4357 Lodgepole CtSEWER & WATER PERMIT
CITY OF EAGAN
3830 Pilot Knob Rd.
P.O. Box 21199
Eagan, MN 55121
;D"
OFFICE USE ONLY
PERMIT DATE ? '
WATER PERMIT #t SEWER PERMIT #
METER # B.P. RECEIPT # ? -
READER # B.P. RECEIPT DATE '
METER SIZE
ISSUE DATE - PRV - BOOSTER PUMP
SITE ADDRESS < OG?4'??'n ?H L f
LOT ?=BLOCK -SEC/SUB
APPUCANT: -_?' ? • -
ADDRESS:
CITY, STATE
PHONE: `i ?s x ? UG?
PLUMBER:
ADDRESS:
CITY, STATE
PHONE: _
ZIP
OWNER: ,. ". _
ADDRESS:
CITY, STATE ZIP
PHONE:
PERMIT REOUESTED
- SEWER - WATER _ TAPS
IZ
L-"64MM/IND - RESIDENTIAL
<
V NEW _ EXISTWG
I AGREE TO COMPLY WITH CITY OF
EAGAN ORDINANCES:
SIGNATURE WHEN METER ISSUED
PLEASE ALLOW TWO WORKING DAYS FOR PROCESSING. FOR STORM SEWER PERMITS, CONTACT
ENGINEERING DEPT.
c . 'A
BUILDING PERMIT
"ATiK
To be used for F'L`!iP
CITY OF EAGAN
3830 Pilot Knob Road, P.O. Box 27-199, Eagan, MN 55121
PHONE: 454-8100
Receipt #
Est.value $4210000
SiteAddress 435] tlJuGEI'(:-LE CT
Lot Block Sec,,Sub. OuZ'LOT A
Parcel No. EVERCR£r.J: PAf;.F:
W Name C17Y QF BAGlIk`
o Address 3330 Pll.O'I' KVUB 2D
City E+?GAN Phone 634-6100
o Name SFIINCOBIZE 1WILTiERS
;a Address 274 H M$Ditia, HOY. ii
? City LORZ4"L'0 Phone 479-1300
3m Name osM
r? Address 2021 f: HEt74iEe 1T:
iw City °:INNlIlJ4MLIS Phone
I hereby acknowlege that I have read this application and state that the
information is correct and agree ro comp4y with all applicable State of
Minnesota Statutes and City of Eagan O}dinances. \
Signature of PermRee i,J"-? . - J- _
A Building Permit is issued ro: i: [;€; 2 i; E: $Lt 1},DEriS
on the express condition that all work shall be done in accordance with all
applicable State of Minnesota Statutes and City of Eagan Ordinances.
Building Official
OFFICE USE ONLY
1989
Occupancy B-4 A-3 FEES
Zoning PF
(Actual) Consl lf-N Bldg. Permit
(Allowable) WN
; t
Surcharge L 1 J, .51.'r
# of Stories
Length 30' Plan Review
Depth '4? 1 SAG City
S.F. Total 1?16 f
1 L8 SAC, MCWCC
S.F. Footprints
On Site Sewage _ Water Conn
On Site Well - Watar Meter
MWCC System _
City Water
_ Acct Deposit
PRV Required _ S,'W Permit
Booster Pump - S/W Surcharge
Treatment PI
APPROVALS
Planner _
Council -
Bldg. OffVariance -
Road Unit
Park Ded.
Copies
TOTAL 21C`.50
' !h?7 2
PermR No. Permit Holder Date Telephone #
V,tTER ? ? '? ?G? ^ " /?•3- /
SEWER
PLUMBING
H.V.A.C.
ELECTRIC
Inspectlon Date Insp. Commenta
Footingsl
Foundation -,p 4c/?S2 pL S
Framin9 d' u in v L? Y D
Roofing
Rough Plbg.
Rough Htg.
Isul.
Fireplace
Final Htg.
