P - 83926I II�I'II�I II III II III II I�I I) II) II I I I� III I� (�� I I��I gEQUEa SsaOAve. REm. S-�1c8ASt.l PauP MNT5O5 04 ���Y�3u
�* 0 2 9 9 4�, 9 2* Phone (612) 642-0800 ��"�y�
ome Duplex Apt. Bldg. Other: 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 request. 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 nof be accepfed without the correct fee:
Olher Fee # Service Entrance $ize Fee # Circvits/Feeders Fee
Mobile Home Park Stall 0 to 200 Amps 0 to 100 Amps
Street Ltg./Traffic $ig. Above 200 Amps Above 100 Amps
Transformer/Generator INSPECT R'suseoN�r TOTALy
Sign/Outline Ltg. Xfmr. �T �Q/)/Z � Cf,�(�(�f �`�' �r�
Alarm/Remote Control � ��,
Swimming Pool
I hereb ceAi thaf I ins eded the eledrical installation described herein on the dates stated
Irrigation Boom Rough-In C Dare
Special Inspedion ' � _
Final - Da /�Z�
Investigative Fee
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
2 9 9� 419 OFFICE USE ONLY This request void 18 months from volidation date printed in this box.
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PLEASE PRINT OR TYPE -- :r� .� ,
Request Da}e Rough-in inspection required2 ❑ Yes ❑ No Inspecfion Ofher Than Rough-In: ❑ Ready Now � Will Call
'� (You must call the inspedor when ready) Date Ready:
I, ❑ licensed contractor owner hereby request inspection of the above electrical work at:
Job Address (Street, Box, or Route No.) Ci1y Zip Code
� g� � 2. r2t �- Sf 3
$edion No. Township Name or No. Range No. Fire No. County
Occupant
Power
Phone No.
' V� ( 7
Elecirical ConTractor (Company Name) � Contractor License No. MasTer Lic. No. (Plant Eled
Mailing Add ss (Co tmdor or Owner Pehorming Inst Ilation)
Authorize Signature (Contrador or ner Performing Installafion Phone Na.
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EB-OOOOlA-10 6/95 STATE BOARD COPY- SEE INSTRUCTIONS ON BACK OF YELLOW COPY