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Home Duplex Apt. Bldg. Other: New
Commercial industrial Farm Remod
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Air Cond. Htg. Equip. Water Htr. Load Mgmt. Other:
Dryer Range Elec. Heat Temp. Service
"k' above the work covered by this request. Enter remarks in this space and on the back of the white copy only.
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Calculate Inspection Fee - This Inspection Request will not be accepted without the correct fee:
Ofher Fee # Service Entrance $ize Fee # Circuiis/Feeders Fee
Mobile Home Park Stall 0 to 200 Amps 0 to 100 Amps
Street Ltg./Traffic Sig. Above 200 Amps Above 100 Amps
Transformer/Generator INSPECTOR'SUSEONLY TOTAL
Sign/Outline Ltg. Xfmr. �. �d
Alarm/Remote Control
Swimming Pool
I hereb cefi that I ins eded ihe eledrical installation described herein on the daks stated
Irrigdtion Boom Rough-In - Date
Special Inspedi6 ` r�t �) '� Z" "
Final � Date
Investigative Fee
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
2 8 6- 9 2 5 �FFICE USE ONLY This request void 18 monihs from validation date printed in �is box.
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PLEASE PRINT OR TYPE �� "��
Request Date Rough-in inspedion required2 �Yes ❑ No Inspedion Other Than Rough-In: � Ready Now Will Coll
(You must call ihe inspector when ready) Date Ready:
I, licensed contractor ❑ owner hereby request inspection of the above electrical work at:
Job Address (Sfreet, Box, or Route No.) City Zip Code
�s � - � d!� i�3-�
$edion No. Township Name or No. Range No. Fire No. County � ,
Occupant
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Power Supplier
Eledrical Con}rador �Company
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Moiling Address (Con ra r or
Aut rized Sign re � ntra�-fc
-00 A-10" 6/95
Phone No�
Address
Contrador License No.
InsTallation)
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Master Lic. No. (Plan
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STATE BOARD COPY- SEE INSTRUCTIONSON BACKOF YELLOW COPY
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