P - 82105REQUEST FOR ELECTRICAL INSPECTION -�_..
�] S�' ��/1 � � Minnesota State Board of Electricity
�. �7 1821 University Ave., Rm. S-128, St. Paul, MN 55104
< Phone (612) 642-0800 `��
' Home Duplex Apt. Bldg. Other. New
Commercial Industrial Farm Remod
Air Cca� Htg. Equip. Water Htr. Load Mgmt. Other:
Dryer Range Elec. Heat Temp. Service
"X" above the work covered by ihis request. Enter remarks in this space and on the back of the white copy only.
����Q�Y� l� V�Q, C��t,
�
Calculaie 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
Sheet Ltg./Traffic Sig. Above 200 Am s Above 100 Amps
Transformer/Generator INSPECTOR�S USE ONLY TOI� �
$ign/Outline Ltg. Xfmr. �%� �
Alarm/Remote Control
Swimming Pool
I hereb certi that I ins the elechical installation described herein on the dates staled
Irrigation Boom RougMn Doie
Special Insp��dfli ;; ,7 __ , _
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
.. . OFFICE USE ONLY This request void 18 months from validation date printed in this box.
Il�lll�lllllll��lll����l���l�ll��n���� � �°'�
* 0 7 9 8 8 4 5 4* �j'r ��
PLEASE PRINT OR TYPE
Reque Dafe Rou h-in ins on r uired?
�—� A— Q� g pecti eq ❑ Yes No Inspection Other'Ihan RougMn: Ready Now ��il CaN
�� (You must call the inspec�or when reody� Date Ready:
I, �licensed contractor ❑ owner hereby request inspection of the above elecfrical work ot:
Job Addre�Sheet, �� te o.) ��� Ci�� Zip Code��
Section No, Township Name or No. . Range No. Fire No. County
Power
' � Phon�� � ^ ����
�
or Owner
��'°&'��'° ��� E: I�� ���3
STATE BOARD COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY