P - 83838I� I II III I� I�� I I��I REGIUEST FOR ELECTRICAL INSPECTION �����
I I��I (�I � I� II III II III II III I) I) Minnesota State Board of Electricity � ��
� � � 1821 University Ave., Rm. S-128, St. Paul, MN 55104 €
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Home -' Duplex Apt. Bldg. Other: � �' ' rc New ddn
Commercial Industrial Farm ��' emod Re air
Air Cond. Htg. Equip. Water Htr. Load Mgmt. Other:
Dryer Ran e Elec. Heat Tem . Service
"X" above the w rk covered by this request. Enter remarks i this space an on the back of the white copy only.
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Calculate Inspection Fee - This Inspection Request will not be accepted without the correct fee:
Olher Fee # $ervice Entrance Size Fee Circuitr/Feeders Fee
Mobile Home Park Stall 0 to '00 Amps 0 to 100 Amps
Street Ltg./Traffic Sig. Above 200 Amps 100 Amps
Transformer/Generator iNSPECTOR'suSEON�Y. TOTAL
t � C' �; ?'
Sign/Outline Ltg. Xfmr. . � � „J J �
Alarm/Remote Control
Swimming Pool
I hereb certi fhat I ins eded ihe eledrical insiallation described herein on ihe dafes siated
Irrig6tion Boom Rough-In �O�
$pecial Inspedion � p�e
Final � ,� � �"
Investigative Fee �
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
2 9 9— 4 0 6 OFFICE USE ONLY This request void 18 monihs from validation date printed in this box.
2 � J � ? � � �_S'6
,� i�G
PLEASE PRINT OR TYPE
Request Date
I, ❑ licensed contrador [j]�
Job Address (Sfreet, Boz, or Route No.)
; 5 G:�, �+��..�. f
Sedion No. Township Name or No.
Occupanf /,
,- a ,
Power $upplier
Contracior (Company Name)
Rough-in inspedion required2 ❑ Yes ❑ No Inspection Other Than Rough-In: Q Ready Now ❑ Will Call
(You must call the inspedor when ready) Daie Ready:
owner hereby request inspection of the above electrical work at:
_ ��5�-I 3 �Z.. "" Zip Code
�,- � , �,. ; � � 5 5 �t 3 Z
� Range No. Fire Na. Counly
No.
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Tes5 �
CS��� C��� c� �r�cj��.
Contrador License No. Master Lic. No. (Plant EI
Only)
dress (Contrador or Owner Performing Installafion) � _�
`3 G' �> C% � �� r �'� �n v S 5� � 3
Signature (Conirador or Owner Performi �1'sfd�afion) Phone No.
�Yi, � � ( — C ! `7
-10 6/95 ATE BOARD COPY - SEE INSTRUCTIONS ON BACKOF YELLOW COPY
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