P - 83875I .!'-���-185 �
REQUEST FOR ELECTRICAL INSPECTION
Minnesota State Board of Electricity
1821 University Ave., Rm. S-128, St. Paul, MN 55104
Phone (612) 642-0800
Commercial Industrial Farm
Air C Htg. Equip. Water Htr. Load Mgmt. Other:
Dryer Range Elec. Heat Temp. Service
"X" above the work covered by this request. Enter remarks in this space and on
New
Remod
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of the white copy only.
Calculate Inspection Fee - This Inspec►ion Request will not be occepted without ihe correct fee:
Other Fee # Service Entrance Size Fee # Circuits/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'S USE ONLY TOTA�.
Sign/Outline Ltg. Xfmr. � , .� �
Alarm/Remote Control
Swimming Pool
1 hereb certi that I ins ted the electrical installation described herein on fhe dafes sfafed
Irrigation Boom C^ RougMn Date
Special lnspecti ! j
9 F��ai _ � � '�
Imesti ative Fee _���-�°` �
_THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This requesf void 18 months from validafion dafe prinfed in this box.
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(IIII I) II) II III II III I) III III II III �I III I�II ! c� �. 7` ...� c�% �'`��/
* � 4 9 8 1 8 5 8* PLEASE PRINT OR TYPE
Request Date Rou h-in ins ecfion r uired?
. g p eq ❑ Yes ❑ No Inspection Other Than RougMn: ❑ Ready Now ❑ Will Call
/� ���— 9 (You musf call the inspetfor when reody) Dafe Ready:
I, �censed contractor ❑ owner hereby request inspection of the above electrical work at:
Jo Address �Streef, Box, pr �oute No.) Ciy � � Zip Code
C�C� i�'►�1 `��� l�-% �-l�YI` SSy3 a
Section No. Township Name or No. Range No. Fire No. County � 1
T1 �1 /1 i�n
upant Phone No.
G(/L �- .�}'y1 n %{Z�� 5%/� �
Power Suoolier Add�a«
�Company Name) Controcior License No.
c��.( �c��:� fic'S,��c, �� �3�
nhacfor or Ow er Performing Installafion)
� ^-�l �c�Gh �v
(�f or ner PerF ng Installafion) �: i �r
STATE BOARD COPY - SEE INSTRUCTIONS ON BACK OF YELLON
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