electrical inspectionTHE NEW YORK BOARD OF FIRE UNDERWRITERS SeeDONOTWRITEHERE-FOR OFFICE USE ONLY
aoe ne =Soe Yr VeronmoeripplehdussLanea;
Lev fe X Ruth WAY YG L
ee)ooh ome sew)sonora 9 coracaresonn)
ISTEFLOWATL EGUIPHENT WiTCH YOU NSTALPED
NOMGEROF OUTLETS]NoofPaesSrANCHCOFFETSE=|Lamp Receptaces|——CIRCUITS ONLYSeeeeeeoor2:
Soe --
Bae |ase —esi oaEa|x
fe i
TREMARIS'UIST OTHER ELECTRICAL DEVIGES NOT SET FORTH ABOVE
‘THIS APPLICATION IS INTENDED TO COVER THE ABOVE.LISTED EQUIPMENT TO BE INSPECTED.BUT IF AT TIME OF INSPECTION,THERE IS
FOUND ADDITIONAL EQUIPMENT NOT ABOVE LISTED.YOU ARE AUTHORIZED TO MAKE THE INSPECTION AND ADJUST THE FEE TO COVER
"THE ADDITIONAL EGUIPMENT,AS PROVIDED BY THE APPLICANT.
SORTER en ord =1 concenBREVARDDRECCHRETES|REO SSRI RE
Doves 1 nanancrveransorenneiamt seam TTT"RIGID DELAYS BY GIVING FULL AND ACCURATE INFORMATION.ALL SPACES MUST BE FILLED IN OR APPLICATION MAY BE RETURNED,
PRINT NAME AND ADDRESS
RANE OF PRON DAE OF APPIN aSTREETADDRESSTELEPHONENO
‘CHVORPOSTOFRCE "BPCODE|DGS WO WEN APPLE
5 85.John Street [41 State Strost {70 Delaware Avenue |-217 Lake Avenue [Ly 202 Arterial Road
NEWYORK Ny 1006
|'7
ALBANY,NY 12207|‘BUFFALO,NY 14202|“ROCHESTER,NY 14808||SYRACUSE,NY 132068
(212)227-3700 (618)463-2102 (716)884-1185,(716)2540141 (15)469-8552[Ir IRA AR AAA Ar cine cine manitene