P - 83872I I��I I�II �� III �! II� II III II �I� II III II II� �I I�I I IIII �REG1Uota StatOe B a dEof ERcCA �INSPECTION ����,�e
1821 University Ave., Rm. S-128, St. Paul, MN 55104 � ;
- f * U 3 ?= �' � % 4 8 * Phone (612) 642-0800 `����.� °a`
ome Duplex Apt. Bldg. Other: New Ad
Commercial Industrial Farm Remod e air
Air Cond. Htg. Equip. Water Htr. Load Mgmt. Other:
Dryer Ran e Elec. Heat Temp. Service
"X" above the work covered by this request. Enter remarks in this space and on the back of the whita copy only.
Calculate Inspection Fee - This Inspection Request will not be accepted without the correct fee:
Ofher Fee # Service Entrance Size Fee # Circuits/Feeders Fee
Mobile Home Park Stall 0 to 200 Amps 0 to 100 Amps
Street Ltg./Traffic Sig. Above 200 Amps r. Above 100 Amps
Transformer/Generator INSPECTOR'SUSEONLY TOTAL �� �
Sign/Outline Ltg. Ximr. �� (! ��� ` '�%��� "KG� ��`�
Alarm/Remote Control �� 1 ��(` �_ `n �._
Swimming Pool %�'�
I hereb certi fhat I ins eded ihe eledrical installation described herein on the dafes stated
Irrigation Boom Rough-In Date
$pecial Insp i
Final �'�' Dat
Investigative Fee f Z�
THIS INSTALLATION MAY BE ORDERED DISCO IF NOT COMPLETED WITHIN 18 MONTHS.
3� O- 414 � OFFICE USE ONLY This requesf void 18 mon}hs from validation date printed in fhis box.
, ��
PLEASE PRINT OR TYPE
���
Request Dafe Rough-in inspedion required� � Yes Inspecfion Other Than Rough-In: eady Now � Will Call
/ ��� �� � (Yoa must mll the inspecfor when reody) Date Ready:
I, icensed contractor ❑ owner hereby request inspection of the above electrical work at:
lob Address (Street, Box, or Route No. City Zip Code
� ,�j,;/%'� ,�L /�"% J1lC/L � �•'
iecFion No. Township Name or No. Range No. Fire No. C nty
�,�'��,��--
Jccup�t� . . Phone No.
Contrador f�� mpany Name) Conirador License No. Masfer Lic. No. (Planf Eled.
' !7`� / .�-£d <� �/ r G J �— ��f ��"l
'�ddress (Contrador or Owner Perfortning Install n)
- ,, �,, �� �- ���<
� 'gnature �Confracior or O r P orming Installation) t-- .=� i-. �.,. Ph ne o.
_�� — ..---� �3 � � % � �j .<-��r_ C�I ��
A-10 6/95 STATE BOARD COPY- SEE INSTRUCTIONS ON BACK OF YELLOW COPY