P - 78501n�uvc�� rV�1 [LCl.11SIl,AL IIY,1'tl.I1VIY
"'X" Below Work Covered by This Request
Add Rep• Type ol Buildinq ApD��ances Wirsd
Home Range
Duplex Water Heater
Apt. Bu�lding Dryer
Commercial Bidg. Furnace
�ndustrial Bldg. Air Cond�tioner
FBrT ther pec� v
c r ueci y t er
�ompute lnspection fee Be1ow
11 fes S�rvic�Entrenc�Site p Fse Faeders�Subtesders A
Otol00Am Oto30Am s
101 to 200 Amps 31 to 100 Amps
Above 200 Am Above 100_Am s
Transformers Remote Control Circ.
Signs Specialinspection S
emarks /� �, _ .r . `� �, i- �
�1
� � � �
Equ�oment Wired
Temporary $grvice
Lighting Fixtures
Electric Heat�nq
Silo Unioader
Bulk Milk Tank
ther ISoecitvl
Fes Circuits
0 to 30 Amns
31 to 100 Am s
Above 100_Am .
artial!Other Fee
�� TOTAL FEE
�e I. ths Elsctriesl
Insvsctor, hsrsby
certif that tM b
D:�te� � � ove
F��a� inspsction Aas been
2 � Q msde.
This reQue51 vo�d
18 nanths f�om �
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� , �, ��V � .. .. �
Th�s reouest vo�d �5�
, 8 ,��t��.f.�„ �,�� 2 2 � 5
qequest Da e F�re No. Rouph-�n Inspection
/ i16Quired? �ReatlV Nuw ['j Will Not�fV InSPec•
❑Ves �No tor When Ready
L�ce� ed Eie nca� Contractor � � ti�r�b� r�qusat inspsct�on of sbovs
❑ a^'^e� r •ISetrical work installed at: �
S�reet r ss, Box or ute No. Crtv
� C� > �f� � /� ��.[J
Occupent (pRINT)
E
ny Namel
�
o► Owner
Ilnstailatfy�)
�p Install lk
Pnone No.
ontractor"s Ucense No.