P - 83258REQUEST FOR ELECTRICAL INSPECTION --
5 J G� 5 2 5 Minnesota State Board of Electricity -
> 1821 University Ave., Rm. S-128, St. Paul, MN 55104
� Phone(612)642-080
Home Duplex Apt. Bldg. Other: y�Z New Addn
Commercial Industrial Farm � �T� �� Remod Re air
Air Cond. Htg. Equip. Water Htr. Load MgmF. Other:
Dryer Range Elec. Heat Temp. Service
"X" above the work ered by this re uest. Enter remarks in this space and on the back of the white copy only.
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Calculate Inspection Fee - This Inspection Request will not be accepted without the correct fee:
Other Fee # Service Entran ize Fee # Circuits/Feeders Fee
Mobile Home Park Stall Amp 0 ro 100 Amps
Street Lfg./Traffic Sig. Abo e 200 Am s Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY TOTAL
Sian/Oudine Ltn. Xfmr. , ��• S�
Irrigation Boom RougMn Daae
Special Inspection
F� °° - �
Investigative Fee
THIS INSTALLATION MAY BE ORDEREQ DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
� -- -------------
� �.� �� OFFICE dSE ONLY This request void 18 months from validafion date prinled in fhis box.
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* 0 5 3 2 5 2 5 3� PLEASE PRINT OR TYPE
R t Dafe Rough-in inspecfion required$ ❑ Yes No Inspeclion Olher Than RougMn: ❑ Ready Now �II Call
� L y� � p (You must call the inspecbr when ready) Dafe Ready:
I, ❑ licensed contractor � owner hereby request inspection of the above elechical work at:
Job Addreu (Sheef, Box, a Roufe No.) � City Zip Code
b�o � o /= J'� �/G-' �v�� ,1''r yJ Z
Seclion No. Township Name w No. Range No. Fire No. Counly �
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Occupant Phone No.
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Power Supplier Address� /
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Electrical Conhactor (Company Name) Contracbr License No. � Master L"K. No. (Plant Elect. Only�
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Mailing Address (Conhocta or Owner Performing Inslallafion)
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Aulhorized SignaNre (Contractor or Owner Per(wming Ins�fi �.. . Plwne No.
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EB-0OOOtA-11 8/96 �7ATE BOARD COPY - SEE INSTRUC710NS ON BACK OF YELLOW COPY