P - 83976REGIUEST FOR ELECTRICAL INSPECTION —
51�� � V� J � Minnesota State Board of Electricity
1821 University Ave., Rm. S-128, St. Paul, MN 55104
• Phone (612)642-0800
Home Duplex Apt. Bldg. Other: New Addn
Commercial Industrial Farm Remod Re air
Air C Htg. Equip. Water Htr. Load Mgmt. Orher:
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 white copy only.
Calculate Inspection Fee - This Inspection Request will not be accepted without the correct fee:
Other Fee # Service Entrance Size Fee # Circuits/Feeders Fee
Mobile Home Park Stall 0 to 200 Amps 0 to 100 Amps
Street Ltg./Traffic Sig. Above 200 Am s Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY T I� �
$ign/Outline Ltg. Xfmr. �
Aiarm/Remote Control .
Swimming Pool
I hereb certi that I ins ted fhe elecirical installafion described herein on fhe dates stafed
Irrigation Boo Rough-In Dafe
Speciallnspec k '
Final �� �
Investigative Fee - �'
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This request void 18 months from validation dafe prinfed in ihis box.
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Requesi Date ,�� Rough-in inspection required? ❑ Yes No Inspection Ofher Than Rough-In: Ready Now ❑ Will Call
(You musf call the inspector when ready) Date Ready:
I, licensed conhactor ❑ owner hereby request inspection of the above electrical+Nork at:
Job Addr ss (Sh f,y8qx, or Ro .� � ' City � �C � Zip Cpde ,-� ...7
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Section No. Township Name or No. . Range No. Firc No. ' C
Occupant � i I �.,^,. _ PhoneNo.rr-`
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Power Supplier Address
Electrical Confmctor (Company Name) tra r License �No. Ma:ter Lic. No. (Plant Elecl. Only)
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Aufhorized Sign re (C fmci�pT- �����@5�� Insfallation� �/� �� . Phone No. '
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E&00 -11 8/ STATE BOARD COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY