P - 84191� ' REQUEST FOR ELECTRICAL INSPECTION
4 2 3� o�� 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 Remoc
Air Cond. Htg. Equip. Woter 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
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Calculaie Inspection Fee - This Inspection Request will not be accepted without the correct fee:
Other Fee # Service Entrance Size Fee # Circuits/Feeders
Mobile Home Park Stall 0 to 00 Amps ( 0 to 100 Amps
Sheet Ltg./Traffic Sig. Above 200 Amps Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY TOTAL�
Sign/Oudine Ltg. Xfmr.
Alarm/Remote Control
Swimming Pool
I hereb certi }hat I ins ed fhe elechical installafion described herein on the dafes stated
Irrigation Boom Rough-In ' Dafe
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Fee
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THIS INSTALLATION MAY BE ORDERED DISCONN�D IF NOT COMPLETED WITHIN 18 MONTHS.
OFFlCE USE ONLY This requesf void 18 months (rom vali�afion date prinfed in fhis box.
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* � 4 2 3 � 9 1 8�K ` y PLEASE PRINT OR TYPE
Request Date Rough-in inspection required? ❑ Yes ,�Wo Inspection Other Than Rough-In: ❑ Ready Now
/��' 2�'";� •— �� (You must call ihe inspector when ready) Date Ready:
I,�] licensed confra�tor ❑ owner hereby request inspection of the above electrical work at:
1ob Address �Skeet, 8ox, or Roufe No.) � Ciy Zip Code
S37i �-73 '� � �_�, � rrc�l� �S: �
Secfion No. Township Name or No. Range No. Fire No. C uny
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Power $upplier
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Electr I Confracbr �Company Name) /
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Mailing ddress �Confractor or Owner Performing Ins}alla
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Aufhorized�$iqnafure�EoMiacfor or Owner Barr(prminolus
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Phone
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Conhactor License No. Masfer Lic. No. �Plant
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1 8/96 STATE.80ARD COPY - SEE INSTRUCTIONS ON BACK
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Phone No.
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