P - 81105REQUEST FOR ELECTRICAL INSPECTION
8�{� � Z(a �� Minnesota State Board of Electricity
.�'-r �� 1821 University Ave., Rm. S-128, St. Paul, MN 55104
� Phone(612) 642-0800
Home Duplex Apt. Bldg. Other: New Addn
Commercial Industrial Farm Remoci Re air
Air Cond. Htg. Equip. Water Htr. Load Mgmt. Other:
Dryer ange Elec. Heat Temp. Service
"X" above the work Govered by this request. Enter remarks in this space and on the back of the white copy only.
� ,� ���/�/1,�.��,
Calculate Inspection Fee - This Inspection Request will not be accepted wiihout the correct fee:
Other Fee #$ervice 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 oN�v T A �
Sign/Outline Ltg. Xfmr.
Alarm/Remote Conhol
Swimming Pool � � �
I hereb certi that I ins the elechical insfallafion described herein on the dates stafed
Irrigation Boom RougMn oara
Special Insp
Investigative F� �re S`X�
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFlCE USE ONLY This requesf void 18 monfhs from validation date printed in this box.
i�i��ili�iii{ii{i{ii{iiii �i�ii�i{�� • �G��
* 0 8 4 4 1 9 2 5* 7� ��
PLEASE PRINT OR TYPE
Requesf Dafe Rough�in inspecfion required? ❑ Yes o Inspection Ofher Than RougMn: Ready Now ❑ Will Call
Z� (You must call fhe inspecfor when ready� Date Ready:
I, ' nsed contractor ❑ owner hereby request inspection of the above electrical work ot:
Job Address �Sfreet, Box, or Route No.� Ci Zip Code
���� �1V�ii� ���
Section No. Township Name or No. Range No. Fire No. County
C]q0upanf ( _ /� � ! � . Phone No. /. �' --
�� _ 1 c
tieciri I Go mctor �Company NameJ Conh r Lic se No. Master Lic. No.
� i �� � �Le-c�,� �'U �� �1 `t�
Mailing Address �CoNy ctor or Owner Performing Insfallafion� _ /�, ,
L1�Yner Performing Install��)" ' � I Ph��^�e No�.
J-+ V � �d-
STATE BOARD COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY