P - 8292165�.�3Q1 �
Home Duplex
Commercial Industri
Air Cond. Hta. Ec
RE(�UEST FOR ELECTRICAL INSPECTION
Minnesota State Board of Electricity
1821 University Ave., Rm. S-128, St. Paul, MN 55104
Phone (612) 642-0800 '�'
A t. Bldg. Other: New Addn
Farm Remod Re air
Water Htr. Load Mgmt. Other:
Elec. Heat Temp. Service
this request. Enter remarks in this space and on the back of the white copy only.
Calculate Inspection Fee - Ihis Inspection Request will not be accepted witl�out the correct fee:
Other Fee # Service Entranc Size Fee # Circuits/Feeders Fee
Mobile Home Park Stall to Amp 0 to 100 Amps
Street Ltg./Traffic Sig. Above 200 Am s Above 100 Amps
Transformer/Generator INSVECTOWS USE ONLY TOTAL
Sign/Outline Ltg. Xfmr.
Alarm/Remote Confrol �
.
Swimming Pool I h�reb cerii that I ins ted the elechical insmllation deuribed herein on the dates stated
Irrigation Boo � Ro�Mn Dar�
Special lnspectwn � ^� '�
final QO�e
Investigative Fee jf
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
- I�I�� OfFlCE USE ONLY This requesf void 1& monfhs (rom validafion date printed in this box.
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� 0 6 5 1 3 0 1 4* 33�3
PLEASE PRINT OR TYPE
R uesf Date Rougfrin inspection required? . Yes ❑ No Inspecfion Other Than RougMn: Reody Now ill CaU
(You must call ihe inspecror when ready� Date Ready: ��—�' �
!, �licensed confractor ❑ owner hereby request inspection of the above electrical work at:
Job Address (Shcet, Box, or Route No.� Ci Zi Code
!�(o — 3R''° �2 A� o �r' � P
Seclion No. Township Name or No. Range No. Fire No. Counly
Occupanf � Phone No. �
7°7- O �R�
Power $upplie Address
1� c
EI icnl Conlracfor (Company Name) Conhacfor License No. Masfer Lic. No. (Planf Eled Only�
�� C-A a �4 6
Mailing Address �Conhacror or Owner Pe rming Installafion)
�1. C�1 � � h. � f�- 1.e. ��,
Authorized Si aiure ontracror or Owner Pe rming Installation� Phone No.
� � �
EB-0OOOlA-11 8/96 STATE BOARD COPY - S TRUCTIONS ON BACK OF YELLOW COPY