P - 84465I IIII II III II III II III (� III II III II II) II II) �� (I� ( I��I gEQUEa s��A e dRm. S-1 BASt.' PauPl, MNT55104 �`�
* 0 2 9 5 1 2 9 1 * Pnone (s12) s�a2-osoo �, ., _` ��
Home Duplex Apt. Bldg. Other: �, New Addn
Commercial Industrial Farm Remod e air
Air Cond. Htg. Equip. Water Htr. Load Mgmt. Other:
Dryer Ran e Elec. Heat Tem .$ervice
"k' above the work covered by this request. Enter remarks in this space and on the back of the white copy only.
i�� --� �Q.�-
Calculate Inspection Fee - This Inspection Request will not be accepted without the correct fee:
Other Fee # Se 'ce Entrance ' Fee # Circuiis/Feeders Fee
Mobile Home Park Stall 0 to 00 Amps 0 to 100 Amps
$treet Ltg./Traffic $ig. Above 200 Amps Above 100 Amps
Transformer/Generator INSPECTOR�suseoN�v TOTAL
Sign/Outline Lig. Xfmr. � �
Alarm/Remote Control
Swimming Pool
I hereb certi ihat I ins ected fhe eledrical installafion described herein on the dafes sMted
Irrigation Boo Rough-In ��
$pecial Inspe " ,,
Investigative Fee - ,. F�nal � �_ / ��
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
2 9 5-12 9� OFFICE USE ONLY This request void 18 months from validation date printed in this box.
�'�
PLEASE PRINT OR TYPE � �� ��/
Request Date Rough-in inspedion required2 ❑ Yes ❑ No Inspedion Other Than Rough-In: � Ready Now ❑ Will Call
(You must call the inspedor when ready) Date Ready:
I, ❑ licensed contractor ❑ owner hereby request inspection of the above electrical work at:
Job Address (Street Boz, or Roufe No.) City Zip Code
� � �.�. � L.JrI�'1'1 ��l �4-Q.�f `-i'� � '�-�C.,C_ � �
$ecfion No. Township Name or No.
Occupant
Power Supplier
Eledriwl Coniracror (Company Nume)
�. � _ � y
Mailing
, �;_
EB-OOOOlA-10
Range No. Fire No. Coun}
Phone
Address
Contrador License No.
t ., n — —
or Owner Perfortn' g Installation)
n r (/K � � �`
idor or Owner Performing Installation)
,� � l� 1
STATE BOARD COPV - SEE INSTRUC'FiONS
YELLOW COPY
Lic. No. (Planf Elect. Only)
No./'�
�`1 