P - 83443REQUEST FOR ELECTRICAL INSPECTION
5����/� /� =m Minnesota State Board of Electricity
, �t `* 1821 University Ave., Rm. S-128, St. Paul, MN 55104
, Phone(612)64a-0800
Home Duplex Apt. Bldg. Other: . ew Addn
Commercial Industrial Farm -5� Remod Re air
Air Cond. Htg. Equip. Water Htr. Load 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.
Calculaie Inspection Fee - This InspecFion Request will not be accepted without the correcf fee:
Other Fee # Se ' trance Size Fee # Circuits/Feeders Fee
Mobile Home Park Stall to 20 mps � 0 to 100 Amps Q.
Sfreet Ltg./Traffic Sig. Above 200 Am s Above 100 Amps
Transformer/Generator INSPECTOR•s use oN�v TOTAL 3/��
Sign/Oudine Ltg. Xfmr. v�, 6�'�g °��
Alarm/Remote Control � �w.nr �B9'-
Swimming Pool Ca�'"�'"
I certi tlwf I ins ihe 'nsfallafion described herein an Ihe doAes slated
Irrigafion B eo�Mo _
Special Ins — 2'
Investigative Fee ' F� —/_od �
THIS INSTALLATION MAY BE ORDERED DISCONNECTED tF NOT COMPLETED WITHIN 8 MONTHS.
OFFiCE USE ONLY This requesf void 18 months from validafion date printed in this box.
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PLEASE PRINT OR TYPE
RequesT Date Rou h-in in an r uiredZ Yes
g spetfi eq ❑ No Inspecfion Olher Thon RougMn: ❑ Ready Now ill Call
I2, . � • q� (You musf call the inspecior when ready) Date Ready:
I, ❑ licensed contractor owner hereby request inspecfion of ihe above electrical work at:
1ob Addreu (Shcet, Box, or Roule No.) Ciy Zip Code
�O 2� C,n,� t, �—�,.�nL N� ���.. S��-( 3 Z
Seclion No. Township Name or No. Ranpe No. Fire No. C nty �
r10 IC..G�.
o���poor Plwna No. � 6( Z,
�t bc ���-z aa
Power S pplier Address
t.t s� 1"� 1� Nd��k O�v�s��n
Electrical Contracror �Company Name) Contrac�w license No. AAas�er lic. No. �Plant Ele
(,,, v� G f
Mailing Address (Contractor w Owner Performi� Installalion) .
5,.+� t,
Authorized Signa �Controcror or Owner P ing Installafion) � Phone No.
v. ���� ` 5�1-z¢�(�-
E����� � 8� STATE BOARD COPY - SEE INS7RUCTIONS ON BACK OP YEI.LOW COPY