Final Plbg.
Const Meter Plbg. Inspector - Noti(y Plumber
Engr./Plan
Bldg. Final
Deck Ftg.
Oeck Final
Well
Pr. Disp
CONTRACT PRICE:
Sife Address '"/j S ?
Lot Block Sec/Sub
y ;-
Name ! >
?
?
. -; .
Address
City Phone
? Name
3 Address
p City Phone
FEES
COMM/IND FEE - 1% OF CONTRACT FEE
APT. BLDGS - COMM RATE APPLIES
TOWNHOUSE & CONDO - RES. RATE APPLIES
MINIMUM - RESIDENTIAL FEE - $12.00
MINIMUM - COMM/IND FEE - $20.00
STATE SURCHARGE PER PERMIT - 50
(ADD $.50 S/C IF PERMIT PRICE GOES
BEYOND $1,000.00)
?
SIGNATURE OF PERMITTEE
FOR: CITY OF EAGAN
PERMIT #
PLUMBING PERMIT RECEIPT #
CITY OF EAGAN
3830 PIlOT KNOB ROAD, EAGAN, MN 55122 DATE: `
PHONE: 454-8100
BLDG. TYPE WORK DESCHIPTION
Res. New _
Mult. Add-on
Comm. Repair
Other
RES. PLBG. ONLY - COMPLETE THE FOLLOWING:
NO. FIXTURES TOTAL
_Water Closet - $3.00 $
_Bath Tubs - $3.00
-Lavatory - $3.00
_Shower - $3.00
_Kitchen Sink - $3.00
-Urinal/Bidet - $3.00
Laundry Tray - $3.00
3-Floor Drains - $1 50
-Water Heater - $1.50
_Whirlpool - $3.00
_Gas Piping Outlets - $1.50
(MINIMUM - 1 PER PERMI'n
Softener - $5.00
-Well - $10.00
_Private Disp. - $10.00
_Rough Ope!nings - $1.50
FEE: ?
STATES/C: 1
?? ? GRAND TOTAL:
.,.. . ur EAGAN Remarks
a,adicion 'Ever•gr. een Park Lot Outlot A
?j
Owner ) -.14 Ui C .,.nSu Stree; -' -`----?
4 ? "7 r2 I ',ls,i vi?, lo
180 010 00
MN 55122
Improvement Date Amount Annual Years Payment Receipt Date
STREET SURF.
STREET RESTOR.
GRADING
SAN SEW TRUNK 1973 16ILl 82,05 20
SEWER LATERAL -
WATERMAIN
WATER LATERAL
WATER AREA
STORM SEW TRK
STORM SEW LAT
CURB & GUTTER
SIDEWALK
STREET LIGHT
WATER CONN.
BUILDING PER.
SAC
PARK
CITY OF EAGAN N? 16372
3030 Pilnf Knob Road, P.O. Box 21-199, Eagan, MN 55721
PHONE:454-8100 -7
BUILDING PERMIT Receipt #
PARK SHELTER & $ , ig 89
To be used for piTMp HOUSE #12 Est. value 421,000 Date APR 28
Site Address 4357 LODGEPOLE CT
Lol Block Sec/Sub. OUTLOT A
Parcel No. EVERGREEN PARK
W Name CITY OF EAGAN
o Address 3830 PILOT lINOB RD
City EAGAN Phone 454-8100
OFFICE USE ONLY
Occupancy B-4_A--3 FEES
Zoning PF
(Actuaq Const V-N Bldg. Permit
(Allowa6le) V-N ? p. n
Surcharge
# of Slories
Length 301 Plan Review
I
o Name SHINGOSEE BUILDERS
;iQ Address 279 N MEDINA, BOX 6
? City LORETTO Phone 479-1300
ww Name OSM
_??-, Address 2021 E HENNEPIN
aW City MINNEAPOLIS Phone
1 hereby acknowlege that I have read this application and state that the
information is correct and agree to co with all applicabie State ot
Minnesota Statutes algL`iZy of E@gan O ina ces. _
Signature of Permitee
Depth 4'2 SAC, City
S.F. Total 1}1-6 $
1
16$ SAC, MCWCC
S F, Footprints i.
