P - 79640�+ n RE�UEST FOR ELECTRICAL INSPECTION ��"��,
O O L- 2 9 6 � 8121eUnivers'ty A ear Rm. SQ72r8,ISt. Paul, MN 55104 �+�-��
Phone (612) fi42-0 0 --
Home Duplex Apt Bldg. Othec Ib� _.�,/ New Addn
Commercial Induslriol Farm � Remod Re air
Air Cond. H}g. Equip. Woter Htr. Load Mgm1. Ofher:
Dryer Range Elec Heat Temp. Service UP(�� S�R✓+G.E ro BREAK6�
"X" above the work covered by Ihis requesl. En/er remorks in this spoce ond on fhe ba<k of fhe whife copy only.
��Pc� �SE {��� �..�/ nis..� ��t�� F�e�
Calculafe Inspechion Fee - This Inspec/ion Requesf will nof be accep�ed withouf the mrrecf fee:
Other Fee # Servi e Entrance ize Fee # Cirwits
Mobile Home Pork Stall 0 to 00 Amps 0 to 100 A
Street Ltq./Tr6ffic Sip. Above 200_Amps � � Above l OC
INSPECTOR'S USE ONLY
ne
Fee
TOTAL
3/�So
Imestigafive Fee N� ` � �j�'��
THIS INSTALLATION MAY BE ORDERED DI CTED IF NOT COMPLETED WITHIN 78 MONTHS.
OFFlCE USE ONLY This reqmst vold 18 momhs Irom vaGdafion dore pnnted In �his box.
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* 0 8 0 2 2 9 6 4* ����
PLEASE PRINT OR TYPE
Requen Date ' M Roughin Inspxnon requked? ❑ Yes o Inspectian Other Than Rough-Im ❑ Ready Now III Call
��f 4(� (Ya m�st coN �he inspMOr when readyl Dafe Ready:
I, ❑ licensed coniracto�owner hereby requesl inspection of the obove electrical work at:
lob Address ISrveet, Bmc, a Rouk No.) Ciy Zip Code
1024- �-�c.�rwt�,J e.�� �.�'O�Y SS4�
G— ]� L—.
�, �{ynQhacro�r ar Owner
S��' `�
STATEBOAPD COPV-SEE
f'M.0
Pho��'�� 1 _�.�'(
! 5 N. 0� ✓1)r�,J
Cono-oclor License No. Moster Lic No. (%om Elect Only�
Phone No.
�3-S�4-osl
IIONS ON BACK OF YELLOW COPY