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 #:
(Owner) Name: Phone:
(Owner Address) Number: Street: City/State/Zip:
Indoor Addition Pool Bsmt 1st Fl Det. Garage
Commercial Outdoor Renovation Hot Tub Attic 2nd Fl Visual Defects
New 2000 Sq. Ft. 2000 Sq. Ft. +
Service Is: Overhead Underground Change
Switches
Receptacles
Fixtures
GFI
Dishwasher
Dryer
Washer
Fans
Furnace
Oil
Gas
Cir
Range Hood
A/C
Microwave
Carbon Monoxide
Smoke Detector
Jacuzzi
Range
Oven
Bell Trans
Date Job is ready for rough
Meter
Amps
Phase
Receptacle:
Switches:
GFI
Fixtures:
Fans:
Smoke Detectors :
Inspection Complete
Fee:
Other Equipment: Comments or Violations:
*Installed By: *Lic#: *BLDG PERMIT #:
*Address: *Fax#: *Phone #:
*City/State/Zip: *Email:
Inspection Dates: First: Second: Third: Re-Inspect: Final:
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