P - 82635'(� REQUEST FOR ELECTRICAL INSPECTION E
1 —V � � -711 � Minnesota State Board of Electricity " - �
� 1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104-2993 �' �_-�� �. �
k � Li
(651) 642-0800 www.electricity.state.mn.us
Home Duplex Apt. Bldg. Other: New Addn
Commercial Industrial Farm Remod Repair
Air Conditioner Htg. Equip. Water Htr. Load Mgmt. Other:
Dryer Range Elect. 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.
� S� 51'�U��i.S S W t TC. �-�'
Calculate Inspection Fee - This Inspection Request will not be accepted without the correct fee.
Other Installations Fee # Service Entrance Size Fee # Circuits / Feeders Fee
Mobile Home Park Stall 0 to 200 Amps 0 to 100 Amps
Street Ltg. / Traffic Sig. Above 200 Amps Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY TOTAL
Sign / Outline Ltg. Xfmr. `�—� �U
Alarm/Remote Control
Swimming Pool
I hereby certity that I inspected the electrical insiallation described herein on the dates stated:
Irrigation Boo Rou9h in Date
Special Inspec io D te
Final � 1 ,. QO
Investigative Fee �
THIS INSTALLATION MAY BE ORDERED ONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
......... .................................l�.......�.......... .......
� OFFICE USE.ONLY�This request void 18 months from validation date printed in this box.
I IIIIII IIIII IIIII IIIII IIIII II I IIIII IIII (III �V �
* 1 0 1 7 7 7* � ����
PLEASE PRINT OR TYP
Re�st Date �� Rough-In inspection required? ❑ Yes No Inspection Other Than Rough-In: Ready Now ❑ Will Call
You must call the inspector when r ! Date Ready:
I,�lice ed contractor ❑ company ❑ owner hereby request inspection of the above electrical work at:
/�
Job Address (Street, Box, or Route No.) Ci Zip Code:
� �: ► � � ►dl � 43�.
Section No. Township Name or No. Range No. Fire No. C nty �
I upant � Phone No.
r L.
Power Supplier A � Address
F,
Electrical Contractor / Company Name Contractor License No. Master Lic. No. (Plant Elect. Only)
6 1 � �
Mailing Address (Contractor, Company or Owner Perform g Installation)
� 1 S4 � 1`�c� M�-� SS I►
utho ized Signature ( on ctor, Co ny or Owner P ' g I stallation) Phone Numbe
(b51)b�- �
EB-0000 A-12 5/1999 STATE BOARD COPY SEE INSTRUCTIONS ON BACK OF YELLOW COPY