P - 84559I I�II�I IIIII IIIII IIIII IIII� IIIII IIIII IIII IIII 1n82`i U�niversaOA e LRm SR 128, St PauPIEMN 55 iQ4 ���� ,
�* 0 3 5 1 8 9 0 9* Pr,o�e �s42) s42-osoo -� �
Home Duplex ' Apt. Bldg. Other: New ' Addn 4i
Commercial Industrial Farm Remo Repair
Air Cond. Htg. Equip. Water Htr. Load Mgmt. Other:
Dryer Range Elec. Heat emp. Service
" above the work covered by this request. Enter remarks in this space and on the back ot the white cqoy only.
Calculate Inspeciion Fee - This Inspection Request will not be accepted without the correct fee:
Other Fee � Service Entrance S' Fee # Circuits/Feeders Fee
Mobile Home Park Stall 0 to 0 Amps 25 . �� 7 0 to 100 Amps 35 . ��
Street Ltg./Traffic Sig. Above 200 Amps Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY lf��L� TOTAL
Sign/Outline Ltg. Xfmr. �=7 _ f' ��� I� -t - /�,� 6� . 5�
Alarm/Remote Control �`''`s� ' %'
Swimming Pool I hereby certify that I inspected the electrical installation described herein on the dates stated
Irrigation Boom Rough-In Date
Special Inspection
Investigative Fee �� _ � o _7 l!�
THIS INSTALLATION RDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This request void 18 months from validation date printed in this box.
351-890,1.�] ,�
PLEASE PRINT OR TYPE ��J v ����Q
Request Dafe Rough-in inspection re uired?
�7 q ❑ Yes � No Inspection Other Than Rough-In: ❑ Ready Now '� Will Call
l� /� 199 7 (You must call the inspector when ready) Date Ready:
I, � licensed contractor ❑ owner hereby request inspection of the above electrical work at:
Job Address (Street, Box, or Route No.) City Zip Code
O�l1 it-.iL.....'^-- ^�--- -' — • --
Section No. I Township Name or No. Range No. Fire No. � County
Occupant
Phone No.
Karyn Jones 434-1858
Power Supplier Address
N.S.P. ls.
Electrical Contractor (Company Name) � Contractor License No. Master Lic. No. (Plant Elect Only)
La 1' E ctri 11
Mailing Address (Contractor or Owner Performing Installation)
Aut rize Signature ntract Owner Performing installa' ) ' ,� a Phone No.
..r;� ;, : ,>
"'w� ' 224-2585
EB-00001 -11 8/95 STATE B ARD COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY