P - 83103~ REQUEST FOR ELECTRICAL INSPECTION -
6 5 7. � 4 5 6� Minnesota State Board of Electricity
1821 University Ave., Rm. S-128, St. Paul, MN 55104 �.
� � ' Phone (612) 642-0800 "�'
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. Heaf Temp. Service
"X" above the work covered by this request. Enter remarks in this space and on the back of the white copy only.
'�;�G►-1-C�,e.�• t'er�•odel a.�d r�,ew Por�
j(`nak i rsp e��dn �e�
o � e.�rh�ad S�exv ► te. -�o� .
Calculate Inspection Fee - This Inspection Requesi will not be accepted wifhou► the correct fee:
Other Fee # Service Entrance Size Fee # Circuits/Feeders Fee
Mobile Home Park Stall 0 to 200 Amps � 0 to 100 Amps
Street Ltg./Traffic Sig. Above 200 Amps Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY TOT/A�/L�
Sign/Oudine Ltg. Xfmr. / J . ��
Alarm/Remote Confrol
Swimming Pooi
I hereb certi that I ins the electrical insfallafion described herein on the dates stated
Irrigation Boo RougMn Dare ^��, p/
Special Inspec d
final
Investigative Fee
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 8 MONTHS.
—T — --_ _ -- — -- --
- OFFICE USE ONLY This requesf void 18 moo'!�.a from validation date printed in fhis box.
IIINIIIIIIIINIIIIIIIIII���HIIIIIN�I��III�I � 7�=�
* 0 6 5 7 4 5 6 0* ,, j'�fJa
PLEASE PRINT OR TYPE
. Request Date Rou h-in ins tion r uired2 Yes
g pec eq ❑ No Inspection O�er Thon RougMn: ❑ Ready Now Will Call
. q—q �q$ �You must call fhe inspecfor when ready� Date Ready:
I, � licensed contractor ❑ owner hereby request inspection of the above electrical work at:
lob Address (Sheet, Box, or Roule No.) City Zip Code
83'1 k an u. Frid l SS�f 3�
Section No. Township Name w No. Range No. Fire No. ouny
14ho I�a.
Occupanf Phone No.
���— �
Power Supplier Address
i� S 1 � l � J`' C,,c�•�- Po i h.�l- /� r.�,a,S.� � i� � e
Electrical Conhacfor �Company Name) Conhaclor license No. Masler Lic. No. (PIaM Elecf. Only)
'�0.1� i C ��'(.. � ii� 4 3�1'
Mailing A ss �ContraMOr or Owner PerForming Insfallation) .
( a,-°13"°� v � . , E • � I �e S �L`��
Aufhorized S' re Conhactor or rformin ' n) �t r/'� O Phone No.
- �" � g -g'-f'7�
E&000 A STATE BOARD COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY