P - 82406' REQUEST FOR ELECTRICAL INSPECTION
��,`� � � � � � � Minnesota SYate Board of Electricity
�f 1821 University Ave., Rm. S-128, St. Paul, MN 55104 -
Phone (612) 642- 8 0� `'�'
Home Duplex Apt. Bldg. Othe %. Q� C� New Addn
Commercial Industrial Farm `' �� e1 emod Re air
Air Cond. Htg. Equip. Water Htr. Load Mgmt. 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.
Calculate Inspection Fee - This Inspection Request will r,of be accepted without the correci fee:
Other Pee # Sewice Entrance 'ze Fee # Cirwits/Feeders F e
Mobile Home Park Stall to 00 Amps ',b0 0 to 100 Amps .
Sheet Ltg./Traffic Sig. Above 200 Am s Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY TOTAL�� L�
Sign/Outline Ltg. Xfmr. � v� �
Alarm/Remote Control �`�L, ,�'°`'�' �
Swimming Pool
I hereb certi that I ins the elechi ' smllation described herein on the dates stated
Irri9ation Bo Rough-In � Da
Speciallnspection — �Z�O' �
Final D
Investigative Fee — 2
THIS INSTALLqTION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WIT IN 18 MONTH .
OFFICE USE ONLY This requesf void 18 monihs from validation date printed in this box.
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* 0 8 0 2 2 2 6 1*�93s �
PLEASE PRINT OR TYPE
Request Dafe Rou h-in ins on r uired$ Yes
g pec8 eq ❑ No Inspecfion O�er Than Rough-In: ❑ Ready Now Will Call
��irl0 � �`(ou musf call the inspecfor when ready) Date Ready:
I, ❑ licensed contractor owner hereby request inspection of the above electrical work at:
Job Address �Skeet, Box, or Roure No.) Ciy Zip Code
G! �5 �z �/Il� F/1��c�Y s's�3 z
Secfion No. Township Name or No. Range No. Fire No. County
�3o zy A•��k.�
Occupant Phone No.
F,c �o �- oi4�l,�rre sr.=r�r.H �vN �z6 3) s7Z -y Z s'/
Power Supplier Address
.s P 2 8 3 7 �.�� a c.� �o, �,�«.;o,�
Electrical Conhacfor �Company Name) Conhacror license No. Master Lic. No. (Planf Elecf. Only)
��1%rJ Cr
Mailiny Addreu �Conhactor or Owner Performing Insmllafion)
6! Gs%Zf.U.. /1« F,�,:(/� tit., s-s-=rsZ
Aufhorized $ign e �Conhaclor or Owne PerForming Inslallafion) Phone No.
�7G�)572-42-s/
�p"� � a� STATE BOARD COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY