P - 83340REQUEST FOR ELECTRICAL INSPECTION
7�, ���� C � Minnesota State Board of Electricity a
V 1821 University Ave., Rm. S-128, St. Paui, MN 55104 �
` Phone (612) 642-0800
Home Duplex Apt. Bldg. Other: ('�v ew Addn
Commercial Industrial Farm Remod Re air
'-.Cond. Htg. Equip. Water Htr. Load Mgmt. Other:
D er Range Elec. Heat Temp. Service
"X" above the work covered by ihis r quest. Enter remarks in this space and on the back of ihe white copy only.
j/(%l�� �1%,f.0 f �� ��a������l��t,
Calculaie 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 Fo 00 Amps 0 to 100 Amps
Street Ltg./Traffic Sig. Above 200 Am s Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY TOT
Sign/Outline Ltg. Xfmr. ��
Alarm/Remote Control ��l.�
$Wimmin9 Poo� I hereb certi that I ins ed the elechical inslollalion described herein on the dates stoted
Irrigation Boom RougMn Dare
Special Inspection ^ � '� �
Final afe
Investigative F �
THIS INSTALL/kTION MA E ORDERED DISCONNECTED IF NOT COMPL�TED WITHiN 18 MONTHS.
OFFICE USE ONLY This roquest void 18 months 6om validatjqn date print �this bo�
lllllllilllllllllllllllllll�lll����l • ����s��'
�
� 0 7 1 5 7 2 6 6* ��
PLEASE PRINT OR TYPE � ��
Requ sf Date Rough-in inspecfion required? Yes ❑ No Inspection Other Than Rough-In: Ready Now � Will Call
��- �You must call the inspecror when ready) Date Ready:
I, �{icensed contractor ❑ owner hereby request inspection of the above electrical work at:
1ob Address (Shcet, Box, or Route No.) Ciy Zip Code
�qZ,S"- �l'1�4��J ST �r�C�f� S`l3
Secfion No. Township Name or No. Range No. Fire No. ounly
3o a �C�}
Occupanf Phone No.
�/a�ro� � �� ��- r��g
�Q����_�� ������ ,� ����.. i.onRacrqr�ucense rvo. _ masrer uc. rvo. �nam ne
T � C"i�yU/(��-`3
Mailing Address �Conhacfor or Owner Pe rming Installafion e ��/
/Y7�0 v �u�t���l C%" ��L� ,��C,E,�
Authorized Signafure Conh or or Owner P rformin� In fion) Phone No.
� ►- 0102 -6!� y�
E&00001A-11 8/96 STATE BOARD COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY