Electrical inspection Inspector's No.: /-1
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.
J
Owner: ,� i,,t / ,o_ C A_
Type Building:Dwelling Other(please specify):
Job Location: 5`-I G r: u,t City: . ,_r " ;; ,r State:
County: ;, :L„� Permit From: Permit# J !
Swimming Pool: Inground: Aboveground: Bonding Date:
Work—New Additional Bldg.— New Old Ready for Inspection
Applicants Signature: License#:
Please Print Name: Phone#:
Applicants Address: Name of Utility:
City: Office To Be
State: Zip: Notified: Job#:
SPACE BELOW FOR USE OF INSPECTORS ONLY
�( Switches Water Heater Service Equipment Other list below
5 Receptacles Paddle Fan/Light Control Service Equipment
GFCI Rece t Paddle Fan Panel
AMP Rece t J Paddle Fan/Light Dryer Rec
Lights Vent Fan Washer Rec
c Lights Air Conditioner Dishwasher Rec
Smoke Detectors AFCI Breaker Microwave Rec
Smoke/CO Detectors GFCI Breaker Garbage Disp Rec
AFCl/GFCI Breakers Refrigerator Receptacle
Additional apparatus for certificate:(Not listed above) Inspector Job Notes:
Ro ii MUMBLO
Electrical Inspector
1 State Street
Glens Falls, NY 12801
(510)?�13-OgO�
Installed By(if other than applicant):
OFFICE USE ONLY
Extra trip dates Ins ection Fee$
Date Received: Service Date: 1 CASH
Certificate No: R.W.Date: 2 Check No.
Final Date: /?_/.3_:! 1 3 invoice
Certificate Needed? 4 CC
Date Sent: Inspector sign in
Yes_Dup next s ace
Please print name Inspector.
Original Progress Final
THIS APPLICATION EXPIRES ONE YEAR FROM DATE MAKE ALL FEES PAYABLE TO C.E.I.S.INC.