P - 82647RE(�UEST FOR ELECTRICAL INSPECTION
^ t� 0- 9 01 Minnesota State Board of Electricity
�'r 1821 University Ave., Rm. S-128, St. Paul, MN 55104
r Phone (612) 642-0800 `' '
Home Duplex Apt. Bldg. Other: New Addn
Commercial Industrial Farm Remod Re air
Air Co c.� Htg. Equip. Water Htr. Load Mgmt. Other:
Dryer Rang Elec. Heat Temp. Service
"X" above t e work covered by this request. Enter remarks in ihis space and on the back of the white copy only.
Calculate Inspection Fee - This Inspeciion Request will not be accepted without fhe correci fee:
Other Fee # Service Entrance Size Fee # Circuits/Feeders Fee
Mobile Home Park Stall 0 to ,?'�0 Amps � 0 to 100 Amps
Street Ltg./Traffic Sig. Above 200 Amps Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY TOTAL O
�
Sign/Outline Ltg. Xfmr.
Alarm/Remote Control �''/ �
Swimming Pool �i
I hereb certi thaf 1 ins the elechical installafion deuribed herein on the� s�fed `� �
Irrigation Boom RougMn ' �a�
Special Inspecti f� v r-'- G`��
final /^ � �n�..-. .�. �=
Investigative Fee -C�=--� �------� - ri S.3 �
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFlCE USE ONLY This requesf void I S months from validation date prinTed in this box.
I IIII II i�l II III II III II III II I il III II III I IIII
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* 0 4 0 0 9 0 L * ����
5 PLEASE PRINT OR TYPE
Request Date Rough-in inspecfion required2 Yes ❑ No Inspection Ofher Than RoughJn: ❑ Ready Now Will Call
1 r a (You must call the inspector when ready) Date Ready:
I,�jicensed contractor ❑ owner hereby request inspection of the above electrical work at:
Job Address (Street, Box, or Route No.) � Cify Zip Code
� �
Secfion No. Township Name or No. Range No. Fire No. Couny
Phone No.
Power
tlecfrical Confmctor (Company N�� ELE��. � �onhacfor License No. I Master Lic.
3100,?25TH ST NL,�,. �4
Mailing Address (Coniractor or Owne�orming Inst� fion� ���
� a
-ed Signature (Contractor y�'Swner Perfo mg ilisf�ll�f�fl� A n� � Phone No.
U `i ��
1 A-1 1 8/96 STATE BOARD COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY