P - 84553` RE�UEST FOR ELECTRICAL INSPECTION -�
� b�-16 6 ^�- . Minnesota State Board of Electricity
i821 University Ave., Rm. S-128, St. Paul, MN 55104
Phone (612) 642-0800
Home Duplex Apt. Bldg. Other: New Addn
Commercia lndusfrial Farm Remod Re ir
Air C n �' Htg. Equip. Water Hh. Load Mgmt. Other:
Dryer Range Elec. Heat Temp. Service
"X" above the work covered by this request. Enter remarks in this space and on fhe back of the white copy only.
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Calculate Inspection Fee - This Inspection Requesi will no► be accepted without lhe correct fee:
Other Fee # Service Entrance Size Fee # Circuits/Feeders Fee
Mobile Home Park Stall 0 to 200 Amps 0 to 100 Amps �..
Sfreet Ltg./Traffic $ig. Above 200 Am s Above 100 Amps
Transformer/Generator INSPECTOR�s use oN�v TOTAL �
Sign/Oudine Ltg. Xknr. �
Alarm/Remote Control
Swimming Pool
I hereb certi fhaf I ins ted fhe electrical insfallafion described herein on the dates sfated
Irri9afion Boom RougM� pa�
$peciallnsp `�
Fn,al t
Investigative Fee ± - � 1t � --/j .-. .'
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONT S.
OFFlCE USE ONLY This request void 18 months (rom validation date printed in this box.
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* � 4 6 8 1 6 6 4� PLEASE PRINT OR TYPE
Requesf Date Rou h-in ins ion r uired?
9 g pecY eq ❑ Yes No Inspecfion Olher Than RougMn: Ready Now ❑ Will Call
y(' • ,� �You must call the inspeclor when ready) Date Ready:
I, licensed contractor ❑ owner hereby request inspection of the above electrical work at:
Job Address (Sheet, Box, or Roufe No.) Ciy Zip Code
3 S� 9�'A�sr Ov�',e��� C�,e �'210�
Seclion No. Township Name or No. Range No. Fire No. Counly
�/�o�.
Occupanf Phorre No.
��r��2 S7y ��sZ
Power Supplier Address
E ri a`r r i s o n�° t:i 1°e c t r i c, I 11 C. Cor�aGrqr�lisansaJVo. Masrer Lic. No. �Planr Elect. Only)
�,�-���ua�a
Mailing Addreu (Conhactor or Owner Perfoiming Installafion)
252 evada Ave. N. #301, Golden Valley, MN, 55�27
Aulhoriz i � r or ner ng Inslallafi � Phone No.
�`5� O � 544-3300
E&00001 A- /96 STA BOARD COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY