P - 84670I(II� (I �I � II) II III I) III (I III II III II III II I�I � I��I SE�Uo 8 StaOq ardR o SRI2sAS f PaulP, MNT55O104 ���`��e
'* 0 2 9 9 3 8 8 9 * Phone (s12) s�a2-osoo ��
Home Duplex Apt. Bldg. Other: New Addn
Commercial Indushial 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.
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Calculate Inspection Fee - This Inspection Request will not be accepted without the correct fee:
Olher Fee # Service Entrance Size Fee # Circuits/Feeders Fee
Mobile Home Pork Stall 0 to 200 Amps 0 to 100 Amps
Street Ltg./Traffic Sig. Above 200 Amps Above 100 Amps
Transfo�mer/Generator INSPECTOR'SUSEONLY TOTAL, ��
$ign/Outline Ltg. Xfmr. � � � � s-�
JI
Alarm/Remote Control t�
Swimming Pool /�� " �� �� ��
I hereb ceAi that I ins eded the eledrical installation describ e in on the aTes sTaTed
Ir�igation Boom Rough-In �,
$pecial Inspedion �� �'"'"�
Final �
Investigative Fee " �
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
2 9 9�� 8 8 � OFFICE USE ONLY This requesf void 18 mo�ths from validafion date printed in this box.
� 2522� �
PLEASE PRINT OR TYPE
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Request te Rough-in inspection required2 es � No Inspedion Other Than Rough-In: � Ready Now Will Call
6_�O ^9 �' (You must tall the inspector when ready) Date Ready:
I, ❑ licensed contracFor� owner hereby request inspection of the above electrical work at:
Job Address (Streef, Box or Route No.) Ci Zip Co e
� (O� �W W � `� , 1 � �' � ��
Seclion No. Township Name or No. Ran e No. Fira No. Counly
30 �� A n ok�—
O« nt Phone No.
�C.VI C7QC� ���1'��
Power $upplier � �� Address � � � �Q � � �1 � ,
Elechical Conhactor (Compony Name) Contrador License No. Masror Lic. No. (Plant Elecf. Only)
� in/✓►e-� �
Mailing Address (�ntrador or Owner Perfortning Instollalion�
or Own erf ing Insfallatio - Phone No.
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EB-OOOOlA-10 6/95 STATE BOAAiD COPY- SEE INSTRUCTIONSON BACKOF YELLOW COPY
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