P - 84669• RE(IUEST FOR ELECTRICAL INSPECTION Ea-0000i-os
��C/� A /� � See instructions for completing this form on back of yellow copy.
� �� � t ��" P " " Thi Re uest �
� X Below Work Covered by s q
Ne Add Rep. Type of Building Appliances Wired Equipment Wired
Home Range Temporary Service
Duplex Water Heater Electric Heating
Apt. Building Dryer Load Management
Comm./Industrial Furnace Other (Specify)
Farm Air Conditioner
Other (specify) Contracror's Remarks �
��0��� �t%�B'�/�C� ��l '/1.� / ' '�
Compute Inspection Fee Below:
# Other Fee # Service ntranc Fee # Circuits/Feeders Fee
Swimming Pool 2 0 ps 0 to 100 Amps
Transformers Above 200 Amps Above 100 Amps
Si ns Inspector's Use On�y: TOTAL .�
Irrigation Booms �""" '�'"i'� ��� �rJ �-5 �
Special Inspection
Alarm/Communication THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT
Other Fee COMPLETED WITHIN 18 MONTHS.
I, the Electrical Inspector, hereby Rough-in Date
certify that the above inspection has Final � oa y�
been made. _�-
OFFICE USE ONLY
This request void 18 months from
0-18 7- 2 9-8 � 7�=5v �. �33�
Request�Date �� Fire No. Rough-In Inspection Required Inspecuon Other Than Rough-In
(You must call inspector w en ready) � Ready Now �, Will Notify Inspector
❑ Yes No Date Ready
I�licensed contractor ❑owner hereby request inspection of above electrical work at:
Job Ad ress (Street, Box or Route NoJ City
� �%!/ C— % ( rf �''� , �
Section No. Township Name or N Range No. County
.�o a �A,�
Occupa t(P INT) Phone No.
� � O`/r � �Gl�'Ol-Z
Power Supplier t � � Addres
N� . �2�� �s'/-I�o�v
Electric ontractor (Company ame) � Contractor's License No.
�ri aP `� c C� C � .7
Maiting A ess (Contracto� or Ownei Making Installation)
� /rl � l/ /l� s
Authorized ' ture (Con actor/ ner Ma ing Installation) Phone Number
52?� � 330�
Bh2ooe� 612g642-0800S oPm SMNB 51041CITY IIIII I�IIIIIIII II I II�I IIIII IIIII III�III�I II�I� ENfC OSEDOP ER INSPECTIONFOEE IDST