P - 83779I I��I ��I �I III I� III I� III II III II III II II) If �I) f I��I rREGlUota StatOe B a dEof ERcCA �INSPECTION �,��s�
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�* 0 2 9 9 4 � 3 6 * 1821 Urnversity Ave., Rm. S-128, St. Paul, MN 55104 �. _��
Phone (612) 642-08 ��z"��`�°°�'
Home Duplex Apt. Bldg. Other: �/��l S� New Addn
Commercial Industrial Farm Remod Re air
Air Cond. Htg. Equip. Water Htr. Load Mgmt. Other:
Dryer Ran e Elec. Heat Tem .$ervice
"X" above the work covered by this requesf. Enter remarks in this space and on the back of the white copy only.
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Calculate Inspection Fee - This Inspection Request will not be accepted without the correct fee:
Olher Fee # Service Entrance ' Fee # Circuiis/Feeders
Mobile Home Park Stall 0 to 00 Amps 0 to 100 Amps
Street Ltg./Traffic Sig. Above 200 Amps Above 100 Amp:
Transformer/Generator INSPECTOR'SUSEONLY TOTAL
Sign/Outline Ltg. Xfmr.
Alarm/Remote Control
Swimming Pool
I hereb certi that I ins eded the eledrical installatiorvdescribed herein on }he dafes st
Irrigafion Boom Raugh-In Dote
Special inspe r— �,�,
Final %
Investigative Fe �Q,.�,'-- � �., �
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHI 16 1
2 9 9- 4 0 3 0 �FFICE USE ONLY This requesf void 18 monfhs from validation date prinied in this box.
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Fee
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PLEASE PRINT OR TYPE
Request te Rough-in inspedion required2 � Yes � No Inspedion OtherThan Rough-In: � Ready Now � Will Call
'�� '�� (You must call the inspedor when ready) Daie Ready:
I, licensed contractor ❑ owner hereby request inspection of the above electrical work at:
Job Address ($treef, 8ox, or Route No.) Ciy Zip Code
Co i � �S (� 1r'''' � � /�/ � /2l �—� S" �
edion No. Township Name or No. Range No. Fire No. Coun
�-, "�� D
Occupanf Phone No.
�''.� h t� L v� wl �,v►
Power Supplier
�I Conimctor (Company Name)
/�E`^ � /%�
Address (Conirador or Owner Performing
ress / J � � �� /� �
/� % k�J<
on}rador License No. Master Lic. No. (Plont Eled. Only)
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I���X �`�?--c� /=-��,�-� L c v �l�v �'S`
Authorized i�aiure (Con oTpr Own�r Performing Installation) Phone
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10 6/95 STATE BOARD �OPY -$EE INSTRUCTIONS ON BACK OF YELLOW COPY