P - 78597REGIUEST FOR ELECTRICAL INSPECTION
8 Or� _� 9 4 Minnesota State Board of Electricity
1821 University Ave., Rm. S-128, St. Paul, MN 55104
� Phone (612) 642-0�00 r� �
Home Duplex Apt. Bldg. Other: �G: . (;1 New Addn
Commercial Industrial Farm �� Remod Re air
Air Cond. Htg. Equip. Water Htr. Load Mgmt. Other. ,Li �� �TS � OdTc,ET$'
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.
I,}� T� ���� -
Calculate Inspeciion Fee - This Inspection Request will not be accepied wifhoui the correct fee:
Other Fee # Service Entrance Size Fee # Circuits/Feeders Fee
Mobile Home Park Stall 0 to 200 Amps Q, 0 to 100 Amps
Sheet Ltg./Traffi i Above 200 Am s Above 100 Amps
Transformer/Ge f f INSPECTOR'S USE ONLY TOTAL�� �
Sign/Outline Ltg. Xfmr.
Alarm/Remote Conhol
Swimming Pool
I here certi that I in the eleclrica ' Ilafion described herein on the dates stafed
Irrigotion Boom Ra„gM„ �/
$pecial Inspection �
Final Da
InvesTigative Fee Q j
THIS INSTALLATION MAY BE ORDERED DIS NECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This request wid�,8�monlhs from wlidation date printed in this box.
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* 0 8 0 2 3 9 4 7� �
PLEASE PRINT OR TYPE a��
Requesf Dale Roughin inspecfion required? ❑ Yes No Inspecfion O�er Than RougMn: ❑ Ready Now Will Call
�� �� � O 3 (You must call the inspecfor when ready) Dafe Ready:
I, ❑ licensed contractor �owner hereby request inspection of the above electrical work at:
bb Addreu �Shcet, Box, or Roufe No.) Ciy Zip Code
�D92 �C � 2t DL %`'!1�l 55�32
Section No. Township Name or No. Bange No. Fire No. Coun .
� 0 �'� l�'No �i4
Occupant ���i�'`� � ��t'�IT� Ph�4N3'S�� "�.�5%
Power Supplier Addreu .
C�c.. MNP� N o2T� Ai t/�St or1
Elechical Contraclor (Company Name) Contractor License No. MasTer Lic. No. (Plant Elecf. Only)
4Gt�NE� .
Mailing Address (Conhactor or Owner Performing Insfallafion) .
s�rM �
Aulhorized Si atu (Conha er rming Installafion) �� Phone No.
�s.�.� �c3-s�� -o2s9
E&00001 A-11 8/96 STATE BOARD COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY