WEBforms\App_Electric_Perm rev 03312017
TOWN OF SMITHTOWN
Suffolk County, NY
Application for
ELECTRIC/PLUMBING ONLY
(no construction)
Electric Upgrade, Generator, Central air-conditioning/HVAC,
Gas Conversion, Pool Heater, Gas/Pressure Test,
Tanks-Installation, abandonment, removal
THE FOLLOWING IS TO BE FILLED IN BY THE APPLICANT
Property location __________________________________ City ________________________________
Owner’s ____________________________Phone_______________Address______________________________
City _____________________State_____________________ Zip____________
Electrician*______________________Phone ______________Address ______________________________
Plumber*________________________Phone ______________Address ______________________________
Contractor*______________________Phone _______________Address _____________________________
*Company/Business name Electrical Inspection Agency ______________________________
Tax Map # SCTM 0800- _______ - ______ -______ Zoning District_________
DESCRIPTION OF WORK:
Authorization from property owner & “letter of Intent” required with Commercial applications
__________________________________________________________________________________________
______________________________________________________________________________________
The following must be submitted before a Certificate of Compliance can be issued:
1. Electrical certificate from approved agency
2. Central Air Conditioning/HVAC* requires a letter of certification from contractor
a. Residential - notarized letter
b. Commercial letter - PE or RA signed & sealed
3. Assessors certificate – for Residential Central Air conditioning and Generators
(To be filled in by Building Department)
Application/Permit No. ___________________________
S.C.T.M. No. 0800- __________ - _______ -__________
Receipt # ______________Permit Fee _______________
Commercial ______ Residential ________
Application/Plan Approved by _________Date_________
Permit Issued ________________20______
Permit Expires _______________20 ______
AFFIDAVIT
I_____________________________________ as the_______________________________ being duly sworn depose and state that to
(Print name) (Owner, Owner’s Agent, Architect, Contractor)
the best of my knowledge and belief the statements contained in this application together with the plans and specifications submitted are a true and complete
statement of all proposed work to be done on the described premises as it has been approved by the Town of Smithtown and that all provisions of the
Zoning and Building Ordinance and the State Building Code and all other laws pertaining to the proposed work shall be complied with, and that such work is
authorized by the owner.
Sworn to before me this: Signature _______________________________________________________________________
(Owner, Owner’s Agent, Architect, Contractor)
_______ Day of ________________________ 20________
_________________________________________________
(Notary Public, New York)
