P - 80754. REQUEST FOR ELECTRICAL INSPECTION —
P��- 211 Minnesota State Board of Electricity
1821 University Ave., Rm. S-128, St. Paul, MN 55104
` Phone(612)642-0800
Home Duplex Apt. Bldg. Other: New Addn
Commercial Industrial Farm Remod Re air
Air Cond. Htg. Equip. Water Htr. Load Mgmt. Other:
Dryer Range Elec. Heat Temp. Service
"X" above the work covered by ihis request. Enter remar s in this space and on ►he back of the white copy o.
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Calculaie Inspection Fee - This Inspection Requesf will not be accepted wiihout the correct fee:
Other Fee # Servic tranc 'ze Fee # Circuits/Feeders Fee
Mobile Home Park Stall 0 0 200 mps , 0 to 100 Amps
Sfreet Ltg./Traffic Sig. Above 200 Am s Above 100 Amps
Transformer/Generator INSPECTOR'S USE OIJ�Y TOT� �
Sign/Oudine Ltg. Xfmr.
Alarm/Remote Control
Swimming Pool
I hereb certi ihat I ins the electrical installa'on described herein on the dates sta�ed
Irrigation Boom RougMn � Dare �,., e�
$�ECIO� �f15 ( �—� F
Final ,q
Investigative e ��3 '(
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This requesf void 18 monfhs bom validation dafe prinied i� ihis box.
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PLEASE PRINT OR TYPE
Request Rou h-in ins ecfion re uired$ Yes
g p q � ❑ No Inspection Other Than RougMn: ❑ Ready Now �YVill Call
(You musf call fhe inspecfo� when ready) Dafe Ready:
I, �licensed contractor ❑ owner hereby request inspection of the above electrical work at:
Job Address �Street, Box, or Route No.) Ciy Zip Gode
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Seclion No. Township Name or No. Ran o. Fire No. Cou
Occupant(�.^L�/�ltiYb � Phone No. �_ / � ��
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Power Su plier � dress
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Eleckical Conkacfor �Co pany Name) � ConhacMr License No. Master Lic. No. (%ant Elecf. Onl�
D�ii3� �'
Mailing Addreu (Confr r or Owner Performing Inslallation�
.�'33�' �.,J. �. �. , /��/
A�gnafure (Con ac r Owner P � rming InsfallaKon� Phone No.
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EB-000 6 S - SEE INSTRUCTIONS ON BACK OF YELLOW COPY