P - 84133REQUEST FOR ELECTRICAL INSPECTION
5 jl � Minnesota State Board of Electricity
E�=r � 7 9 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 this request. Enter remarks in this space and on the back of the white copy only.
jJ�%"�t�� �'� %l��G'�?�� �
Calculate Inspection Fee - This Inspection Request will not be accepted without the correct fee:
Other Fee # Service Entrance Size Fee # Circuits/Feeders Fee
Mobile Home Park Stall 0 to 200 Amps 0 to 100 Amps
Street Ltg./Traffic Sig. Above 200 Amps Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY TOTAL S(}
Sign/Outline Ltg. Xfmr. ��
Alarm/Remote Control
Swimming Pool
I hereb certi that I ins ted the electrical installation described herein on the dates stafed
Irri9ation Boo - Rough-In pa�
Special Inspe
Final
Investigative Fee - d _
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This requesf void 1 S monfhs from validafion date prinfed in fhis box.
II I * �SS�
IIIII II��I IIIII IIIII I III IIIII I) III N� Illlf 1�5�7Q
* � 5 E+ 4 a 7 9 5* PLEASE PRINT OR TYPE �5���✓
Request Date Rou h-in ins ection re uired? p g � dy ❑ Will Call
g p q ❑ Yes o Ins ection Ofher Than Rou h-In: Now
�� �` /�p ��� � (You musf call the inspecfor when ready) Dafe Ready:
I, �,licensed contractor ❑ owner hereby request inspection of the above electrical work at:
Job Address (Sfreet, Box, o. Roufe No.) `/ ' Ciy J Zip Code
� �1�.-� �7� ���. �y,� ��� ; j ,��� .
Secfion o. Township Name or No. Range No. Fire No. Co ty �f-��
Occupanf ' Phone No. r -
�e'r "�' L��'r ��i��..� �� � �3�
Power $ plier Ad ss /An
l�,�.5,1� :.�I � � �� �/1 f -�=-,�'� ��- e�/rl � ���
Elecfrical nhacfor �Company Name� Con ctor License No. Master ic. No. (Planf Elect. Only)
� j�--�%�%C�, C��� �� ��i/G�f�S
Maili dress (Contrqctor or Owner Performing Installafio
7 %r�UU �,��r� �'�'1 � ��� �'�7��d�-�✓"�� ,-�'�� _
Authorized Signa�ad�e�orming Insfallation) � : f! Pho��� "' ���/'
' 3 U
EB-0OOOlA-11 8/96 � TATE BOARD COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY