P - 81630�� 1��-� REt�UEST FOR ELECTRICAL INSPECTION
C3 ('�_ � s�� O � Minnesota State Board of Electricity
0�� 1821 University Ave., Rm. S-128, St. Paul, MN 55104
Phone(612)642-0800 "�'
Home Duplex Apt. Bldg. Other/ New Addn
Commercial Industrial Farm /i �o � Remod Re air
Air Cond. Htg. Equip. Waler Htr. Load Mgmt. Other:
Dryer Range Elec. Heaf 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 Request will 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 TO@/IIA� I s�
Sign/Oudine Ltg. Xfmr. �Cfb, cAt( /_-vt �l'/f��"^ !S
Alarm/Remote Confrol
$Wimmin9 � hereb certi ihat I in the elechicai installafion described herein on the ddfes stated
Irrigation RougMn Dare
Special Inspection
Find Dat
Investigative Fee %Z(o- � � r'P'P�
THIS INSTALLATfON MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This request void 18 monfhs from v' ion afe pri 'hrfhis.�iox.
I II�� I� II) II I�I I) III II III II III II �{ II � I�{ C� ��LA' O�
* 0 8 0 2 2 4 0 2* °� j'�
PLEASE PRINT OR TYPE
Requesf Da^ �� Rough-in inspecfion required? ❑ Ye: No Inspection Other Than Rough-In: ❑ Ready Now i{I Coll
�— G! (You must call the inspedor when ready) Date Ready:
I, ❑ licensed contractor.��owner hereby request inspection of the above electrical work at:
Job Address (Sheef, Box, or Route No.) Ciy Zip Code
�.22t- .R� ,� �'s�r�
Section No. Township Name or No. Ran e No. Fire No. Cou fy
' ��� �L. �/ ���
Occupont ' Phone No.
wer Supplier �
� % (, �%� �CciCC
Elechical Conhacfor (Company Name� 2 8 5 Conhactor License No. Master Ua No. {Plant E
`'
Mailing Address �ConMacfor or Owner Performing Installafion)
Authqrized Sipnature (Contra or Ownef'Perfamina Installationl Vhone No.
1� �C3 -�7 / �-3 /
BOARD COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY