P - 82919� REQUEST FOR ELECTRICAL INSPECTION
� � � � � /� /� � Minnesota SCate Board of Electricity
i� �t 1821 University Ave., Rm. S-128, St. Paul, MN 55104
Phone(612) 642-0800
Home Duplex Apt. Bldg. Other: New Addn
Commercial Industrial Farm Remod Re air
Air Cor�j Htg. Equip. Water Htr. Load Mgmt. Other:
Dryer Range Elec. Heat Temp. Service
"X" above the work covered by this request. Enter remarks in this space and on ►he back of the white copy only.
Calculate Inspec►ion Fee - This Inspecfion Reques► will not be accepted withoui the correct fee:
Other Fee # Service Entrance Size Fee # Circuits/Feeders Fee
Mobile Home Park Stall 0 to 200 Amps 0 to 100 Amps
Sfreet Ltg./TraFfic Sig. Above 200 Am s Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY TO,T�A�L�y
Sign/Outline Ltg. Xfmr. }�•� �J��
AlarmJRemote Control
Swimming Pool
I hereb certi that I ins the elecfrical installafion described herein on fhe dates stated
Irrigation Boom Rough-In Date
Speciallnsp �.
Final � te
Investigative ee
THIS INSTALLATION MAY BE ORDERED DI NNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
� ---- —
� s _ OFFICE USE ONLY This request void 18 months from validotion dale printed in ihis box.
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PLEASE PRINT UR TYPE
Request Date Rou h-in ins tion r uired?
9 P� eq ❑ Yes No Inspection Other Than RougMn: Ready Now � Will Call
.� �3 �9� (Yo� must call the inspecror when ready) Date Ready: ��! �
I, �licensed contractor ❑ owner hereby request inspection of the above electrical work at:
1ob Address (Sfreet, Box, or Route No.) City Zip Code
!i73/ -1�'l�tGiQ[ so h 57"NE �r i �le
Seclion No. Township Name or No. Range No. Fire No. County
k.d �
Occupant Phone No.
3a1�� n 1��� sr�-y.�d
Power Supplier Address
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Eleclrical Conhacror �Company Name) Contractor License No. Master Lic. Na �Plant Elect. Only)
2'Ts Ec��7",2� C�+o� y
Mailing Address (Contractor w Owner Performing Installation) �
�7.�0 � �f.4 v� Nw ��.,►+►n . h. ss3 98"
Authorized Sig�hacfor or Own Perfortning Installafi ��� Phone No.
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E OlA-11 8/96 � • STA BO COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY