P - 83759I I�II II ��I II III I� (II II III II (II II II) II III I� �ll � I��I 82�� Ea SsaOA o dR o S-�1c BASt.I PauP M`N 505104 A����_:
*� 0 2 9 9 3 9 9 6 * Phone (612) 6��-0800 '�"�'"s°'
, ome Duplex Apt. Bidg. Other: ew Addn
Commercial Industrial Farm Remod Re air
Air Cond. Htg. Equip. Water Htr. Load Mgmt. Other:
Dryer Ran e Elec. Heat Temp. Service
"k' abo the work covered by this equest. Ent�em rks in this space and on the back of the white copy only.
���llC�'IL,�"C� ����1� �l��%�G� ������� -�.'�'��"� _,
Calculate Inspection Fee - 7his Inspection Request will nof be accepted without the correct fee:
Ofher Fee # $ervice Entrance $ize Fee # Circuits/Feeders Fee
Mobile Home Park Stall 0 to 00 Amps 0 to 100 Amps
Street Ltg./Traffic $ig. Above 200 Amps Above 100 Amps
Transformer/Generator INSPECTOR'suseoM�r �j �'/�� TOTALj
Sign/Outline Lig. Xfmr. 1/�-G� G'� S-�s` �? � s�
Alarm/Remote Control � �7 �-��-� �'�1��
$wimming Pool � � / �. � �- '
I hereb certi that I ins eded the eledncal inst �ation Hescribed herein on ihe dates stated
Irrigdtion Boom Rough-In � � ��� �� � , � �'
Special Inspectio
Final Dat€7 �� �''�'c
Investigative Fe � / - %l
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
2 9 9- 3 9 9� OFFICE USE ONLY This reques} void 1 S monihs from validation date printed in ihis box.
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PLEASE PRINT OR TYPE
Request Date �� Rough-in inspedion required2 ❑ Yes ❑ No Inspedion Other Than Rough-In: � Ready Now ❑ Will Call
�^2Q 7 (You must call ihe inspedor when ready) Dafe Ready:
I, ❑ licensed contractor �wner hereby request inspection of the above electrical work at:
Job Addrezs (Street, Boz, or Roufe No.) City Zip Code
Z7S..L'�rp/l1`0 �F'����/r %�7/I. �Y3Z
$ecFion No. Township Name or No. Range No. Fire No. County
:� C� � /�i�o/�f�'
Occupanf Phone No.
nJ /i/el� �% � t3�o � 7>`'z
Power Supplier Address n
5 % �S �jU lJ l l% '
Elecfrical Contra�or (Company Name) Coniractor License No. Maater Lic. No. (Plant Elect. Only)
Mailing Address (CoyfLador or Owner Perfortning Installation)
or Owner Performing Ins Phone No.
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STATE BOARD COPY- SEE INSTRUCTIONS ON BACK OF YELLOW COPY