P - 81872RE�UEST FOR ELECTRICAL INSPECTION
"'X'" Below Work Covered by This Request �� `
Add R�v• Type o1 6u11dinp ApO�iane�s Wirsd
Home Range
Ouplex Water Heater
Apt. Bu�lding Dryer
Commercial Bldg. Furnace
Industrial Bldg. Air Conditioner
c...� ther peci v
�ute inspeci�on fee tleiow
F�� S�rvic�Entr�nc�Sii•
0 t Am
101 to 200 Amps
Above 200_Am
Transformers
Signs
rks
�-in _
F�nal
Thls request w�d
18 nqnths f�om
-T —
Fse Fssdera�Subleedera p
Oto30Am s
31 to 100 Amps
Above 100_Am s
Remote Control Circ.
Spec�al Inspection S
08022618
Equiomsnl Wir�d
Temporary $ervice
Lighting fixtures
Electric Heatmq
Silo Unloader
Bulk Milk Tank
the� lSoec��vl
Fes Circw�
0 to 30 Am
31 to 100 A
Above 100_
TOTAL FEE
r �
ate ' t, th� Elsetrie�l
�/_5.-Ur InsDSetor, M��by
� c�rtity th�t tM ebov�
Onle insD�etion has b��n
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OFFlCE USE OI�Y This roquest void 18 monlhs from validation dafe printed in this box.
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PLEASE PRINT OR TYPE
Requ Date Rough-in inspection required? Yes ❑ No Inspection Other Than Rough-In: ❑ Ready Now Will Call
��� (You must call the inspecror when ready) Date Ready:
I, ❑ licensed contractor � owner hereby request inspection of the above elechical work at:
lob Address �Street Box, or � oute ,N�}.) ,�/ Ci�! ! Zip Code
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Secfion No. Township Nam�� Ran� o. Fire No. o ry
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Occ�anf � �, � Phone No.
Elechical Con r �Company Na� ��
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Mailing Address onha�tqr or Owner Performing
//'7_1�n�i�_ ✓1 .
License No.
(i[�s<4�
��3-�a -88aa�
STATE BOARD COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY