P - 83188REQUEST FOR ELECTRICAL INSPECTION
�� vrA'� � O Minnesota State Board of Electricity
� 1821 University Ave., Rm. S-128, St. Paul, MN 55104
�.` ,� Phone (612) 642-0800
Home Duplex Apt. Bldg. Other: ew Addn
Commercial Indushial Farm Remod Re al
Air Cond. e tg. Equip. Water Htr. ' aad Mgmt. Other:
Dryer Range Elec. Heat Temp. Service
"X" above the work covered by ►his request. Enter remarks in this space and on the back of the white copy only.
Calculate Inspection Fee - This Inspection Request will not be accepied without fhe correct fee:
Other Fee # Service Entrance Size Fee # Circuits/Feeders Fee
Mobile Home Park Stall ro 00 Amps 0 to 100 Amps
Street Ltg./Traffic Sig. Above 200 Amps Above 100 Amps =
Transformer/Generator INSPECTOR'S USE ONLY TOTAL �f
Sign/Oudine Ltg. Xfmr. � V���
Alarm/Remote Conhol
Swimming Pool
I hereb certi lhat I ins the eleckical installafion described herein on the dales stated
Irrigation Boom Ro„9�,.�„ p�
$pecial Ins ' � � —1 '�
Final -Zl�—
Investigative ee ' �
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF f�T COMPLETED WITHIN 18 MONTHS.
O�RCE USE ONLY This roquesf void 18 months hom validation dale printed in this box.
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* � 5 6 6 9 7 8 3* d
EASE PRINT OR TYPE
Requesf Dafe Rough-in inspection required$ Yes � ❑ No Inspecfion Other Than Rough-In: ❑ Ready Now Will Call
� '_ _�, ��-. (You musf call fhe inspecbr when readyJ Date Ready: .
I, icensed contractor ❑ owner hereby request inspection of the above elecfrical work at:
Job Ad�dr}ess Sheet, Bo or Route No.) Ciy w Zip Code
' �5� � �'i' {�.�5 � b L.�
Secfion No. Township Name or No. Rarge No. Fire No. Counly
� �o�
�t . � � � Phone No.
�w - {
upplier Address
���P �1
I Con�qpjy� �� ON Conhaclor License No.
y,,••-'� 5TH ST. W.�
3100-�
Address (Gontracror w Perfoii�ning nstallafion) .- "
0_L _ . n oI.I 1
or Owne� Peftorming Insfallafion� + � . I P
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STATE BOARD COPY - SEE INSTRUCTIONS ON BACK OF VELLOW COPY