Affidavit of No Electrical Work

State of New York ss: Building Permit #:
County of Nassau Plumbing Permit #:

I/We: are the Owner(s} of real property located at:

Address:

Section: Block: Lot:

Making application for a Building permit, being duly sworn and depose that there will be no electrical work whatsoever.

I/we hereby attest and affirm that shall the scope of work change, and electrical work will be required, a separate Electrical Permit will be applied for and no electrical work shall begin until such permit has been issued.

This affidavit is submitted in accordance with New York State Executive Law.

Applicant Signature

NOTARY CERTIFICATION

Dated: Signature:

Sworn before me this day of , 20

Name (print): NOTARY SEAL:

FALSE STATEMENTS MADE HEREIN ARE PUNISHABLE AS CLASS A MISDEMEANOR PERSUANT TO SECTION 210.45 OF THE PENAL LAW THE STATE OF NEW YORK