P - 82781659-�38 �
ome Duplex
REQUEST FOR ELECTRICAL INSPECTION �
Minnesota State Board of Electricity
1821 University Ave., Rm. S-128, St. Paul, MN 55104 �`
Phone (612) 642-0800 `�'
Other: New Addn
Commercial Industrial Farm Remod Re air
Air Htg. Equip. Water Htr. Load Mgmt. Other:
Dryer Range Elec. Heat Temp. $ervice
"X" above the work covered by this request. Enter remarks in this space and on the back of the white copy only.
Calculate Inspecfion Fee - This Inspection Request will not be accepied withoui fhe correct fee:
Other Fee # Service Entrance Size Fee # Circuits/Feeders Fee
Mobile Home Park Stall 0 to 200 Amps 0 to 100 Amps
Street Ltg./Traffic Sig. Above 200 Am s Above 100 Amps
TransFormer/Generator INSPECTOR'S USE ONLY TOTAL�
Sign/Outline Ltg. Xfmr. •-�-
Alarm/Remote Control
Swimming Pool
I hereb certi that I ins the electrical installation described herein on the dafes sfafed
Irri9ation Boom RougMn Dare
Special inspecti `° `1
Investigative fee ""' � F���I �- 2��--0 v
THIS INSTALLATION MAY BE ORDEREO DI ECTED iF NOT COMPLETED WITHIN 18 MONTHS.
I�� II I�I II III II III II I OFFICE USE ONLY This request void 18 months from validation date prinfed in this box.
I� ���I������n���� • �5-�
� 0 6 5 9 5 3 8 3* ,�/� 6�
PLEASE PRINT OR TYPE
Request Da1e Rough-in inspeclion required$ ❑ Yes No Inspecfion Other Than Rough-In: eady Now ❑ Will Call
'7 12�� (`!ou must wll ihe inspecror when ready) Date Ready: ? ��%�✓
I, �, licensed contractor ❑ owner hereby request inspection of the above electrical work at:
Job Address (Skeef, Box, or Roufe No.� City Zip Code
S8o - 37��¢ v� Fi-�e��e
Secfion No. Townshio Name or No. Ranae No. Fire No_ Cn�mn� .
47 �''`IQh 'f"
Power Sopplier � Addreu
��
Eleckical Conhacfor �Company Name� Conhacior License No. Masfer Lia
2TS ���`�2 �C o � 8
Mailing Addreu �Conhacbr or Owner Pe�forming Installafion) �
1U � w rr, ►'Y! n. SS3 ��
Authorized $ignature (Conhocfor or Owner Performing Insfallafi r� �} Phone No.
. � '� �-� � �.
E&00001A-11 8/96 ST BOA COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY