P - 80264� RE(�UEST FOR ELECTRICAL INSPECTION �
C�("i �, (a /I � � Minnesota State Board of Electricity
�� ��j (7 �f 1821 University Ave., Rm. S-128, St. Paul, MN 55104
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Phone (612) 642-0800 `�°'
Home Duplex Apt. Bldg. Other: New Addn
Commercia{ Industrial Farm Remod Re air
Air Cond. Hig. Equip. Water Htr. Load Mgmt. Other:
Dryer Range Elec. Heat Temp. Service
"X" above the work covered by this request. Enter remarks in � is space and on the back of the white copy only.
�o�V' S�'�o� �Dfc�`�
Calculate Inspection Fee - This Inspection Request will not be accepfed wiihout the correct fee:
Other fee # Service Entrance Size Fee # Circuits/Feeders Fee
Mobile Home Pork Stall 0 to 200 Amps 0 to 100 Amps
Street Ltg./Traffic $ig. Above 200 Am s Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY TOTA4`„�t
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SignJOudine ttg. Xfmr.
Alarm/Remote Control � !�� ���� �,.� �� �, S�`
Swimming Pool
I hereb certi that I ins the elechical installation described herein on the dates stated
Irrigation Boom Ro�gl,-io - Dare I+�►7 _ Q4s
Special Insp �
Fiou� oare �7 �3 .,.O.a
Investigative Fe ��
THI$ INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFlCE USE ONLY This requesf void 18 months from validation daTe prinfed in fhis box.
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* 0 6 8 0 8 4 0 6* °���
PLEASE PRINT OR TYPE
Request Date � Rou h-in ins �on r uired$ es
/�a''� g pecf eq ❑ No Inspeclion Other Than RougMn:
/.�-, (./V �You must call the inspector when ready) Date Ready:
!
I, � licensed contractor ❑ owner hereby request inspection of the above electrical work at:
106 Addrest �Sheet, Boz, or Roote No.� City
�7 �r�sfF►� -f-, �r��iF
Section No. Townshio Name or Na RanAe No. Fire No. C unry
Occupanf %
�l�G � ,�v�d �YSC7 Y\
(Conhocfor or
Signafure
�0 �
Phone No.
� �� i
Ready Now i�Will Call
Zip Code
,s �Y3
'ame) Conhactor License No. Master Lic. No. �Plant Elect. Only)
��c�r .� �� c . r� da �3 0
�wner Performing Insiallafion) /
o v d- �f/ao �j v r %l/ d���o2�'
or Owner Performing Installafion) Phone No.
,� � 152 /-�36-3�a�
STATE BOARD COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY �--�--