P - 80830' REQUEST FOR ELECTRICAL INSPECTION
8������ � Minnesota State Board of Electricity
t 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 ihis request. Enter remarks in this space and on the back of the white copy only.
Calculate Inspection Fee - This Inspection Request will nof be accepted wilhout the correct 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 oN�Y TOTAL s�
Sign/Oudine Ltg. Xfmr. ��
Alarm/Remote Confrol
Swimmiog Pool
I hereb certi that I ins the elechical installafion described herein on the dades stated
Irrigation Boom RougMn p�
$pecial Inspecti
Investigative Fee — 2 �—oo
THIS INSTALLATION MAY BE ORDERED pISCONNECTED IF NOT COMPLETED WITHIN 18 MOI�THS.
OFFICE USE ONLY This request void 18 months from validafion date printed in this box.
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PLEASE PRINT OR TYPE
Requost Date Rough-in inspection required2 ❑ Yes No Inspec.7ion O�er Than RougMn: Ready Now ❑ Will Call
�6 � (You must call fhe inspecfor when ready) Da�e Ready:
I, �licensed conhactor ❑ owner hereby requesf inspection of the above electrical work at:
Job Addreu �Sheet, Box, or Ro�te No.) Ciry Zip Code
S�� "/ct�o ri tor, �v- Fr�a�l
Secfion No. Township Name or No. Range No. Fire No. Counly
h
u nf Phone No.
OY� wQ�iGh �t7'I�+�r �5�"7�--/D y.5�
Power Supplier � Address
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Elechical Conkacfor �Company Name) Conhacfor License No. Master Lic. No. (Planf Elecf. Only)
T's �[.��T�'-� C �'�o iY
Mailing Address (Conhactor a Owner Performing Installafion)
�70�-0 �-v�-S'7 �� v , �j , .�539�
Aufhorized Si naNre (Confractor or Owner rforming Installafion) �,� 4 9� Phone No.
(01-Y4//
E 1 A-1 1 8/96 STA OA COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY