P - 81931REQUEST FOR ELECTRICAL 1NSPECTiON �-
V o�� 2 6 6� Minnesota State Board of Electricin�
1821 University Ave., Rm. S-128, St. Paul, MN 55104
Phone (612) 642-0800 fJ Jr( � 7�,� '�`
1�—g+^-S" U
Home Duplex Apt. Bldg. Other: New Addn
Commercial Industrial Farm � Fv� �/�y� 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 Requesf will rot 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
Street Ltg./Traffic Sig. Above 200 Am s Above 100 Amps
;;:, Transformer/Generator INSPECTOR'S USE ONLY TOT
Sign/Oudine Ltg. Xfmr. � � � (� 7
m/Remote Conhol -'
wimming Pool
I hereb certi that I ins the elechical insMllation dexribed herein on Ihe dates slated
Irrigation BQ4m�'-=a=:' RougMn Date
Special Inspection �� � l Z ✓ � �
Fi�wl [�o�a�_"
Investigative Fee • Z- 03 T� r�
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 1 MONTHS.
OFFICE USE ONLY This requeat void 18 montht from validatio� date pri�ted in this box.
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PLEASE PRINT OR TYPE �' �
Requesf�Dale � Rougltin inspecfion required2 ❑ Yes ❑ No Inspecfion Olher Than RougMn: ❑ Ready Now ❑ Will Call
(You must call the inspectw when ready� Date Ready:
'�wti
I, ❑ lice�sed confractor owner hereby request inspection of the above electrical work at:
Job Address��5Mce1, Box, w Route No.) City Zip Code
�` �v, � i� L-E �s`� 3 '�.
Section No. Township ame w No.�'-. Range No. Fire No. Coun
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Occupant Phone No.
AL� JQ�ii/���. l
Power $upplier Address � (� ('� (7 ('\ �� .
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Flectrical Conkacfor IComoonv Namel Conhocfor License No. Mas�er Lit. No. (Plant E1eC. Onl�
o�crwnerYertorming msmnanon�
LJ� �
or Owner Performi I 'on) Phone P1o�
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STATE BOARD COPY - SEE INSTRUC710NS ON BACK OF YELLOW COPY