P - 84555REQUEST FOR ELECTRICAL INSPECTION
`-F•�� J- 0 6 3 Minnesota State Board of Electricity
� 1821 University Ave., Rm. 5-128, St. Paul, MN 55104
Phone(612)642-0800 _ _ �
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Commercial Industrial Farm od Re
Air Cond. 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 the back of the whife copy only.
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Calculate Inspection Fee - This Inspection Requesi 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 Amps
$treef Ltg./Traffic Sig. Above 200__ Am s Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY TOTA `..�{or
Sign/Oudine Ltg. Xfmr.
��L
Alarm/Remote Confrol
Swimming Pool
I hereb certi fhaf 1 ins ed the elechical installaKon described herein on the dates stated
Irrigation Boom Rough-In pa�
Investigative Fee ` r��� � D°�' �.5 —� 7
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY ihis requesf void 18 months from validafion date printed in this box.
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* 0 4 2 9 � 6 3 L* P SE PRINT OR TYPE
� �e� � Rough-in inspection required? ❑ Yes o Inspeclion Olf�er Than RougMn: ❑ Ready No
(You musf call the inspector when ready) Date Ready:
/•
icensed contractor ❑ owner hereby request inspection of the above elechical work at:
'e�s (Sheet, Box, or Route No.� Ciy Zi Code
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/i � / %�r�i�/� � /� /,1�„�i _i�l�.�' .�f/�f /i �
Power
(Company
or No. � Range No. � Fire No.
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Plwne
Mailing Addreu (Conhacfor or Owner �irformin Insfallafion)
/ %l / �-�/�/i�� .y�%� � �
Master Lic. No.
or CJwner Y Insfallafion) -- ''�/ I p
? � 25�.0(°�
STATE BOARD COPY - SEE INSTRUCiIONS ON BACK OF YELLOW (:�PY
Call