New York Codes, Rules and Regulations
Title 21 - Miscellaneous
Appendices
Appendix 10-B

(cf. Part 458)

(Name of Municipality or Cooperative)

CERTIFICATE OF COMPLIANCE

Expansion of Existing Electric Service for the Purpose of Conversion to

Electric Heat

The undersigned certifies that the

[ ] Existing Dwelling(s) [ ] Mobile Home(s)

[ ] Existing Commercial Structure(s)

at ____________ (Location)

is (are) or will be in compliance with the "Minimum Insulation and Heating System Standards" prescribed by the Power Authority of the State of New York and which are incorporated in the service rules of (name of municipality or cooperative) , not later than 30 days after completion of expansion of existing electric service for the purpose of providing electric heat.

It is understood that electric service will not be connected or will be disconnected if, upon inspection, the structure is found not to be in compliance with the conditions set forth.

The undersigned certifies that a properly executed copy of this certificate will be delivered to the owner on completion of the electric work; and agrees that any successor in title to the owner shall be deemed a beneficiary of the undertakings described in this certificate.

Dated: ____________

______________

Signature of Builder or Contractor

Dated: ____________

______________

Signature of Representative of

Municipal Electric Department, Building

Code Enforcement Inspector or

Qualified Representative of the Municipal Government