P - 84434L
��(�I il �� II II� (I II) II (II II III (I II) II III (� NI I(�II M 21� Uotv SsaOAve., dRm. S-ic BASt! PauPI,EMN 5O5 04 ���v�
* 0 2 6 5 8 z 1 9* Phone (612) 642-0800 `�
Home Duplex Apt. Bldg. Other: New Addn
Commercial Industrial Farm e air
Air Cond. Htg. Equip. Water Htr. Load Mgmt. Other:
D er Ran e Elec. Heat Tem . Service
"k' above the work covered by this request. Enter remarks in this space and on the back of the white copy only.
Calculate Inspedion Fee - This Inspection Request will not be accepted without the correct fee:
Ofher Fee # Service Enh�ance Size Fee # Circuits/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 INSPECTOR'S USE ON�V TOTAL .
$ign/Outline Ltg. Xfmr. _� � �$�
Alarm/Remote Control '��%Q f ����
Swimming Pool
I hereb ceAi that I ins ecied fhe eledrical insMllafion described herein on the dafes stated
Irrigation Boom Rough-In A� .� �� Date ����
Special Insped '� �
Investigative Fee �% ��� � /t �
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
2 6 5� V� 1 � OFFICE USE ONLY This request void 18 months from validation daTe printed in this box.
�1
� ✓� , �� ����
PLEASE PRINT OR TYPE
Request Date Rough-in inspedion required2 Yes � No Inspection Other Than Rough-In: � Ready Now � Will Call
�� (You must call the inspedor when reody) Date Ready:
I,� licensed controctor ❑ owner hereby request inspection of the above electrical work at:
Job Address (Sheef, Box, or Route No.) City Zi ode
Ov / . ` ` , � �s��z .
Sechon No. Township ame or No. Range No. Fire No. C nty �� ,
Vccu n Phone No. - "
� �� j !��
Power Supplier Address
�"__,_, _
Elechiml C nhactor Company Name) Co ira r License No. Master Lic. No. (Plant Elecf. Or
. ' � � � � v'J� �`� �/
Mai�n� dress (Contrador or Owner erfortning Installation) ��
� 2 / � � �t��- � �� 3�
Authoriz $igna (Contracfor or Owner rf ing stallafion) Phone No.
� ��� : � a�i-o3aJ
EB-00001 10 5 STATE BOARD COPY - SEE INSTRUCTIONS ON BACK OF VELLOW COPY