P - 84420R��EST FOR ELECTRICAL INSPECTION
�'.
� See insVUCtions for completing this form on back of yellow copy.
0 9 4 ��� „X„ Below Work Covered by This Request
4dd�Re� Tvne of Buildinq Appliances Wired �
��E�'� EB-00001-09
���..� � 'i
� �
��..- �
Rt,��t �
quipment Wired
Home Range � C���N�rary Service
Duplex Water Heater Electric Heating
Apt. Building Dryer Load Management
Comm./Industrial Furnace Other (Specify)
Farm Air Conditioner
Other (speclfy) Contractor's Remar . �� �� ���� �
om ute Ins ection Fee Below: f� v !/4�'�!�
C p p %:�
# Other Fee # Service Entra e Size Fee # Circuits/Feeders Fee
Swimming Pool 0 to 200 Amps 0 to 100 Amps
Transformers Above 200 Amps Above 100 Amps
Signs �nspector's Use on�y: TOTAL
Irrigation Booms ��b
Special Inspection
Alarm/Communi ti THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT
Other Fee , COMPLETED WITHIN 18 MONTHS.
I, the Electrical Inspector, hereby Rough-in Date
certify that the above inspection has Final Date�r„Z� �6
been made. ` �>
OFFICE USE ONLY
This request void 18 months from
.._ .. - - - - - -._. .._ � - - - �- - - - ._ .- - —._�.�--
) 0 9 4 9 3'�` 0� S� '� �����
Request Date Fire No. Rough-In Inspection Required Inspec,��n Other Than Rough-In
(You must call inspector when ready) �Ready Now � Will Notify Inspector
/1r �� � � ❑ Yes �No Date Ready
I,�.licensed contractor ❑ owner hereby request inspection of above electrical work at:
Job Address (Street. Box or Route No.) City
✓
�r � ' �
Sec ion No. Township Name or No. Range No. County � �
Occupant (PRINT)
Po er Su pli
Electrical ontractor (Company Name)
�-�('/� �j�i !i
Mailing Address (Contractor or Owner M�aky'ng Installation)
1 n i I .� �_/ !J. /
Address
J
Contractor's License No.
Authoriie ignature (Contracto - er Nt ng Insiallation� Phone Number
��..� 8 j ��� �
I S BO D OF LE RICITY THIS INSPECTION REQUEST WILL NOT
Griggs-Mi d oom S BE ACCEPTED BY THE STATE BOARD
1821 University e., St. Paul, MN 55104 UNLESS PROPER INSPECTION FEE IS
Phone (612) 642-0800 . ENCLOSED.