On Site Sewage __ Water Conn
On Site Well - Water Meter
MWCC Sysiem -
Acci. Deposit
Ciry Water _
PRV Required S/W Permit
Booster Pump - S/W Surcharge
Treatment PI
APPROVALS
Road Unit
Park Ded.
Copies
TOTAI 210.50
A Building Permit is issuvto: SHINGOBEE T.D .R Planner
on the ezpress condition that all work shall be done in accordance with all Council
applicable State of Minnesota Statutes and City o?t Eagan Ordinances. Bldg. Oft.
Building Official fl-l.lQ A , ? J Variance
This reques[ void
???/?'G
18 nwnths from ?
70589 ryt&,? "'9
nequesl DateJ
j p
/ CJ Fire No. Rouph-f(I?nsper.lion
eq Iree
?ReadY Now?Will Notify InsPec-
Yes ? N.
ar When Ready
Licensed Electrical Contractor I heraby requast insoection of above
Owner
electricai work installed at:
Street Address. Box or Route No. ?
4 Od? e p1-/F_ City
ecuon o. Township Name or No. ? Rangu No.
ArVe ro Counly
Occupant (P NT)
/??
?? Phone No,
0
?
Pow¢r Supplier
r-y /
.!/cE-f?QJ?a. .?/? ??i:rl-'?; .
Address
.?',.?J"111 ? N?O ?c??: ?. ??I. ? ? p z ?
Elect ir.al Conlra.?rtor (Company Name) Contractor's Lir.r.nse No.
e r- ?
e15I ee
??r-?,.???iga-,6;t
e ?yfy- ?
'1--la - f r?
_
,
,
Mailmg Address (Contractor or Owner Making Instailation) /
/?
?
?
-/
?x -
43 12SI /??r.s???%? ?
d. ?1??c
a??e,/I?/!• 7
Au "zed Signature (C ractor/ ncr king. nstallation? Phone Nmnb
er
?j
MINNESOTA STATE BOAND OF F/LEC7RICITV THIS INSPECTION NEQUEST WILI T
Griggs•Midway Bldg. - Hoom N•791 BE ACCEPTED BV THE STqTE BOA
1621 Universitv pve., St. Pau1, MN 56104 UNLESS PROPER INSPECTION FEE
PhOne(612)642-OSOO ENCLOSED.
/31'Sv REQUEST FOR ELECTRICAL INSPECTION . ee-ocoooi-u,o ?
, See insiruCtions for compilatin9 this form an back ot Yellow copy.
0 ',1705 89 "X'" Below Work Covered by This Request ?
ev4 Add Rep. Typa of Builtline AvVliancna Wired Equipment Wired
Home Range Temporary Service
Duplex Water Heater Liyhtin,y Fixtures
Apt. Building Dryer Electric Heatno
Commercial 81dy. Fumace Silo Unloader
industrial Bidg. AIr Conditioner Bulk Milk Tank
Farm Olhur SPecafy Cthnr(SPCr,ifY,
1 er uocitY Other Other
omoute lnsoection Fee Below
M Pee SBfvicaEntreoceSize e Fee FppderS/Suhfeeders # Fee Circurts
V" 0 to 200 Am s 0 to 30 qm s tn 30 An )s
Above 200_Amps 31 to 100 Amps ? 1 to 100 'Am s
Swimming Pool Above 100_Amps 9 24(Ae,', Above 100_Amps
Transformers Irrigation Booms Partial•'Othe
Signs Special Inspection $? ? TOTAL F E Qa
/
?'y
Rerrarks '""" ' ? r .-_ . J
-
?
/) ?
