P - 83171RE(�UEST FOR ELECTRICAL INSPECTION
6 2 2-�) �� Minnesota State Board of Electricity
1821 University Ave., Rm. S-128, St. Paul, MN 55104
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ome Du lex Apt. Bldg. Other: New Addn
Commercial Industrial Farm emod Re air
Air Cond. Htg. Equip. Water Htr. Load Mgmt. Ofher:
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.
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Calculate Inspection Fee - This Inspecfion Request will not be accepted wifhout the correct fee:
Other Fee # Service Entrance Size Fee # Circuits/Feeders Fee
Mobile Home Pork 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 ON�r TOTA�
Sign/Oudine Lig. Xfmr. �
Alarm/Remote Control
Swimming Pool
I hereb certi that I ins led the electrical installation described herein on �e dates stated
Irrigation Boom RougMn Dare
Speciallnspectio L '���
Final
Investigative Fee � { i�
_ THIS INSTALLATION MAY_BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFRCE USE ONLY This requesf wid 18 months from validation date printed in this box.
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* 0 6 2 2 6 7 3 2* a-3�� '
PLEASE PRINT OR TYPE
Request Dafe Rougffin inspecfion required$ es ❑ No Inspecfion Olher Than RougMn: ❑ Ready Now �N1�ill Coll
� � (`fou musf mll the inspeUor when ready) Date Ready:
I, icensed contractor ❑ owner hereby request inspection of the above electrical work at:
Job Address (Sheef, Box, or Route No.) ^ C�A,�r� , ZiP �ode
E� 'f $ !; /
Section No. Township Name or No. Range No. Fire No. Coun
�j'10%G�.
Occu Phone No.
rUC� rm �� 7/-G D5�/
il Contracfor (Company Name) � Conhacror License No. Master Lic. No. (Plant Elect. Only)
Address (C ac or Owner Performing Insfallati .
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:ed SignaNre C�actor or Owner PRdormina Installafionl \ v.,� N., 6
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BOARD COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY