P - 81124�38-795 �
REQUEST FOR ELECTRIC�L INSl�ECTION
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
Commercial Industrial Farm Remod
Air Cond. Htg. Equip. Water Htr. Load M mt. Other:
Dryer Range Elec. Heat Temp. Service
"X" above the work covered by this request. Enter remarks in this space and on the back of the white copy only.
����Tt�e�- f�Gwto�G� Ct�t� lSo lc�� �Se/lr�r`c�
Cplculate Inspection Fee - This Inspection Request will not be accepted without the correct fee:
Oiher Fee # Service Entran ize Fee # Circuits/Feeders Fee
Mobile Home Park Stall 0 to p,o� 0 to 100 Amps p,OG�
Sheet Llg./TraFfic Sig. Above 200 Am s Above 100 Amps
Transformer/Generator iNSPECTOR'S uSE ONLY TOT /
Sign/Oudine ltg. Xfmr. Q'JO/ ��
Alarm/Remote Conhol
Swimming Pool I hereb cerli that I ins ted the elechical installation described herein on ihe dates slated
IrriQation Boom R,,,,,,�.a„ �er�
Imestigative F� � U '� .0 C7 ^ !
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This requesf void I 8 months from validafion dafe prinfed in this box.
���IIIIiII�I�I1�Nlll��l�li��lllh�M�(� • �G �
* D 8 3 8 7 9 5 3� ��7
PLEASE PRINT OR TYPE
Request Date Rough-in inspection required$ ❑ Yes No Inspect:on Other Than RougMn: Ready Now � Will Call
j/ — 3 Q` � (You musf call }he inspector when ready� Dafe Ready: �!— 3(7
I, icensed contractor ❑ owner hereby request inspection of the above electrical work ot:
Job Address (Skeef, Box, or Route No.� Ciy � Zip Code
31 (o S a.. �,rJ� �i�ldl�.
Sechon No. Township Name or No. Range No. Fire No. County
'ho�u
Occupanf Phone No.
acee ,� ,C�o%'ec?v1. tel�e�5a�. G/,2 , S�� � lS�s,�
Power Suonlier na.1.o«
�
Mailing Ad�
�a�
�mpany Name�
`L��r/��c .�� �-
icror or Owner Performing Installafion�
�►%/�i ce U �a/��,1'"ceiQ //h. S� � �
onhactor or Owner Performina nstall4tion) Phone No.
-- ��2 �6-so�s�
- EE INSTRUCTIONS ON BACK OF YELLOW COPY
ConkacMr License No. I Masier Lic.
�'/.1GO l92
��.�
STATE BOARD