P - 83778o ���� ���!�� ��� �� ��� �o ��� �� ��� �� ��� �� ��� �i ��� � i���
�* 0 2 9 9 4�] 2 8*
Home
Commercial
REGIUEST FOR ELECTRICAL INSPECY'�OPi
Minnesota State Board of Electricity
1821 University Ave., Rm. S-128, St. Paul, MN 55104
Phone (612) 642-0800
Other: � �% (1/� �� ��� New
� Remod
Air Cond. Htg. Equip. Water Htr, Load Mgmt. Other:
Dryer Ran e Elec. Heat Temp. Service �(i� ��(..
obove the work covered by this request. Enter remarks in this space and on the back of the whita copy
�yo v 5'O/�r�f' Gr-ow�t f�,zr�lt' �v;''�
����
�F.
�� a
�'�?;�,,��@�
Addn
Calculate Inspection Fee - This Inspection Request will not be accepfed without the correct fee:
Ofher Fee # Service Enirance Size Fee # Circuih/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'SUSEONLY TOT �
Sign/Outline Ltg. Xfmr. �
Alarm/Remote Control � � � � t)
$wimming Pool �� L
I hereb ceAi }hat I ins eded }he eledrical insfallotion described herein on the dafes siated
Irrigdtion Boom Rough-In ` Date �
Special Inspection ��r��
Final — � . ..
Investigative Fee -�' ���
THIS INSTALLATION MAY BE ORDERED DISCONN6CTED IF NOT COMPLETED WITHIN 18 MONTHS.
2 9 9- 4 0 2� OFFICE USE ONLY This reqvest void 18 months from validation dafe prin ed in this box. �
� � 1
; � -�
� �
25�5�� �. _
�: �
PLEASE PRINT OR TYPE '� I�� �
Request Daie Rough-in inspetlion required2 � Yes � No Inspedion Other Than Rough-In: ❑ Ready Now � Will Call
(You must call }he inspedor when ready) Date Ready:
I, ❑ licensed cantractor ❑ owner hereby request inspection of the above electrical work at:
Job Address (Sireef, Box, or Roufe No.) City Zip Code
l�'1$ �71 '� wcZ N� Fr� dLe �N3 z...
$ec6on No. Township Name or No. Range No. Fire No. County
Occupant
Power $upplier
Eledrical Confrador �Compony Name)
Mailing Address (Confrador or Owner Perfo�
AuThorized Si n ure (C frador or Owner P
EB-OOOOlA-10 6/95 / STATE
�/I Q ��
No µ S-�6 6 9�i
� �7_0 6gZ
Address
Conirador License No. Master Lic. No. (Plant Eled. Only)
on) Phone No.
�Z�o 6 8 ��-
SEE INSTRUCTIONS ON BACK OF YELLOW COPY