P - 81109REQUEST FOR ELECTRICAL INSPECTION us
8������ � 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
Commercial Industrial farm Remod
Air Cond. Htg. Equip. Water Htr. Load Mgmt. Other:
Dryer Range Elec. Heat Temp. Service
"X" above ►he work covered by this request. Enier remarks in this space and on the back of the white copy
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Calculote Inspection Fee - This inspection Request will not be accepted without the correct fee:
Other Fee # Service Entrance Size Fee # CircuitsJFeeders Fee
Mobile Home Park Stall 0 to 200 Amps , 0 to 100 Amps
Sfreet Ltg./Traffic Sig. Above 200 Amps Above 100 Amps
Transformer�Generator INSPECTOR'S USE ONLY TO
SignjOutline Ltg. Xfmr.
Alarm/Remote Control
Swimming Pool
I hereb certi ihaf I ins the eleclrical install `' on the dates sfafed
_ Irrigation Boom RougMn o
Special Inspection '��f"
Fiml
Investigative Fee �,
THIS ItdSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This requesf wid 18 months from validafion dafe prinfed in fhis box.
� II� II �II II III II III I� I�I �I �I� (II I� �I I I�� "' � � Y� U� e�
� 0 8 D 2 1 7 1 9 * �' '�� �� ��S
PLEASE PRINT OR TYPE �`�'
Req,est Date Roo h-in ins n r uired$ ❑ Yes
+' 0� g peclio eq ❑ No Inspeclion Other Than Ro�gf�ln: ❑ Ready Now ❑ Will Call
� (You must call the inspecfor when ready) Date Ready:
I, ❑ licensed confractor � owner hereby request inspection of the above e{ectrical work ot:
Job Address (Skeef, Box, or Route No.) City Zip Code
1e`11A � 1�1lY�isrm S�finC . �rr�I,p.f '��'�[3 �.
Nwiling Address �Conhactor or
or No. - � Range No. � Fire No.
Phone No.
Lt ►2��s� I -�393
tolte i �a��sov� 5t vl�
or Own Performing Insfallafion� Phone No.
� CA��� C4 G?'�5�`ll
STATE BOARD COPY - SEE INSTRUC'IIONS ON BACK OF YELLOW COPY