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electrical inspection
:Q.c, th-%�Fa _ 20 vl c Inspector's No. / 0 / 7.S.2— Date -5-1 3 20 ,2O • 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 demand,applicant agrees to pay for inspection service'in accord with schedule of charges. PLEASE PRINT f� Owner / /� 0 v 2 A).� Type Building:Dwelling Other (please specify) ,--1 Job Location 2 3 n 0/4a 4 !J AL, v Cif)/ Q U c c,1 3 b u 7 State ,..4.7 r County( /a eI A-c`'^' Permit From Permit# 'M/C# Swimming Pool:Inground ' Aboveground Bonding Date ,i, Application For:Rough Wiring 0 Fixtures ❑ Service'© or o h l - U Work-.New 0 •'; Additional 0 '"Bldg..-New❑ Old❑ Ready for Inspection APPUCAANTS LICENSE# SIGNATURE PLEASE .^e (� m �- PHONE# PRINT NAME J APPLICANTS t NAME OF /U/�,/ C-iz ) .2 9 C 3:/3 2 / UTILITY t CITY - STATE ZIP CODE. OFFICE TO BE NOTIFIED :JOB# - SPACE BELOW FOR USE OF INSPECTORS ONLY Switches Water Heater Service Equipt /U a A 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 N Microwave Rec Smoke/CO Detectors , GFCI Breaker Garbage Disp Rec ,, C Inspector's Comments: Inspector: For Certificate Job Notes SON MUMBLO Electrical Ins ector i ; p 1 State Street L Glens Falls, 14.dY 1.2801 MAY 1 2 l (518) 798-0905. 2n 9 T®Wv OF du-E EN""YIN' , Installed By.(ifother.than applicant)". BUILDI,NG& C ES` } OFFICE USE ONLY WORK INSPECTED REPOR- 9 NOTIFIED TED ¢ O FEE PAID U SERVICE DATES')3 2p CON- TOTAL $ Date Received: TRACTOR /Sac a R.W.DATE OWNER CHECK NO. FINAL DATE 5-)3-2C) OCCUPANT CREDIT CARD Certificate No.: CERTIFICATE NEEDED AGENT 1- CASH Date Sent: DYES ❑DUP ELEC. 11 CHARGE LT.CO. INSPECTOR FINAL FEE 0 - 51----, • PROGRESS FEE THIS APPLICATION EXPIRES ONE YEAR FROM DATE MAKE ALL FEES PAYABLE TO C.E.I.S.INC.