P - 83989ipl, `� RECIUEST FOR ELECTRICAL INSPECTION ����;
I�III II III II III II III II III II III II III I� I�) I II�I Minnesota State Board of Electricity ; '�,v i
1821 Urnvers�ty Ave., Rm. S 128, St. Paul, MN 55104 �.•�
�* 0 2 9 9 4 2 5 9 * Phone (612) 64�-0 �"�'�"
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ome Duplex Apt. Bldg. Other: r New dn
Commercial Industrial Farm �" `�"t 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 the back of the white copy only.
Calculate Inspection Fee - This Inspection Request will not be accepted without the correct fee:
Olher Fee # $ervice Enfrance ize Fee # Circuits/Feeders Fee
Mobile Home Pork Stall to 200 Amps 0 to 100 Amps
Street Ltg./Traffic $ig. Above 200 Amps Above 100 Amps
Transformer/Generator INSPECTOR•SUSEON�Y TOTA �
Sign/Outline Ltg. Xfmr. �(,� ! S (6�
Alarm/Remote Control � .. Qx�-�-/�fti
Swimming Pool �J;�� pN /1� �s.?�-
I hereb certi fhat I ins eded the eledrical install ion scribed herein o e dates stated
Irrigation Boom Ro�gh-I Dore
$pecial Inspedi �Z — —
Final I � Dat " �
Irnestigative Fee /[.cG
THIS INSTALLATION MAY BE ORDERED DISCON CTED IF NOT COMPLETED WITHIN 18 MONTHS.
2 9 9- 4 2 5� OFFICE USE ONLY This requesf void 18 months from validafion dafe printed in }his boz.
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PLEASE PRINT OR TYPE ��o S�
Reques} Date Rough-in inspedion required2 Yes � No Inspedion Other Than Rough-In: � Ready Now Will Call
C� �,��_ (You must call the inspedor w n ready) Dote Ready:
I, ❑ licensed contrador owner hereby request inspection of the above electrical work at:
Job P,ddress (S}reei, Box, or Ro e No.) Ciy „�.. Zip Code
� _i� ,- ' � .ST� � ��C����� ' �.i � �-
Sedion No. Township Name or No. - Range No. Fire No. County �
-� v � n.� C,Ic��
OccupanT / . Phone No.
L'�/t,� �- �v��2.SG,�i
Power $upplier � Address ] i
�-� %�7 � � �'D ��� ��
Eledrical Conira/d'�or �Company Name) /� CoMrador License No. Master lic. No. (Plant Eled. Only) '
\� / �, � 1� /��
Mailing Address (Con�or or Owne�rforming Installafion)
�
Authoriz d Signafure �Conirador or Owne P orming Installafion) /'� r Phone No.
' - �::;%� L�!�y�y�.e- tlZe o'L� � n � 7 �l " �a2 a.
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