P - 84508I II� ��) II I�� II III �) I� 11 III I) III II II) I� �II I IIII ME� Uota s�OAve. dRm. S-1' SA� PauPEMN �104 �v.:..
"* 0 2 9 9� 6 1 6 * Phone (612) 642-0800 "�'
Home Duplex Apt. Bldg. Other: � New Addn
Commercial Industrial Farm .,5� Remod Re air
Air Cond. Htg. Equip. Water Htr. Load Mgmt. Other:
D er Ran e Elec. Heat Tem .$ervice
X" above the work covered by this request. Enter remarks in this space and on the back of the white copy only.
t��� '�s=-c� �a cz �c�w�-- �-4- C� � c.� NN���
' Calculate Inspection Fee - This Inspection Request will not be accepted without the correct fee: ��,
' Ofher Fee � Service Enhance $ize Fee # Circuits/Feeders Fee
Mobile Home Pork Stall 0 to 200 Amps 0 to 100 Amps
$treet Ltg./Traffic Sig. Above 200 Amps Above 100 Amps
Transformer/Generator INSPECTOR'SUSEONLY � �'�
Sign/Outline Ltg. Xfmr. �
Alarm/Remote Control � (,� O � �
$wimming Pool
v
1 hereb certi fhat 1 ins ecled the electrical insfallation described herein on the dates stated
Irrigation Boom Ro�gh-In ��
Special InspecFion
Final Date
Investigative Fee —
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
2 9 9— 3 61 � OFFICE USE ONLY This request void 18 months from validation date printed in this box.
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PLEASE PRINT OR TYPE
Req�est te Rough-in inspedion required2 ❑ Yes � No Inspeclion Other Than Rough-In: Ready Now � Will Call
��° (You must call ihe inspedor when ready) Da}e Ready:
I, � licensed contractor ❑ owner hereby request inspection of the above electrical work at:
Job Address (Sfreat, Boz, or Route No.) City Zip Code
^ SS� -� t� C-��� l,. �S 1.3 �-
$ecfion No. Township Name or No. Range o. Fire No. County
/�-�.la K A
, - \"i�,�,P ;`.�- !..� !-z i--��' �,r�
Power $upplier Address
Phone No.
��' /�l �
�nTractor (Com ny Name) Co rador License No. Master Lic. No. (Plant Elecf. Only)
?[�.� �5���-A��i�-�'�5 ��'C2�-,3��
lress (Con dor or Owner Performing Installation)
� ���:�-� �, C� S� �� � t�►� 1,�
iigno (� fracio r er mg Ins Ilafio Phone No.
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10 6/95 STATE BOARD COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY