P - 78643���-389 �
Home Duplex
Commercial Industri
Air Cond. Htg. Eq
Dryer Range
"X" above the work rnvPrPrl
REQUEST FOR ELECTRICAL INSPECTION -
Minnesota State Board of Electricity
1821 University Ave., Rm. S-128, St. Paul, MN 55104
Phone(612)642-08
Apt. Bldg. Other:� � �� New Addn
Farm / Remod Re air
Water Htr. Load Mgmt. Other:
Elec. Heat Temp. $ervice
request. Enter remarks in this space and on the back oi the whiie copy only.
Calculate Inspection Fee - This Inspedion Requesi will not be accepied wifhout ihe correct fee:
Other Fee # Service Entrance Size Fee # Circuits/Feeders Fee
Mobile Home Park Stall 0 to 200 Amps � 0 to 100 Amps a
Street Ltg./Traffic Sig. Above 200 Am s Above 100 Amps -
Transformer/Generator INSPECTOR'S USE ONLY ' �J TOTAL
Sign/Outline Ltg. Xfmr. 1i� 1G� �d L.�X
Alarm/Remote Conh V� � ,(�/
Swimming Pool "//'�
hereb certi thof I ins ed the electrical installafion described herein on the dates sfaled
Irrigation Boom RoigMn �
Special Inspection � �' � � ,3
Investigative Fee Final De�
C, "'_..2�.�
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
� OF'RCE I�E ONI.Y This request wid j,B'�monihs from validafion date printed in ihis box.
lilllllllillllllllllllllllitll '� �
IIIIINIII��II�i
* 0 8 0 2 3 8 9�� "�� �
�il �
PLEASE PRINT OR TYP �"f�
R��� � Rou h-in ins
( g peclion required2 es No Inspecfion O�er Tfwn RougMn: ❑ Ready Now ill Call
1' � 3� � 3 (You must call the inspecror wh ready� pa� R�Jy.
I, ❑ licensed confractor �owner hereby request inspection of the above electrical work at:
Job Address (Sheet, Box, or Roufe No.) City Zip Code �
0 o e►.� f. N� �G Fr,�� je s`s"Y3Z
Seclion No. Townghip Name or . Range No. Fire No. Counfy
3° 2� �4tio
Occupanr Phone No.
5���e�e � k►`� �a-k l.er ?�3 ?8"D -Oz E�'
Power Supplier
��l � I � ! 55 l , �(i e � e.
t v.
Eleclrical Conhactor (Company Name) � A��' Contractor License No. Master Lic. No. (Planf Elect. Only)
� t,(1 y� 2 il� � j ,
Mailing Address (Conhactor w Owner PerForming Installafion)
or ner Performing Insfallafion� P�e
�3
STATE B RD COP - SEE INSTRUCTIONS ON BACK OF YELLOW COPY