P - 83459RE(�UEST FOR ELECTRICAL INSPECTION
C���� 11 � Minnesota State Board of Electricity
J `f 1821 University Ave., Rm. S-128, St. Paul, MN 55104
� Phone (612) 642-0 0 �
Home Duplex Apt. Bldg. Other: New
Commercial {ndustrial Farm � ` Remod
Air Cond. Htg. Equip. Water Hh. Load Mgmt. Other:
Dryer Ronge 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
Calculafe Inspection Fee - This Inspection Requesi will not be accepted wifhout the correcF fee:
Other Fee # Service Entrance Size Fee # Circuits/Feeders
Mobile Home Park Stall 0 to 200 Amps 0 to 100 Amps
Sfreet Ltg./Traffic Sig. Above 200 Am s Above 100 Amp:
Transformer/Generator INSPECTOR'S USE ONLY M1� F 7^Q g TOTAL
SignjOutline Ltg. Xfmr. ��� o
Alarm/Remote ConKol
Swimming Pool
I he ceAi t1w11 in the eleclrical inslallalion described herein on the dales st
Irriaation Boom R,,,�,�,.�„ ..+. /_ Dar�...,
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THIS INSTALLATION MAY BE ORDEREO DISCONNECTED IF NOT COMPLETED WITHIN 18"MONTHS.
OFRCE ll� ONLY This roquesl void 18 months 6om validafion date printed in this box.
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Request Date Rougftin inspeciion required$ Yes ❑ No Inspecfion Olher Than RougMn: � Ready Now �II Call
�� '� �-- y,� (You must call the inspector when ready) Date Ready:
I, ❑ licensed conhactor` t�owner hereby request inspection of the above electrical work at:
1ob Address �Street, Box, w Route No.) City Zip Code
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$ecfion No. Township Name or No. Raige No. Fire No. Coun �
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Power Supplier Addreu
llJSl� l�1 PLS , �Vl��iH 1�� �/�S�a.�1
Elecfrical Contracbr (Company Name) Conkactor Lice�se No. Master lic. No. (Plant Elect. OnlyJ
U UJ,vE�
Mailing Addreu �Contracb� or Ovmer Performing Insbllation)
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Authoriz nature (Contracror or Own Performin� Insrollation) .�_� Phone No.
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��,&00001 A-1 1 8/96 �p� g�ppD CO - SEE INSiRUCTIONS ON BACK OF YELLOW COPY