P - 83236REQUEST FOR ELECTRICAL INSpECTION
6 O,�y�� ��� � Minnesota State Board of Electricity ��
0 f 821 University Ave., Rm. S-128, St. Paul, MN 55104
. Phone (612) 642-0800 '���
Home Duplex Apt.8ldg. Other: New Addn
Commercial industrial Farm Remod Re air
Air Cond. Htg. Equip. Water Htr. Load Mgmt. Other:
Dryer Range Elec. Heat Temp. Service
"X" above the work covered by this request. Enter remarks in Ihis space and on the back of the white copy only.
/UGr.� lod ��1"� D�elt�ie� �%vi`ce. �� TGLi�GL /cet.cj0%��
-�G�/�Caf l� /ti�u7"�ie I��c'6S � ,��G��T�f� l�,��74�� ivotidd�'
Calculate Inspection fee - This Inspection Request will not be accepted wiihout the correci fee:
Other Fee # Service Entrance Size Fee # Circuits/Feeders Fee
Mobile Home Pork Stall 0 to 200 Amps �OD 0 to 100 Amps Oiva
Street Ltg./Traffic Sig. Above 200 Am s Above 100 Amps �,$�o
Transformer/Generator INSPECTOR'S USE ONLY T L�-^
Sign/Oudine Ltg. Xfmr. ,3�7i S a
Alarm/Remote Conhol
Swimming Pool
I here certi that I ins the eleclrical installafion described herein on the dates stated
Irrigation Boom Rougl�ln Date
Special lnspecti
F��wt p�
Investigative Fee ��
THtS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
. OFFICE USE ONLY This requesf void 18 months 6om validation dafe prinfed in fhis box.
��all��ll��ll��lll��illl����ll�����1� • � 3�--�
� 0 6 8 2 5' 6 5 7* ��Q
" PLEASE PRINT OR TYPE
R uesf Date Rough-in inspecfion required2 ❑ Yes No InspeMion O�er Than Roughln: . eady Now � Will Cail
�� �Q ��� �You must call the inspecror when ready) Date Ready: �--��
I, (�licensed contractor ❑ owner hereby request inspection of the above electrical work at:
Job Address (Street, Box, or Roule No.) � . Zip Code
1��� C'�av� PL�e��" . _�Q�.�/ �.sy3�.
Secfion No. Township Name or No. �� � Range No. Fire No. County
�4�uoKA�
o«���r ri,«�e No.
Fn r� e�2 �7a - i a 7�
Power Supplier Address
/�, s l e�?
Elechical Conhacror �Company Name) Conhaclor license No. Master Lic. No. (Planf Elec1. Only)
�hl �IecTrzrc TN � C,4 Oo 19
Mailin Addre Conhacfor or Owner Performin I I i �
8ao� °�nraa� � 9 /l7� s�'�6' ,��n�� 1.��? �RK �-�3
Auf ' e Si oNre (Conhactor or r Perfor ' nstallafi Phone No.
�.? �O -,�'o �S
EB-00001 A- /9 STATE BOARD COPY - SEE TR IONS ON BACK OF YELLOW COPY