P - 82621REGIUEST FOR ELECTRICAL INSPECTION �
8 0�� 2 0 7� Minnesota State Board of Electricity 3
, 1821 University Ave., Rm. S-128, St. Paul, MN 55104 �
Phone (612) 642-0800 '���
Home Duplex Apt. Bldg. Other:% 6O �/�' New Addn
Commercial Industrial Farm C' 3`'� Remod Re air
Air Cond. Htg. E ui . Water Htr. Load M mt. Other:
ang Elec. Heat Temp. Service
"X" abov e work covere y this request. Enter remarks in this space and on the back of the white copy only.
Calculate Inspection Fee - This Inspection Request will not be accepted withouf the correct fee:
Other Fee # Se ' nce S'ze Fee # Circuits/Feeders Fee
Mobile Home Park Stall to 00 Am to 100 Amps
Street Ltg./Traffic Sig. Am s Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY TOTA (
Sign/Outline Ltg. Xfmr. �. _ C���- 4� .J�
Alarm/Remote Control �� �v -/ 2 -�u � - � J
Swimmi� Pool � � �
9 I hereb certi thaf I ins ecfed fhe electrical insfallotion described �iI?n the e a(ed
Irrigotion Boo Rough-In Date
Special Inspe — —��
Investigative Fee F�"°I D . � �
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This request void 18 monfhs from validation dafe prinfed in this box.
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PLEASE PRINT OR TYPE
Request Da Rough-in inspecfion required? � Yes
��/ o ❑ No Inspection Other Than Rough-In: ❑ Ready Now ❑ Will Call
� (You musf call �he inspector when ready) Dafe Read
Y
I, ❑ licensed contractor�owner hereby request inspection of the above electrical work at:
Job Address �Street, Box, or Route No.) City / Zip Code
��30 ,- u� S' . ,� �Y'�({
Secfion No. Township Name or N � Range No. Fire No. Coun
Occupanf �O � n a��
� � Phone No. /�
Power Supp ier � � �� �` O v/ � � " � � �U /� � `�-' Q �
�/J Address
/
Elecfrical Con cf (Company Name) Conhactor License No.
�� �^ Moster Lic. No. (Plant Elect. Only)
�t
Mailing Address (Confractor or O�er Performing Installafion)
l �ll - 2 � -� �� �� �s , .�Sl// �
Authorized S� nature o racfor or ner rFor ing Installa}ion)
Phone No.
i /
E lA-1 1 8/96 �` �— (�L l� lJ �
S ATE BOARD COPY - SEE INSTRUCTIONS ON BACK OP YELLOW COPY