P - 84316f� REQUEST FOR ELECTRICAL INSPECTION ��.
: 4 4 4� i �� � Minnesota State Board of Electriciry
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. Heat Temp. Service
"X" above the work covered by this request. Enter remarks in ihis space and on the back of the white copy only.
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Calculate Inspection Fee - This Inspection Request will not be accepted without fhe 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 TOTAL 5
Sign/Outline Ltg. Xfmr. ��. 1�e>�
Alarm/Remote Control
Swimming Pool
I hereb ceAi fhat I ins ted }he elechical insfallafion deuribed herein on fhe dafes stated
Irrigation Boom Rough-In Date
Special Inspecti ;� � —' �
Final Dafe .
Investigative Fee
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 ONTHS.
OFFICE USE ONLY This requesf void I S months from validation date printed in this box.
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* � 4 4 i 7 L� 6* PLEASE PRINT OR TYPE
Request Date Rou h-in ins ecfion r uired? �
� g p eq es ❑ No Inspection Ofher Than Rough-In: ❑ Ready Now ill Call
�You must call fhe inspector wh n ready� Date Ready:
I, icensed contractor ❑ owner hereby request inspection of the above electrical work at:
Job Address (Street, Box, or Route No.) City f� Zip Code
� �.�5� i. �P L= n� _ �, -�,Q .i�J = � � ' . > �
Section No. Township Name or No�. Range No. Fire No. Coun
C, � (. �� �
Occupant Phone No.
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Power Supplier Address
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Electriml� Conhactor� (Company Name) onhacfor License Iro. Master Lic. No. (Plant Elect. Only�
� L.E'C',... �-G/li � � cU � � � � �j
Mailing Address (Contrac}or o� Owner PerForming �nstallafion� .
' T � .�� ti� �i P��t.�. �.� ic�.�'
� Authorized Si nature (Con acfor r w erforming Installation) Phone No.
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E&OOOOIA-t /96 STATE BOARD COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY