electrical inspection i// -4_
DO NOT WRITE HERE-FOR OFFICE USE ONLY f ttrH1It-UM t
INSPEC O
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TEMP# DATE BUILDING PERMIT#
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CITY OR VILLAGE ZIP CODE TOWNSHIP COUNTY
STREET#AND OR ROAD Pole Number
Additional helpful directions Section Block Lot
OCCUPANTS NAME BUILDING OCCUPANCY
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OWNER'S NAME&ADDRESS HOME TELEPHONE
CURRENT SUPPLIED BY FROM THEIR OFFICE WORK TELEPHONE
BUILDING IS NEW OLD
WORK IS NEW ADDITIONAL DEFECTS REMOVED
Inspection or Electrical Premises Survey:We have attended at the premises named herein to inspect the electrical installation and regret that we can not issue a
certificate of compliance for the reason(s)listed hereunder;
Concealed work not exposed suffiently for inspection. Additional work observed with no application for inspection being filed.
Installation not completed sufficiently for inspectiion. Installation not in compliance with the NEC for reasons listed hereunder.
Key:Code number printed under column A listed below combined with code number printed under column B listed below indicates condition.
NEC VIOLATIONS Level NEC VIOLATIONS Level NEC VIOLATIONS Level NOTES
INSPECTION INSPECTION INSPECTION
Size of service APPLICANT ATTESTS THAT THERE IS NO OTHER APPLICATION PENDING WITH A QUALIFIED
Feeders _.., ELECTRICAL INSPECTION AUTHORITY FOR INSTALLATION LISTED HEREIN.THIS APPLICA-
Work is exposed TION IS VALID FOR A PERIOD NOT EXCEEDING ONE YEAR FROM THE DATE RECEIVED.
Work is concealed
Service enters me structure overhead— If The Inspector,LLC or anyagent thereof is the prevailin
g 8 p g party in any litigation,arbitration,or other proceed-
Service enters the structure underground ing resulting from a dispute relating to the Inspection site listed herein,The Inspector,LLC or its agent(s),as
Date inspection requested the case may be,shall be awarded its reasonable attorney fees,and costs and expenses incurred.
PLEASE GIVE FULL AND ACCURATE INFORMATION.ALL SPACES MUST BE FILLED OR APPLICATION MAY BE RETURNED.
PRINT NAME AND ADDRESS
NAME OF APPLICANT .__ DATE/OF APPLICATION SIGNATURE OF APPLICANT
CA/ ; fe/'' S!! t
STREET ADDRESS TELEPHONE#
CITY OR POST OFFICE , / LICENSE NUMBER
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1 .8nn_4 _ 53 5390 State Route 11
Burke, NY 12917