P - 83945_�1'FII �I�II II� Illli II III II II� II III IIII) IIIII I I�I) 8EQUota S I�e B a REof S-�icSAS .IPauPI, MNT O 04 �� ���-
* 0 2 `? C 4 3 9 3* Phone (612) 642-0800 ��"�'�
me Duplex Apt. Bldg. Other: New Addn
Commercial Industrial Farm Remod Re air
Air Cond. Htg. Equi . Water Htr. Load Mgmt. Other:
Dryer Ran e Elec. Heat Tem . Service
"k' above the work covere y 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 not be occepted without the correct fee:
Olher Fee # Se 'ce Entrance Sjze Fee # Circuiis/Feeders Fee
Mobile Home Park Stall to 00 Amps 0 to 100 Amps
Street Ltg./Traffic Sig. Above 200 Amps Above 100 Amps
Transformer/Generator INSPECTOR�suseoN�v TOTAL
Sign/Outline Ltg. Xfmr. ' S�
Alarm/Remote Control
Swimming Pool
I hereb ceAi ihat I ins eded ihe eledrical installaTion described herein on fhe dates state.d
Irrigation Boom Rough-In Date
Special Inspedi
Final �cye
Irnestigative Fee t ( `+ ���7
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
2 1 0- 4 3 9 OFFICE USE ONLY This request void 18 months from validation date printed in ihis boz.
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1� �# il/�:.� .-� % - �'� `�' Li
PLEASE PRINT OR TYPE
Request Date Rough-in inspecfion required� ❑ Yes � o Inspection Other Than Rough-In: Q Ready Now
/� .�. (You must mll ihe inspedor when ready) Date Ready:
I� licensed contractor ❑ owner hereby request inspection of the above electrical work at:
Job Address (Street, Box, or R fe No.) � City A /�� Zip Code
� u .Q � �GY/r SS �'/
Sedi o. Township Na r No� Range No. Fire No. ounty
, i n
Occupant
�rv �
Phone No.
cau I I
Power $up lie{ � Addr r3 `
J�is I�"1 jl.s ,C;�,irl � � ��s�o�
Eledriml ConTrodor (Company Name) Confmctor License No. Master Lic. No. (Plant Eled. Only)
m� � ' ��c . �'l9'D/ � :��
Mailing Address (Cont dor or Owner Performing Installafion) �
�6 .j�s�,ti sf ^ r�o�i¢
Authorized Signature (Contra r or Owner Performing Insfollation) � Phone No.
� 2 � � �y3
EB-00001 A-10 6/95 ATE BOARD COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY