P - 79844��2°343 �
REQUEST FOR ELECTRICAL INSPECTION
Minnesota State Board of Electricity
1821 University Ave., Rm. S-128, St. Paul, MN 55104
Phone (612) 642-08
� Home Duplex Apt. Bldg. Other: � � New
Commerciql Industrial Farm Remod
Air Cond. Htg. Equip. Water Htr. Load Mgmt. Other:
Dryer Range Elec. Heat Temp. Service
"X" above the work covered by ►his request. Enier remarks in this space and on
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of the white copy only.
Calcvlate Inspection Fee - This Inspection Request will not e accepfed without the correct fee:
Other Fee # Service Ent Size Fee # Circuits/Feeders Fee
Mobile Home Park Stall 0 to 00 A s 0 to 100 Amps
Sfreet Ltg./Traffic Sig. Above 200 Am s Above 100 Amps
Transformer/Generator tNSPECTOR'S USE ONIY TOTAL
Sign/Oudine Ltg. X M ' � .5�
Alarm/Remote Confro �
Swimming Pool
I hereb certi that I ins the el ical insmllation described herein on the dates stated
Irrigation Boom RougMn �� � J���
Special Inspecfion
Final Da `o
Investigative Fee d�--
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This request void 18 months from validation date printed in this box.
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PLEASE PRINT OR TYPE
Request Date Rou h-in ins ection re uired?
g p q ❑ Yes No Inspection Other Than RougMn: �❑ Ready Now Will Call
� a J� O� �You must call the inspector when ready) Date Reody:
I, ❑ licensed contractor owner hereby request inspection of the above electrical work at:
hb Addreu �Streer, Box, or Route No.� Ciy Zip Code
S�yy � �' 3Y
Secfion No. Township Name or No. Range No. Fire No. ounty
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o«upa�r —�
Ja,�- �.m�
Power Supplier
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Electrical Conhador (CompanY Nomel
. , �Q� Phone No.
�,.. �63 � S7.z -� SP'i
Addre
/�LS �l.�ort�� �t v'
Conhacfor License No. Master lic. No. IPlant Elecf.
dress �Conhactor or Owner P� orming Installation)
Syf� �
Signafure �Conk or Owner Per(orming} � fallo
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Phone No.
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STATE BOARD COPY - SEE INSTAUCTIONS ON BACK OF YELLOW COPY