P - 83771. REQUEST FOR EL�CTRICAL INSPECTION �
5(�•°�`� s Q/1 � Minnesota State Board of Electricity
6.J J V�E 1821 University Ave., Rm. S-128, St. Paul, MN 55104
� Phone(6i2)642-0800 '
ome Duplex Apt. Bldg. Other: New Addn �I
Commercial Industrial Farm Remod Re air II
Air Con 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 wifhoui fhe correci 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 A�
Transformer/Generator INSPECTOR'S USE ONLY TOT,
$ign/Oudine Ltg. Xfmr. ,�
Alarm/Remote Control
Swimming Pool
Fee
/S,..sa
I hereb certi �af I ins ected the elechical installafion described herein on the dafes sfafed
Irrigation Boom Ro„9M„ Dare
Special Inspection
Investigative Fee �" Final Cy'
�"'d
THIS INSTALLA ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This request void 18 months from validafio date Qri �is box.
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II III I IIII
* � 5 0 3 8 4��� PLEASE PRINT OR TYPE
Request Date Rough-in inspecfion required? ❑ Yes No Inspecfion O�er Than RougMn: Ready Now � Will Call
Q� �f w d�C/1 � �You musf call the inspector when ready) Dafe Ready: � ��+.� C,� �
s.i arv
I, '�licensed conhactor ❑ owner hereby request inspection of the above electrical work at:
Job Addreu �Sfreet, Box, or Roufe No.) Ciy Zip Code
�dod - H�t�� � ci� �'�c �l/� �
Section No. Townshio Name or No. Ranqe No. Fire No. County
Occupant
Power Supplier
/E"TS' E1,EeT,� � C
Mailirg Address (Contracfor or Owner I
�7�0 -as5�,4�
Authorized Signature (Conkacfor or Ow
r+o
lA-1! 8/96 • ST�
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Phone No.
'�_
Conhactor License No.
;,,„, r»n. Sss3 9 8'
m�2544�a
iEE INSTRUCTIONS ON BACK OF YELLON
No.
(Plant Elect.