P - 83094, REQUEST FOR ELECTRICAL INSPECTION
6 O. �- 4 3 4� Minnesota State Board of E{ectricity a
1821 University Ave., Rm. S-128, St. Paul, MN 55104 �
, , Phone (612) 642-0800
ome Duplex Apt. Bldg. Other: New Addr
Commerrial Industrial farm Remod Re a
Air C Htg. Equip. Water Htr. Load Mgmt. Other:
Dryer Range Elec. Heat Temp. Service
"X" above ►he work covered by this requesl. Enter remarks in this space and on the back of the white copy only.
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Calculaie Inspection Fee - This Inspection Request wil not be accepted without 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 Am s Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY TOTAL F
Sign/Outline Ltg. Xfmr. %�• J �
Alarm/Remote Conhol
Swimmi�g Pool
I here certi that I ins ed the electrical insiallafion described herein on ihe da�es stated
Irrigation Boom RoogM� Dane
Speciallnspection [" � 4 p�
Investigative Fee �� �---�sti- (fl � 2v' da
THIS INSTALLATION MAY BE ORDERED DISCON ED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFlCE USE ONLY This requesf void 1 B months 6om validation date printed in this box.
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*06824346* ��a9
PLEASE PRINT OR TYPE
Requesf Date Rou h-in ins on r uired? ❑ Yes
�-�, �� g pecti eq ❑ No Inspeclion Other Than RougMn: Ready Now ❑ Will Call
(You musf call fhe inspector when ready� Date Ready:
I, licensed conhactor ❑ owner hereby request inspection of the above electrical work at:
lob Ad�ss�eet, BOx, or Route� �� � Ciy L /�� Zip Code ��
/ � /�}1��
or No. I Ranqe No. I Fire No.
Occupant � / /IM � �.fi^ I Ph� �/ " �
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r. '�A C actor License No. Masfer Lic. No.
\l�V. ��oa�3:� ��
�fqining Insfallafion)
$ignature �Conha ►6iOwner Performi I tallafionJ Phone No.
SOr2�
1 1 8/96 ST OARD COPY - SEE INSTRUCTIONS ON BACK OF