P - 82660.
4�4-627 �
Commercial
Air Cond.
Dryer
"X" above the �
Industrial
Hta. Eaui
REQUEST FOR ELECTRICAL INSPECTION
Minnesota State Board of Electricity � `�
1821 Universiiy Ave., Rm. S-128, St. Paul, MN 55104
Phone (612) 642-0800 `����
Apt. Bldg. Other: New Addn
Farm emod Re air
Water Htr. Load Mgmt. Other:
Elec. Heat Temp. Service
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 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 '7 S' a'd
Street Ltg./Traffic Sig. Above 200 Amps Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY _, TOTAL�
Sign/Outline Ltg. Xfmr. �F���:, � Ldwt� ��y'��" f ��7 s S�
Alarm/Remote Control
Swimming Pool
I hereb certi fhat I ins fed the electrical installafion described hereA ' dates stafed
Irrigation Boom Rough-In � A� _ 2� Dare C�
Special Inspecti � — <
Final /� " Date� � �^+.
Investigative Fee � 't'�-- — y—
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
�_ _ _ —
OFFICE USE ONLY This request void 1 8 monihs from validafion date printed in this box.
I IIII II Ifi ii Ili II III ii III II II
IIIIIillllll►
�L�G � � � �
* 0 4 0 4 6 2 7 2*
PLEASE PRINT OR TYPE
Requesi D� Rough-in inspecfion re uired? � QS
9 ❑ No Inspecfion Other Than Rough-In: ❑ Ready Now
�� �i � ��- (You musf call fhe inspecfor when ready) Date Reod :
Y
I, �icensed contractor ❑ owner hereby request inspection oF the above electrical work at:
Job Address (Sireet, Box, or Roufe tye7l � City Zip Code
!� , � ' t: o� - y��'�r �
� � � . I`, r �'e?� � ��`� �`� c,�,
Sechon No. Township Name or No. ��
Range No. Fire No. o` ��n,
Occupant
E' %%
/�r�`r / �t — ��.; �� C 'f '�i I
Power Supplier �� Address
f ' _;` f-�
Elechico Contracfor (Company� }Name)
� l.�£ ]�-'�C{�/ ���1/'?��.�j'`}�/
Mailing ddress (ContracL or,(�wner Performing Insfallafion)
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Authonz�d.$�pna�ure �Conhac}or or Cawtmn �,.,��.. i..��,.n..«:...,i ZS
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STATE BOAR6
I Phone No. ,
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Conhacfor License No. Masfer Lic. No. (Planf Elecf. Oi
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,�._� L-� �y'.to' SSl/�
- %� P�o No.
11 �'` � � .lc�.:�`
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- SEE INSTRl1CT1nNR nu Rec�t nc vc� i nw rnov
Call