P - 84604( III�•fll II II) II III II (II (I III II III I) III �I I�� I I��I 82�U� eSsaO B a Rm� SR�BASt.' PauP MNT55O104 u��
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Home Duplex Apt. Bldg. Other: c� .�./Y1 - New Addn
Commercial Indushial Farm ��-- • S�1 i� Remod Re air
Air Cond. Htg. Equip. Water Htr. Load Mgmt. OtherE4A
D er Ran e Elec. Heat Tem .$ervice +�I—rT ���� �@A' �
"X" above the work covered by this request. Enter remarks in this space and on the back of the white copy only.
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Calculate Inspection Fee - This Inspection Request will not be accepted without the correct fee:
Olher Fee # Service Enhance Size Fee # Circvits/Feeders Fee
Mobile Home Park Stall 0 to 200 Amps 0 to 100 Amps
$treet Ltg./Traffic Sig. Above 200 Amps Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY TOTAL �z
$ign/Outline Lig. Xfmr. � JZ r. (�- �� ��'
Alarm/Remote Control � '
wimming Pool �� 27��
I herebvi certifv that � insoeded Ihe elechical installation described herein on the dates smfed
0
Investigative Fee �-f�--�' "�'LPG r
THIS INSTALIATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 1 MON HS
2 9 9- 3 7 3 � OFFICE USE ONLY This request void 18 menlhs (rom volidofion date prinfed in fhis box.
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PLEASE PRINT OR TYPE
Request Dak Rough-in inspattion required2 Yes � No Inspeclion Other Than Rough-In: Q Ready Now Will
�'`�"R� (You must call fhe inspedor when r dy) Date Ready:
I, ❑ licensed contractor� owner hereby request inspection of the above electrical work at:
Job Address (Streef, Box, or Route No.) Ciy Zip Code
�SS'l l,ew��D'CER- �0.�p Lt`'� SS� � Z-
$eclio� No. Township Name or No. Range �lo. Fire No. Counfy
71.7 %�{ t9aOK4
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P Phone No.
00'� �it.FKy4a4E� ��`'f -�7l� �
Power Supplier Address
/�/S P MP�S nk� p�� c� � o.�
Elethiwl Conhacfor (Company Name) Contrador License No. Master lic. No. (Plant Eled. Only)
DwN�-
Mailing Address (Confracfor or Owner Performing Insfallafion)
SA�.E
Authori ig n or Pe in ns lafion) Phone No.
� 7% `�'D'1 (. !
EB-OOOOlA-10 6/95 STATE BOARD COPY- SEE INSTRUCTIONSON BACK OF YELLOW COPY
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