Hough-in Da t e[ ihe Electncnl
., ? „ . ' spector.
heroby
4 ertify Ihet the nbove
iinal ? ?1e? nspection has been
ade.
(his repuest voiC 18 months irom
1989 Bl7iiDING PERMTT 6PPLICATION - CITY OF gAGAN cv??
SIAGLE FAMILY DWELLINGS 3
INCLUDE 2 SETS OF PLANS, 3 CERTIFICATES OF SURVEY, 1 SET OF ENERGY CALCULATIONS
NOTEs ADDRESSES FOA CORNER LOTS - CONTRACTOR/HOMEOWNER MUST DESIGNATE WfiICH ADDRE6S
IS DESIRED. NO CHANGES WILL BE ALLOWED ONCE BIIILDING PEAMIT IS IS3tJED.
MUI.TIPLE DWELLINGS REN!'AL [JNITS FOR SALE ONITS
1 OF UNITS
INCLUDE 2 SETS OF PLANS, CERTIFICATE OF SURVEY - CHECg WITH BLDG. DEPT., 1 SET OF ENERGY
CALCULATIONS
COMMERCIAL
0
INCLUDE 2 SETS OF ARCHITECTURAL & STRUCTURAL PLANSt
1 SET OF SPECIFICATIONS AND 1 SET OF ENERGY CALCULATIONS
.RiC `?i GL."? R, ?
To Be Used For:?I?aU1LtS L/2Valuation: Z1 (J1C Date: 3"
Site Address y2),5r] 1-ocX.-fE ffit? GT OFFICE DSE ONLY
Lst Black 0?-4 7"1 CT ? ?
Parcel/Sub t;9ff K AAz)/U,
Owner 0,1 Address --*-? ?1.), J ( i Lo-7
City/Zip Code <A(z4Fj '!? -T / 2?' I
Phone L-? ' Ll _ C41 vt?
Contractor 5h n(?P u% jc?e d
Address Z?`? in 4
City/Zip Code (Mh _SS-2,5
occupaney g'y , /4-3
Zoning PF
Aetual Const V-N
Allowable V-1`)
# of stories 1
Length 30
Depth y2
S.F. Total II4')?
Footprint S.F. J1LIK
On site sewage
On site well _
MWCC System _
City water _
PRV required _
Booster Pump _
APPROVALS
Phone ?7 1 - (5 (f) C) Planner
Couneil
Arch./Engr. ? -S Bldg. Off.
L/ Variance
Address NNPrZ'`! Couneil
4h+
FEE3
Bldg. Permit
Surcharge '210,50
Plan Review
SAC, City
SAC, MWCC
Water Conn
Water Meter
Aeet. Deposit
S/W Permit
S/W Surcharge
Treatment P1.
Road Unit
Park Ded.
Copies
TOTAL odl D, ,. z>
City/Zip Code V?101S , lrLr A-' SS y13
Phone #
NOTS: Sewer & Water Permit fees aud aecsount deposit fees will be included in the building
permit fee. Processing time for sewer and vater permits is txo days onee a lioensed
plumber has applied for a permit at City Iiall.
??) i(
E:-'d
To I
-.-
?L = -?t xs
?h xsi
?? "+c ?l Tl??+
f7'9
Qy?bd ?^?-?
Z : oo? ? 8h h=?? x gz
?
)w»d va?!L
oS' 'O/,:?o = -5000 ' ?-e dQ4'( Z t7
g
,. .
0c.? , t??^ A ?v E12C? ?2?A1 ?^fz, v,- A'?A? &1 ,
MEMO T0: PAT GEAGAN - POLICE DEPT.
ED gIRSCHT, SR. ENGINEERING TECH.
CRAIG KNUDSEN, ENGINEERING TECH.
TOM COLBERTt DIRECTOR OF PUBLZC WORIGS
JIM STURM, PLANNING DEPT.
JON HOHENSTEIN. ADMINISTRATION
BILL ARINS, ELECTRICAL INSPECTOR
JOE CONNOLLY, WATER DEPT.
