P - 83138RE(�UEST FOR ELECTRICAL INSPECTION
J� J- 211 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 Indushial Farm Remod Re air
Air Cond. Htg. Equip. Water Htr. Load Mgmt. Other:
Dryer Range Elec. Heat Temp. Service
"X° above Ihe work covered by rs request. Enter remarks in this space and on the back of the white copy only.
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Cakulate Inspection Fee - This Inspecfion Request will not be accepted witf�out tf�e correct fee:
Other Fee # Service EMrance 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 on��v TOTAL �
Sign/Oudine Ltg. Xfmr.
Alarm/Remote Confrol
Swimming Pool
I h certi thaf I in fhe elechical installafion described herein on the dares staled
Irrigation Boom ' Ro�Mo
Speciallnspecti �^ ��
finol
Investigative Fee
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
� _ _ - — ----._.._��
OFRCE USE ONLY This request void 18 months hom validation date printed in this box.
II�IIIIIIIlOII�I �I�NIII(�M I • 3�� ��
I! I �11� � � 95�
* � 5 3 5 2 L L 7* PLEASE PRINT OR TYPE
R�� �O� R h-in ins tion r iredZ es �
/'� °U9 P� �W .� ❑ No Inspection Other ihan RougMn; ❑ Ready Now�Will CaN
'� �� �� �You must call the inspeclor when reody) Dute Ready;
I, licensed contractor ❑ owner hereby request inspection of the above electrical work at:
Job F�ddreu (Street. Box, or Ra�Ae No.� Cib Zp Code
167� � r ��/� �s"s 3z
Section No. 7ownship Nome w No. Range No. Fire o. Co fy
3o a �o�,�
�NP°p� Phone No.
P�. S� ��� n�' F� e. r -�3
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�xn f.4 �;f nr � h t'v,:f iov�
Elecirical hacfor ( mpany Name) � � Conhacto� License No. Muster lic, No. �Planf Elecl. Only)
� �.' £ � .z- c.,�9- c� 3 0
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Moiling Address �Contractor or p�y�er Performi Inslallolion) _-
� F ��. Gt/ o� �� /�� �; s' �
A�Ahwized Signah�re (Co er Performing Installation) Phone No.
� �'= � � 36 3,
E&OOOOIA-11 8/96 �p� g�ppD COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY