P - 82811RE(�UEST FOR ELECTRICAL INSPECTION
6��} ���� � Minnesota State Board of Electricity
>, (� 1821 University Ave., Rm. S-128, St. Paul, MN 55104 �'.
� Phone(612)642-0800
Home Duplex Apt. Bidg. Other: New Addn
ommerc' I Industrial Farm Remod Re air
Air Htg. Equip. Water Hfr. Load Mgmt. Other:
Dryer Range Elec. Heat Temp. Service
"X" above the work covered by this request. Enter remarks in this space and on the back of Fhe white copy only.
� (c,.�,,.� c�.w C�v�'.�;�A-c.vv<<-U''
Calculate Inspection Fee - This Inspection Request will not be accepted without the correct fee:
Other Fee # Service Entrance Size Fee # Circuits/Feeders Fee
Mobile Home Park Stall 0 to 200 Amps 0 to 100 Amps
Street Ltg./Traffic Sig. Above 200 Am s Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY TOT�L f,r�
Sign/Outline Ltg. Xfinr. 6 7�
Alarm/Remote Control
Swimming Pool
I hereb certi ihaf I ins ted the eleclrical insrollotion dexribad herein on the dates stafed
Irrigation Boom RougMn Dare -
Special Inspecti
Final DateZ _ /� _ � �
Investigative Fee
THIS INSTALLATION MAY BE ORDERED DISCONNEGTED IF NOT COMPLETED WITHIN 18 MONTHS.
_ OFFICE USE ONIY This request void 18 monfhs from validation date printed in this box.
IIINIIIIINIIIIIIIII��llllll��lllm��l� s �s�
* 0 6 3 8 3 0 4 6* ��3
LEASE PRINT OR TYPE
R vest fe Rough-in inspection tequired? ❑ Yes No Inspection Other Than RougMn: Ready Now � Will CaU
� `"'�, � (You must call fhe inspeclor when ready) Date Ready:
I, licensed contractor ❑ owner hereby request inspection of the above electrical work at:
Job dreu ISheet, Box, ar Roufe No.l Ci6r,� � Zip Code _ .
Range No. � Fire No.
Phone . �
onhacfor (Compan Name) � Co aclor License No. Masler Lic. No. �
� �'J9zj t C�1
dres � onhocfor or Owner Performin ns Ilofion) �
�
1 �
Signature �Conhactor Owner PerForming Installaiion� � J P ne No.
� /,, t� 1 �-jj -
1 1 8/96 STATE BOARD COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY