P - 83336REGIUEST FOR ELECTRICAL INSPECTION °"
7 V`t -17 3� Minnesota State Board of Electrir�yty
1821 University Ave., Rm. S-128, St. Paul, MN 55104 �
f ' Phone (612) 642-0800 "�'
Home Duplex Apt. Bldg. Other: New Addn
Commercial Industrial Farm Remod Re air
ir CondO Htg. Equip. Water Htr. Load Mgmt. Other:
Dryer Range Elec. Heat Temp. Service
"X" above the work covered by this reques►. Enter remarks in this space and on the back of the whi►e copy only.
��r�ac�� A�E� ffK�nr��t��2i? �e�l4Ge�c��T
Calculate Inspection Fee - This Inspection Request will nof be accepted 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 $, o O
Street Ltg./Traffic Sig. Above 200 Am s Above )00 Amps
Transformer/Generator INSPECTOR�S USE ONLY TO r
Sign/Outline Ltg. Xfmr.
�J `S'O
Alarm/Remote Control
Swimming Po
I hereb certi that I ins the electrical insfallafion described herein on the dates sMfed
Irrigation Bo Rough-In Dafe
Special Inspection
Final � D y^ c
Investigative Fee 7
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This request wid 18 months from validatio printed in this box.
� ���?��-
IIIIIiiillllllllllllllllllll!!��lIIIl�illlllillll /,.
* � 7 � 4], 7 3 4* `"� �
PIEASE PRINT OR TYPE
Request Date Rou h-in ins ion r uired?
p/ g pecY eq ❑ Yes o Inspeclion 01her Than RougMn: eady Now ❑ Will Call
/� '� /� z�� Q (You must call fhe inspedor when ready) Date Ready: j� �� �
I, �'licensed contractor ❑ owner hereby request inspection of the above electrica! work at:
Job Address (Sheet, Box, or Roufe No.) � '�.�� ���� Zi Code
P
ss/ � Dbe� /� h C��c�e �� �e
$ecfion No. Township Name or No. Range No. Fire No. County
��/� Q
Occupa�t Phone No.
Ti� �'Ik l �i vQ 6iz - s�h� /y3�
Power Supplier Address
Elechical Contractor (Company Name) � Conhaclor license No. Master Lic. No. (Planf Elecf. Only�
�� ��ET fG h . C Aoa / �
Mailing Address (Confracfor or Owner Performing Installation�
�ao/C��TiPa � U� Su r%�'!%S �I!+ �a �Ce /�it� ��// s .S y3oZ
Auf 'z ure (Confracfor or Owner Perform' Install fion (, � Phone No.
O� � �/2�%�'6AS.2 S�
E&000 8/96 STATE BOARD COPY - S I TRUCTIONS ON BACK OF YELLOW COPY