P - 83881, I�lII II III II III II III I[ III II III II III I) III ii III I II�I MEC1Uota StatOe B a dEof ERcCA �INSPECTION ���°�
1821 Urnversity Ave., Rm. S 128, St. Paul, MN 55104 �
'* 0 2 9 9 4 1 4 3 * Phone (612) 642-0800 �������
Home Duplex Apt. Bidg. Other. ��,� �� w Addn
Commercial Industrial Farm Remod Re air
Air Cond. Htg. Equip. Water Htr. Load Mg . Other:
Dryer Ran e Elec. Heat Tem . Service
"X" above the work covered by this request. Enter remarks in this space and on the back of fhe whita copy only.
Calculate Inspection Fee - This Inspection Request wili nof be accepted without the correct-fee:
Ofher Fee # Service EMrance $ize Fee # Circuits/Feeders Fee
Mobile Home Park Stall 0 to 200 Amps 0 to 100 Amps
$treet Ltg./Traffic $ig. Above 200 Amps Above 100 Amps
Transformer/Generator INSPECTOR'SUSEONLY TOTAL
�'( ' �j�,i%l�
Sign/Outline Ltg. Xfmr. �
Alarm/Remote Control � � • s-Q
Swimming Poo,�
I hereb ceAi fhaf I ins eded the eledrical installation described herein on the dates sfafed
(rrigation Bo , �I ,� Rough-In i Date.
$pecial Inspection ♦ ' — —/ d ' �d
Dat�Investigative Fee (
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
2 9 9- 414 0 OFPICE USE ONLY This requesf void 18 monihs from va�Ild�D date printed in fhis bo` j/������4�!/ 7
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PLEASE PRINT OR TYPE
Request Date Rough-in inspedion required2 �'es � No Inspeclion OtherThan Rough-In: � Ready Now �Will Call
(You must call ihe inspedor when ready) Date Ready:
I, ❑ licensed contractor ❑ owner hereby request inspection of the above electrical work at:
Job Address (StreeT, Bo , or Ro te No.) City Zip Code `
. �� ��� .3-s�`3�
Sedion No. Township Name or N. Range No. Fire No. County /
� � Occupant
I. - �.9s�.✓ 9�- l� ,�-��,rr-�- �
rower Supplier Address
me No.
.5�'7a - d �7d�
S
Elecfrical Con}rador �Compan Name) Conirador License No. Masfer Lic. No. (Plant Eled. Only)
S£(�
Mailing Address �Conimdor or Owner Performing Installation)
Aufhorized Signature (Confrador or Owner Performing Insfallafion) Phone No.
EB-OOOOlA-10 6/95 STATE BOARD COPY- SEE INSTRUCTIONS ON BACK OF YELLOW COPY