Electrical Inspection Services Inc.

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

*REQUIRED

* Date: A value is required.	* Township: A value is required. * Village: A value is required.	(Hagstrom) Map:	Grid:
* Number:	* Street:	* Zip: A value is required.	Pole:
* (Between) Cross St: A value is required.		* (AND) Cross St: A value is required.
(County) Map#:	Section #:	Block #:	Lot #:
* (Owner) Name: A value is required.		Phone:
(Owner Address) Number: Street:		City/State/Zip:

Residential *	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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