P - 83502653=�57 .6
f'
REQUEST FOR ELECTRICAL INSPECTION �.
Minnesota State Board of Electricity
1821 University Ave., Rm. S-128, St. Paul, MN 55104 �
Phone(612)642-0800
Other: New Addn
Commercial Industrial Farm Remod Re ir !
Air Cond. Htg. Equip. Water Hfr. Load Mgmt. Other.
Dryer Range Elec. Heat Temp. Service
"X" above ihe work covered by this request. Enter remarks in this space and on the back of the white copy only. '
�I�P�A-� �,2UGC� ,o�n�,�� �i�I� T b �`�
Calculate Inspection Fee - Ihis Inspection Request will nof be accepted withoui the correct fee:
Other Fee # Service Entrance 'ze Fee # Circuits/Feeders Fee
Mobile Home Park Stall to 00 Amps 0 to 100 Amps
Street Ltg./Traffic Sig. Abo e 200 Am s Above 100 Amps
Transformer/Generator INSPECTOR•s use oN�v TOTAL ��
Sign/Outline Ltg. Xfmr. 8
Alarm/Remote Control
Swimming Pool
I hereb certi that I ins ected the elechical insmllation deuribed herein on the dates stated
Irrigation Boom RougFfln �r�
Special Insp 'o
Final Date�;
Investigative -.2� p
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
� OFFICE USE ONLY This request void 18 months from validation date prinfed in this box.
� IIIIIIIIiIIIIIIIIIIIII���illIIIIIIIIIIIIIIII(I�I • �/3G ��
* 0 6 5 3 6 5 7 7* 7�`3�
PLEASE PRINT OR TYPE
Requesf Dafe Rough-in inspection required2 ❑ Yes �No Inspection Other Than RougFfln: �.Ready Now � Will Call
J� �� (You must call the inspector when ready) Dafe Ready:
I, ,�1icensed contractor ❑ owner hereby request inspection of the above electrical work at:
Job Address �Sheet, Box, or Route No.� Ciy Zip Code
53 �� �1� .t� � �i�Gp� � �
Section No. Township Name or No. Range No. Fire No. C unly
�I r ��
Occupanf / Phone No.
l��i�I'� 6 � C.. � � � �
Power Supplier Address
�
Elecfrical Contractor (Company Name) Confractor License No. Master Lic. No. (Plant Elect. Only)
i'il � ��t.C'�'Yi , S \ _ C �
Mailing Address (Conhactor or Owner Performing Instal ation)
�. `' l H�.0 C� � �ii � �M �;`�� 3a-
Author' ed Signafure (Co r or Owner Perfor Insfallafion� � j, ('� (j �" Phone No.
�j ' ' D �.a c.l ) � 7�-7o�ip
E&00001 A-11 8/96 STATE BOARD COPY - SEE INSTRUCTIONS ON BACK OF VELLOW COPY