P - 84345I I�� II II) II III II III II III II III (I III I) III I) III I(III 8E1�Uota SsaO Be dR o S-�icBASt.I PauP MNT5�5 04 �����
* 0 3 3 6 1 7 6 3* Phone (s12) srya2-osoo �`"�'�
Home Duplex Apt. Bidg. Other: New Addn
Commercial Industrial Farm Remod Re air
Air Cond. Htg. Equip. Water Htr. Load Mgmt. Other:
D er Range Elec. Heat Tem . Service
"k' above the work covered by this request. Enter remarks in this space and on the back of the white copy only.
Calculate Inspection Fee - This Inspection Request will not be accepted without the correct fee:
Olher Fee # Service Entrance $ize Fee # Circuih/Feeders Fee
Mobile Home Park $tall 0 to 200 Amps 0 to 100 Amps
Street Ltg./Traffic $ig. Above 200 Amps Above 100 Amps
Trans{ormer/Generator INSPECTOR'SUSEONLY TOTAL
Sign/Outline Ltg. Xfmr. � • �
� Alarm/Remote Control , (J�
Swimming Pool
I heieb ceAi that I ins ecTed }he eledrical insTallation described herein on the dates stated
Irrigation Boom Rough-In Date
Speciallnspe �
� Final � r Da�� ` _q
Investigative Fee .� !
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
3��-17 6 0 OFFICE USE ONLY This request void 18 months from validation date printed in }his box.
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a� •
PLEASE PRINT OR TYPE
Request Dote Rough-in inspection required2 ❑ Yes � No Inspedio� Other Than Rough-In: ❑ Ready Now � Will Call
��/ � (You must call the inspedor when ready) Date Ready: / C`'�
I, licensed contractor ❑ owner hereby request inspection of the above electrical work at:
Jo Ad ess �Sireef, Box, or R ufe No.) City Zip Code
E.. �, . ��
Secfion No. Township Name No. Range No. Fire No. Co
. , c� � �.'�v► t/� /�e�SG �,-.-� �7� � ' 7 �7 �
Power $upplier Address
Elechi Conhactor Company Name Confrador License No. Master Lic. No. (Plant Elect. Only)
�� � �. es � � a�
Mailing Address (Co dor or Owner Performing stallafion)
�9 �rv< <n. � e � � /3,� �� r�� /yt u ss ��/
Authoriz at dor or Owne erfortning Installafion) � Phone No.
2�� r2 ���'/
EB- -10 /95 STATE BOARD COPY- SEE INSTRUCTIONS ON BACKOF YELLOW COPY