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Home Duplex Apt. Bldg. Other: New Addn
Commerciai Industrial Farm Remod Re air
Air Cond. Htg. Equip. Water Htr. Load Mgmt. Other:
Dryer Ran e Elec. Heat + Temp. Service
"X" above the work covered by this request. Ente remarks in this space ond on the back of the white copy only.
Calculate Inspection Fee - This Inspection Request will not be accepted without the correct fee:
Other Fee � Service Enirance Sae Fee # Circuits/Feeders Fee
Mobile Home Park Stall � 0 to 00 Amps � � 0 to 100 Amps ��
Street Ltg./Traffic Sig. Above 200 Amps Above 100 Amps
Transformer/Generator INSPECTOR�suseoN�r TOTAL
Sign/Outline Lig. Xfmr. ��
Alarm/Remote Control
Swimmina Pool . .. .. . .
Special Ins�ct�n
Investigative Fee F�nal
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONT S.
2 1 �./ - 6 4 3 OFFICE USE ONLY This request void 18 months from validation date printed in this box.
� .�,��. �
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PLEASE PRINT OR TYPE
Request te Rough-in inspection required2 ❑ Yes ❑ No Inspection Other Than Rough-In: � Ready Now '�Jill Call
� � (You must call the inspedor when reody) Date Ready: �
I, }licensed contractor ❑ owner hereby request inspection of the above electrical work at:
Job Address ($treet, Box, or Route No.) Ci Zip Code
�
Section N ownship ame or No. � �� Range No. Firq o. County �
al.J
Omupf �nt � � ' � . Phone No.
V�C11 iIV1 �. �lirALri 10 ci i �(�,4L4 � I(irr'74
Power Supplier " �� �� � Address
Mailing Addreas (Contracior or Owner Performing Installafion)
5f41 1.�4tr,Fa.�t � �StE�
Authorize�,5'Lqnature (Conhacfor or Owner Pprforming Instal a
Conhacror License No. � Masier Lic. No. (Plant Elecf.
Phone No.
6/95 STATEBOARDCOPY-SELrINS7XMCTION30N�ACkOFYELLOWCOPY
U