P - 81956I IIII II III IfTll II II� II III (I III II III II II� II III ( IIII MEGIUota StatOe B af dEo ERcCA rylNa P MNTIO 04 ������
� 0 3 4 7 5 9 6 9* 1821 University Ave., Rm. S 128, sc. P, s ;� ��
Phone (612) 642-0800
Home Duplex Apt. Bldg. Other: � . �' New Addn
Commercial Industrial Farm Q� r�'����AC� Remod Re air
Air Cond. Htg. Equip. Water Htr. 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�.
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Calculo�lnspection Fee - This Inspection Request will not be accepted without the correct fee: %i •i�.�G!' f�
Olher Fee # Service Enhance Sae Fee # Circuiis/Feeders Fee
Mobile Home Park Stall 0 to 200 Amps 0� 0 to 100 Amps
Street Ltg.%Traffic Sig. Above 200 Amps Above 100 Amps
Transformer/Generator INSPECTOR�suseoN�v TOTAL3D'�O
Sian/Outline Lta. Xfmr.
Boom � � Rough-In
herein on the dafes slaled
Date
Special Inspection
Finol ��e�7 q,!�/
Investigative Fee /�/ (
THIS INSTALLATION MAY BE OiiDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
3 �� 7- 5 9 6 OFf10E UaE ONLr This nqwst void 18 monlhs hom validafion dah printed in this box.
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PLEASE PRINT OR PE
Request Date �r O Rough-in inspection required2 ❑ Yes o Inspeclion Other Than R9ugh-�: Ready Now ❑ Will Coll
7 � / (You must call the inspedor when ready) DaM Ready: �/�,hr
I, � licensed contractor ❑ owner hereby request inspecFion of the above electrical work at:
Job Address (Street, Boz, or Route No.) Ciy �r; ���
���s �m�d �ah�,
$ecfion No. Township Name or No. Range No. Fire No. Counl�yJ
1 / � !� 0��,,
Occu ant ,. Phone No.
L o r r c� � h. �t. G a r, �.� �6 ��
Power Supplier Address
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Eleclricol Contractor (C mpany Name) Conhador License No. Master Lic
pb�orc� �' ��4��� t�GN� C f�'� a2`�� �
Mailing Address (ConTractor Owner Perfortning InsTallation) ',�/ l y � ��
3 o`Z ?�u h i .B r S�, !"' � N I d 1� -�� �
Authorized Signature ontracror er P o irg I Ilation) Phoya�Jo
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EB-00001 A-10 6/95 STAT OARD COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY
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