P - 83863REQUEST FOR ELECTRICAL INSPECTION _— � 1
4 2 7-118 � Minnesota State Board of Electricity I
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. tg. 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 ►he back of ►he white copy only.
Calculate Inspection Fee - This Inspection Request will not be accepted without the correcf fee:
Other Fee # Service Entrance Size Fee # Circuits/Feeders
Mobile Home Park $tall 0 to 200 Amps to 100 Amps
Street Ltg./Traffic Sig. Above 200 Amps Above 100 Amp:
Transformer/Generator INSPECTOR'S USE ONLY TOTAL
Sign/Outline Ltg. Xfmr. � �
Alarm/Remote Control
Swimming Pool
I hereb certi thaf I ins ed the elechical installation described herein on fhe dates sf
Irrigation Boom Ro„yM„ Date
Soecial Insoectioo r r .
Fee
�i�
Investigative F ���� � �!�l�'�— ���" Z�`� �
THIS INSTALLATION MAY BE ORDERED DISCONNEGTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFlCE USE ONLY This requesf void 18 months from validofion date prinfed in this box.
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* � 4 2 7 1 1 8 5* PLEASE PRINT OR TYPE IS�
Request Date /� � Rough-in inspecfion required? ❑ Yes o Inspection Ofher Than Rough-In: dy Now ❑ Will Call
%�/ (You musf call fhe inspector when ready) Date Ready:
I, �.Jicensed contractor ❑ owner hereby request inspection of the above electrical work at:
Job Address (Street, Box, or Route No.) City Zip Code
��� 3��r� s�- �% �--� � � s y 3�
Section No. Township Name or No. Range No. Fire No. County
.� �v � �
Occupant Phone No.
�► I J� , V v v �l
Power Suoolier Address
Elecfrical Coniracfor (Company Name)
SYJGU(.I2 �.eeC�'IC�(.0
Mailing Address (Conkactor or Owner Performing Installation)
2114 Gla�h.i.vig�av� S� N . � .
Authorized Signature (Conh9ctor� Owner Performing Inslullati�
Conhacfor License No.
CU,(7 � %� �
2554.�
Elect. Only)
No.
7�1-6200