P - 82886RE(IUEST FOR ELECTRICAL INSPECTION -
���� �, � O� Minnesota State Board of Electricity
1821 University Ave., Rm. S-128, St. Paui, MN 55104
; Phone (612) 642�800
Home Duplex Apt. Bldg. Other: � New Addn
Commercial Industrial 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.
Calculate Inspection Fee - This Inspection Request will not be accepted wifhout fhe correct fee:
Other Fee # Service Entrance Size Fee Circuits/Feeders
Mobile Home Park Stall 0 to 200 Amps 0 to 100 Amps
Street Ltg./Traffic Sig. Above 200 Am s Above 100 Amps
Transformer/Generotor INSPECTOR'S USE ONLY i ,.�� TOTAL �/� ("T
Sign/Ouiline Ltg. Xfmr. �G�� r{ � °1�f 1L1
�
Alarm/Remote Conhol -
Swimming Pool
I here ceAi tfwt I in the el 'cal inslallafion described herein on Ihe dates staAed
Irrigation Boom RoogM� � ^ �--
Special Inspect
Pind -7
Investigative Fee ,} �
" THIS INSTALLATION MAY BE ORDERED CTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This request void 18 months from validafion date prin�ed in this box.
������� • �� ��
III II III il lll l II II III II ill il ill l llll
* 0 5 3 2 5 0 1 4 * ��OZ
PLEASE PRINT OR TYPE
Request Dafe Rou h-in ins on uired$ ❑ Yes pecY g ❑ Ready Now ❑�II Call
� 9 P� .�q ❑ No Ins �on OTher Than Rou Mn:
� (You must call the�inspec�or when ready� Dare Ready:
I, ❑ licensed confractor ❑ owner hereby request inspection of ihe above elechical work at:
Job Addreu (Sheet, Box, or RouAe No.) Ciy � Zi Code
S� � �"Sw�2.
'on No. Township Name or �No. Range No. Fire No.
3d �
Occu�M � � Plwne No.
Power Supplier�� � — �
Electrical Conk ompany Name)
��=-i�— � /L�
Mailing Address�cror or Owner Performing Insfallafion�
� �/ � / _
Authorized Si naNre lonfractor w Owner �P orm in Insta�a
. 9 .+1 /� N � 9 /
STATE BOAqP'A,p Y - SEE
u�,�
�
l v �
I SZ �r•a
OF YELLOW COPY � ��
�E