FROM: DOUG REID, CHIEF BUILDING OFFICIAL
DATE: 3- Z 9- 89
The prelimi.nary construction
plans for -PtAM p H OUSC #12
are in our plan review seetion for your
?
4--_3
comments.
Please return this form to Joe Merehak with your initialed comments and the
date o£ review. Failure to return form to Joe xithin five (5) days iri.ll be
eoasidered your approval. If you have anq objeotions to approval of these
plans, it is your responsibility to notiPy this department and reaolve any
problems.
Thank-you.
/JS
(Signat
(Date)
4J
MEMO T0: PAT GEAGAN - POLICE DEPT.
ED KIRSCHT, SR. ENGINEERING TECH.
CRAIG KNUDSEN, ENGINEERING TECH.
TOM COLBERT, DIRECTOR OF PIIBLIC WORKS
JIM STURM, PLANNING DEPT.
JON HOHENSTEIN, ADMINISTR9TION
BILL AKINS, ELECTRICAL INSPECTOR
JOE CONNOLLY, WATER DEPT.
FROM: DOUG REID, CHIEF BUILDING OFFICIAL
DATE: 3-29-89
The preliminary eonstruetion ^
plans for j"tnM P Fi pi
are in our plan reniew sec
?
or your
Please return this form to Joe Merchak with your initialed camments and the
date of review. Failure to return form to Joe xithin five (5) days vill be
considered qour approval. If you have any ob3eetions to approval of theae
plaas, it is your responsibility to aotify this department aad reaolve any
problams.
Thank-you.
JJS
(5ignature) ?(Da e)?
4--3
MEMO T0: PAT GEAGAN - POLICE DEPT.
ED KIRSCHT, SR. ENGINEERING TECH.
CRAIG KNUDSEN, ENGINEERING TECH.
TOM COLBERT, DIRECTOR OF PQBLIC iiORKS
JIM STURM, PLANNING DEPT.
JON HOHENSTEIN, 9DMINISTRATION
BILL AKINS, ELECTRICAL INSPECTOR
JOE CONNOLLY, NATER DEPT.
FROM: DOUG REID, CHIEF BUILDING OFFICIAL
DATE: 3- Z 9- 89
The preliminary
plans for {?tAM P
are in our plan revie
construetion x
4t 17_
your
Please return this form to Joe Merehak with your initialed comments and the
date of review. Failure to retura form to Joe xithin five (5) days will be
considered your approval. If you have any objeebions to approval of these
plans, ib is your responaibility to notify this department and resolve any
proDlems.
Thank-you.
/IJoTe -1 .. .&,,x A - ? .
4.1 ?lf/' 0-s?A..,:4.(, ?Ch.?Cw?°?eh"°°C. ? '?.l..tti.E,?..?..?h`,,,d•a? f ?.s?r?
/JS
(Signature) (Date)
4-:3
lIII90 T0: P9T GEAGAN - POLICE DEPT.
ED KIRSCAT, SR. ENGINEERZNG TECH.
CRAIG KNUDSENt ENGZNEERING TECfi.
TOM COLBERTo DIRECTOR OF P[JBLIC ilORBS
JIM STORM, PLANNING DEPT.
JON HOHENSTEINt 9DMINISTRATION
HILL AKINSp ELECTRICAL INSPECTOR
JOE CONNOLLY, iIATER DEPT.
FROM: DOUG AEID, CHIEF BUILDING OFFICIAL
DATE: 3- Z 9- 89
The preliminary
plans for -rNM P
are in our plan review
coastruetion ^
your review and
Please return this form to Joe Merchak with your initialed comments and the
date of reviex. Failure to return fom to Joe vithin five (5) days will be
considered your approval. If you have eay objections to approval of ttiese
plans, it is pour responaibility to notify this department and resolve any
problems.
Thank-you. ?f!
