P - 8276064�-633 �
Commercial
Air Cond.
Dryer
"X" above the v
REQUEST FOR ELECTRICAL INSPECTION
Minnesota State Board of Electricity
1821 University Ave., Rm. S-128, St. Paul, MN 55104 =
Phone(612) 642-0800 "�'
Apt. Bldg. Other: New Addn
Farm Remod e air
Water Htr. Load Mgmt. Other:
Elec. Heat Temp. Service
request. Enter remarks in this space and on the back of the white copy only.
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Calculaie Inspection Fee - This Inspeciion Request will not be accepted withovi the correct fee:
Other Fee # Service Entrance Size Fee # Circuits/Feeders Fee
Mobile Home Park Stall 0 to 200 Amps 0 to 100 Amps
Street Ltg./Troffic Sig. Above 200 Am s Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY TOT ��\
Sign/Outline Ltg. Xfmr. . V V
Alarm/Remote Control
Swimming Pool
I her certi ihat I ins the eleclrical installation deuribed herein on the dates stated
Irrigation Boom Rough-In Dore
$pecial Inspecfion f `i ��
Investigative Fee F� �� -- ap
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFlCE USE ONLY This request void 18 months 6om volidation date printed in fhis box.
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EASE PRINT OR TYPE
Requesf Da�� —�� Rough-in inspecfion required? ❑ Yes No Inspecfion O�er Than RougMn: eady Now ❑ Will Cdll
(You must call ihe inspecfor when ready Date Ready:
I, licensed contractor ❑ owner hereby request inspection of the above electrical work at:
Job Ad� ($(�eef, $ox, r Roufe No.) Cily� � Zip Code �
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SecFion No. Township Name or No. Ronae No. Fire No. Cou .. �
�f - i Cl P'�� ��-� l
ipplier ress
Contractor (Company m „ Contraclor license No. Master Lic. No. (Plant
4ddress Conkacfor or Owner PerFo 'ng InstallaKon) � �
ad Sign re ( or or ner Performing Insfallafion� 6j (� ry� ^^ Phone o. �
�GiO(JUU �
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- 1 8/96 STATE BOARD COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY