P - 820448�2-�.84 �
Commercial
Air Cond.
Dryer
"X" above the u
REQUEST FOR ELECTRICAL INSPECTION �
Minnesota State Board of Electricity 3
1821 Uni�ersity Ave., Rm. S-128, St. Paul, MN 55104
Phone (612) 642-0804,,. _ _ �� '
Industrial Farm r�(.� +3{i•
Htg. Equip. Water Htr. Load Mgmt. Other:
Range Elec. Heat Temp. Service
overed by this request. Enter remarks in this space and on
New
Remod
copy only.
Calculate Inspecrion Fee - This lnspectron Requesi wi!! 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 Lt ./Traffic Sig. Above 200 Am s Above 100 Amps
Transformer/Generator INSPECTOR�s use od�v TOTAL �g �
Sign/Outline Ltg. Xfmr. �jr�g C Q�C� �. 2�.� �'° `
Alarm/Remote Control ^r� z�-FS'�
Swimming Pool �` Z�`r 7 7�� —'� `t'°�'
I hereb certi that I ins fed ihe e echical insta ation described herein on the dates stafed
Irrigatibn Bo "' RougMn �r�
Special Inspection
Investigative Fee F��� ��' �G —� �
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This requesf void 18 months 6om validation date printed in this box.
I���II�I�III����I���������I��I����I�II�� • a� "�
* 0$ 0 2 Z 8 4 2* 1���
P E PRINT OR TYPE
Requesf Dafe Rough-in inspeclion required$ ❑ Yes No Inspeclion Olher Than Rough-In: Ready Now �❑ Will Call
��� C. � Qzi' (You must call the inspecfor when r�dy) pute Ready:
I, ❑ licensed contractor�ywner hereby request inspection of the above electrical work at:
Job Address �Streef, Box, or Route No.� City � Zip Code
�"'7� � a ! -f� <� �/1-L �
Section No. Township Name or No. Range No. Fire No. Coun
%i-<�a 6C,4
Occupanf
�A-�-l� �S
Power Supplier
� �. ��
Elechical Conhactor (Company Na
�_�
Mailing Address �Con_h�acror or Owner
�, � _t� t ,�.r
J ��
Installation)
Phone No.
License No.
or Owner Perfor ' g Installafion� Phone No.
.��� r`a-z$�-� 7;
STATE BOARD COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY