P - 84486„. 1I��II IIIII IIIII IIIII IIII) (IIII IIII) IIIII IIIII SE1�UEv Ssiry Ave., dRm. S�-1c8ASt.lPauP MNT O 04 �����-���
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Home Duolex Apt. Blda. Other: New Addn
Air Cond. tg. Equip. Water HTr. Load Mgmt. Other:
Dryer Range Elec. Heat Temp. Service
"k' 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 # $ervice E�ironce Sae Fee # Circuiis/Feeders Fee
Mobile Home Park Stall 0 to 200 Amps 0 to 100 Amps
$treet Ltg./Traffic $ig. Above 200 Amps Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY TOTAL �
Sign/Outline Lti
Alarm/Remote �
$wimming Pool
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I hereb ceAi that I ins ecFed the eledrical installotion described herein on the daMs sfated
Irfl9afion Bo Rough-In pate
Speciallnsp '
Irnestigative Fee Final ���„` f ��_^ �,.�
THIS INSTALLATION NH4Y BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
3�/� �/� ^^ OFFICE USE ONLY This request void 18 months from validafion date printed in this box.
1.E L.E O L ,�
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PLEASE PRINT OR TYPE
Request Date Rough-in inspedion required2 � Yes No Inspection Other Thon Rough-In� Ready Now � Will Call
� � �.� (You musT call ihe inspedor when ready) 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
� � � �.K��1 'U1., �u�-Q �.��
$eclion No. Township Name or No. Range No. Fire No. _ . „
Ph�N�� 1 �� � �
Power Supplier
EI 'cal Contrador (Company Name) •. Confractor Licen e No. Master Lic. No. �Plant Eled. Onl}
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Mailin d (Contrador or Owner Performing Installation)
o� � ..�'n �
Authorized Signatu ntracfor or r e Ilafion) ^ ho o. '��..-� e--�
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