P - 84635. REGIUEST FOR ELECTRICAL INSPECTION
4`�F '� 2 4 3 Minnesota State Board of Electricity
1821 University Ave., Rm. S-128, St. Paul, MN 55104
• Phone(612)642-OS00
Home Duplex Apt. Bldg. Other: " New Addn
Commercial Indusfrial Farm Remod Re ir
ir Co,d. Hig. Equip. Water Htr. Load Mgmt. Other:
Drye i Range Elec. Heat Temp. $ervice
"X" above lhe work covered by this request. Enter remarks in this space and on the back of the white copy only.
Calculate Inspection Fee - This Inspection Request will noi be accepted wiihou► the correct fee:
Other Fee # Service Entrance Size Fee # Circuits/Feeders Fee
Mobile Home Park Stall to 00 Amp 0 to 100 Amps
Street Ltg./Traffic Sig. A e 200 Am s Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY TO�L
�ign/Oudine Ltg. Xfmr. 1� �, S
Alarm/Remote Control ��
Swimming Pool
I hereb certi that I ins the elechical insfallation dexribed her �on da
Irrigafion Boo RougMn Dare
Special Inspec �` �` f ��
Final
Investigative Fee O -L '— �
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This request void 18 months from validafion date p�inted in this box.
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Requesf Date Rou h-in ins ion r uired? Yes
g pecf eq ❑ No Inspection O�er Than RougMn: ❑ Ready Now - ill Call
�- � 9 7 (You must call the �nspec�or when ready� Date Ready:
I, licensed contractor ❑ owner hereby request inspection of the above electrical work at:
1ob Addreu �Sfrcet, Box, or Route No.) Ci • Zip Code
by � I i sre sa �e a ��.
Section No. Towns io Name or No. Ronae No_ Fire No_ Cou
Phone No.
Eleclrica� Conhacror (Company Name) Conhactor License ho. Master Lia No. �Planf Elecf. Only)
M��A�••'��1�. �u
MOI�II19%� 9 __a`�p��'�
Phone No.