P - 80257I I I��� III II II III I RE�UEST FOR ELECTRICAL INSPECTION �,����
� II II ��� I) III I� (II II �II III I�II Minnesota State Board of Electricity ��a
1821 University Ave., Rm. S 128, St. Paul, MN 55104 �.. ��
`�* 0 2 7 9� 4 6 4*� Pnone �si2� saz-osoo ��'�' �°
Home Duplex Apt. Bldg. Other: New Addn
Commercial Industrial Farm Remod e air
Air Cond. Htg. Equip. Water Htr. Load Mgmt. Other:
D er Ran e Elec. Heat Tem . Service
"X" above the work covered by this request. Enter remarks in fhis space and on the back of the white copy only.
vli��J�r � ��� va�L.�'f1�Av
Calculate Inspection Fee - This Inspection Request will not be accepted without the correct fee:
Olher Fee # Service Entrarroe $ize Fee # Circuits/Feeders Fee
Mobile Home Park Stall 0 to 200 Amps 0 to 100 Amps
$treet Ltg./Traffic $ig. Above 200 mps Above 100 Amps
Transformer/Generator INSPECTOR'SUSEONLY i T�OTALS�� • �
Sign/Outline Ltg. Xfmr. �
Alarm/Remote Control
$wimming Pool I hereb certi that I ins eded the eleckical inslallafion described herein on the dates sfated
Irrigation Boom Rough-In Da+e
$peciallnsp F�
Investigative ee Final Da d.` /��
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
2 1 �J - 6 4 6 OFFICE USE ONLY This request void 18 months from validafion daM printed in this box.
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PLEASE PRINT OR TYPE
Request Date Rough-in inspeclion requiredZ ❑ Yes ,�lo Inspection Other Than Rough-In: � Ready Now Will Call
O.. .� � (You must cali the inspecror when ready) �� Date Ready:
I, �icensed contractor ❑ owner hereby request inspection of the above elecFrical work at:
Job Address (Sfreet, Box, or Route No.) Ci Zip Code
T �
Secfion No. Tow�ship Name or No. � Ranae o. Fire No. ounly
Address
or
Phone No.
Master Lic. No. (Plant Elecf.
Signoture (Conhacfor or awner orming InsTullation) f, � 1'� �� Phone No.
� , �
70 6/95 STATE BOARD COPY - E IN CTI NS ON BACK OF YELLOW COPY