P - 83862REQUEST FOR ELECTRICAL INSPECTION
����� r� /� � Minnesota State Board of Electricity
L L�-f 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 air
ir 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.
Calculate Inspection Fee - This Inspection Request will not be accepted without the correct fee:
Other Fee # Service Entrance Size Fee # CircuitsjFeeders
Mobile Home Park Stall 0 to 200 Amps 0 to 100 Amps
Street Ltg./Traffic Sig. Above 200 Am s Above 100 Ar
Transformer/Generator INSPECTOR'S use oN�v TOT,
Sign/Outline Ltg. Xfmr.
Alarm/Remote Control
Swimming Pool
I hereb certi fhat I ins ected ihe electrical installation described herein on the dafE
Irriaation Boom R���„h_i„ Dare
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smred
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Investigative Fee � "�' —
THIS INSTALLATION AY�B ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This request void 18 monihs from valida}ion date prinfed in ifiis box.
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* � 4 2 7 1 2�i 3�K PLEASE PRINT OR TYPE �5�
Request Date �� �� Rough-in inspection required? ❑ Yes o Inspecfion Other Than Rough-In: Ready Now ❑ Will Call
�You must call ihe inspector when ready) Dafe Ready:
I, �icensed contractor ❑ owner hereby request inspection of the above electrical work at:
lob Address (Sfreet, Box, or Route No.) City Zip Code
� 0 S� 3�^� s�- � �� �5' .3 a-
$ection No. Township Name or No. Range No. Fire No. County
41� c�
Occupant
J � �s�
Power Supplier � Address
Elechical Conhactor �Company Name)
S i�lCf2 ��Q.C�'h-(,C
Mailing Address (Conhacfor or Owner Performing Insfallafion)
2114 wcush.�v�q�ov� S� N.�.
Authorized Signature (Contractor or�Owner Performing Insfallation)
Phone No. q
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Conhacfor License No.
CQO�%��
Phone No.
J � i� 7�1-6200
� ON BACK OF YELLOW COPY
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