P - 83289REQUEST FOR ELECTRICAL INSPECTION
�� �� p p� Minnesota State Board of Electricity
J O O 1821 University Ave., Rm. S-128, St. Paul, MN 55104
Phone (612) 642-0800 '�'
Duplex Apt. Bldg. Other. New Addn
Commercial Industrial Farm mod Re air
Air Cond. Htg. Equip. Water Hh. Load Mgmt. Other:
Dryer Range Elec. Heat Temp. Service
"X„ above ihe work covered by thrs request. Fnier remarks in this space and on the bock of the white copy only.
Calculate Inspecfion Fee - This Inspeciion Requesf will not be accepted withouf fhe correcl fee:
Other Fee # Service Entrance Size Fee # Circuits/Feeders Fee
Mobile Home Park Stall 0 to 200 Amps 0 ro 100 Amps
Sheet Ltg./TrafFic Sig. Above 200 Am s Above 100 Amps
Transformer/Generafor INSPECTOR'S USE ONLY // . L� T�s ��
$ign/Oudine Ltg. Xfmr. �;�..; �.�G'��^" ��"�i � """� �
Aiarm/Remote Conhol �
Swimming Pool
I hereb certi that I in the electrical inslallaKon described herein on ffie dales sfaled
Irrigation Boom Rough-In ��
Special Inspecti
Final ..
Investigative Fee O —
THIS INSTALLATION MAY BE ORDERED CTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFlCE USE ONLY This requesf wid 18 months from validafion dafe pri� i is box.
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I IIII II III II III II � I) III II III I) III II III I IIII �
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* 0 4 3 7 8 8 4 �* p EpSE PRIN7 OR TYPE
Request Da1e Rou h-in ins fion r uired2 0 Will Cafl
� o g pec eq ❑ Yes No Inspecfion Olher Than RougMn: Ready Now
f'� Q D (You musf call the inspecfor when ready) Dafe Ready:
I, licensed contractor ❑ owner hereby request inspection of the above elecfrical work at:
Job Address (Sheet, Box, w Roure No.) City Zip Code
$'�@ � �-- �S .t/, Z �= �L[ � .�. �
Seclion No. Township Name or No. Range No. Fire No. Counly
Occupant Phone No.
�Lt ��- �c� ldirz
Power Supplier Address
Eleclrirnl Conkacror (Company Name) Contracior license No. Master Lic. No. (Plant Elect. Only)
�� �� �'^ LC�t'�Li� �'�00 �� �
Mailing Address �Conhac�or or Owner PerForming Installalion)
�J� �� �`l^� /�U'f� L,o N' a^ �, �Y�-�
Authoriz ' nature (Conhactor w Owner Performing Insfallafion, 2 65 ��. �e �. �� �
G�r � � 9
E�00001 A-11 8/96 �p� gpARD COPY - SEE INSTRUCiIONS ON BACK OF YELLOW COPY