P - 828015�2-514 :
: /�
RE(�UEST FOR ELECTRICAL INSPECTION —�
Minnesota State Board of Electricity
1821 University Ave., Rm. S-128, St. Paul, MN 55104
Phone(612)642-0800 �
r Home Duplex Apt. Bldg. Other. f—C'/C//I �" Ne
Commercial Industrial Farm �C 5� emoc
Air Cond. Htg. Equip. Water Htr. Load Mgmt. Other:
Dryer Range Flec. Heat Temp. Service
"X" above the work covered by this request. Enfer remarks in ihis space and on the back of the white copy
Calculafe Inspection Fee - This Inspection Request will not be accepfed without the correct fee:
Other Fee �i Service Entrance Size Fee # Circuits/Feeders Fee
Mobile Home Park Stall 0 to 200 Amps 0 to 100 Amps l%
Street Ltg./Traffic Sig. Above 200 Am s Above 100 Amps
Transformer/Generator INSPECTO1R;S uSaE ON�Y � TOT/1�i�/. ��
Sign/Oudine Ltg. Xfmr. �"i(. 7� /L!�"�
Alarm/Remote Conhol
Swimming Pool �1/( —�y
I c�1i tlwl I ins the eledri I installation described herein on the Stated
Irrigation Boom � Ra„�,�„
Special Inspecfi �" � "'�d �
Final
Investigative Fee �
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFlCE USE aNLY This request void 18 months from validafion date prinfed in this box.
I IIII u Ili II iil II III il li II III II lil II HI I IIII
��.5� ����
* � 5 3 2 5 1 4 7� PLEASE PRINT OR TYPE
R�� �.°� �� ��� Rough-in inspection required? Yes ❑ No Inspecfion Other Than RougMn: eady
`� ❑ R Now Will Call
�You must call the inspecior wh n ready� Date Ready:
I, ❑ licensed contractor�yner hereby request inspecfion of the above elecirical work at:
Job Address (Sheef. Box, or Route IVo. Ciy „ Zip Code
� l � -� , � � � �Z� � e �5�`l Z
Section No. Township Name or No. Range No: Fire No. Counly
_ 3/� �S� �Nd l��4
Occupant
Power
� ����
Confractor (Com�any Name)
Phone No.
Contracbr License No.
Nloiling Addreu (Conhacbr w Owner P I�slallation) �
1
�
� �s� F �� �
nfraclor or Owner P rmirg lion) 2 6 3 41 . �one D�
�-�— �
STATE BOARD COPY - SEE INSTRUCiIONS ON BACK OF YELLOW COPY