P - 82594-� I II�� I� III �� II II �I� II II� II III II III II II) II III I IIII 8E1�U E eSsaOAve., Hm� S-�ic BASt.' PaulP, MNT55O104 �� ���_�
* 0� 3 4 7 5 8 9 4�K Phone (612) 642-0800 ��'a�'y"�'
Home Dupiex Apt. Bldg. Other: New Addn
Commercial Industrial Farm Remod Re air
Air Cond. Htg. Equip. Water Htr. Load Mgmt. Other:
D er Range Elec. Heat Tem .$ervice
"X" above fhe work covered b this request. Enter remarks in this space and on the back of the white copy only.
Q' ���,rp u w�.Q � p:.�.f L..�-t-S TO Bc� t- m s� a�.. d� � a2dL
0 o a� �.. P GFI' fib �af L, � Q a� d� � o a� ►�.(� r�.� .� P7`� 7`a
�l'�'fC.��R ►�. - lr'6 uJ %-i k b s mrt" ro o�,. ct N cf -F� n; 5 l�. 8s�.%
Calculate Inspection Fee - This Inspection Request will not be accepted without the correct fee:
r°��.
Olher Fee # Service E�hance Size Fee # Circuiis/Feeders Fee
Mobile Home Park Stall 0 to 200 Amps 0 to 100 Amps
Street Ltg./Traffic Sig. Above 200 Amps Above 100 Amps
Transformer/Generator INSPECTOR'SUSEONLY TOTA
Sign/Outline Ltg. Xfmr. d D�S�
Alarm/Remote Control
Swimming Pool
I hereb ceAi that I ins eded }he eledrical instollation described herein on ihe dates sTated
IrrigdtionE$ prn + r. Rough-In ��e ��
Special I i t� � �
Final Dat Z,_O Z�
Investigative Fee --
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
3 4 7�� 8 9 �, OFFICE USE ONLY This requesf void 18 mon}hs from validation date printed in ihis box.
+ �G ��
����
PLEASE PRINT OR TYPE
Request Date Rough-in inspeciion required2 Yes � No Inspedion Other Than Rough-In: Q Ready Now � Will Call
Z� a o (You must call the inspedor when ready) Dafe Ready:
I, licensed contractor ❑ owner hereby request inspection of the above electrical work at:
Job Address (Streef, Box, or oufe No. Cify Zip Code
� !� �� �1 v.� . .t/� � , �r� e�L sz �'si�3 Z
Sedion No. Township Name or No. Ranqe No. Fire No. Co nty
Occupant
�0. k �.- �a-E'�S ah
Power Supplier Address
�S� [`' , �, ,
EIe�D� o,�r-�brc9mP�'� c.� � y�
d� G�� 1"� G., rt � i
Mailing Address (Con}rador or Owner PerforminCg Insfallation)
o`t7 �i.tni ,r�r 5��
Authorized $ignature (Controdor or Owner Perfd�mina InstallafiorJ
EB-OOOOlA-10 6/95 STATE BOARD COPY- SEE
,�n o c�'t
Phone No.
�,� Z So z. 67.�a
Confrodor License No. Master Lic. No. (Planf Eled. Only)
�f�-D.� �7� —
{�la. �fa /°k.2 d1 �' :�S-l�S
, Phone No.
�s� �s3 ���.s
fIONS ON ACK OF YELLOW COPV