P - 83439II�IUItII� I�III IIII� I�III �III) IIIII I�III I�II �I�) R82�1 UEiSersFORve.LRm. SR 1C8, St PaPEMN 5�5N04 ����:
Minnesota State Board of Electricity �
* 0 3 8 9 7 0 4 8* Phone (612) 642-0800 ������
Home Duplex Apt. Bldg. Other: New Addn
Commercial Industrial Farm Remod Repair
Air Cond. Htg. Equip. Water Htr. Load Mgmt. Other:
Dryer Range Elec. Heat emp. Service
"X" ab�ihe work covered by this request. Enter remarks in thi� ac��on the back, the whr cqoy only.
���,�1''i�L.e�..�-� � ���s����
J ��
Calculate Inspection Fee - This Inspection Request will not be accepted without the conect fee:
Other Fee # Service Entranc ize Fee # Circuits/Feeders Fee
Mobile Home Park Stall to 00 Amps 0 to 100 Amps
Street Ltg./Traffic Sig. Above 200 Amps Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY TOTAL
Sign/Outline Ltg. Xfmr. 1%
Alarm/Remote Control
Swimming Pool I hereby certify that I inspected the electrical installation described herein on the dates stated
Irrigation Bo R«,9n-in Date
Speciallnsp t
Fnal D
Investigative Fee -�
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED W HIN 18 MON HS.
OFFICE USE ONLY This request void 18 months from validation date printed in this box.
389-704�81 • aG. �
� o��
�
PLEASE PRINT OR TYPE
Request Date Rough-in inspection required? ❑ Yes No Inspection Other Than Rough-In: Ready Now ❑ Will Call
�� ��J .� ��% (YOU must call the inspector when ready) Date Ready:
I,� licensed contractor ❑ owner hereby request inspection of the above electrical work at:
Job Address (Street, Box, or Route No.) City Zip Code
�/� �
Section No. Township Name or No. Range No. Fire No. County
Occupant Phone No.
�+�/�O c� /' ..`�7 -' o�,1y
Power Supplier Address
/i/.�+ J�%
Electrical CoMractor (Com rry Narne) Contractor License No. Master Lic. No. (Plant Elect. Ony)
� l-�. � � 4a ��
Mailing Address (Contractor or wner Performing Installation) ��
�.� l� y�� ✓r.� J
Authori Signature (Contractor or Owner Performing Installation) �� A�� � Phone No. ✓
`� G
EB-00001A-11 8/95 � STATE BOARD COPY - SEE INSTRUCTIONS ON BACK�OF YELLOW COPY