P - 84281IIIIIII IIHIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII SE�UEaSsFOAe. Rm� 3 cBASt.'PauPMN5O5104 �� ���
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.� D 3 3 1 0 5 7 0* Phone (612) 642-0800 ��s��'�
ome Duplex Apt. Bldg. Other: New Addn
Commercial Industrial Farm Remod Re air
if Cond. tg. Equip. Water Htr. Load Mgmt. Other:
D e Ran e Elec. Heat Tem . Service
"X" above he work covered by 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 correct fee:
Olher Fee # Service Entrance $ize Fee # Circuiis/Feeders
Mobile Home Park Stall 0 to 200 Amps to 100 Amps
Street Ltg./Traffic Sig. Above 200 Amps Above 100 Arc
Transformer/Generator INSPECTOR�SUSEONLY TOTp
Sign/Outline Ltg. Xfmr.
Alarm/Remote Control
Swimming Pool
I hereb certi that I ins ected }he eledrical installoiion described herein on the dafe:
Irriqation Boomn i _ Ro���h-In Date
Fee
. . Final ,...� 1e 6 C1 '
Invesiigative Fee �.....-- �_ � — —_— '' - .c= �' / ,
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
3 31 � O� 7 OFFICE USE ONLY This request void 18 mon}hs from validation date printed in this box.
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PLEASE PRINT OR TYPE
Request Dafe � �� Rough-in inspecfion required2 � Yes o Inspedion Other Than Rough-In: eady Now � Will Call
(You must call the inspedor when ready) Date Ready:
l� licensed contractor ❑ owner hereby request inspection of the above electrical work at:
Job Address (Str� o�r Rou o.) - , /� Ciy . e Zip Code
� � u�7 �: � �I�~ � ���2
Section No. Township Name or No. Range No. Fire No. County ��-, `:S` .
�f
Occupant Phone No. /
. �%?C� �l.d �� oZ�9 �GJ� 7
( �Power
Authorized Signature
EB-OOOOlA-10 6/95
o ing Ins4
T�s�l
Performing
�,�
STATE BOARD
Address
No. I Master Lic. No.
��%�V
� 'Y Phone
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: INSTRUCTIONS ON BACKOF YELLOW COPY
Only)
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