P - 82712. ..,�..... ,,. �,, . �,., a .,.,_.,� ,.,. „
REQUEST FOR ELECTRICAL INSPECTION
"X"" Below Work Covered by This Request
Add Nep. Type ot Building Appliancea Wired
. Home Range
Duplex Water Heater
Apt. Buiiding Dryer
Commercial Bldg. Furnace
Industrial Bidg. Air Conditioner
F3rm - ther pec� v
� � uecify
ite lnspecteon Fee Below
Fse Ss�viceEntrsnc�Sise
0 to 1 UO Am s
101 to 200 Amps
Above 200 Am ,
Transformers
ema r ks
ouah- i n
lf
1Q�52
Equipment Wirod
Temporary $ervice
Lighting Fixtures
Electric Heat�ng
Silo Unloader
Bulk Milk Tank
�her ISpecifvl
Other
Fee Feeders/Subfeeders !� fee Circuits
0 to 30 Am s 0 to 30 Am
31 to 100 Amps 31 to 100 Am
Above 100_Am s Abov 100_Am ,
Remote Control Circ. — Partial�Other Fee
Specia� Inspection S���� TOTAL FEE
��
Date �. �h� Electrical
� . Inspseto►, her�by
, csrtify that tb� nbovs
Flnal ���P inap�Ction h�s b�en
D'-� m�d�.
This repuest voA � n O(�
18 months from;� J J
This request vo�d • � 1 O 0 5 2
18 months from �'7
O�
Request Date F1re No. pequired?��g�ection �Ready Now Q W��1 Noufy Inspec-
�-(p ` q ❑ Yes ❑ No tor WAen ReadY
� L�censed E�ectncal Contractor
Owner
Street Address, Box or Route No.
9
Occu � t (Pfi1NT1
����� 5��2
Power $upplier � _ .
Electncal Contractor lGompanv Nama!
Maillnp Address ICoMractor a Owner
ns ta i I a
1 h�r�by rsqu�st inspsction of abov
elsctrical work installed at:
Pnone No.
L-.JL V �
tor's L�cense No.
ad Sipnature (Contractor�Owner Maki�p Installation) Pho�e Number
�Q �