P - 84721'`rIlll�lll II III (I (II (I III II III II III II III (II�� I I�II 82��Ea Ss OA e RE�c SRI 8p►S' PaulP, MNT O o4
�* 0 2 9 9 3 9 4 7 * Phone (s�2) s�a2-osoo
Home Duplex Apt. Bldg. Other: �'� .� � Q� New
Commercial IndusMial Farm �dP � Remo�
Air Cond. Htg. Equip. Water Htc Load Mgmt. Ot i
D er Ran e 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
�-1,l� G'.e•� o�.� y E��v- �� 6°i�� � F��' ?b
2 00 .9*z� 4'�.c�„ :/i�� s/-�a(�..t� S G'�.�cc..c..�3
Calculate Inspection Fee - This Inspection Request will not be accepfed without fhe correct fee:
Olher Fee � Se ' ira Size Fee # Circuiis/Feeders
Mobile Home Park Stall 0 200 ps 0 to 100 Amps
$treet Lig./Traffic $ig. Above 00 Amps Above 100 Amps
Transformer/Generator INSPECTOR'SUSEON�Y TOTA�,
�'���
��:�:��
Addn
Fee
/ �i
<�
Alarm/Remote Control ��.� V
Swimming Pool
I hereb cerfi That I ins dad the eledri I installation described herein on fhe dates stafed
Irrigdtion Boom Rough-In �a� r�c��
$pecial lnspedion � `
Final �a} f 7/_
Investigative Fee �F�
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
2 9 9- 3 9 4� OFFlCE USE ONLY This request void 18 months from validation date printed in this boz.
'� ,�-3f��S
PLEASE PRINT OR TYPE
Request Dak Rough-in inspecfion required2 �es � No Inspeciion Olher Than Rough-In: $.&eady Now ❑ Will Call
7�Z 3^ �� (l'ou musf coll the inspecior when ready) Date Reody: ? Z 3 �
I, ❑ licensed contractor'�owner here6y request inspection of the above electrical work at:
Job Address (Street, Box, or Route No.) City Zip Code
6 20 l�.Tn' .,Sj, '^ � r✓ `1`3 2
Seclion No. Township Name or No. Range No. Fire No. Counly
Occuy�nt
C� % G � �f�,cf�
Power Supplier
� V
Elecirical Contracror (Companr Nome)
� Mailing Address (Contractor or Owner
Phone No.
�lb• 3/j
Address
Confmdor License No.
,3g_21�o
Master Lic. No. (Plant Eled. Only)
Authonzed Signature (C ntrodor or Owner Perfo nstallotion) I Phone No.
R -y,
��� � L�t ����
EB-OOOOlA-10 6/95 STATE BOARD COPV - SEE INSTRUCTIONS ON BACKOF YELLOW COPY