P - 84502' REQUEST FOR ELECTRICAL INSPECTION �.
��,� O��� C] Minnesota State Board of Electricity
� � 1821 University Ave., Rm. S-128, St. Paul, MN 55104
/ Phone(612)642-0800 .
�1� Home Duplex Apt. Bldq. Other: New Addn
"X" above the
Industrial Farm
Htg. Equip. Water Htr. Load Mgmt. Other:
ang Elec. Heat Temp. Service
overe y this requesi. Enter remarks in this space and on
Calculate Inspection Fee - This Insp<
Other Fee
Mobile Home Park Stall
Street Ltg./Traific $ig.
Tra nsformer/Generator
Sign/Oudine Ltg. Xfmr.
Alarm/Remote Confrol
Swimming Poo)
Irriaation Boom
copy only.
m Request will not be accepted without the correct fee:
# Service Entrance Size Fee # Circuits/Feeders Fee
0 t 00 Amp � 0 to 100 Amps
Above 200 Amps Above 100 Amps
INSPECTOR'S USE ONLY TOTAL .CL
the elechical installation dexribed herein on the dates stated
' Firwl . D " . �;..�
Investigative F - 3 � �
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This request void 18 months kom validafion date printed in ihis box.
/� ��
I IIII II III II III I II �/ ��� �i(,�/ ^/'�
I IIIIIIIIIIIIIIIIIIIIIII�IIIIINII '//[ /�
* 0 4 4 8 2 2 9 5* LEASE PRINT OR TYPE
Request Dafe Rou h-in ins fion r uired? Yes
�� g pec eq ❑ No Inspeciion Other Than RougMn: ❑ Ready Now Will CaII
!D .., �You musf call the inspecfor when ready) Dafe Ready:
I, licensed confractor ❑ owner hereby request inspection of the above eaectrical work at:
Iob Address (Sheef, Box, or Route No.� City Zip Code
�� �r'�lS%-��%�.°i�I �' �%IlbL�°�
$ection No. Township Name or No. Range No. Fire No. Co �����
��H�^�% Phone No.
� V�
Conhacfor (Company Name)
CIl'fE8 ELECTRIC. MIC.
Moiling Address (Conhacfor w Owner erf��
� D • .
n�thoriZed
Conhactor License
1 1 K'.
017i�81`1.Allprming Insfallafion� 2 5 0� t I Phone No.
V
STATE BOARD COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY
No.