P - 83183REQUEST FOR ELECTRICAL INSPECTION =-°�.
5��'e C� O O Minnesota State Board of Electricity '
� � o 0 1821 University Ave., Rm. S-128, St. Paul, MN 55104
�` Phone (612) 642-0800
Home Duplex Apt. Bldg. Other: New Addn
Commercial Indushial Farm Remod Re ir
Air Cond. ; Htg. Equip. Water Htr. Load Mgmt. Other.
--'Dryer�/,, v Range Elec. Heat Temp. Service
"X" above the work covered by this request. Enter remarks in this space and on ihe back of the white copy only.
Calculate Inspection Fee - This Inspection Reqvest will not be accepted wiihout the correct fee:
Other Fee # Service Enirance Size Fee # Circuits/Feeders
Mobile Home Park Stall � 0 to 00 Amps 0 to 100 Amps
Street Ltg./Traffic Sig. Above 200 Amps Abpve 100 Amps
Transformer/Generator INSPECTOR's uSE oN�r TOTA� �
Fee
SignjOudine Ltg. Xfmr. �� b �
Alarm/Remote Conhol " - -
Swimming Pool
I hereb certi that I in the eleclrical installafion described herein on ihe dafes stated
Irrigation Boom �' Ro�gMn Dare _�
Speciallnspecti t� � �
Final Date
Investigafive Fee � - � �
THIS INSTALlAT10N MAY BE ORDERED DISCONNECTED If NOT COMPLETED WITHIN 18 MONTHS.
OPR� USE OlN.Y This request wid 18 months Irom validafion dafe prinfed in this box.
� �S�
IIIIIII�IIIIIIIIIlIII 111111141NV�1� ��as
' * � 5 6 6 9 8 8 2 � p�pSE PRINT OR TYPE
Request ��/' Rough-in inspeciion required8 Yes ❑ No Inspecfion Ofher Than RougMn: ❑ Ready Now Will Call
�� (You musf call the inspecfor when ready) Dafe Ready:
I, licensed conhactor ❑ owner hereby request inspection of the obove elecfrical work at:
Job Address �Streef, x, w Roule No. Ciy Zip Code
1R.� C��r s �� �d,1�-�-
or
Moiling Address (Conhaclor�
Au�hwized Signoture (Conhac�or or
Range No. � Fire No.
Phone No.
License No.
ST. W., FG 7M., MN
ii InsfallaN�n) •-i8�0
1
STATE BOARD COPY - SEE INSTRUCTONS ON BACK OF YELLOW COPY
No.