Electrical InspectionInspector's No-_—__�
Date 1'ZE-7— zo
COMMONWEALTH ELECTRICAL INSPECTION SERVICE, INC.
(Consulting and Fire Inspection Services)
(Incorporr ed in the Or", of Nrw York and Pennsylvania)
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
Owner _ r o a irff r 1.>.. it _
T/yc Building: Dwellinl Other (please speafy) S C PJ-.e 4m. x 5X(lem
Job Location 6(7 fz—pr l r,I S+ " City el py o / e (� Stare
County (rJ A. * a_ n Permit From Permit # WC#
Swimming Pool: Inground Aboveground Bonding Date
Application for (lough Wiring ❑
Fixtures ❑
Service ❑
or
Work -New ❑ Additional ❑
Bldg. -New ❑
Old ❑
Ready for Inspection
{7"
m
MAN
SPACE BE[nW FOR USE OF INBPECtt1aB ONLY
SHtrlm
I
Weter Heeler
ul
Equipt
Fwartacks
Pump
Serves Egvo
GFICIRecect
Patltlle Fan
Panel
AMP Faster
PaetlelF
M
DryerR
Ms
vent Fan
Wasllt Rea
ab
Air ConEltlwpr
D%M1waMer Rec
S,Me Dal vas
MCI Breaker
Mlrrowave Rac
YrcNvOD Debclps
GFCI Brmkt
Garbage CaRw
Inspector's Comments:
For Certificate
AON MUMBLID
Elachiral Iasla"tor
1 State Stoat
Gera Falls, NY 12WI
(91 RI "/alldlaM
Inspector.
Job Notes
Installed By (if other than applicant): _
OFFICE USE ONLY
Dare Received:
FEE PAD
TRACT TOTAL 8 / 50. O
R,W DATE OWNS CHECK NO. 75
Certificate No: FINAL DATE I L?-2 3 DCGl1PANr CREDIT CARD
Dam Sent: CERTIFICATE NEEDED AGENT CASH
❑ YES ❑ DUP CHARGE
FINAL FEE
THIS APPLICATION EKIBRES ONE YEAR FROM DATE MAKE ALL FEES PAYABLE TO C.E.I.S. INC.
pis 11171