P - 80653REQUEST FOR ELECTRICAL INSPECTION --e
C� 2 e C O C �a Minnesota State Board of Electricity
, F� �� � J 1821 University Ave., Rm. S-128, St. Paul, MN 55104
r Phone(612)642-0800
Home Duplex Apt. Bldg. Other: New Addn
Commercial Industrial Farm Remod Re air
Air Cond. Htg. Equip. Water Htr. Load Mgmt. Other:
Dryer Range Elec. Heat Temp. Service
"X" above the work covered by this request. Enter remarks in this space and on ihe back of the whiie copy only.
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Calculafe Inspection Fee - This Inspection Request will not be accepted without fhe correct fee:
Other Fee # Service Entrance Size Fee # Circuits/Feeders Fee
Mobile Home Park Stall 0 to 200 Amps 0 0 Amps
Street Ltg./Traffic Sig. Above 200 Am s A 00 Amps
Transformer/Generaror �NSVecroR'S USE ONLY TOTA� �
Sign/Outline Ltg. Xfmc fljs CDC(F� �"t��'
Alarm/Remote Control
Swimming Pool
I hereb certi that 1 ins ted ifre elechirnl installalion described herein on fhe dates stated
Irrigation Boom RougMn Da�e
Special Inspection �
Investigative Fee F�� y_Z.Y-a�-- �� /'�-�°�
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPI.ETED WITHIN 18 MONTHS.
OFFICE USE ONLY This request wid 18 monlhs from validafion date printed in this box.
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I III) I) III II III II II) II III III II III II III I IIII 5
* � 5 3 2 5 8 5 7* PLEASE PRINT OR TYPE ���O
Request Date � Rough-in inspection �equired? �Yes ❑ No Inspecfion Olher Than Rough-In: ❑ Ready Now ❑�II Call
G=� g� (You musf call the inspector when ready) Dale Ready: -
I, ❑ licensed contractor..�owner hereby request inspection of the above elechical work at:
Job Ad re �Sheet, Box, or Route No.) �'� 1 „} ;^ /i Ciy L� Zip Code
^ �� Ssy
Secfion N. Township Name or No. Range No. Fire No. C ny
� �17
o«���� r�� No: � - -
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nr (Company Name Con r License No. Master Lic. No. (Pla�
� w� �/� �o
Conhactor w Ovmer PerForming Installation�
r ��/� � �. J��, Fl�i,p �"�iV -5S'y2 �
ure (�nhacfor r Owner Performing Installafion) Phone No.
%�.57/-
96 STATE BOARD COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY