P - 83322REQUEST FOR ELECTRICAL INSPECTION >°�w�..
J������ Minnesota State Board of Electricity
1821 University Ave., Rm. S-128, St. Paul, MN 55104
Phone (612) 642-0 0 �? '�'
Home Duplex Apt. Bldg. Other. �� New Addn
Commercial Indusfrial Farm v Remod Re air
Air Cond. Hig. Equip. Water Hfr. Load Mgmf. Other:
Dryer Range Elec. Heat Temp. Service
"X" above the work covered by this request. Enter remarks in this space and on the back of the white copy only.
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Calculate Inspection Fee - This Inspeciion Requesi will not be occepted without the correct fee:
Other Fee # Service Entrance Size Fee # Circuits/Feeders Fee
Mobile Home Park Stall � 0 to 200 Amps 0 ro 100 Amps d�
Street ltg./Traffic Sig. Above 200 Am s Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY TOTAL
Sign/Oudine Ltg. Xfmr. i
Alarm/Remote Control
Swimming Pool y�-�{�. ' � �ji "%�' �lf�
I here ceAi that I ins the elechical inslallafion described e in on dates
I�ri9ation Boorn - RougMn /
Special Inspect � L '�'�L'_
Final
Investigative Fee � —pz -�
THIS INSTALLATiON MAY BE ORDERED DISCONNECTED � NOT COMPLETED WITIi1N i8 MONTHS.
OFRCE I�E ONLY This reques� vad 18 months from volidafion dote printed in this box.
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* 0 5 3 � 5 3 3 7 * PLEASE PRINT OR TYPE �� ��
Request Date Rougi�in inspecfion required$ ❑ Yes ❑ No Inspecfion Olher Than RougMn: ❑ Ready Now 0 Will Call
-�--1 �� & (You must call the inspeclor when readyj Date Ready:
I, ❑ licensed contractor � owner hereby request inspection of the above electrical work at:
Job Address �Sheet, Box, or Route No.) Ciy ' Zip Code
�o Y�,31 a k er /9 v z �' F� �7X �'�� � PJ �
Section No. iownship Name or No. Range No. Fire No. Couny �
3 � �
Occupant Phone No.
�-' � r�s ��'ri ci�i e.k�r� ck S o v� .� 7� '��' !3
Power Supplier � Addreu
� �.J� L C:. f,/ W �
Elechicnl ConhaMor (Company Name) Conkacror License No. Masler lic. No. (Plant Elecf. Only)
Mailing Addreu (Con or Owner Perfwmirog Inspllation�
Auihori Signature �Contr r w Owner P irg Installation) Q� Phone No.
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EB-00001 A-11 S/96 �A7E gppRD COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY