electrical inspection Inspector's No.
Date 20
COMMONWEALTH ELECTRICAL INSPECTION SERVICE, INC.
(Consulting and Fire Inspection Services)
(Incorporated in the states of New York, Pennsylvania, and West Virginia)
Desiring Certification of Approval, application is made for inspection of electrical installation in the premises
described below.On tlentand, applicant agrees to pay for inspection service in accord with schedule of charges.
PLEASE PRi4 ( j.- i/l1(Il" \,
Owner , r
Type Building wec ij.. Other (please specify)
Job Location , ti,, City , State
County Permit From # Permit# M/C#
Swimming Pool;Inground Aboveground Bonding Date
Application For Rough Wiring❑ Fixtures ❑ Service❑ or
Work-New❑ Additional 0 Bldg.-New❑' Old 0 Ready for Inspection.:'.
APPLICANTS - .7
SIGNATURE LICENSE# -
PLEASE `..f. r± PHONE#
PRINT NAME F
APPUCANTS NAME OF
ADDRESS UTILITY
CITY STATE ZIP CODE OFFICE TO
BE NOTIFIED JOB#
`--~" SPACE BELOW FOR USE OF INSPECTORS ONLY
l>' Switches Water Heater Service Equipt
Receptacles Pump Service Equipt
GFCI Recept Paddle Fan Panel
AMP Recept Paddle Fan/Light Dryer Rec
Lights Vent Fan Washer Rec
Lights Air Conditioner Dishwasher Rec
Smoke Detectors AFC!Breaker Microwave Rec
Smoke/CO Detectors GFCI Breaker Garbage Disp Rec
Inspector's Comments: + /�,, ;.I(/,,/,;. --; >/fit. /v C= ,C_ Inspector:
F'or:Certificate :' . ., Job Notes
Installed By(if other than applicant):
OFFICE USE ONLY WORK INSPECTED aePOR-
NOTIFIED TED ¢ O FEE PAID -
U ! L
SERVICE DATE
Date Received: CON-
OTRRACTOR TOTAL $ t' -,'_ -
R.W.DATE OWNER CHECK NO.
FINAL DATE OCCUPANT CREDIT CARD
Certificate No.:
OffRTIFICATENEEDED AGENT CASH
Date Sent: OYES ODUP ELEC. CHARGE
LT.CO.
%.//4-0, INSPECTOR FINAL FEE
' PROGRESS FEE
...j
THIS APPLICATION EXPIRES ONE YEAR FROM DATE MAKE ALL FEES PAYABLE TO C.E.I.S.INC.