P - 84149'� REQUEST FOR ELECTRICAL INSPECTION
5���' Minnesota State Board of Electricity
`.�� �. � 4 7 9 1821 University Ave., Rm. S-128, St. Paul, MN 55104
Phone (612) 642-0800 `�'
Home Duolex Aot. Blda. Other: New Addn
Commercial Industrial Farm Remod
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 Requesi will not be accepted wiihout 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 Amps Above 100 Amps
Transformer/Generator INSPECTOR�s use oN�v . TOTAL /`
Sign/Oudine Ltg. Xfmr. �� G�l/ �'N �S/'n-�t"' ,�l.a
Alarm/Remote Control
Swimming Pool �
I hereb ceAi thaf I ins the elxtrical installafion described herein on ff�e dafes stafed
Irrigation Boom RouaMn Dare
Investigative�_.- ` t_ — r��i — — — ----- --`—, -- — ua� /R-e�- �
THIS INSTALL T O 11� Y BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 1 MONTHS.
OFFlCE USE ONLY This requesf void 18 monfhs from validation dafe prinfed in fhis box. �
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I IIII (I III II (II II !I� I�II II III II III II III I���I �S�aS"
* � 5 3 2 4 7 9 3* PLEASE PRINT OR TYPE ��
Re°quesf te Rou h-in ins on r uired? Yes pecfi g y ❑ Will Call
,�� /�g g pecli eq ❑ No Ins on O�er Than Rou h-In: ead Now
(You must call the inspeclor when ready� Date Ready:
I, ❑ licensed contractor �owner hereby request inspection of the above electrical work at:
Job Address (Sheef, Box, or Roufe No.) City Zip Code
�3 t� Lv� ST ��' �Y-." � Q 5'�iZ
Section No. Township Name or No. Range No. Fire No. C nty
� t� �`� ��C�`�-�
Occupanf Phone No.
yr1,' ��� ��-d�3
Power Supplier Address
/�' S f � �.S b�.�'t� ��lSl (� 0�
Electrical Conhacfor �Company Name� Conhactor License No. Master Lic. No. (Plant Elect. Only�
or Owner Performirg Installation)
� ! I Ph�-��%
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