P - 82646I 1111J) �I! �4�HI II III II I'I II II II III II III II i�l I I�ii
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Home Duplex Apt.
Commercial Industrial Farn
RE(�UEST FOR ELECTRICAL INSPECTION ���
Minnesota State Board of Electricity �'�
1821 University Ave., Rm. S-128, St. Paul, MN 55104 � ,*� ,s�
Phone (612) 642-0800 �"� �
Other: New Addn
Remod Re air
Air Con��,�} Htg. Equip. Water Htr. Load Mgmt. Other:
er �(; an C( � Elec. Heat Temp. Service
"X" above t e work covered by this request. Enter remarks in this space and on the back of the whits copy onfy.
Calculate Inspection Fee - This Inspection Request will not be accepted without the correct fee:
Olher Fee # Service Entrance Size Fee # Circuits/Feeders
Mobile Home Park Stall 0 to 0 Amps l 0 to 100 Amps
Street Ltg./Traffic Sig. Above 200 Amps Above 100 Amp:
Transformer/Generator INSPECTOR'SUSEONLY TOTAL
Sign/Outline Ltg. Xfmr. �
Alarm/Remote Control
Swimming Pool
I hereb ceAi ihat I ins eded fhe eledrical installafion described herein on the�a� e1
Fee
Irrigation Boom Rough-In Dafe
Special Inspecti j ' Z' �' " ��'
� Final � C„'. c—,._ -�.��"�- C-
Investigative Fe
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS. '
3 2 3- 3 5 0� �FFICE USE ONLY This request void 18 months from validation date prinfed in fhis box.
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PLEASE PRINT OR TYPE
Request Date Rough-in inspedion required2 Yes � No Inspedion O}her Than Rough-In: Q Ready Now Will Call
1, � D q� (You musf call the inspedor when ready) Date Ready:
I, licensed contractor ❑ owner hereby request inspection of the above electrical work at:
Job Address (Sfreef, Box, or Roufe No.) ^ . C'ty � Zip Code
1-t � � �
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Sedion No. Township Name or No. Range No. Fire No. Counly �
No.
Address
Eledncal Contrador (Company Name) �, r,_ � r, ,^ Contr 1 r' g� No. Master Lic. No. (PlanT
CITIE� tiL4_'„ i Rf.,, : ,�. �
a100-225TN :',T trd., FG . AN �'Jp04
Mailing Address (Contrador or Owner Performing InsTallation t16$ '•.�i�
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Authorized Signature (Confrador or Ow e orming s allafion ` /� ��A (; Phone No.
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EB-OOOOtA-10 6/95 STATEBOARDCOPY-SEEINSTRUCTIONSONBACKOFYELLOWCOPY