P - 83040REQUEST FOR ELECTRICAL INSPECTION ���
6���'1 2� � Minnesota State Board of Electricity ����
•L 1821 University Ave., Rm. S-128, St. Paul, MN 55104
� C]C7 11 �Q Phone (612) 642-0800 '���
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Home Duplex Apt. Bldg. Other: New Addn
Commercial Industrial Farm Remod Repair
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
5r�-vicst. fY1G.-��--
the white copy
Calculate Inspection Fee - This Inspecfion Request will noi be accepied without the correcf fee:
Other Fee # Service Entrance Size Fee # Circuits/Feeders Fee
Mobile Home Park Stall to 00 Amps 0 to 100 Amps
Street Ltg./Traffic Sig. Above 200 Am s Above 100 Amps
Transformer/Generator INSPECTOWS usE oN�v T � AL�
$ign/Outline Ltg. Xfmr.
Alarm/Remote Contro! '
$wimming Pool
I hereb certi thal I ins the elechical insfallaHon described herein on the dates staied
Irriqation Boom R,,,,,,i,.i„ n,,,e
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This requesf void 18 from valid �d e' i. �box.
� �I,I II ��I II III II I�� I III �I (II �I III (I �I � � �
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PLEASE PRiNT OR TYPE
Request Dafe Rough-in inspecfion required2 ❑ Yes �No Inspecfion O�er Than Rough-In: ❑ Ready Now Will Call
8�/ -+ (You must call the inspeclor when ready) �� Date Ready:
I, � licensed contractor ❑ owner hereby request inspection of the above elecfrical work at:
hb Address (Sheef, Bou, w Roule No.) Ciy� Zip Code
8 ' � —T�� T `�
Seclioo No. Township Name or o. Ranae No_ Firn No_ G���
Phone No.
5 � I —3
Addre:s
necmcai �.onvacror �i.ompany Name� Contracbr License No.
�1 �— �C�`�'i G � � � Z�
Mailing Address �Con r or Owner Performing Ins fion) �
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Aufhoj'r�d $ipnature IC9u4'atfor or Qwner ormma Installationl
Lic.
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STATE BOARD COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY