P - 84314REQUEST FOR ELECTRICAL INSPECTION '= Ee-0000i-os
/ ,ISee instructions for completing this form on back of yellow copy. .�
. ��'�J ���i� X Be/ow Work Covered by This Request
New Add Rep. Type of Buildinq Appliances Wired Equipment Wired
Home
Duplex
Apt. Building
Comm./Industrial
Farm
Other (specify)
Compute Inspection Fee Below:
# Other Fee
Swimming Pool
Transformers
Signs
Range Temporary Service
Water Heater Electric Heating
Dryer Load Management
Furnace Other (Specify)
Air Conditioner
Contractor's Remarks: . �
� C`G��rr��= �t�i�<-� %'�fa� .�
# Servi e Entrance Size Fee # Circuits/Feeders
0 t 200 'Amps �`( 0 to 100 Amps
Above 200 Amps Above 100 Ar
Inspector's Use Only: TATdf
Fee
Irrigation Booms ?��
Special Inspection
Alarm/Com THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT
Other Fee ' COMPLETED WITHIN 18 MONTHS.
I, the Electrical Inspector, hereby Rough-in Date
certify that the above inspection has Final � Date
been made. �,��j" _ ;,�. 3 � 97
OFFICE USE ONLY
This request void 18 months from
0-187-23 ��� . �
Request Date Fire No. Rough-In Inspection Required Inspection Than Rough-In
f (You must call inspector when ready) � Ready Now '�,Will Notify Inspector
� � ❑ Yes No Date Ready
I�licensed contractor ❑owner hereby request inspection of above electricai work at:
Job Address (Street, Box or Route No.) City r /'',",
� .(� �G `� [ /.:�f �
Section No. Township Name or No. Range No. County
yP �� � ` � Q
Power Supplier Y S � �Q _ Address
v-
Electrical Contractor (Company Name)
i� r / �. : i
(Contractor or Owner N
.,. —� .� r ,
Authorized
�;PofINNESOTA STATE BOARD OF ELECTRICITY
Griggs-Midway Bldg. - Room 5-128
7821 University Ave., St. Paul, MN 55104
Phone (612) 642-OS00
Phone No.
Contractor's License No.
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io� �� j— � Phone Numbe
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III (I III II III �) III �I (II I IIIII �(II II II .III THIS INSPECTION REQUEST WILL NOT
BE ACCEPTED BY THE STATE BOARD
UNLESS PROPER INSPECTION FEE IS
ENCLOSED.