P - 84724REQUEST FOR ELECTRICAL INSPECTION
4���, Q Q/� Minnesota State Board of Electricity
u u�t 1821 University Ave., Rm. S-128, St. Paul, MN 55104
Phone(612)642-0800
Home Duplex Apt. Bidq. Other: New Addn
Commercial dusfrial Farm Remod
Air Cond. Htg. Equip. Water Hh. 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 while copy only.
.�oG C �77- 7�F�5
Calculate Inspection Fee - This Inspection Request will not be accepted without �he correct fee:
Other Fee # Service Entrance Size Fee # Circuits/Feeders Fee
Mobile Home Park $tall 0 to 200 Amps 0 to 100 Amps
Sheet Ltg./TraFfic $ig. Above 200 Am s Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY TOTi � I
$ign/Oudine Lig. Xfmr.
Alarm/Remote Confrol
Swimming Pool
I hereb certi that I ins ted the elecrrical installation dexribed herein on the dares stated
Irrigation Boom RouoMn Dare
rmai � 3-� �� I� 4�l C'Z
Investigative
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFlCE USE ONLY This requesf void 18 months 6om validation dafe prinied in this box.
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Requesf Date RougMin inspeclion required? ❑ Yes o Inspecfio� O�er 1}�an RougMn: ❑ Ready Now ill Call
7�� f �� (You must call the inspecfor when ready) Date Ready:
I, ❑ licensed conhoctor ❑ owner hereby request inspection of the above elecfrical work at:
Job Addreu (Sheef, Box, or Route No.� City � Zip Code
t� �a.ne���ili� 5� � E �rt��� 554��a
Seclion No. Township Name or No. Range No. Fire No. Counly
Occupant
n�
Power
Phone No.
7�s-��c��
Electrical C.qphatqr��•a���ar��+ E���� 'NC, Conkacfor License No. Master Lic. No.
d{.A117c n � v
135fl2 CENTFWL AVE. _N.E. � � [ "]a (p
Addreu
r erfo mi gThstallafion, 5 2,� � Phone No.
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STATE BOARD COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY