P - 84262� III� II �I II III (! III II III II III II III II III (� I�I I I��I BE�Uota SsaO Be dR o S-�ic BASt.I PaulP, MNT5O5104 ���_��
* 0 2 9 9 3 5 0 9* Pnone (s� 2) srya2-oaoo �°�`'��a"�
ome Duplex Apt. Bldg. Other: New Addn
Commercial Industrial Farm emod Re air
Air Cond. Htg. Equip. Water Htr. Load Mgmt. Other:
Dryer Ran e Elec. Heat Tem . Service
C' 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:
OFher Fee # Service Entrance $ize Fee # Circuits/Feeders Fee
Mobile Home Park Stall 0 to 200 Amps 0 to 100 Amps
Street Ltg./Traffic Sig. Above 200 Amps Above 100 Amps
Transformer/Generator INSPECTOR'suSEONI.Y TOTAL
Sign/Outline Lig. Xfmr. ��'�
Alarm/Remote Control
$wimming Pool
I hereb certi that I ins eded the eledrical insfallation described herein on ihe dates stated
Irrigation Boom Rough-In ��
Special Inspe (�' f .
Final Dat ,6
Investigative Fee t 1 '� �
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
2 9 9- 3 5 0� OFFICE USE ONLY This request void 18 monfhs from validation da}e printed in fhis box.
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PLEASE PRINT OR TYPE
Request Date Rough-in inspedion required2 ❑ Yes � No Inspecfion Other Than Rough-In: � Ready Now ❑ Will Call
1�- /�—� (You must call the inspedor when ready) Date Ready:
I, licensed contractor ❑ owner hereby request inspection of the above electrical work at:
Job Address treei, Boz, or R/ouie No.) City r� Zip Code
�� " CCa� L C_�i`�L_- `"%� �� � r. SSz��
Secfion No. Township Name or No. Range No. Fire No. Counly
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Occupant �—�
Phone
Power Supplier � Addre;S ` j
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Eledrica n}mcfor (Company Name) � CoMmdor License No. MasMr Lic. No.
or Owner Perfo ing Insfallation)
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Authonzed Signature (Contrador or Owner Perfo i I tallation) Phone No.
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EB-OOOOlA-10 6/95 STATE BOARD COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY