P - 81654REQUEST FOIi ELECTRICAL INSPECTION
8'J �° 2 4 2� Minnesota State Soard of Electricity�
1821 Universiry Ave., Rm. S-128, St. Paul, MN 55104 �;
Phone (612) 642- 800 " '
ome Duplex Apt. Bldg. Othe��b� S� New Addn
Commercial Industrial Farm � Remod e air
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 spoce and on the back of the whiie copy only.
Calculate Inspection Fee - This Inspection Request will r,ot be accepted without the correct fee:
Other Fee # Service Entrance Size Fee # Circuits/Feeders Fee
Mobile Home Park Stall 0 to 200 Amps 0 to 100 Amps
Sheet Ltg./Traffic Sig. Above 200 Am s Above 100 Amps
Transformer/Generator iNS%�croR'S USE ONLY \ TOTA
Sign/Oudine Ltg. Xfmr. � 1��� �,�/� J ��� �O
Alarm/Remote Control
Swimming Pool
I hereb certi thot I ins the elechical installafion described herein on the dofes sfated
Irrigation Boom Rough-In Dare
Speciallnspect �`
Final D d j
Investigative Fee
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18. MONTHS.,
OFHCE USE ONLY This requesf void 18 months from validation date printed in this box.
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* 0 8 0 2 2 4 2�' � a�,SC�
PLEASE PRINT OR TYPE
Request Date Rough-in inspecfion required$ ❑ Yes No Inspeclion O�er Than RougMn: ❑ Ready Now �'�/ill Call �
�/'�✓D r (You must call the inspector when ready) Date Ready:
I, � licensed contractor ❑ owner hereby request inspection of the above electrical work at:
Job Address (Street, Box, or Route o.) Cily Zip Code
0�5` y � .s-F �/� ��-, d �� : �/� �
Section No. Township Name w No. Range No. Fire No. Couny
�o a�' A��-�
Occupa t � Phone No.
�J �n.ba�w ,cn 57��70�� `�
Power Su lier Address
/,�S 2 8 61 �
Elechical Co ha (Company Name) � Conhactor License No. Master Lic. No. �PIan1 EIecF. Only)
� ��•v /��r'%�. .� ^-e � C� �40 1 / 3 i �G �. Sco.�
Mailing Address ontraclor or (Performing Installafion)
� ? � °:�-�� ,�a �,� ,-�-� mw ' � �
Authorized ' Nre �Conhactor or er Perfer ing Installation� Phone No.
533-3u38
EB-0OOOlA-11 8/96 STATE B ARD COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY