P - 80931ilIUI1111I I�IIIIIII�II�I� IIII�III IIIII I� III ME�neso a S atOe Board o� �ICALt�NSPECTION
, 1821 University Ave., Rm. 5-128, SL Paul, MN 55104
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�Home Duplex Apt.Bldg. Other.Sv���-� ,,,/�� New
Commerci — Industrial Farm �"r�H Rem
Air Con . Htg. Equip. Water Htr. Load Mgmt. Other:
Dryer - Range Elec. Hea} emp. Service
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above the work coveretl by th iequesf Enter remvks m th�s ace antl on ihe back of fhe �[e copy wrty.
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ulate Inspection Fee - This Inspection Reques[ will not be accepted without fhe co�ect /ee: �
Other Fee ++ Service Entrance Size Fee ++ Circuils/Feetlere Fee
Mobile Home Park Stall 0 to 200 Amps ( 0 to 100 Amps �(�
Street Ltg./Traffic Sig. Above 200_Amps Above 700_Amps
TransformeNGenerator INSPECTOF'S USE ONLY TOTAL .
SIgNOutllne Ltg. Xfmr.
Alarm/Remote Controi
Swimming Pool
Irrigation Boom h
Special Inspection
Investigative Fee
lechical inslella[ion tlesoribetl herein on �he tla�es statetl
Dale
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THIS INSTALLATION MAY BE ORDERED DIS��.`�NECIED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This reques! vatl 18 moNhs from vslqation �ate printetl'm Ihis Cox.
399-463 �
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tASE PRINT OR TYPE J�`� �
usst �ate RougMn inspeclion requirea? � y s �NO Ins cEOn Olher TM1an Rpl p.
���yAy � g In: ❑ Ready No � N✓ill Cal
- s r r- {o / � �� (YOU mus� call �he InspecloY when reatly) ' D 1 q tly
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�licensed contractor ❑ owrier hereby request inspection of the a6ove eleclrical work at'.
Atltlress (5trest, Bw, or Rw�e No.) �i�y ���
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ncal Gon�rac�or (Company Name)
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ig Pdtlress (COntracror or Owner Petlorming Installa[ii
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�rt�ef SgnaN� (GOntr�ptq� or Owner Perfo�'mino Inst
ConVac�or
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8/95 STATE BOARD COPV - SEE INSTRUCTIONS ON BACK OF YELLOW COPV
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No. fPIaN Eled.