P - 82679.r-- —
REQUEST FOR ELECTRICAL INSPECTION ��
4`t,2 - 9 5 4 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 RemocJ Re air
Air Cond. Htg. Equip. Water Htr. Load Mgmt. pther:
Dryer Range Elec. Heat Temp. Service
"X" above the work�cov�d by fhis request. Enter remarks in this space and on the back of the whiie copy only.
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Calculaie Inspection Fee - This Inspection Request will not be accepied 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 TOTA/L� (��'
Sign/Oudine Ltg. Xfinr. �� w�� 7 V L� �
Alarm/Remote Conhol �
Swimming Pool
I hereb certi tFwf I ins the elechical insfallafion described herein on the dafes sMled
Irrigation Boom RougMn
Special Inspection � Z � � �
Investigative Fee Finol ° Z � 27 F�
THIS INSTALLATION MAY BE ORDERED DISC ECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE l�E ONLY ihis roq�sf void 18 monfhs from validafion dafe printed in this box.
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* � 4 4 2 9 5 4 4�k PLEASE PRINT OR TYPE
Requesf Dafe R h-in ins on r uired$ � Yes
�� l L���� oug pecfi eq ❑ No Inspection Olher Than RougMn: Ready Now ❑�II Call
�`/ou must call fhe inspector whe ready) Dafe Ready:
I, �] licensed contractor ❑ owner hereby request inspection of the above electrical work at:
lob Addreu (Street. Bo�c, or Route No.� City Zip Code
, o� o L,,ri'J �'� Y r/L� � L e �'�'
Secfion No. Township Name a No. Range No. Fire No. Couny� �
0
Occupant �� Phone No.
Go �� y�'� n n. L' N1 A�c e�4 S? �
Power $upplie� Address
� j�
Electrical Confractor (Company Name) . Conhactor License No. Master Lic. No. (Plant Elecl. Only�
� �� E—r2 � 7'� � c���` c► � Q�' �
Maili ddress �Conkactor or Owner Performing Installafion
�- � Z � � � � 1-.�. �^-t S^�7� �
Authori ig re ( or or Owner Performing lnsfallation) P{ane N
�.� �}�T o�s
E A-11 S/96 STATE BOARD COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY