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P - 81083REQUEST FOR ELECTRICAL INSPECTION ��� U�`8 9 5- 612 � Minnesota State Board of Electricity 1821 University Avenue Suite S-728, Saint Paul, Minneso[a 55704•2993 F � (651) 642-0800 www.electricity.state.mn.us `��'"'�� Home Duplex Apt. Bldg. Other: New Addn Commercial Indusirial Farm Remod Repair Air Co ner Htg. Equip. Wafer Hfr. Load Mgmt. Other: Dryer Range Elec. Heat Temp. Senice "X" above the work covered by this request. Enter remarks in this space and on the back of the white copy only. / � � � C�ii�J �' �J Calculafe lnspection Fee - This fnspection Req st rl! not be accepted witho�i the correct fee: Ofher Installations 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 TOTAL Sign / Outline Ltg. Xfmr. • � Alarm/Remote Control Swimming Pool `` I hereb certi that I ins cted the elechicol installation described herein on the dates stafed: Irrigation Boom�' F n Roughdn Date Special Inspec i n Final �ar� Investigative Fee G—� �a THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS. OFFICE U8E ONLY This request void 18 months from validation date printed in this box. IlIII�I��(��1111lIII��(l�i�� 111��� i �°�� � * 0 8 9 5 6\1 2 0* ��� PLEASE PRINT OR TYPE . Request Date Rough•in inspection required2 ❑ Yes ❑ No Inspection Ofher Than Rough-In: Ready Now ❑ Will Call. I��� You musf call fhe inspector when ready Date Ready: , licensed contractor ❑ company ❑ owner hereby request inspection of the above electrical work at: J Address (Sfreef, Box, or Rout No City Zip Code � • � ��l Section No. Township Name or No.� e No. Fire No. Coun Q� Occupanf - ... Phon�� � �� Power Supplier _ Address Elechical Con}wcror / Company Name Contractor License DEPENOABLE ELECTRIC. Ii�C• /����dd��nt�grp�p��r�wMr�rforming Install rj�- �;. � ��, C�on Ra ida; MN 55433 �� V�' � Aufhorized �Siqnature ICon}ract mpany or Owner PerformiM InsfallaKon� � �► y �—)v�Ul REF WSTRl1CT1[1N5 ON BACK OF YELLOW COPY