P - 83288�
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REQUEST FOR ELECTRICAL INSPECTION
Minnesota State Board of Electricity �-
1821 University Ave., Rm. S-128, St, Paul, MN 55104
Phone(612)642-0800
New
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Commercial Industrial Farm Remod e
Air Cond. Htg. Equip. Water Htr. Load Mgmt. Other:
Dryer Range Elec. Heat Temp. Service
"X" above the work covered by this request. Enier remarks in this space and on the back of the white copy only.
��l��e se�e��c,e��s �� �de1`e�e Sa�k�T'a H� w���,S -.
Ti�ee �el� o vt cr��/��s
Calculate Inspection Fee - This Inspection Request will not be accepfed withouf the correct fee:
Other Fee # Service Entrance 'ze Fee # Circuits/Feeders Fee
Mobile Home Park Stall 0 to �00 Amps ' pa 0 to 100 Amps
Street Ltg./Traffic Sig. Above 200 Amps Above 100 Amps
T�.,.,<F���.,o./ro.,o�.,t.,� iusoFCrno�s nsF nui v T L
Sign/Outline Lig. Xfmr.
Alarm/Remote Control
Swimming Pool
Irriaation Boom
I herebvi certifv that I
Final
Investigative fee
THIS INSTALLATlON MAY BE ORDERED
S, .�Q
the elechical installafion described herein on the dares stated
Date
�% � ��� G
IF NOT COMPLETED THIN 18 MONTHS.
OFRCE USE ONLY This requesf wid 18 months from validation date printed in this box.
I�IIIIIIIII�IIiNII������l�l� +r ����
* 0 6 8 2 5 9 8 8* ��'�
PLEASE PRINT OR TYPE
Requesf Date Rou Itin ins ion r uired?
g petf eq ❑ Yes No Inspecfion Other Than Roughan: eady Now ❑ Will Call
f Q� `�� (You must call fhe inspecfor when ready) Date Readyl6 .-6 ^�i �
I, �ensed contractor ❑ owner hereby request inspection ��he above electrical work at:
Job Addreu (Sheet, Box, or Route .) � Zip Code
S�' � 7 e �e Sa �t .S?'N �" �`�'� �le
Sectio� No. Township Name or No. Range No. Fire No. Couqry ,.
Occupanf /
��"Cc.RV G��S
Power Suppl r �
�/S� �
�E hical Con octor (Company Name�
s��e� ��ec��c ,��c_
Mailing Address (Conhacror or Owner PerForming Insfallafion)
8'•?olCep�if�ti�ie tU �SriTtl�
Auf ' aNre �Coohactor or Owner Performin Ins Ilafio
,
8-0 001 A 8/96 STATE BOARD CO
No.
�ice�u No.
� �Pa`' La.`t'C /�/�i� SS 32
Phone No.
2 555 6�.�. ��'o-s2s'
INSTRUCTIONS ON BACK OF YELLOW COPY