P - 829221
6a�-788 �
RE(�UEST FOR ELECTRICAL INSPECTION
Minnesota State Board of Electricity ^ —
1821 University Ave., Rm. S-128, St. Paul, MN 55104
Phone (612) 642-0800 '�'
Home Duplex Apt. Bldg. Other: New Ac
Commercial Industrial Farm Remod e
Air Cond. Htg. Equip. Water Htr. 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 the white copy only.
,��sT@l/ �Ve� ���C� �'ocl�r.��a �� �a�e
pr.r�n�/c's l�ah�e� iQ� .�e�ir°
Cqlculate Inspection Fee - This Inspection Request will noP be accepted without ihe correct fee:
Other Fee # Service Eotran ize Fee # Circuits/Feeders Fee
Mobile Home Park Stall 0 to 00 Amps / � 0 0 to 100 Amps
Street Ltg./Traffic Sig. Above 200 Am s Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY T AL[�
C�.,.,/Cl��+lioolr., XF�,� �Ji�O
Alarm/Remote Control
Swimming Pool I hereb certi fhat I ins the elechical installafion described herein on the dates sroted
Irriqation Boom R���{.io Dafe
Investigative fe � Final /�"� +�������I �arer�� q.�
` CO ^�O
THIS II�STALLATION MAY E ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This request void 18 months from validafion date prinfed in this box.
����I�II�I����l��ill�l�lll�i�������������ll� i �� .�
* 0 6 4 2 7 8 8 4* 3���
PLEASE PRINT OR TYPE
Request Date Rough-in inspection required? ❑ Yes o Inspection Other Than RouBh-In: eady Now ❑ Will Call
�-- �Z ��� �You must call the inspedor when ready) Date Ready �� .r`�
I, icensed contractor ❑ owner hereby request inspection of the above electrical work at:
Job Address �Sfreef, Box, or Roufe No.) Ci / Zip Code
a ST,�e�T �d e
Section No. Township me or Nor � Range No. Fire No. � ounfy _
������
C>e� =S ?"/�a H �
Power Supplier �
Elechjcal Co actor (Company Name�
s��e l;�ec
Mailing Address (Con acror or Owner PerFc
�'�o� Ce�T/�I�l �
Authorize1l $j8nafure (Conhacfor or pwner
. � o�'R
:� �'- Y�'i3
c
�Q<G �G G�adi Z
�g Insmllation � �
se �✓, �� Sk�Tr%� S,o.��
, �A�
STATE BOARD COPY
; b� 6� - �
ON BACK OF YELLOW COPY
u�. No.
�°�rks"sy3.
No.
� --SozS-