P - 83091l IVLL.LI rnaiey, MIf1f185IIi3 D049Z '- YA7C �oiz� oi i-izor �� y-; ,
�.a �� %
REQUEST FOR ELECTRICAL INSPECTION
""X'" Below Work Covered by This Request
Add Rep. ype ot Buildinq ApDliancea Wired Equ�pment Wired
Home Range Temporary Service
Duplex Water Heater lightin Fixtures
Apt. Building Dryer Electric Heatin
Commercial Bldg. Furnace Silo Unloader
Industrial Bidg. Air Conditioner Bulk Mllk Tank
Farm � ther peci y ther (Soec�fy)
t r pecify t er 01her �
ompute lnspection Fee Below
a Fse SsrviesEntrancsSizs p Fee Feeders/Subfeeders N fee Circuita
OtotUOAm Oto30Ams Oto30Am
101 to 200 Amps 31 to 100 Amps 31 to 100 Am
Above 200 Am Above 100—Am s Above 100._Am
Transformers Remote Control Circ. Partial�Other Fee
Signs Special Inspection /�
Remarks ,/r S U� TOTAL FEE
� !
RouQh-in �°�� 1, th� Eleet�ic�l
Inspscto�, henby
- c�rtily th�t tfa ebow
F�nal �^�P insp�etion hss be�n
�/6�^ msda.
This reqp7l.�d� �
18 nantj�r
.��:� � �
�� 10079
This request vo�d • -- /
18 mpnths from � � /� �
V �
Request Da �� fi�e No. RequAed?�nsDection �qeady Now Q W�n NoUfy Inspec-
'� ❑ Yes ❑ No tor Whe� Ready
❑ icensCd EIecV�cal Contractor � I h�rsby r�quest inspscNOn of �bow
Owner slectrical work installed at:
Street Addr s, Box or Route Np,/ Citv
a % � r�2 �-� ; � �r� � f
Occupant ` NT) �� Pnone No.
� �
Power Suppl�er
S
Electrical o actor 1 oqivF
N
Ma�tin0 Addr ontroctor
1�
AuMorizad Sipnatur� (ComrE
k�np insta
Aak�np I�u
48�
ontractor s �icense No.