P - 81742��s
_ lINS�������
T Foa E�EC�RICa ''
REQU�$ ��,,,p R�ard ot ESectricity _ �
- - r Remod Re
��/� ���,�..r. Water Hh. Load Mgmt. Other:
� �` v SrF Range Elec. Heat Temp. Service
X" above the work covered by this requesi. Enter remarks in this space and on the back of the white copy only.
Calculate Inspection Fee - This Inspection Request will not be occepted without the correct fee:
Other Fee # Service Entrance Size Fee # Circuits/Feeders Fee
Mobile Home Park Sta11 0 to 200 Amps 0 to 100 Amps (�� �
Street Ltg./Traffic Sig. Above 200 Am s Above 100 Amps . J a
Transformer/Generator INSPECTOR'S USE ONLY TOTAL
Sign/Outline Ltg. Xfmr. c�� S O
Alarm/Remote Control
Swimming Pool
I here6 certi that I ins the e al installrnion described herein on the dates stafed
Irrigation Boom Roughan Dare a.,
Special Inspection
final D te��d �.�
Investigative Fee /
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFlCE USE ONLY This request void 18 moMhs from validafion date prinfecl in this box.
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ll�l�l i
* 0 8 0 2 2 4 9 3* �j.,s0
PLEASE PRINT OR TYPE
Request Dafe Rough-in inspecfion reqoired$ �'`(es ❑ No Inspection Olher Than Roughln: ❑ Ready Now 0 Will Call
��- ,� ]- ' �� � �You must call the inspector when ready) Date Ready:
I, ❑ licensed confractor L�Jowner hereby request inspection of the above electrical work ot:
Job Address (Sheet, Box, or Route No.) Ciry Zip Code
/� y T.9-L �,F-� .�. �r/ . Lt � , � �� s 3 "t�-3 z-
$ection No. Township Name or No. Range No. Fire No. County
� (� o� �'�o ��
Occup t Phone No.
_ �l>�.%. _��i.i�e.[, %(93' 5�71 - Of63
o� � L
�me�
�.
g Address—(Coniractor or Owner Performing Insfallafion)
� �4" �u -C..�
�ized SignaNre �Conhacror or r PerForming Inslallafion) Phone No.
�,J� ���� �63 -.S 71-OYG3
OlA-1 1 8/96 STATE BOARD COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY