P - 81621REQUEST FOR ELECTRICAL INSPECTION
8 f1`L _ 2 3 9� Minnesota State Board of Electricity '3
+� 1821 University Ave. Rm. S-128, St. Paul, MN 55104 =
� Phone (612) 642- 00 "�
Home Duplex Apt. Bidg. Other: O S' � New Addn
Commercial Industrial Farm �� � Remod Re air
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 �he white copy only.
Calculote Inspection Fee - This Inspection Request will not be accepted wi►hout the correct fee:
Other Fee # Service Entrance Size Fee # Circuits/Feeders Fee
Mobile Home Park Stali 0 to 200 Amps 0 to 100 Amps
Street Ltg./Traffic Sig. Above 200 Am s Above 100 Amps
Transformer/Generator INSPECTOR'S US,E ONL�J TOTA
Sign/Outline Ltg. Xfmr. G-o�w Le�C ��'F!4J/ �/�O
Alarm/Remote Control
Swimming Poo)
I hereb certi that 1 ins the el ' al installafion described herein on the dates stated
Irrigation Boom RougMn Dare
Special Inspecti ����� �
Investigative Fee F��� - ' �
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY Thia raqueat void 18 monfhs from validation date printed in this box.
� �li� �I I�I �� �!� �� ii� �1 ��� �i ��� �� M �e� 7��� •
�(�linl
* 0 8 0 2 2 3 9 4* /�� 5(�
PLEASE PRINT OR TYPE
Requesf Dafe Ro h-in ins on uired? Yes
n ug pedi req ❑ No Inspection Other Than RougMn: ❑ Ready Now Will Call
-���/� (/ O (`fou musf call the inspector when ready) Dafe Ready: � �
I, ❑ licensed conhactor �owner hereby request inspection of the above elecfrical work at:
Job Address (Street, Box, or Roufe No.) Ciry Zip Code
�i3�'d ✓/kC�KSD/Y �T. /1l � ,2�,?�t.� �S 3 �.
Secfion No. Township Name or No. Range No. Fire No. County �
�30 � Nd,Kr4
Occu,p�as Phone No. � � �
,�ec � L`D/v�ri � C� u �tl 17.�-�q-c f� "7� 3-�5�/ -/�8-�
Power Supplier � � Address �. �. �
S /� 1-S �o � �>Y,
Elechical Conkactor (Company Name) Contracror License No. Master Lic. No. (Plant Elect. Only)
� GtJ�I � � 8 5 $ �
Mailing Address �Conhacror or Owner Performing Installation)
S�r-�s
Aufhorizea Signature (Co tor or er Performing Installation) Phone No.
������� 63 S71-l4�gd
EB-00001 A-1 1 8/9 STATE BOARD COPY - SEE INSTRUCiIONS ON BACK OF YELLOW COPY