P - 83039�_.,. � � Cy, M�r�„dsv�a ooq�z YAX (ti12) 5/1-11tl/
REQUEST FOR ELECTRICAL INSPECTION
"'X"' Below Work Cove�ed by This Request
Add Nsp. Type ot Buildi�9 ApOliancea Wired
Home Range
Duplex Water Heater
Apt. Building Dryer
Commerciai Bfdg. Furnace
Industr�al Bldg. Air Conditioner
Farm tner oec� v
t r yeci y t er ,
ompute lnspect�on Fee Below
��,'���`l
Equipmant Wired
Temporary $ervice
Lighting Fixtures
Elecuic Heating
Silo Unloader
Bulk Mllk Tank
ther lSpec�fyl
Other
k � Fse SsrviesEntranc�Sizs p Fee Feeders/Subteedars b Fes Circuita
OtotUOAm Oto30Am 5 Oto30Am
101 to 200 Amps 31 to 100 Amps 31 to 100 Am
Above 200 Am s Above 100—Am s °^"'�"" Abov 100_Am ,
Transformers Remote Control Circ. /' Partial�Other Fee
Signs Special I�spection S `i�
I Flnal
Thig reQUest void
18 n�onths fr
°�64�3��
rn�s .eoues� �o�d •
18 rtqnths }rom
t
. � ��i�r - �••�� - i i
❑ �icensed Electncai Contractor
�Owne�
Street 9ddress, Box or Route._No,
I Occupent INTI
Electncal Con�c.tor
/ �l .
l,/l..t..
Maitinp Addr Cor
AuMorized Sipneture
�� TOTAL FEE
I a(L�`7�
Date �, th� Elsctrical
Inspsctor, h�r�by
c�rtity th�t th� abov�
, � Date, insp�ction hss b�en
4o Q �,7 � mede.
re No. Ro
Re
r ���
��
Ad�
any amel
� or Owner MakinQ Instailat
actor Ow�er Mak��p Instal
/� �`��� 10 0 7 7
/�
uph-in InsDect�o�
qu�red? �Readv Now Q W�11 NoUfv InsPec•
Q ves ❑ No tor When Ready
I h�r�by r�qu�st inspectlon of abov�
el�etriesl wwk iratslled at:
C �ty
�� N
Pno�ie No.
��a - ��� g
��v-
tor's License No.
umber