P - 84565IIII�II IIIII IIIII IIIIIIIIII IIIII IIIII IIIII IIIII 8E°�� ess °A e Rm° sR�AS'Pa P MNT5° ��� :�
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. Phone (612) 642-0800
Home Duplex Apt. Bldg. Other: New Addn
Commercial Industrial Farm Remod Re air
Air Cond. Htg. Equip. Water Hir. Load Mgmt. Other:
D er Ran e Elec. Heat Tem . Service
"X" above the work covered by this request. Enter remarks in this space and on the back of the white copy only.
Agl�q S-- �
Calculate Inspection Fee - This Inspection Request will not be accepted without the correct fee:
Ofher Fee # $ervice Enha Sae Fee # Circuits/Feeders Fee
Mobile Home Park Stall 0 to 00 Amp; S'� ' 0 to 100 Amps
Street Ltg./Traffic Sig. Above 200 Amps Above 100 Amps
TransformedGenerator INSPECTOR'S USE ONLY TOTAL
$ign/Outline Ltg. Xfmr. �, S�O
Alarm/Remote Contro
Swimming Pool (� I7
ereb certi thaf I ins cied }he eledric I' stallation described herein on the tes �fe(f � /
Irrigdtion Boom Rough-�n � Dare � __
Speciallnspedion -�`-'�--� –='�6—r
Final
Investigative Fee .� —
THIS INSTALLATION MAY BE ORDERED DISCONNE D IF NOT COI�IPLETED WITHIN 18 MONTHS.
2 9 9- 3 6 8� OFFICE USE ONLY This request void 18 monMs from validation date printed in this box.
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PLEASE PRINT OR TYPE �°�3 ��J
Request DaM` Rough-in inspection iequired2 �s � No Inspecfion Other Than Rough-In: eady Now � Will Call
� 'C � ' � � (You must call ihe inspedor when reody� Date Ready: � � / � —7
I, ❑ licensed contractor � owner hereby request inspedion of the above electrical work ot:
Job Address (Street, Boa, Route N � City Zip Code
� %2 � }�'y�i� �' � I � -C Lj�� 3 Z_
$ection No. Township Nome or No. Range No. Fire No. County ��
Vcc� ant Phone No.
-P,✓V �- t 1 Gt. ru ' 3'3-.S
Power $upplier ^ Address
�l � I J
Eleciriwl ConfracTor (Compony Name) C Li ans N Master Lic. No. (Plant
Moiling Addross (Conkador or Owner Perfortning Insfollafion)
Authori ignature (C trpdor or O n erfortning Installafion) Phone No.
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EB- A-10 6/95 STATE BO D COPY - SEE IN UCTIONS ON B OF YELL COPY