P - 82986� � • "s
� �
REQUEST FOR ELECTRICAL INSPECTION
Minnesota State Board of Electricity
1821 University Ave., Rm. S-128, St. Paul, MN 55104
Phone (612) 642-0800
Home Duplex Apt. Bldg.
Commercial Industrial Farm
Air Cond. Htg. Equip. Water Htr.
Dryer Range Elec. Heat
"X" above the work covered by this reque Enter
�� S� ��-)1/7i%� � lt�
�P�f�� ,
New
� �,�.;�_�;;"�
M1r�'�,� 4
� �Q.�:�
Load Mgmt. Other:
Temp. Service
narks in thi space and on the back of the�ite c_�y only. _
,��i4-tj� ! c� �,p ��c.�t �-C; �
1
Calculate Inspection Fee - This Inspection Requesf will not be acce
Other Fee # Service Entrance Size
Mobile Home Park Stall 0 fo 200 Amps
Street Ltg./Tra�fic Sig. Above 200 Am
Transformer/Generator INSPECTOR�S USE ONLY
line Ltg. Xfmr.
moFe Control
� Pool
without the correct fee: �� / (J
Fee # Circuits/Feeders Fee
�('i0 0 to 100 Amps
Above 100 Amps
s�
��� ���������� I her certi that I ins Ifie elachical insrollafion described herein on the dales staled
Irrigation Boom RougMn Dare
Special Inspecti
Final � Dafe
Investigative Fe t — .—��
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFlCE USE ONLY This requesf void ths from validafion date printed in this box.
( ���) II ��� II �I� �� III �� ��) �� ��I �I (I� I� I�� a� 5a
��) � �,, /d 0 /
* � 4 3 9 8 1� 8�K PLEASE PRINT OR TYPE
Requesf Date n Rough-in inspection required$ ❑ Yes Inspecfion Other Than RougMn: eady Now � Will Call
�`� G� 9� �You must call the inspec�or when ready) Date Ready: 2�`�,r.►
I, �licensed contractor ❑ owner hereby request inspection of the above elechical work at:
Job Address (Skeet, Box, or Roufe No.) City Zip Code
� � � � %. � � . ��+�,� �� 2.
Secfion No. ownshiu Name or No. Rance No_ Fire No_ Cou tv
�o
3f
s�
�
Phone No.
S'�Z -!6 Z_
�W f
co�tracro� ucense rJo. nAaSte. �ic. No.
Crq 00$'2�
i�5ro����,�
" r 1 I..+ q �; l, �.s��. 1 L"• V�.� G�
1�neRPerFo ' '°� � � �+�..: - P �' NV U ' �V �
�
STATE BOARD COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY