P - 84150� � 1
•
,
REQUEST FOR ELECTRICAL INSPECTION
Minnesota State Board of Electricity
1821 University Ave., Rm. S-128, St. Paul, MN 55104
;..._i
Phone (612) 642-0800 � _ „ �
ome Duplex Apt. Bldg. Other. ,�j C.' <�� �"` � �i
Commercial Industrial Farm ,(,%CJ ��
Air Cond. Htg. Equip. Water Htr. Load Mgmt. Other: _,
Dryer Range Elec. Heat Temp. Service
"X" above ►he work covered by this request. Enter remarks in this space and on the ba
Remod
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 Am s
Street Ltg./Traffic Sig. Above 200 Amps Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY TOTAL C
Sign/Outline Ltg. Xfmr. �j J�
Alarm/Remote Confrol ^� �� �--���1 �
Swimming Pool
I hereb certi that I ins fed the elecfrical installation described herein on fhe dafes sfated
Irrigation Boom Rougl�l � �O� �Ca Z�
Special Inspecti �3 : ' p
� � _, �,. Final � ( ��
Investigative Fee
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN�1 MONTHS
�-- -------
---- -------------
OFFlCE USE ONLY This requesf void 18 months from validafion dafe prinfed in this box.
�
I IIII II III II III �II II III II III II III II III I IIII
* � 5 3 2 4 8 �]� �K PLEASE PRINT OR TYPE �
Request Dafe Rough-in inspection required? Yes ❑ No Inspection Other Than Rough-In: ❑ Ready Now Will Call
— (You must call fhe inspecPOr when ready) Date Ready:
I, ❑ licensed contractor �'owner hereby request inspection of the above electrical work at:
Job Addren (Sheef, Box, or Route No.) City _ Zip Code
�' �p � - � /�. � .i 3
Section No. Township Name or No. Range No. Fire No. County
�� � � ����
Occupant
�
Power $ui
ic61 Conkacror �Company Name�
� � � �e�
ng Address �Conhacror or Owner
�
xized S nature IContrqFtor or O�
�
Address
Conha�
��5m��ar�o�)
ning Installafio
�� `�5���'
,RD COPY - SEE INSTRUCTIONS
Phone No.
S� 71 ����' �
/�er�. Ol v
License No. Masfer Lic. No. (Planf Elecf. 1
IPh��/ �7 �
OF YELLOW COPY