P - 80398REQUEST FOR ELECTRIGAL INSPECTION .�-�
8�,� ,� Q O� a Minnesota State Board of Electricity x
V 1821 University Ave., Rm. S-128, St. Paul, MN 55104 -
• 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 fhis request. Enter remarks in this space and on the back of the white copy only.
Calculate Inspection Fee - This Inspeciion Request will not be aa
Other Fee # Service Entranc 'z
Mobile Home Park Stall ro 00 Amps
Street Ltg.jTraffic Sig. Abo e 200 Am
Transformer/Generator INSPECTOR'S USE ONLY
Sign/Outline Ltg. Xfmr.
Alarm/Remote Control
wiihouf the correct feei
Fee # Circuits/Feeders Fee
0 to 100 Amps
Above 100 Amps
Swimming P I � µtZ-�"�Od
hereb cerfi Ihaf I ins el lation described herein on the ates stated
Irrigation RougMn Da
Special Inspection �
Final ^ , DoW �
Investigative Fee -- ' ��
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WI IN 18 MONTHS.
OFFICE USE ONLY This requasf wid 18 months 6om validation date printed in this box.
I�II�IIIIIIIIIIIIIIiIIIII�M�I��nl�ll�l ��07.� ���
* 0 8 4 9 8 0 2 4*
PLEASE PRINT OR TYPE
R�� =�/ _�QD Ro h-in ins on uired? �Yes
ug pecli req ❑ No Inspecfion Other Thon RougMn: ❑ Ready Now� Will Call
(You musf call fhe inspec�or when ready� Dafe Ready: ��
I, �licensed conhactor ❑ owner hereby request inspection of the above elecfrical work at:
Job Address �Sheef, Box, or Roufe No.) Ciry Zip Code
S80 ( ��Z S7 ��ir���'�� �55 3Z
Secfion No. Township Name w No. Ran e No. Fire No. County
�� � ��ti
OccupaM P ne No.
. �. /!/ . . ��(/�"�� / J� y� � ��
wer upplier Address
/ f / ��
� tSechicaf ContracTOr (Company Name) Conhactor License No. Master Lia No. (Plant Elecf. Only)
`L L� �`c�c �',�t . G.4 d 3 02 --
Mailing Address (Confracfor or Owner Performing Insfallafion) �
2.7 D� �e � h TS,�iJ
Authorized Si a Contra r r Own i i � (7� � , � � � Pho 0
C.S � G ! �� .�
EB-00001 A-11 /9 STATE BOARD COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY