P - 83309REQUEST FOR ELECTRICAL INSPECTION
6��7(� �� Minnesota State Board of Electricity
l� 1821 University Ave., Rm. S-128, St. Paul, MN 55104
^ Phone (612) 642-0800 `'�'
Home Duplex Apt. Bldg. Other: New Addn
Commercial Industrial Farm Remod Re air
ir Co . E ip. Water Htr. Load Mgmt. Other:
Dryer ang Elec. Heat Temp. Service
"X" above the work covere by this request. Enter remarks in this space and on the back of the white copy only.
Calcvlate Inspection Fee - This Inspection Request will not be accepted without the correct fee:
Other Fee # Service Entrance ize Fee # Circuits/Feeders Fee
Mobile Home Park Stall 0 00 Amps 0 to 100 Amps
Street Ltg./Traffic Sig. Abo 200 Am s Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY TOTAL
Sign/Outline Ltg. Xfmr.
Alarm/Remote Control
Swimming Pool
I hereb certi that 1 ins ed the electrical installation described herein on the dates stated
Irrigation Boom RougMn Dare
Speciallnsp � �
F�� - 2
Investigative — -
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This request wid 18 monlhs (rom v'� date printed in this box.
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* 0 6 7 8 7 0 2 2* ��'�
PLEASE PRINT OR TYPE
Requesf Dafe Rou h-in ins on r uired$ es
'� � g pecti eq ❑ No Inspection O�her T}wn RougMn: ❑ Ready Now ill Call
(You must call the inspecfor when ready) Date Ready:
I, licensed contractor ❑ owner hereby request inspection of the above electrical work at:
Jo �Address'Street, o� w Route No.) . ^, Ciy� � Zip Code
i
�] `�
Secfion No. Township Name or No. Range No. Fire No. Cou �
nt ��� """`S.�- Phone No. " _
Contractor License No. I Master Lic. No.
Addreu (Conhactor or Owner Performing Insfallafion)
ed Signalure (Conhacfor or Owner Performing InsAallation) P�
� fi.ri''l E;
I A-11 8/96 STATE BOARD COPY - SEE INSTRUCTiONS ON BACK OF YELLOW COPY