P - 84758( IIII II �II I� (II I� III II III II III II III II III II III I IIII 821�Un�N Ssf OAve., dRmo tS-1 SAst.' Pau�l, MNT55O 04 ,. ��:: i
* 2 9 5 1 2 5 9 * Phone (612) 642-0800 � "�'
ome Duplex Apt. Bidg. Other: Ne Addn
Commercial Industrial Farm emod Re air
Air Cond. Htg. Equip. Water Htr. Load Mgmt. Other:
D er Ran e Elec. Heat Tem . Service
"JC' above the work covered by this request. Enter remarks in this space and on the back of the white copy only.
1�..�-�, r�.� .
Calculate Inspection Fee - This Inspection Request will not be accepted without the correct fee:
Ofher Fee # Service Entrance 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'SUSEONLY TOTAS �
$ign/Outline Ltg. Xfmr. � '
Alarm/Remote Control
$wimming Pool
I hereb certi ihaf I ins ected the eledrical insMllafion described herein on fhe dafes stafed
Irrigation Bo Rough-In ' � �� �
Special Inspe ion
Final �� �° � Q— .7
Investigative Fee — — +
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
2 9 5-12 5 OFFICE USE ONLY This requesT void 18 months hom validafion dafe prinfed in this box.
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PLEASE PRINT OR TYPE �L J' � ��`3
Request Date Rough-in inspecfion required2 � Yes No Inspeclion Other Than Rough-In: Ready Now � Will Call
��� �� (You must call The inspedor when ready) DaTe Ready:
I, � licensed contractor ❑ owner hereby request inspection of the above electrical work at:
Job Address (Sheet, Box, or Route No.) ^ City Zip Code
1 l n n T.� I A ! 1 . i i �. I n r+l�—� 17 �
Sedion No.
Occupanf
Power Supplier
i�m�r No. /\ I Range No.� Fire No.
U " � /'
EI drical Conirador (Company Name)
�L�,r� h` S �. �� �
Mailing Addr ss (Contrador or,Owner Perforrt�g Insiallation) �
A-10
or Owner Performing Insfollotion)
( S� I • � ss�
1'��0 /�i �� i
License No. Master Lic. No. (PlanT Eled. Only)
� o �t.� 4
STATE BOARD COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY
No.