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Electrical Inspection Services Inc.

375 Dunton Avenue
EAST PATCHOGUE, NEW YORK 11772
(631) 286-6642
Fax: (631) 286-6683
www.EISLongIsland.com

*REQUIRED

* Date:
* Township:
* Village:
(Hagstrom) Map: Grid:
* Number: * Street: * Zip: Pole:
* (Between) Cross St: *(AND) Cross St:
(County) Map#: Section #: Block #: Lot #: Contact:
* (Owner) Name: *Phone:  Phone2:
(Owner Address)
Number: Street: City/State/Zip:
Indoor 1st Floor Attic/3rd Floor Pool  
Commercial Outdoor 2nd Floor Basement Hot Tub No Visual Defects
New Bldg. Renovation Addition Out Bldg. CSST Bond  
  Service Only     Plastic Pipe  Service Is:    Overhead    Underground    Change Meter    Amps    Phase   
Switches
Receptacles
Fixtures
GFI
Fans
 Smoke Detector
CO/Combo
CAC
Furnace
Oil
Gas
Circ
Heaters
Range/Amps
Oven/Amps
 Dishwasher/Amps
 Washer/Amps
Dryer/Amps
Microwave/Amps
Hydro Tub/Amps
Date Job is ready for rough
Inspection Complete
Fee:
Photovoltaics System Size
Panels
  # Size
1
2
3
Inverters
  # Size
1
2
3
For Shut Down Purpose,
No Inspection Required
Other Equipment: Comments or Violations:
*Installed By: *Lic#: *BLDG PERMIT #:
*Address: Fax#: *Phone #:
*City/State/Zip: *Email:

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