P - 84584I(li� ��� � III II III II III 11 III II II) I) (II II I�I I IIII M 21� Un'rversaOAve. dRm. SR1 SASt.' PauP MNT O 04 �.,�
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'� 0 2 9 5 1 4 4 0 * Pnone (si 2) s�a2-osoo � ' '�'�"
ome Duplex Apt. Bldg. Other: New Addn
Commercial Industrial Farm Remod Re air
Air Con . Htg. Equip. Water Htr. Load Mgmt. Other:
D er Ran e Elec. Heat Tem . Service
"' above the work covered by this request. Enter remarks in this space and on the back of the white copy only.
Colculate Inspection Fee - This Inspection Request will not be accepted without the corred fee:
OIF�er Fee � Service Enfinnce Sae Fee # Circuits/Feeders Fee
Mobile Home Park Stall 0 to 200 Amps 0 to 100 Amps
Street Ltg./Traffic $ig. Above 200 Amps Above 100 Amps
Trans{ormer/Generator INSPECTOR'SUSEONLY TOTA
Sign/Outline Ltg. Xfmr. �� ��
Alarm/Remote Control
Swimming Pool,
I hereb cerli that I ins ecfed the alechital installation described herein on the dates slated
Iffl9aiiOn BOO ~ Rough-In paK
Special Insp , —
Finoi
Investigative Fee - .r � . L- - 7
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
2 9 5-14 4�] OFFICE USE ONLY This request void 18 monlhs from validafion date printed in this box.
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PLEASE PRINT OR TYPE
Request Date Rough-in inspecfion required2 � Yes No Inspection Other Than Rough-In: Ready Now � Will Call
��'p •�� (You must call the inspedor when reudy) Dafe Ready:
I, [�licensed contractor ❑ owner hereby request inspection of the above electrical work at:
Job Address (Street, Box, or Route No.) ^ Ciy Zip Code
� 3 C�,r�-o.n�, r i. ;-�ri �43�
.,�.{�r,�-
$edion No. Township Name or No. Range No. Fire No. Co
Occupant
� ���� Phone No.
Power Supplier Address �� � �� �
Elechical ConTracfo; (Compan Name) � Conhactor License No. Mas�er Lic. No. (Planf Eled. Only)
�t t')►1 S � �.,e_�YI �— C.A-n��t�g
•••-����•a ��, •+,,,,��,�� r vwnar eno ing msrouaeon /� �
'L.6�,
.
Autho Si hador or Owner Performing Installafion) ��� �� � Phone No.
EB-OOOOlA-10 6 5 STATE BOARD COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPV