P - 84624�illl�ll IIII) (IIII IIIII II III IIIII IIIII IIIII II�II ME�Uota Ss' OAve. REm. S-�1' BASt.IPauP MNT55104 :.:��
_ 1821 Urn er dy
* 0 2 9 9 3 7 7 2 * Phone (612) 642-0800 � � ����
Home ' Duplex Apt. Bldg. Other: C New Addn
Commercial Industrial Farm -S� "�Z� 2� Remod Re air
Air Cond. Htg. Equip. Water Hir. Load Mgmt. Other:
D er Ran e Elec. Heat Tem . Service
"JC' above the work covered by 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 accepted without the correct fee:
Ofher Fee # Service EMrance Sae Fee � Circvits/Feeders Fee
Mobile Home Park Stall 0 to 200 Amps 0 to 100 Amps
Street Ltg./Traffic Sig. Above 200 Amps Above 100 Amps
Transformer/Generator INSPECTOR'SUSEONLY T A�
$ign/Outline Ltg. Xfmr.
Alarm/Remote Control � ��, ��'j
Swimming Pool
I hereb certi thaf I ins etled }he eledrical 'nsMllafion described herein on the daMs sfited
Irrigation Boo Rough-In � Daro A r �+
Special Inspe , �
Investigative Fee �� ��d` �l'�
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
2 9 9- 3 7 7 � OFFICE USE ONLY This request void 18 months from validafion dafe printed in this boz.
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PLEASE PRINT OR TYPE
Request Dafe/+ ^• Rough-in inspetTion required2 �Yes � No Inspedion Ofher Than Rough-In: � Ready Now � Will Call
�'� �(p y 7 (You must call ihe inspedor when ready) Date Ready:
I, � licensed contractor ❑ owner hereby request inspection of the above electrical work at:
Job Address (Street, Box, or Ro No.) Ciry Zip Code
1z.s-� s��%�� ��•✓� h/� F�' �.� c-�,�/ --
$ection No. Township Name or No. Range No. Fire No. Cou ���
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G �G� � � ` �� � ��� Phone No.
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Power Supplier Address
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g Addreas
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Jame) Confrador License No. Master Lic. No. (Plant Eled. Only)
L�'LE'C"�� C QI� 00%CG'�
Tmer Performin InstallaBon)
' Sr I3RaoKL�i✓ ct^�✓>�'P r1r��'�"�3 .
or Qwner Parforming �nstallafion Phone No.
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STATE BOARD COPV - SEE INSTRUCTIONS ON BACK OF YELLOW COPY