?JaTL 2 /?.F.O 4.???.?-,1t
.2 )
/JS
'3
(Signature) (Date)
?
4..13
!+M0 T0: PAT GEAGAN - POLZCE DEPT.
ED KIRSCIiTp SR. ENGINEERING TECH.
CRAIG KNUDSEN, ENGINEEAING TECH.
TOM COLBERTt DIRECTOR OF POBLIC FiOAKS
JIM STURM, PLANNING DEPT.
JON HOHENSTEIN, ADMINISTRATION
BILL ARINS, ELECTRICAL INSPECTOR
JOE CONNOLLY, WATER DEPT.
FROM: DOUG REIDp CIiIEF BUILDING OFFICIAL
DATE: 3' 2 19 " 8 9
The preliminary construetion
plans for -PtAM P H OUSC # 12
are in our plan reniew seetion for your
x
comments.
Please return this form to Joe Merchak with your initialed comments and the
date of review. Failure to retura form to Joe rrithin Pive (5) days xill be
considered your approval. If you have any objeetions to approval of these
plans, it is your responsibility to notify this department and reaolve any
problems.
Thank-you.
/JS
(Signature) (Date)
Contract No.:
Project No.:
Submittal Date:.-?LX
CITY OF EAGAN
PROJECT DESCRIPTION:
,
Substantial Campletion of Sewer & Water ??7J ?7-0/
Date of Occurrence
STEP I: PERMISSION TO HOOK UP
SANITARY SEWER
X Lines Lamped and Acceptable
Deflection Mandrel Test Passed
Manhole Structures Properly Constructed
(cstg. & cover, rings, cone, 1 ft.
sections, final rim setting, & build
and invert)
Infiltration Test
SERVICES
WATER MAIN
X Properly Chlorinated & Flushed
b< Entire System Pressure Tested
X_ Entire System Conductivity Tested %
X_ All Valve Boxes Accessible,
Straight & keyed
All Valves Opened or Close
as Approp.
? All Hydrants Set to Proper Grade
?.T6ni/?' ? ?si n/lE.c.JTis it//???
All Wye Locations Confirmed
All Curb Boxes Exposed, Set to Proper Grade & Marked w/Fence Post
COMMENTS:
r
STEP II: FULL USE PERMIT (OCCUPANCY)
STORM SEWER
Lines Lamped & Acceptable
CB Structures Properly Constructed (cstg.
& cover, rings, 1 ft. section, invert,
final cstg. setting & build, DL-DR
correctly set rings & cstg. set in full
bed of mortar)
Aprons, Dissipators & Rip Rap properly
install
STREETS
Material Tests Checked & Passed
(Conc. compressive strength & Air
Content, Bitum. Exact & gradation,
gravel base gradation).
Utility Structures & Lines Clear &
Free of Debris & Gravel (Gate
Valves keyed)
COMMENTS:
RECOMMENDATION: I herein verify that the tests and inspections indicated above have been
successfully completed. Any deviations or exceptions are described in my comments. With
this considered I recommend that permission to hook up or permission for occupancy be
granted as appropriate to the above conditions. r ,
$1
Confirmed by
e5.t-?rnspector.
ubli-c Works
,?Vco?IV4 I a ? o
OF
3830 PILOT KNOB ROAD. P.O. BOX 21199 VIC ELLISON
EAGAN. MINNESOTA 55121 MOm
PHONE: (612) 454-8100 7HOM0.S EGAN
DAVID N. GUSTAFSON
PAMEL4 AAcCREA
iHEODOfiE WAC4{tER
N E W Cquncil Memben
REQUEST FOR IRMW7tff ADDRE55 TM°^^°SNE°GEs
c.nv aarr,inmxator
EUGENE VPN OVERBEKE
Cik/Clerk
NOTE: NOTIFY DAKOTA COUNTY UTILITY SERVICES OF ADDRESS CHANGE
NAME: GI T`( OF EAGAN
ADDRESS:
PHONE #:
ADDRESS CHANGE REQUESTED FOR:
ADDRESS
F-r=QuEST"
REASON FOR &MSE- dSM 1ZEQUE57F-0 QN A0P2E55 FoR ,4 R1MPl-?5E
I K1 ?V?iZCa? - PA-F-K .
