P - 80248RE(�UEST FOFi ELECTRICAL INSPECTION .�;�
Q(� �� �� Q � Minnesota State Board of Electricity
ta'U v 1g21 University Ave., Rm. S-128, St. Paul, MN 55104
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Phone (612) 642-08 C� � `' '
Home Duplex Apt. Bldg. Other: � �[ New Addn
Commercial Industrial Farm f� t3 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 this space and on ihe back of the white copy only.
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Calculate Inspection Fee - This Inspi
Other Fee
Mobile Home Park Stall
Street Ltg./Traffic Sig.
Tra nsformer/Generator
Sign/Outline Ltg. Xfmr.
Alarm/Remote Conhol
�n Request will rot be accepted without the correct fee:
# Service Entrance Size Fee # Circu"Rs/Feeders
0 to 200 Amps 0 to 100 Amps
Above 200 Am s Above 100 Ai
INSPECTOR'S USE ONLY TOT,
��� �-�Y�`
Fee
,` �O
_ ............' . . . - .
I hereb certi that I ins fhe elechical installotion deuribed herein on the dales sla
Irrigation B Roo Mo Drne
Special Inspection 9 ' � �15 `�'
Investigative Fee ��e�'1� 7%�C�
THIS INSTALLATION MAY BE ORDERED DISCONN F O COMPLETED WITHIN 18 MONTNS.
OFFICE USE ONLY This request void 18 months from validafion dafe printed in this box.
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PLEASE PRINT OR TYPE
Requesf D Rou h-in ins �on r uirad? Yes
g pecf eq ❑ No Inspection Other Than RougMn: ❑ Ready Now Will Call
��S ' O O (You must call the inspecfor when ready) Date Ready:
I, ❑ licensed contracror�owner hereby request inspection of the above electrica) work at:
Job Addreu (Street, Box, w Route No.) City� Zip Code
� 3 �./
SecTion No. Township Nar�e or No. ^ �(. Range No. � Fve No. ou�y� j
Power Supplier ��
Electrical onh i �.�Company Noi
� �.
Moiling Address ( cror or Ow
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Authorized Signature (ConhacMr or
N�.S'- 95��
/
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Masfer Lic. No. (Plant Elecf.
Phone No.
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STATE BOARD COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY