P - 84692I I�I ��I) III I) (II (I (II II (II II III I) III (� II� I I�II M821�Un'nrersaO Ae., dRm. S�-1c8ASt! PauPl, MNT O 04 ���
'* 0 2 9 9 3 9 2 1 * Phone (s12) s�a2-osoo �`��
Home Duplex Apt. Bldg. Other: New Addn
Commercial Industrial Farm Remod Re air
Air Cond. Htg. Equip. Water Htr. Load Mgmt. Other: �.�� � f �a�,,� f��
D er Ran e Elec. Heat Tem . Service
"X" above the work covered by this requesf. Enter remarks in this space and on the back of the white copy only.
Calculate Inspection Fee - This Inspection Request will not be accepted without the correct fee:
Olher Fee � Service Enirance Size Fee # Ciraiis/Feeders Fee
Mobile Home Park Stall 0 to 200 Amps to 100 Amps �O, O
Street Ltg./Traffic $ig. Above 200 Amps Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY TOTAL �� ��
$ign/Outline Ltg. Xfmr. ��G�/- ��/���
i
Alarm/Remote Control j /�
$wimming Pool ��� < 0 Y ��'� 7
I hareb certi ihat I ins ed the elechic inslallofion des rein on the dates sMted
Irrigdtion Boom Rough-In fe �c�
$pecial Inspedion � �
FiweH+ Da� � ...� _ /i
Investigative Fe . /�AC
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 1 MONTHS.
2 9 9- 3 9 2� OPFICE USE ONLY This request void 18 months from validation date printed in this box.
/�\
3���� � -� ��y�
PLEASE PRINT OR TYPE
Request DaM Rough-in inspecfion required2 Yes � No Inspeclion Other Than Rough-In: � Ready Now ill Call
� I 4 t' �� (You musT call the inspedor when ready) Date Ready:
I, ❑ licensed contractor ['�owner hereby request inspecFion of the above electrical work at:
Job Address (Street, Box, or Route No.) City Zip Code
-7300 ����� � �� �r�d� �S5-�3z
Seclion No. Township Name o�o. Ran� o. Fire No. County� ���
C� � �
Occuponf ' Phone No.
(Z.�� ��� �84 -?�f7�
PowerSu�er � Address /
5 L� /�- v-� �_ � c;�l�: e� �
Eleclriml Confrador (Company Name) onkocior License No. MasMr Lic. No. (Plont Elecf. Only)
W`i �Q/�
Mailing Address (Conhador or Owner Performing Installation)
7300 ,�ac�� �t. F�;c�� Ss�32
Aufhorized Si a (Co trador r er Performing Installa j � Phone No.
�8 `F'7'F7�
EB-OOOOlA-10 6/95 STATE BOARD COP - SEE INSTRUCTIONS ON BACKOF YELLOW COPY