P - 83376REGIUEST FOR ELECTRICAL INSPECTION -� �
5',� �`� A't � Minnesota State Board of Electricity
`f 1 1821 Universily Ave., Rm. S-128, St. Paul, MN 55104
' Phone (612) 642-0800
Home Duplex Apt. Bldg. Other: New Addn
Commercial Industrial Farm Remod Re ir
Air Cond. Htg. Equip. Water Hfr. Load Mgmt. Other: _ /
Dryer Range Elec. Heat Temp. Service �Pil'I/'I (/NEyI�
"X" above fhe work cov�`ed by this request. Enter remarks in this space and on ihe back of the white copy only.
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Calculate Inspection Fee - This Inspection Request wi!! not be accepted wiff�out fhe correct fee: S�
Other Fee # Service Entrance S" e Fee # Circu e ee
Mobile Home Park Stall 0 ro mps // 0 to 100 Am
Street Ltg./Traffic Sig. Above 200 Am s Above 100 Amps
7ransformer/Generator INSPECTOR'S USE ONLY TOTAL �� U
Sign/Outline Ltg. Xfmr.
Alarm/Remote Confrol
$Wimmin9 Poo� I here certi that I in �he elechical insmllahoti�ile8aibe�herein on the doles staled
Irrigation Boom Ra,gMn --- . Dore
Special ins
Find jr
Investigative � 2..� !i
THIS INSTALLATION MAY BE ORDERED DISCONN CTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This request void 18 monfhs from volidation date printed in this box.
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* O S 3 G� � 4 L��!C PLEASE PRINT OR TYPE
Requesf Dafe � Rou h-in in fion uired? eady �N
g spac req ❑ Yes �'I�lo Inspecfion Olher Than Rough-In: ❑ R Now il� CaA
/`' 7�� �`/ou musT cqll the inspaclor when ready) Dale Ready:
i, �licensed contrador ❑ owner hereby requesf inspection of the obove electricai work at:
Job Address �Sheet, Box, w Roupe No.� Ciy �� Zip Code
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Secfion No. Township Name or No. Range No. Fire No. C ny
Occupanf Pho� No.
��sl� i-a'sz Lrca U S Lr �' S7 /�� S�
Power Supplier � Address
Ns
Eleclrical Conhactor (Company Name) � Conhaclor License No. - Master Lic. No. (Planf Elecf. Only� �
l/ , ` / �f�v��-rc f�/�O? �1u2-
Mailing Address (Conhaciw w Owner Performing Installaiion� / ` � �
�3�6 ! vivu� � Y�°� �i � �� 7 �'/
Aufhorized Si re �Conhactor or Own rformi Insfallafion) Pho� No.
� 266�� ��,-7ra
E 1 1 8 6 STA7E BO COPY - SEE INSTRUCTONS ON BACK OF YELLOW COPY