P - 84497REQUEST FOR ELECTRICAL INSPECTION --
4,� p 9 2 4 Minnesota State Board of E�ectricity �~�
� 1821 University Ave., Rm. S-128, St. Paul, MN 55104
Phone (612) 642-0800 � .--•
Home Duplex Apt. Bldg. Other:
Commercial Industrial Farm Ne�'�' Addn
Air Cond. Ht E ui emod Re air
9• q p• Water Htr. Load Mgmt. Other:
ryer Z Range Elec. Heat Temp. Service `
"X" above e work covered by this request. Enter remarks in this space and on the back of the white copy only.
Calculate Inspeciion Fee - This Inspection Request will not be accepied without ihe correct fee:
Other Fee # Service Entrance Size Fee # Circuits/Feeders Fee
Mobile Home Park Stall to 00 Amps 0 to 100 Amps
Street Ltg./Traffic Sig. Above 200 Am s Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY
Sign/Outline Ltg. Xfmr. TO�L
TS
Alarm/Remote Confrol
Swimming Pool
Irrigation Boom I hereb certi that I ins ed the electrical installation described herein on the dates stated
RougMn
Special Inspection � ' Q
Final ��Y (
Investigative F �
THIS INSTALLA N MA ORDERED DISCON IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This requast void 18 months (rom validation date printed in this box.
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PLEASE PRINT OR TYPE
Requesf Dafe Rouglfin inspection required2 es
❑ No Inspecfion O�er Than Rough-In: ❑ Ready Now Will Call
7 (You musf call the inspecfor when ready) Dafe Ready:
I, icensed contractor ❑ owner hereby request inspection of the above electrical work at:
Job Addreu �Sheef, Box, or Roufe No.) �
� � C�y Zip Code
ion No� Township N�e o� � �
Range No. Fire No. Coun
o��� ! //��t'�f�
Phone No.
Power Supplier Address
/ V � �
Elechical Conkactor �Company Name)
� Confracfor License No. /vlasfer Lic. No. (Planf Elect. Only�
GTIE3 ELECTt�C. NC. C�Ai000�1
Mailing bwne p ation)
� �
AWhorized n rming InstallaKon)
O Phone No.
EB-0pOplA-11 8/96 � � � •�
STATE BOARD COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY