P - 84748. REQUEST FO ELECTRICAL INSPECTION
���— 2 4 9 M,��eSOta Stat Board of Electricity -
1821 Univers' Ave., Rm. S-128, St. Paul, MN 55104
Phone(612) 2-0800
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. Heat Temp. Service
"X" above the work covered by this request. Enter remarks in this space and on the back of the whiie copy only.
(�e�� CQ.�,�,c,ae�, ���—�BS�
Calculate Inspection Fee - This Inspection Request will not be accepted without the correct iee:
Other Fee # Service Entrance Size Fee # Circuits/Feeders Fee
Mobile Home Park Stall 0 to 200 Amps to 100 Amps
Street Ltg./Traific Sig. Above 200 Am s Above 100 Amps
Transformer/Generator INSPECTOR�s use oN�v TOTAL
Sign/Oudine Ltg. Xfmr. �. 5�
Alarm/Remote Control
Swimming Pool
I hereb certi that I ins fed fhe electrical installation described herein on the dates stafed
Irrigation Boo Ro„9�i„ pare
Special Insp �{� '
Final �� c�
Investigative Fee � Z
THIS INSTALLATION MAY BE ORDERED DIS D IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This requesf void 18 months from validation date printed in fhis box.
/�-� � �.
IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII �
* � i 3 5 2 4 9 8 * PLEASE PRINT OR TYPE
Requesf Date �� Rough-in inspection required$ ❑ Yes No Inspection Other Than RougMn: ❑ Ready Now Will Call
(You must call the inspecfor when ready) Dafe Ready:
I, �licensed contractor ❑ owner hereby request inspection of the above electrical work at:
Job Address �Skeef, Box, or Roufe No.) Ciy Zip Code
c�a �s �+ N� � � I 55��
$ecfion No. Township Name w o. Range No. Fire No. Counly
1�'rl���.
OccuPant Phone No.
n `' Z.A,�I- �G�,r�l `7 �- J� �3
Power Supplier Address
Elecfrical Conhacfor (Company Name� Conhactor License No. Masfer Lic. No. �Planf Elect. Only�
�/1N�Mi./Y��T.. NQ O � �l g
Mailing Address
��
Aufhorized S ture (Con actor o er Per(ormip8 Installafion� `' /��� Phone No.
� �� ��7
E&00001 A-1 8/96 STATE BOARD COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY