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Home Duplex Apt. Bldg. Other: New Addn
Commercial Industrial Farm Remod Re air
Air Cond. Hig. Equip. Water Htr. Load Mgmt. OTher:
D er Ran e Elec. Heat Tem .$ervice
"X" obove 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:
Other Fee � Service EMra Size Fee # Circuits,
Mobile Home Park Stall 0 to 0 Amps 0 to 100 Ai
Street Ltg./Traffic Sig. Above 200 Amps Above 100
Transformer/Generator INSPECTOR'SUSEONLY
5ign/Outline Ltg. Xfmr,
Alarm/Remote Control
Swimminq Pool
Fee
Amps �
TOTAL
3 0•�
5mr�d
miyu�ron ovvr Rough-ln Dak
Special Inspe n c�
Investigotive Fee Flr,al D
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THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
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2 2�- 5 7 3� OFFICE USE ONLY This request void 18 months from validation daie printed in mis oox.
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PLEASE PRINT OR TYPE
Req�est Date Rough-in inspedion requiredZ ❑ Yes � No Inspedion Other Than Rough-In: Q Ready Now� Will Call
� t"') (You must call the inspedor when ready) Daie Ready:
I, � licensed contractor ❑ owner hereby request inspection of the above electrical work at:
1ob Address (Street, Boz, or Route No.)
Ciry Zip Code
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Secfion No. Township Name or No. Ra�ge No. Fire No. Co nty �
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Phone No.
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Power $upplier Address
Conhador License No. Masffir Lic. No. (Plant Elecf.
:driml Coniroctor ompany Nama) �A _ � r�
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ailing Address (Contrador or Owner Perfo ing Insmllation) � � �� � ��
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Phone No.
,Ahori ed Signature (Contracl r O ner Pe�orming lostallafiga�, �^ �
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_ A-10 6/95 N STATE BOARD COPY - SEE INSTRUCTIONS ON BACKOF YELLOW COPY