P - 79505�02-327 �
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Industrial
REQUEST FOR ELECTRICAL INSPECTION ��
Minnesota State Board of Electriciry
1821 University Ave., Rm. S-128, St. Paul, MN 55104 �.
Phone(612)642-0800 R `�'
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Apt. Bldg. Other: � 0� ('' „ New Addn
Farm -��'� Remod Re air
Water Htr. Load Mgmt. Other:
Elec. Heat Temp. Service
request. Enter remarks in this space and on the back of the white copy only.
Calculate Inspection Fee - This Inspecfion Request will not be accepted withouf the correct fee:
Other Fee # Service Entrance Size Fee # Circuits/Feeders Fee
Mobile Home Park Stall 0 to 200 Amps 0 to 100 Amps �
Street Ltg./Traffic Sig. Above 200 Am s Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY TOTAL� �'SQ
Sign/Outline Ltg. Xfmr.
Alarm/Remote Control
Swimming Pool
I hereb certi thaf I ins ted the electrical insfallation described herein on Ihe dates stated
_ Ifri9ation Boom RougMn Date
Investigative �ei] �J ( � �
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED ITHIN 18 MONTHS.
OFFICE USE ONLY This request void 18 months ftom validation date printed in this box.
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* 0 8 0 2 3 2 7 7* � �� �
PLEASE PRINT OR TYPE
Requesf Date Rouglr7n inspecFion required$ ❑ Yes �lo Inspecfion Ofher Than RougMn: ❑ Ready Now Will Call
w �O � (You must call the inspecror when ready) Date Ready:
I, ❑ licensed contractor�owner hereby request inspection of the above electricol work at:
Job Addr��� t, Box, or RO� nlo'�/v / �/ / I/ � City� /J J Zi�� /��
G � %v < << �. � a' � �
Section No. Township Name or No. Range No. Fire No. County
oc�upanr
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Power Supplier
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Elechical Confracfor (Company Name
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Mailin�g }Address (Conkacclor w Owner
�"1 L'► / Y � !/ A
(�/ J
1.2- P7G3 �?� 39GG
Address
P� ,�(.'� � o�/r1 is !0 �✓
Contractor License No. Masler Lic. No. (Plant Elecf.
or'�� e�yg�orming Installafion� Phone No.
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STATE BOARD COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY