P - 84441I�I�� II II� II III I �.� REf�UEST FOR ELECTRICAL INSPECTION ^
II I III II III i Minnesota State Board of Electricity �����
�/ II III II III �I I�) I II�I • w
* 0 2 9 9 3 4 1 8 * 1821 Urnversity Ave., Rm. S-128, St. Paul, MN 55104 �
� Phone (612) 642-0800 .;�:�
Home Duplex Apt. Bldg. Other: �5����� Ne Addn
Commercial Industrial Farm emod Re air
Air Cond. Htg. Equip. Woter Htr. Load Mgmt. Other:
D er Ran e Elec. Heat Tem . Service
"X" above the work covered by this request. Enter remarks in this space and on the back of the white copy only.
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Calculate Inspection Fee - This Inspection Request will not be accepted without the correct fee:
�ef F� # Service EMrance Size Fee # Circuits/Feeders Fee
Mobile Home Park Stall 0 to 100 Amps /�
Street Lig./Traffic Sig. Above 200 Amps Above 100 Amps
Transformer/Generator INSPECTOR�s use oN�v TOTAL�j�
Sign/Outline Ltg. Xfmr. � J�� , � �� ,�� � �
Alarm/Remote Con rol r�'�
Swimming Pool � �%� �% �
. I hereb certi thaf I ins ecied ihe elechical insfallation descri66d`hdrein }e sta/ed � �
Irrigtltion Boom Rough-In
Special Insped' _ L �O C�
Investigative F . ,� F��al - � – —
_ THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
2 9 9- 3 41 � OFFICE USE ONLV This request void 18 months from validafion date printed in fhis box.
�\ � �1
��PLEASE PRINT OR TYPE
Request Do}e Rough-in inspedion required2 es No Ins ection Other Than Rou h-fn:
a� P 9 ❑ ReadY Na�' ill Call
(� (Y ust call the inspedor when ready) pate Ready:
I, ❑ licensed contractor owner hereby request inspection of the above electrical work at:
Job Address (Sfreef, Box, or Route No.)
� � L C�� Zip Code
Sedion No. Township Name or No. ` �� e ��-� I
Range No. Fire No. unty
Occu anf � O � v�G'�
�� Pho/n`e No.
PowerSupplie��_ � �"' f ������ �,J'
Address
Elethical Confracfor (Compony Nome) �� � ' J��S � V--.J
Confraclor License No. MasTer Lic. No. (Planf Elecf. Only)
Moiling qddress (Con}racfor or Owner Performing InsTallation)
�N "�i
ignature �Conf r or Owner Performing Installa' � �.
, � R -� ;-� Phone No.
EB-OOOOIA-10 6/95 �r �U���—
_ STATE BOARD COPY- SEE INSTRUCTIONS ON BACK OF YELLOW COPY
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