P - 84259��Z6-989 w¢
�
X Home- Du
Commercial Inc
Air Cond. Htc
Dryer Ra
"X" above the work cov
REQUEST FOR ELECTRICAL INSPECTION
Minnesota State Board of Electricity
1821 University Ave., Rm. S-128, St. Paul, MN 55104
Phone(612)642-0800
Farm
Water Htr. Load Mgmt. Other:
Elec. Heat Temp. Service �,� �l�y)
request. Enter remarks in this space and on the back of the
New
Remod
,;�.
:,�
� '.�` n
-11� :�
copy only.
Calculate Inspection Fee - This Inspeciion 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 Amps Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY TOTA'L
Sign/Outline Ltg. Xfmr. � J f��
Alarm/Remote Control
Swimming Pool
I hereb certi fhat I ins cted fhe elechical installation described herein on the dafes sfafed
Irrigation Boor{'] A!1 .�^a Rouah-In Dare
Investigative Fee ' �►�
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONT S.
OFFICE USE ONLY This request void 18 months from validation date printed in this box.
� ���� �� ��� �� ��� �� II� �i ��I11�1� �I� �� ��I �� u� � � �
III --a
* 0 4 2 6 9 8 9 0 * ���`� �`�
PLEASE PRINT OR TYPE
Requesf Date Rough-in inspection required? ❑ Yes No Inspecfion Ofher Than RougMn: ❑ Ready Now Will Call
I� j� ��% (You must call the inspector when ready� Date Ready:
,�,� �
I, 1� licensed contractor ❑ owner hereby request inspection of the above electrical work at:
Job Address �Street, Box, or Route No.) City Zip Code
`�ciS � S�-I- I� �, �--aq � � e SS�13�
Secfion No. Township Name o. Range No. Fire No. Coun � j
occopoor
Power
�oNx1��� ���,�e�,�
N� � Address
/�-t �p �Cff
Phone No.
�7�C� �'C�
-actor (Company Name� Contractor License No. Master Lic. No. (Plan
���✓ F1 �-��ic ���. C1��..3�Z�
ss �Conhactor or Ow er Performing Installation)
�- �s� � D� �' A �cl �v � l'�'��% ���0�
no �(Conhacror or Owner PerForming Insfallafion� ��('� �� Phone No.
� � } � �-� r d fa/ � �� �!�
8�96 STATE BOARD COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY