P - 84000RE�UEST FOR ELECTRICAL INSPECTIOIV �� o� 7
""X" Below Work Covered by This Request
Add Rep. Type ot Building Appliances Wired Equipment Wired
HO� ��9e Temporary Service
Duplex Water Heater Lighting Fixtures
Apt. Building Dryer Electric Heat�n
Commercial Bldg. Furnace Silo Unloader
Industrial Bldg. Air Conditioner Bulk Mllk Tank
Fdrm O�her pec� � O�her ISaec�f�1
< < peci(y ther Other -
Compute lnspection Fee Below
t� � Fse ServicsEntrancsSize JJ Fee Feeders/Subfeeders b fee Circuits
0 to 1 UO Am s 0 to 30 Am s 0 to 30 Am
101 to 200 Amps 31 to i �0 Amps 31 to 100 A
Trans
�i gns
rks
_/2�h f I
i-�n
final �
Th�s request void
18 nanths fro� � n
�
lJ � ��
Th�s repuest void �
18 mpnths fwm
nequest Date
1�-�-�7
❑���yyy licensed Electncal Contractor
�Owner
Stree� Address, Box pr Route No.
o���irvri
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Power $upplier
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Elecvical ontractor ICompany N
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Ma�Unp A ress IContrector w O�
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AuMonzed Slflnature (ConlractoN
Fire No
m
Above 100_.Am s Above 100_Amp,
Remote Control Circ. Partial!Other Fee
Speciai Inspection S /���1
/� � TOTAL FEE
�
Date
I, ths Electrical
. Inspecto�, hersby
certify that the above
�"�P inspsction has bee�
1 / ✓ 7 � '�l'�% mads.
asb 9�� � � 3 9
6� 9�
��i�O
Rouph-in InsDec[�on
Required? �Ready Now Q W�II Noufy Inspec-
❑ Yes � No tor When Ready
I heroby request inspectlon of above
electrical work installed at:
C ity
_� ` , �/� l.4 �,�_
Pnone No.
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Addre
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BI
ir MakinQ Instailation)
�ner Makinp Installationl
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Contractor"5 License No.
umber