P - 84768.
—T 3 V w V V�
Home
Commerci
Air Cond.
Dryer
� "X" above thE
y
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: New Addn
�
Farm �� Remod e air
Water Htr. Load Mgmt. Other:
Elec. Heat Temp. Service
request. Enter remarks in this space and on the back of the whiie copy only.
Calculate Inspection Fee - This Inspection Request will not be accepted without the correct fee:
Other Fee # Service Entrance Size Fee # Circuits/Feeders Fee
Mobile Home Park Stall 0 to 200 Amps 0 to 100 Amps
Street Ltg./Trar`fic 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 ted fhe elechical installation described herein on the dates stated
Irri9ation Boom RougMn Dare
Special Inspectio
InvestigatiVe Fee / � � Final - Da� `
THIS INSTALLATION MAY BE ORDERED DISCONNE�TED IF NOT COMPLETED WITHIN 18 MO HS.
OFFICE USE ONLY This request void 18 months from validation date printed in this box.
��� � ��� � ����
� �) II� �� I�� II ��� �) ��) ��� I) I�� �� ��I � ��I�
* O 4 3 � 9 B S�' '' PLEASE PRINT OR TYPE
Requesf Date Rough-in inspecfion required? ❑ Yes � o Inspection Other 1}ian RougMn: Ready Now ❑ Will Call
(You must call �he inspecfor when ready) Dats Ready:
I, licensed contractor ❑ owner hereby request inspection of the above elechical work at:
Job Address (Sireef, Box, or Route No.) City Zip Code
�" ���►�1 N�+� �1�}�S N � �i2i �D�� ��%3
Secfion No. Township Name or No. Range No. Fire No. ountyn
Occupant
�`
1
Power Sui
ny Name)
�.���� c
or Owner Performing Insfallafion) ��
�� i�'% �
idor or Owner PerFo ' g Insfallafi
Phone No.
� � �
Conhacfor License Na b
4 '�
�%%�_ /_; ,- .�
/ _r
STATE BOARD COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY
�Planf Elecf.
�537.;
No.
r/ � �