P - 79614REQUEST FOR ELECTRICAL INSPECTION �
, V t�f �— 313 � 812f Uni ersity A earRm. S-128,fSt. Paul, MN 55104 �
Phone(612)642-0800 �
Home Duplex Apt. Bldg. Other: �Q (' t� New Addn
Commercial Industrial Farm � J Remod Re air
Air Cond. Htg. Equip. Water Htr. Load Mgmt. Other:
Dryer Range Elec. Heat Temp. Service
"X" above the work covered by this request. Enter remarks in this space and on the back of the white copy only.
Calculate Inspection Fee - This Inspection Request will not be accepied wifhout the correct fee:
Other Fee # Service Entrance Si Fee # Circuits/Feeders Fee
Mobile Home Park Stall to 00 Amps 0 to 100 Amps
Sfreet Ltg./Traffic Sig. Above 200 Am s Above 100 Amps
Transformer/Generotor INSPECTOR'S USE ONLY � TOTAL.,�� �y
�� _ 1�� 'A�, � ,� r.,a ��
Sign/Outline Ltg. Xfmr. „�� - . /�r�c
Alarm/Remote Control y���G_C��.�,p
Swimming P ``""
I hereb certi that I ins the elechical inatallafion described herein on the dotes sfated
Irrigation Boo RougMln
Special Inspection �- � � � G •
Final Dafe
Investigative Fee � �e �a �43
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF T COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This requesf void 18 monihs from validation date printed in this box.
I III) II III II III I) III II III II III II III ���
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PLEASE PRINT OR TYPE
Request Dale Rough-in inspecfion required$ Yes ❑ No Inspeclion Other Than RougMn: ❑ Ready Now ill Call
� O� �You must call fhe inspector when ready) Dafe Ready:
I, ❑ licensed contractor owner hereby request inspection of the above elechical work at:
Job Address (Street, Box, or Route No.) City Zip Code
/(./ �.e c c ss y3 z-
Secfion No. Township Name o�� Range No. Fire No. Counly
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Occupanf � � �� � ^ a � � Phone No.
V4 ,
Power Supplier Address
L, L s �.11D,�
Elechical Contraclor �Company Name) Conkacfor License No. Master lic. No. (Planf Elect. Only)
/
Mailing Address �ConhacTOr w Owner Performing Insfallation)
� SS 3 � -
Authorized $ignalure (Confracfor or Owner Performing InstallaKon) . Phone No.
EB-00001 A-11 8/96 STATE BOARD COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY