P - 82894REQUEST FOR ELECTf�ICAL INSPECTION °�
5������ Minnesota State Board of E�ectricity
� 1821 University Ave., Rm. S-128, St. Paui, MN 55104 -
Pho�e (612} 642-0800
Home Duplex Apt. Bldg. Other: (� ('�; , �1 ew Addn
Commercial Industrial Farm ��{f���� Remod Re air
Air Cond. Htg. Equip. Water Htr. toad Mgmt. Other;
Dryer Range Elec. Heat Temp. Service
"X" above the work covered by this requesf. Fn►er remarks in tl�is space ond on tf�e back of fhe whife copy only.
Cakulafe Inspection Fee - This Inspecfion Request wrll rtot be accepied 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
Street Ltg./Traffic Sig. Above 200 Am s Above 100 Amps
Transformer/Generoior INSPECTOR'S USE ONLY TOTAL
Sign/Oudine Ltg. Xfmr. �i� �� ���
Alarm/Remote Conhol � \ %1��0
Swimming Pool
I hereb certi N�o11 i the elecki al insmllafion descri6ed herein on Ihe dates sroted
irrigation Boom Roughan ' oo _���
Speciallnspecti •
� Final
Investigative Fee - —�'
THIS iNSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MO S.
OFFICE I�E ONLY This request void 18 months 6om validafion dale prin�ed in this box.
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* � 5 8 8 7 1 1 G� * PLEASE PRiNT OR TYPE
Request Date Rou h-in ins
g pection required$ Yes ❑ No Inspecfion O�er Thon Roughdn
�' �"�, (Vou m�st call the inspeclor n reody) pate Ready: /
I, licensed conhactor ❑ owner hereby request inspection of the above etechical work at:
Job�ddreu (Street, Box, or�Roule No.) � Cii�.���
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Sectfon �`10. iownship Name No. Range No. Fire No. County
�c� a �.�o�
Occupant � Phone No,
(Company Name
Y �-
atracfor or Per(orming Mskil tion)
� !�'�'Y1�c�.:v�(',�.�r
(Contra r Owner Performing Installalion)
'1 •
. TATE BOARD COPY - SEE 11 TFIU�'
Ready Now � WiN Cal!
Zip
/�•� ,�� ri/S/ U�•.�
� cFa license No. Master lic. No.
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ON BACK OF YELLOW COPY
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