P - 83313REQUEST FOR ELECTRICAL INSPECTION -
C Q��'1 Q� � Minnesota State Board of Electricity
V,4' .L J 1821 University Ave., Rm. S-128, St. Paul, M1AN 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 fhe work covered by this request. Enter remarks in this space and on the back of the white copy only.
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Calculate Inspection Fee - This Inspection Request will not be accepted wiihout the correc� fee:
Other Fee # Service Entrance Size Fee # Circuits/Feeders Fee
Mobile Home Park Stall 0 to 200 Amps 0 to 100 Amps
Sheet Ltg./Traffic Sig. Above 200 Am s Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY TOTAL � C SQ
Sign/Outline Ltg. Xfmr. �� •
Alarm/Remote Control
Swimming Pool
I hereb certi that I ins ected the elechical installation described herein on the dates stafed
trrigation Boom Rough-in Dore
Special Inspecti
Investigative Fee � ���e —�8 =o(
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
� OFFICE USE ONLY This requesf void 18 months from validation dafe printed in this box.
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PLEASE PRINT OR TYPE
Request Dafe Rough-in inspecfion requiredZ ❑ Yes Inspection Other Than RougMn: Ready Now ❑ Will Call
�You must call the inspeclor when ready) Dafe Ready:
I, icensed contractor ❑ owner hereby request inspection oF the above elechical work at:
Job dress (Sheef, Box, or Route No.� 1 � City Zip e
�-i' �� �7�-c � �, � e ; -��d-� .
'on No. Township Name or No. Range No. Fire No. Coun ���
Occupan %� � % / _ Phone [� �/�'�n
(Tf� if �i� � 7 � �✓
Power Suppl'er Address 1
/�S 3/!�5 .� �� �I � y� �i� �G�rl,c �S�1�3
EI Contractor o pan a) . � Conhactor License No. Masfer Lic. No. (Phnt Eleci. Only�
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Mailing Address (�ortracror or Owner P�rforming Installation) �j / �� �`�����
C.i' � 6� ��r �
Authoriz Si nafure (Conhacfor or Own erformi g Installafion) Phone NO�� �
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EB-0000 A-11 8/96 S BOARD COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY