Electrical Inspection Inspector's No.:. I I A. J =�
I c) j
COMMONWEALTH ELECTRICAL INSPECTION SERVICE, INC.- ,
(Consulting and Fire Inspection Services)
(Incorporated in the states of New York; Pennsylvania, and West Virginia)
Desiring.Certificate 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.
Owner:
Type Building:�Dwelling Other(please specify):
Job Location: .: 3 City. c) :r 4„ State: . �.
County: Imo, ,t, Pen-nit From: Permit#
Swimming Pool: Inground: Aboveground: Bonding Date: ..
Work—New Additional Bldg.-7 New:. Old Ready for Inspection
Applicants Signature: . License#:
Please Print Name:,; Phone#:
Applicants Address: Name of Utility: A,
City: Office To Be
State: Zip: Notified: Job#: .
SPACE BELOW FOR USE OFINSPECTORS ONLY
Switches Water Heater Service [Equipment Other list below
Receptacles Paddle Fan/Light Control -Service Equipment. a c,
GFCI Rece t Paddle Fan Panel
AMP Rece t 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
AFCUGFCI Breakers Refrigerator Receptacle :
Additional apparatus for certificate: (Not listed above).. Inspector Job Notes:
C C. Lr,6. 9RONMUMBLO
IRE
1
Electrical Inspector State street OCT 0 7 2021
Glens Falls, IVY 1.2801. .
(518) 798-0905 TOWN OF QUEENSBURY
COMMUr•i;iY.DEVELOPMENT
Installed'By(if other than applicant):
OFFICE USE ONLY
Date Received: Extra trip dates Inspection Fee$ -? ,ti"n
Service Date: 1 CASH
Certificate No: R.W.Date: 2 Check No. ..
Final Date: I o ,-1. Z i 3. `Invoice.
Certificate Needed? 4 CC
Date Sent' yes Dup Inspector sign in j
next space
Please.print name Inspector:
Original Progress Final
THIS APPLICATION EXPIRES ONE YEAR FROM DATE MAKE ALL FEES PAYABLE TO C.E.I.S.INC.
66