P - 84215REQUEST FOR ELECTRICAL INSPECTION �
� �r'` � Minnesota State Board of Electricity
l� �-151 1821 University Ave., Rm. S-128, St. Paul, MN 55104 �
Phone (612) 642-0800
Home Duplex Apt. Bldg. Other. New Addn
ommercial Industrial Farm Remod Re air
Air Cond. 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 ;pa ' and on the back of the w.hite copy only.
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Calculate Inspection Fee - This Inspection Request will not be accepted without the correct fee:
Other Fee # Service Entrance Size Fee # Circuits/FeFders Fee
Mobile Home Park Stall 0 to 200 Amps 0 to 100 AmFts (`s
$treet Lfg./Traffic Sig. Above 200 Am s Above 100 Amps
Transformer/Generator INSPECTOR•s use oN�v TOTAL ��'}'
Sign/Oudine Ltg. Xfmr.
Alarm/Remote Control
Swimming Pool '
I hereb certi fhat I ins ted the elechical installation described herein on:fhe dates stated
Irrigation Boom RougMn �Dare _ q
Special Insp i � r �� g �
F�d ,�asL— 8-. �a
Investigative ee �
THIS INSTALLATION MAY BE ORDERED DISC ED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This requesf void 18 months from validation dafe prinfed in fhis box.
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* � 5 6 � 1 5 L B* PLEASE PRINT OR TYPE "
Requesf Dafe Rougffin inspection required? �Yes ❑ No Inspection Other Than Rough-ln:. �- �0 Ready Now Will Call
.-� �� � �You musf call the inspecfor when ready) Date Ready: ��
I, � licensed contractor ❑ owner hereby request inspection of the above electrical work at: '
Job Address �Sheet, Box, of Route No.) City ; Zip Code
`13 i �) en r.v� � � fi✓Lt �l 1Q ? .5.�� Z �
Section No. Township Name or No. Range No. Fire No. C unty . ��
nc���
p������ Phone No. �
2 t � 1h r i i --� p..._. ..
Power Supplier Address . � �
Elecfrica� n�cfor �Company Name) Conhacfor License No. '�Masfer Lic. No. �Plant Elecf. Only)
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Mailing Address (Contrador or Owner Pe rming Installation�
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Au �' ed Signature (Confr r or er P rming Installafion) I-� '� ��� P
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EB-0OOOlA-11 8/96 STATE BOARD COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY
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