P - 82644I�REGIUEST FOR ELECTRICAL INSPECTION
� I��� II III I� III II III IR II) II III II III II III I I�II Mg21 Uni essi teA earRmf S-128cSt. Paul, MN 55104 �.-��
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� 0 3 � � � � 8 3 * Phone (612) 642-0800 `��
Home Duplex Apt. Bidg. Other: New Addn
Commercial Industrial Farm
Remod Re air
Air Cond. Htg. Equip. Water Htr. Load Mgmt. Other.
er f' Ran e � Elec. Heat Tem . Service
"X" above the work covered y this request. Enter remarks in this space and on the back of the white copy only.
Calculate Inspection Fee - This Inspection Request will not be accepted without the correcf fee:
Ofher Fee # Service Entrance Size Fee # Circuits/Feeders Fee
Mobile Home Park Stall 0 to 0 Amps 0 to 100 Amps
Street Ltg./Traffic Sig. Above 200 Amps Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY TOTACL 5 O
Sign/Outline Ltg. Xfmr. '�
Alarm/Remote Control vll�
Swimming Pool I hereb ceAi that I ins ecled ihe eledrical insfallafion described herein on 1he,Qa%s�tateQ �
Irrigation Boom Rough-In � Date
v C— 26 — G
Special Inspecti Dafe rl7
_ Final !
Investigative Fee r
ru�e iNSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 ONTHS.
3 2 3- 3 4 g 0 OFFICE USE ONLY This request void 18 monfhs (rom validafion daie prinfed in this box.
`¢� �
°�t'75s�C� ,�j -_
PLEASE PRINT OR TYPE '' IpZ�ZZ
Request Date Rough-in inspedion required2 Yes � No Inspedion Oiher Than Rough-In: � Ready Now Will Call
1�� aQ 9� (You must call the inspedor whe reody) Dote Ready:
I, ❑ licensed contractor ❑ owner hereby request inspection of the above electrical work at:
Job Address (Sireet, Box, or Roufe No.) City Zip Code
S� ion N� Township Name or No. � •
Range No. Fire No. County
Occupont
('� Phone No.
1\
Power Supplier _ eaa,e��
Contrador
Cont� No. Master Lic. No. (Plani Eled. Only)
Mailing Address (Confracfor or Owner Performing Installa}io
► �
Aufhorized Signoture (Contmdor or O ormin a i A s Phone No.
L� ; �
EB-000p1q_ 10 6/95 STATE BOARD COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY