P - 80237�3�-145 �
Home Duplex
Commercial Industrial
Air Cond. Htq. Equ
„X" above ihe work
REQUEST FOR ELECTRICAL INSPECTION =-� �
Minnesota State Board of Electricity
1821 University Ave., Rm. S-128, St. Paul, MN 55104
Phone (612)642-0800
Apt. Bldg. Other: ��t,��� ��' New Addn
Farm ��,N �9 F 1� 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.
CalculaFe Inspection Fee - This Inspection Request will noi be acce
Other Fee # Service Entrance Size
Mobile Home Park Stall 0 to 200 Amps
Sheet Ltg./Tralfic Sig. Above 200 Am
Transformer/Generator INSPECTOR'S USE ONLY
Sign/Oudine Ltg. Xfmr.
Alarm/Remote Control
Swimming Pool
I hereb cerli 'thaf I ins the
Irriqation Boom R�,�,i,i„
without the correct fee:
Fee # Circuits/Feeders
0 to 100 Amps
Above 100 Ar
Fee
ZO.SO
electrical installation described herein on the dc
Date
� Investigative Fee - - � — � ( Y Z�i —P"
THIS II�STALLATION MAY BE ORDERED DISCONNEC IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This request void 18 months 6om validation date printed in this box.
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*.�p 8"3 8 1 4 5 1* ��
PLEASE PRINT OR TYPE
Requesf Dafe . Rou h-in ins fion r uired$ ❑ Yes
g pec eq ❑ No InspecFion Other Than Rough-In: ❑ Ready N ill Call
2�,3 ��.p0 C� (You musr call the inspecror when ready) Date Ready:
I icensed confracror ❑ owner hereby request inspection of the above electrical work at:
Job Addreu �Street Box, Route No.) Ciy Zip Code
1l l /,�,� c iR c% �e c`�L �
Sedion No. Township Name or No. Range No. Fire No. Coun
(� � l?� N aLCr�d
Occupanf Phone No.
C'r�ie.oL /3��9NLi �n� s�%/- ?d''6o
Power Supplier jj *1/` /� Addres �{
1 V� J�1 N L� . !\�� l�/ 1� sV! (/ �
�I Conhactor (Company Name)
�lN N rQ�R ��'_,
Address �Conha r or Owner
'6a ��N �
ced �ignafure �CoMractor or�
C �'v . �t/�. �' i9 0 a'7 � �
�slallaKon� /� ,,,Q
P/,�: aC�._Q_ r4 �"' L�eL€N Y�A
� g�96 STATE BOARD COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY