P - 84655'I I��� III II III !� III II III II III �I III II III �) I�I (���� M 21�Un'rv SsOAve. dRm. S-1I BcSt.I PauP M`N 55104 �: e
`* 0 2 9 9 3 8 4 8 * Phone (si 2) s�a2-osoo � �
Home Duplex Apt. Bldg. Other �! ,� Y New Addn
Commercial Industrial Farm �� F'�-,�'�� Remod Re air
Air Cond. Hig. Equip. Water Hh. Load Mgmt. Other:
D er Ran e Elec. Heat Tem . Service
"X" above the work covered by this request. Enter remarks in this space and on the back of the white copy only.
Colculate 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 0 to 100 Amps 0-OG
Street Ltg./Traffic Sig. Above 200 Amps Above 100 Amps
Transformer/Generator INSPEC70R'SUSEON�Y TOTAL
Sign/Outline Ltg. Xfmr. ��. S�
Alarm/Remote Control
Swimming Pool p
I hereb certi thaf I ins }he elechical insfollofion described herein on tha d�r s �( 7
Irrigation Boom Rough-tn pa�
Special Inspe �-� ---° k� "� F -$%
Investigative fee ����� "�- � -� � � %
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
2 9 9- 3 8 4[� OFFICE USE ONLY This request void 18 months from validafion date printed in this box.
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PLEASE PRINT OR TYPE h
Request Dak Rough-in inspeclion required2 Yes � No �nspection Other Than Rough-In: � Ready Now Will Call
� 2 3 � (You must call the inspedor wh r y) Date Ready:
I, ❑ licensed contractor �jCiwner hereby request inspection of the above electrical work at:
Job Address �Sheet, Boz, or Rouk No.) City Zip Code
"" � 3 2� c�- C� T w�^pc�. �'n- t�'l ��- ��
Section No. Township Nome or No. Range No. Fire No. Counly
1� �i U Z¢ �1,� rl>_ a4
� Occupanf
IPower
Eleclriml Confroctor Comp y N me)
�C�N��-
Mailing Address �Confrador or Owner Performing
� Authorized Sianb'ture (Contm�r or
Phone No.
ceZ s � L o.r���
Address
Contrador License No. Master Lic. No. (Plant Eleci. Only)
'' 2520�
pjlR) Phone No.
STATE BOARD COPY- SEE INSTRUCTIONS ON BACK OF VELLOW COPY