P - 83363REQUEST FOR ELECTRICAL INSPECTION
5`�'r� �, C� O 9 Minnesota State Board of Electriciry
.,� J O i821 University Ave., Rm. S-128, St. Paul, MN 55104
, Phone (612)642-0 0
ome Duplex Apt. Bldg. Other: C��' _ New Addn
Commercial Indushial Farm
S� -�X� Remod Re air
Air Cond. Htg. Equip. Water Hfr. 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 whife copy only.
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Calculate Inspeciion Fee - This Inspection Request will not be occe
Other Fee # Service Entrance Size
Mobile Home Park Stall 0 to 200 Amps
Sheet Ltg./Traffic Sig. Above 200 Am
Tronsformer/Generator INSPECTOR'S USE ONLY
$ipn/Oudine Ltq. Xfmr. /tL� �
� Pool
Boom
fhof I insuecFed the
without the correct f�e:
F # Circuits/Feeders
0 to 100 Amps
Above 100 A�
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on �he dares swled
Fee
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Investigative F F��� C�� I��Q�/nl �-
THIS iNSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 ONTHS.
OFFlCE U8E ONLY This request void 18 months from validation duie prinTed in this box:
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* 0 5 3 2 5 3 8(a �: PLEASE PRINT OR TYPE
Reqqe;f � �� Rough+n inspeclion required$ es No Inspection O�er Than RougMn: ❑ Ready Now �II Call
/! (You must wll ihe inspeclw when ready) Dale Ready:
I, licensed contractor owner hereby request inspecfion oF the above elecirical work at:
.bb Addreu (Street, Box, or Rou�e No.� Ciy Zi Code
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Seclion No. Townshi �� No. Ranyg No. Fire No. wn
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Eleclrical Conhacror (Compan Name) � Contracfor license No. Masfer lic. No. �Wanf Eleel. Only)
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Muiling Address (Conhacpor w Owner Performing Installalion�
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Authori Signature �Conh �grf�rforming �nslallatio 2 6 Phone I��r�
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&OOOOIhI l 8/96 ' y�ATE BOARD COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY