P - 84675RII�� II III I) II) II IiI II III II II) II II) I� II� I I��I g21�Un'rvers�OAve. dRm. SR 28ASt.I PauP MNT55�104 ����e,
* 0 2 9? 2 4 L 2* Pnone (s12) s�a2-osoo � � �'_�
Home Duplex Apt. Bldg. Other: New Addn
Commercial Indushial Farm Remod Re air
Air Cond. Htg. Equip. Water Htr. Load Mgmt. Other:
D er Ran e Elec. Heat Tem .$ervice
above the work covered by this request. Enter remorks in this space and on the back of the white copy only.
,A G
Calculate Inspection Fee - This Inspection Request will not be accepted without the correct fee:
Ofher Fee # Service Entrance Sae Fee # Circuits/Feeders
Mobile Home Park Stall 0 to 200 Amps 0 to 100 Amps
$treet Ltg./Traffic $ig. Above 200 Amps Above 100 Am
Transformer/Generator INSPECTOR'SUSEONI.Y T� A
$ign/Outline Ltg. Xfmr. �
Alarm/Remote Control
$wimming Pool
Fee
1 hereb cerfi that I ins ecled the elechical installafion described herein on fhe dates sMfed
Irrigation Boom Rough-In Dare
Special Inspedi
Final Date
Investigative Fee
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
2 9 7- 2 41 �] OFFICE USE ONLY This requeat void 18 months from volidafion date printed in this box.
/�
�/S S� �'<3�'Sv
PLEASE PRINT OR TYPE
RequesT Dafe � Rough-in inspedion required2 � Yes ❑ No Inspedion Ofher Than Rough-In�.
Q(`(ou must coll the inspector when ready) Dafe Ready: �
I, licensed contractor ❑ owner hereby request inspection of the above electrical work at:
Jo� �ress Sheeti Bpx, or Roufe No.) C� �, ��� - Cify t\ 1 ^''
, �-
Is«ho� No.
�
I�ctriml Conhacror (C ompany Name) r,
/\
or
Range No. Fire No. �
Address
, - CNnhactQr License No.
11 J► � '
Ready Now � Will Call
ya
Master Lic. No. (Plant Elecf. Only)
�
Phone No.
A-10 6/95 STATE BOARD COPY - SEE I ST U I BACK OF YELLOW COPY