P - 83374REQUEST FOR ELECTRICAL INSPECTION ��
7(� (,�. Minnesota State Board of Electriciry �'
. �J v� 5 6 2� 1821 University Ave., Rm. S-128, St. Paul, MN 55104 �`�`
` Phone (6i2) 642-0800 "�'
Home Duplex Apt. Bldg. Other: New Addn
Commercial Industrial Farm Remod
ir Cond. Htg. Equip. Water Htr. Load Mgmt. Other:
Dryer Range Elec. Heat Temp. Service
"X" above th ork covered by this request. Enter remarks in this space and on the back of the white copy only.
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Cakulate Inspection Fee - This Inspection Request will not be accepted withoui the correci fee:
Other Fee # Service Entrance Size Fee # Circuits/Feeders Fee
Mobile Home Park Stall 0 to 200 Amps 0 to 100 Amps
Sheet ltg./Traffic Sig. Above 200 Am s Above 100 Amps
Transformer/Generptor INSPECTOR'S USE ONLY TOT/� �
Sign/Outline Ltg. Xfmr. �
Alarm/Remote Control
Swimming Pool '
I hereby certify that I inspecled the elechical insfallafion described herein on the dafes sMted _ _
Irrigation Boom �_ RouaMo Dare
� Investigative Fee �—` L��� � - � 7. 2-. %-6%
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This request wid 18 months 6om validation date prinfed in fhis box.
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Job Ad
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Secfion
Occup
Power
PLEASE PRINT OR TYPE
�� Rough-in inspeclion required? ❑ Yes No Inspeclion Olher Than RougMn: eady Now ❑ Will Call
(You must call the inspector when ready) Date Ready:
licensed contractor ❑ owner hereby request inspection of the above electrical work at:
Iress �Sheet, Box, or Roure � Ciyf+/
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No. Township Name or No. Range No. Fire No. C ty,� ,
'L1'`'/ jY ���1�
dreu (Conka r or Owner erFormi Installation�
°� l�r/G/�%C� �i/� �l/ �
SignaNre (Confractor or Owner Pe rmi Installafion�
11 S/96 STATE BOARD COPY - S�!
Master Lic. No.
266�� � / Ir
CTIONS ON BACK OF YELLOW COPY