- f
(DATE) (SIGNATURE)
OFFICE USE QNLY
NEW ADDRESS 4357 Lj?)DISE.FL)LE L-F-
OU Z'
LOT A BLOCK
NAME OF PLAT CVG(ZLyTLEE1J F"?'
THE LONE OAK TREE ..THE SYMBOL OF STRENGTH AND GROWTH IN OUR COMMUNITY
(
? 11)
.
? / ? _ ? • /;
ii
,jl?v??3y REQUEST FOR ELECTRICAL INSPECTION . Ee-cooo/o?i-/?[j ,L ? /
II, See instructions for eompleting this form on back of yellow copy.
[)--q 0 5 gq "X" Be/ow Work Covered by Thls Request `
HAd Rep. Typa of BuilOing .4DOliances Wired Equiument Wired
Home Range Temporary Service
Ouplex Water Heater Lightiny Fixtures
Apt. 8uildinc? Dryer Electric Heatin
Commercfdi Bldy. Fumace Silo Unloader
Industrial Bldg. Air Conditionei Bulk Milk Tank
Farm oln?, pec? y oine.r tsnedrYi
t er Specify Olher piher
N Fee ServiceEntrenceSize b Fee Feeders/5u6feeders b Fee C"cuits
?b U to 200 qm s 0 to 30 qm s to 30 An s
/, vJ Above 20 _qmps 31 to 100 Amps , 1 to 100 q y
Swinuning Pool Above 100-Amps C? Above 100_Am %
Transformers Irrigation Booms PartialOther Fee
Signs Special Inspectfon S
? I
pemarks ? TOTAL FEE
Aouph-in Dale
I, the Elecbical
Inspactar, hereby
Final
?'?7e cerlify thet the above
inspection has heen
mede.
...o.?,. ?....?? ?.,?.?..??...a?..,..?
rThis request void
18 mnnlh5 ffom /?1 1
D 7 058 9/?1„-?7?;..?1 <, y'?tn,•. ?
i/ S/S1
LFIeqest
/
? Fire No. Rouph-ip ynsPection -
R q i,etl
E]Ready Nuw Will Nnfify. Inspec-
Ves ?No or When Ready
ucensea ciectncai Contractor 1 hereby request inspection ot a6ova
Owner electrical work installed at:
Street Address, Box or Route No. City
/' oo/ e pa /e G°f WC?? *;/,Z
ecUOn o. I Township Name or No. ? J Range No. County
?1/d r U!'c? er1 rk D40-1-4, f'c't
i OccuUantlPNT Phone No.
?
?+. r,
l.?°
? Power SuPPlier G
Y??fl ?. ?`?9. ?.???r Address
??i / ?' .-
Elect ical Contr tor ICompany Namel
151?/?? Contrac.tor's License No.
? ?? ?? •
'_ ( F i
° ? • ?;` Mailine Address iContrec[or or Owner Makine Installationl
/?c?i? '??.3 ?2.5"7 /l??rs e?i.c%/ .Cd.
S?ec?oP&?
i'I?/!. J??.37
? O.1 Au zed Signawre (C ractorz ner king4nstallation) .
Phone Number
-' ? - -- - - ' ? MINNESOT STATE BOARO OF LECTRICITY
GrigBS-Midway Bldg. - floom N•191 THIS INSPECTION REQUE57 WILL d
BE ACCEPTED BV THE ST0.TE BOAf
' 1821 Universitv Ave.. St. Pau1, MN 55104
Phone (612) 642-0800 UNLESS PROPEB INSPECTION FEE f.
ENCLOSED. ,