Electrical Underwriters of NY, LLC

ELECTRICAL UNDERWRITERS OF NY LLC
50 Hy-Vue Drive
Newburgh, New York 12550
Office (845) 569-1759 Fax (845) 562-7371

Section:

Block:

Lot:

Date:

City, Town or Village:

County:

State:

Pole #:

Location / Address:

Permit #:

Owner:

Phone#: ()

Building: New Old

Occupied As:

Occupant:

App. For: Wiring Service Survey Pool Ready For Inspection:

Fee Remitted $ Cash Check M.O. Make Payable to: E.U.N.Y.

Applicant's Name:

Applicant's Signature:

Company Name:

License #:

Permit #:

Applicant's Address:

City:

State:

Zip:

Utility: Office Location: Service Request#:

Phone #: () Electrician:

DATE RECEIVED: DATE INSPECTED:

Correct Location: Same as Above or:

Red Notice Label:

Elect. Heat	500	750	1000	1250	1500	1700	2000	2250	2750	2500	2750	2500	3000
Elect. Heat

Notes:

CERTIFICATIONS	USE FOR INITIAL VISIT ONLY	NOTIFIED	DATE	CORRECT FEE	FEE PAID
RW CFT L/A L/A IPA	Progress: INC. LKD Violation: Work Comp. Inc Other Side	Contractor Owner Municipal Utility		Fee	CASH CHK# MO# INV# Applicant Owner
Date:

Cut in Card#: Date:

Inpectors Signature:

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