P - 80282�? �.y RE(�UEST FOFi ELECTRICAL INSPECTION
� " " � � � � � 8'21eUnivers� A ea,rRm. S-128,ISt. Paul, MN 55104 -
� Phone (612) 642-0800 '�'
Home Duplex Apt. Bldg. Other Qv �� New Addn
Commercial Industrial Farm �' ��� Remod Re air
Air Cond. Htg. Equip. Water Htr. Load Mgmt. Other:
Dryer Range Elec. Heat Temp. 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 rot be accepted wifhout tF�e correcf fee:
Other Fee # Service Entrance Size Fee # Circuits/Feeders Fee
Mobile Home Park Stall 0 to 200 Amps Z 0 to 100 Amps
Street Ltg./Traffic Sig. Above 200 Am s Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY TOTAL
Sign/Outline Ltg. Xfmr. /•S�
Alarm/Remote Control
Swimming Pool
I hereb certi thot I ins fhe eleclricat installation described herein on the dates stated
Irrigafiort Boom RougMn Date� �j�
Special Inspect �j —`�
Investigative Fee F��� _O � ��� ��
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This request void 18 months from validation date prinfed in this box.
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PLEASE PRINT OR TYPE
Requesf Dafe . Rough-in inspection required$ �Yes ❑ No Inspection O�er Thon RougMn: ❑ Ready Now Will Call
�� 3 •� � � b� �You musf call the inspecfor when ready) Date Ready:
I, ❑ licensed contractor � owner hereby request inspection of the above elecfrical work at:
Job Address (Street, Box, or Roufe No.) City Zip Code
/O L� �,rzr �P� �' 1 �� 5 31-
Section No. Township Name w No. Range No. Fire No. County
3b .� C�ho�0.
Occupant Phone No.
�a�r r C' �a� n 7�o r�
Power Supplier Address
�%S P lV� ls /1%• c�f ✓r`S �or�
Elechical Conhacfor �Company Name� Conhaclor License No. Masler Lic. No. �Planf Elecf. Only�
0 w n ,2 �' ----+
Mailing Address (Conhactor or Owner Performing Installafion� � •
Sam
Auff�orized Signature (Contracror or Owner Performing Installafion Phone No.
CGv�(bL � 7 �/ - `� � $ a�-
E 1 A-11 8/96 S ATE BOARD COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY