P - 80818�26-�59 �
Home Duplex
Commercial Industri
Air Cond. Htg. Ec
Dryer Range
"X" above the work covered
REQUEST FOR ELECTRICAL INSPECTION �
Minnesota State Board of Electricity �
i821 University Ave., Rm. S-128, St. PauV, MN 55104 `��.
Phone(612)642-0800 "�'
Apt. Bldg. Other: New Addn
�I Farm Remod Re air
uip. Water Htr. Load Mgmt. Other:
Elec. Heat Temp. Service
by this request. Enter remarks in this space and on the back of the white copy only.
Calculate Inspection Fee - This Inspection Requesi will not be accepied without 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./Traffic Sig. Above 200 Am s Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY TOT �O
Sign/Outline Ltg. Xfmr. �
Alarm/Remote Control �
Swimming Pool
I hereb cerfi thaf I ins the elechical installation dexribed herein on the dates stated
Irrigation Boom RougMn Da�
Special Insp
Fi�F Da � C^
fnvestigative J
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
� QFFICE l�E ONLY This request wid 18 months From validation date printed in this box.
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* 0 8 2 6 6 5 9 5* � 7��
PLEASE PRINT OR TYPE
Requesi Dafe Rough-in inspeclion required$ ❑ Yes No Inspection Ofher Than Rough-In: Ready Now ❑� Will Call
��� 9 (`/ou must wll the inspector when ready) Date Ready:
I, � licensed confractor ❑ owner hereby request inspection of the above electrical work at:
Job Address �Sheet, Box, or Roule No.) City Zip Code
55�97-,E. f��+h+�be, FrYa�/e
Seclion No. Township Name or No. Range No. Fire No. Counly
/q-na l�
Occu nf Phone No.
��C�(C. ro�e� S72 •�/y
Power Supplier Address
Elechical Confracror �Company Name� Confracror License No. Master Lic. No. (Plant Elect. Only)
I�Ts ,E�'cT�rc C�o�y85'
Mailing Address (Conhacror or Owner Performing Insmllafion)
87�0 �1S'7���e Nw Z��+•+•. n't►, . SS3 98
Authorized Signature �Conhacfor or er Performing Insfallafion Phone No.
�..� , � �� 6��-yy�-�a9
E 1A-11 8/96 pRD COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY � �