INGROUN
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A/C
_ _ _
lq
uantity
l (CHECK
ONLY
IF
PART OF INSPECTION!
0 GENERATOR (size) (CHECK
ONLY
IF
PART OF INSPECTION)
C<O~
(T
OTHlA
SERVI
CE
AUTHORIZATION
TO
INSTALL:
0 FIRE RECONNECT (EMERGENCY!
0
SHUTDOWN
lJ
MOVE
0 SOLAR
0
NEW
U OUTSIDE REPAIR 0 RECONNECT !EXISTING)
0 TEMPORARY 0 UPGRADE
SERVICE
#METER
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0
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0
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~J
300A
8
400A
U
600A
'.J
BOOA
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A
METER SERIAL U
T
h•
applicant roquo11ln9 this
lntpect
i
on
(Su,,,cyl
ones
ts
thot
there
are
no
opM
opplic<>1lont for
the
•bove
,
whh
ony
other
•uthorited
lnspot\
lon 09ency. Also they
undout3nd
and
agree
10
pay
all
f~
5
until
the
obove
passes
the
Nationol
Elcc
tr
ic,
,l
Code
and
/
or
all locol codes. The
undersigned
o
ho
a16rms
they
have
the
outhor
lzo
tlon
of
the property owner to
submit
this
appl
i
cat
ion.Onl
y
th•
•1>pll<dnt will
be
given
any
informat
ion
pcrtolnin9 to t
he
Inspection. local codes nioy
requ
ire
homeowner
to
toke"
i.st
to
perform
any
clcc1rlul work
In
the
ir
own
home
pri
or
to
lns
poctlon.
It
mny
also
be
ntccuary
to
obtain
o buildln9
perm
it
lrom
your TownNlllogc/Chy Ouildl
ng
Deportme
nt
before commencing with
•ny
clccttlc•l work
•nd
/or
Inspection of this work. Electrical Inspector>. Inc.
is
not
listing, l•belln9. underwriti
ng
or
certifying ony
equipment,
m•tNi
~
ls
or
devices which ore
perform
ed by other cortified 1cstln9
l;,bor•t
ories.
ln1pccdon
•9cnclcs,
or
othor
or9onltotions
concerned
wilh
product
cvolu•
tion. The Applicont/Owncr/Authorizcd Age
nt
agrecs
tooli
Terms
and
Conditions
set
forth
on
the
front
•nd
b
ac
k ol
th11
3pp
lic•tlon.
FORM
OF
PAYMENT
: 0
MASTER
CARD
O VISA D
AMEX
0
CHECK
II
..
,,___
0
BILL
ACCOUNT
(
Otll
Yl
fAPPll{llO
LIJ
MY
CREDIT
CARD
NUMBER
____
______
_______
_ CVVtl
____
EXPIRATION
DATE _
___
_
~
AND
H
EREBY
AUTHORIZE "ELECTRICAL INSPECTORS, INC.
(dba
NYBFU)" TO CHARGE
SERVICES
ON
THIS ACCOUNT
FOR
PAYMENT
THIS ACCOUNT FOR PAYMENT. I
AGREE
TO
THE TERMS AS DESCRIBED
FOR
THIS CARO.
PRlllT llllME AS
IT
APPEARS
ON
CARO
f,PPllCANT
PRINT
NAME
SIGNATUflE OF CAllDHOlOER
DATE
SIGtlAT
URE
OF
AP
PU
CANT
OAH
PU.t.U
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\T
NASSAU
SUFFOLK
ELECTRICAL
INSPECTORS
Nassau Suffolk Electrical Inspectors
159 Rt. 25ABldg.
1,
Suite B
Miller Place, NY 11764
Voice: (631) 495-8136
Fax: (631) 509-4538
Email: Requests@SuffolkBEl.com
REQUEST
FOR
INSPECTION FAX FORM
REQUESTED
BY
Company
Name:
Name:
License No.:
Address:
Phone
Number:
Date:
---------
--------
-
··
-·
··
···
-··-
..
---·
-
-----------------------'
JOBSITE
INFORMATION
c
..
. indicates required
information)
*Name:
*Address:
*Cross
Street:
*Phone:
Permit
No.:
Hagstrom
map:
Tax
map
District:
_____
_ _
Section:
__
Block: Lot:
----
*BRIEF
DESCRIPTION
OF
WORK
(Please
Print
Clearly)-------------
{Please
Circle
All
That
Apply)
*
Is
job
ready
for
inspectio
n :
*Do
you
need a
Temp
Certificate:
Temp
Information
(if
ncected):
Yes/
No
Yes/
No
Rough
In Final
*Service
Size:
lPhase
3Phase
100
150
200
300 350
400
Other:
*New
Service Re-connect Underground
Number
of
Meters Change
of
Service
Overhead
*Fax
Temp to
UPA
Additional
Information:
Fax T
emp
to Contractor
Fax
Temp
to
Contractor and LIPA
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Completed 12 July 2020

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