P - 81118REQUEST FOR ELECTRICAL INSPECTfON
8 O���% O � Minnesota State Board of Electricity �
� 1821 University Ave., Rm. S-128, St. Paul, MN 55104
�;
Phone (612) 642-0800 ?-�
�'
Home Duplex Apt. Bldg. Other. 0 S(�' ew Addn
Commercial IndusMial Farm .�! 5�' Remod Re air
Air Cond. Htg. Equip. Water Htr. Load Mgmt. Other:
Dryer Range Elec. Heat Temp. Service
"X" above tl�e w k covered by this request. Enter remarks in fhis space and on the back of the white copy only.
G"�/%/ �:� �Cl�4 J'
�
Calculate Inspection Fee - This Inspection Request will r,ot be accepted without the correci fee:
Other Fee # Service Entrance Size Fee # Circuits/Feeders Fee
Mobile Home Park Stall 0 to 200 Amps 0 to 100 Amps � 1'fb
Sfreet Ltg./Traffic Sig. Above 200 Am s Above 100 Amps
Trpnsformer/Generator INSPECTOR'S USE ONLY TOTA / ti1
� �,,� v
Sign/Outline Ltg. Xfmr. �`' � jy f
Alarm/Remote Conhol � ���
y
Swimming Pool
I hereb certi �at I ins ected the elechical insfallation described herein on the dates sfafed
Irrigation Boom RougMn D
Speciallnspection `�—� `��'
Final D
Investigative Fee �
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE U8E ONLY This request void 18 months from validafion date printed in fhis box.
' ii�i��iiiii���iiiiiii�iuiiii�i�ii�iiiiiiil ,Q�% •1//
* 0 8 0 2 1 7 0 1* (�,� `��� �
PLEASE PRINT OR TYPE
�`
Request Date Rou Irin ins on r uired$ ❑ Yes
g pecli eq ❑ No Inspecfion Other Than RougMn: ❑ Ready Now � Will Cafl
(You must call the inspector when ready) Dore Ready:
I, ❑ licensed contractor ❑ owner hereby requesf inspection of the above electrical work ot:
Job Address (Sheet, Box, or Route No.) City Zip Code
� 70� S�h✓�-VG N� � I���d Li � S.�L/32
Seclion No. Township Name or No. Ranpe No, Fire No. County
�i; � h�-��C t �"oha�sa� ��-s�i-���s
Power Supplier Address
S, �'
Electrical Conhacror �Company Name) Conhocror License No. Master Lic. No. (Plant Elecl.
Mailing Address �Conhactor or er Performing Instollafion)
G 7� Y��"� vP 1� �� 'It�
Aulhorized�ahire �Con Owrrer P i Instal ) . Pho�e N�7o. �f
Sr ! �^ l 7 �.�0'
E&00001 A-11 8/96 STATE ARD COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY