P - 82830REQUEST FOR ELECTRICAL INSPECTION --
5��� C, � Q Minnesota State Board of Electricity
`� V 1821 University Ave., Rm. S-128, St. Paul, MN 55104
Phone(612)642-0800
Home Du lex Apt. Bldg. Other. � w Addn
Commercial Indushial Farm � Remod Re air
Air Cond. •- Htg. Equip. Water Htr. Load Mgmt. Other:
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 Inspection Request will not be accepted without the correcF fee:
Other Fee # Service Entrance Size Fee # Circuits/Feeders Fee
Mobile Home Park Stall 0 to 200 Amps 0 ro 100 Am s
Sheet Ltg./Traffic Sig. Above 200 Am s Above 100 Amps
Transformer/Generator iNSPecroR'S USE ONLY TOTA
Sign/Oudine Ltg. Xfmr.
Alarm/Remote Conhol
Swimming Pool
I her cerli that I in the elecrri I installa�ion dexribed he�ein on the dales slaled
Irrigation Boom eougMo
Special Inspec
C Final J
Investigative F
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE U8E ONLY This requestvoid 18 months 6om validafion date printed in this box.
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* O S 3'L� S L B 8� PLEASE PRINT OR TYPE
Request Date � RougMin inspeclion required$ ❑ Yes ❑ No Inspeclion O�her Than RougMn: O Ready Now O�11- Call
� f �—�8 (You must call the inspector when ready) Date Ready:
I, ❑ licensed conhactor ❑ owner hereby request inspecfion of the above electrical work at:
Job ddress f5treef. Box, w Rou�e No.� Ciy Zip Code
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Secfion No. Township Name or No. Range No. Fire o. Counly �
�C'� -� /(id
or rhone No.
Ai � S --�3Z
ower $upplier � � Address � � �
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Elecfrical Controctor (Company Name Contracror License No. Master lic. No. (Planf Elecf. Only)
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Mailing Addreu (Con� Owner Performing Insrollafion�
Auth i Signature (Con r Owner e r ng Ins I � Phone No.
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T 1 8/96 y� 7E gOAR COPY - SEE INSTRUCiIONS N BACK OF YELLOW COPY