P - 80692RE(IUEST FOR ELECTRICAL INSPECTION «�
7 8 7� V�� � 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 dn
Commercial Industrial farm Remod e air
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 white copy only.
�%r�S�''p rn s �-/� �9
�-'Gt-✓h
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 Amps , d
Street Lig./Traffic Sig. Above 200 Am s Above 100 Amps
Transfarmer/Generator INSAECTOR's usE ON�Y- TOTAL
Sign/Outline Ltg. Xfmr.
Alarm/Remote Control �/�.��
Swimming Pool ��V
I hereb certi thaf I ins ed the elechical insmllation deuribed herein on the dafes stated
Irrigation Boom Ra„9h-�n �ate
Special Inspect ' -
_ F��ai �� _ 2� —o�i
Investigative Fee
THIS INSTALLATION MAY BE ORDEREU DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFlCE USE ONLY This request void 18 monlhs kom wlidation date printed in this box.
I��IIIIIIIIIIIIIIIIIIIIIIIII�I�IMlIlll��ll�l) • G 5�
* 0 7 8 7 8 5 1 5* ���
P�EASE PRINT OR TYPE
Request pate Rough-in inspection required$ ❑ Yes lrtspecfion Olher Tlwn RougMn: eody Now 0 Will Call
� a,� (You musf call the inspecfor when ready) Dafe Ready:
I, icensed contractor ❑ owner hereby request inspection of the above electrical work at:
Job Address �Sheet, Box, or Route No.� City Zip Code
- — .� - l t , d i )�_. .1 �
V�
� Power
• v i i �/ c.. • / i[/l I"Lf�
or No. Ronge No. Fire No. Co �
Phone No.
Conhactor License No.
R�(`r'j' �",C�
Mailing Address (Conhacfor or Owner PerFormirg
�� �- ✓�/'�v� �
Aufhwized Signature �Contmctor or Owner Perfori
�
STATE BOARD COPY -
Master Lic. No.
I
YELLOW COPY
��,/
No.