P - 80651�I I�II� II�I IIIII IIIII IIIII (I'll IIIII IIIII IIII II�I
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REQUEST FOR ELECTRICAL INSPECTION ��
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 Addn
' ommercial Industrial Farm Remod Repair
ond 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.
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Calculate Ins,oection Fee - This Inspection Request will not be accepted without the correct fee:
Other Fee x Service Entrance Size Fee # Circuits/Feeders Fe
Mobile Home Park Stall 0 to 200 Amps 0 to 100 Amps
Street Ltg./Traffic Sig. Above 200 Amps Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY TOTA
Sign/Outline Ltg. Xfmr.
Alarm/Remote Control
Swimming Pool I hereby certify that I inspected the electrical installation described herein on the dates stated
lrrigation Boom Rough-In Date
Special In
Final Oate � �1
Investigative e � Z-Y �`/`
THIS INSTALLATION MAY BE ORDERED DISCO NECTED IF NOT COMPLETED WITHIN 8 M NTHS.
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OFFICE USE ONLY 7his request void 78 months from validation da[e printed in this bwc.
396-214 � ` aU - �
�53
PLEASE PRINT OR TYPE
Request Da Rough-in inspection required? ❑ Yes No Inspection Other Than Rough-In: Read Now il Call
(You must call the inspector when ready) Date Ready: 3
I, �licensed contractor ❑ owner hereby request inspection of the above electrical work at:
Job res�r�et, B, or Rouj� Nq.�t � �� City ��� Zip �^
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Section No. Township Name or No. nge No. Fire No. County
Occ �`/LJ�t� Gr Phone No�� V
Power Supplier Address
Elect c ontractor (Company Contract icense No. Master Lic. No. (Plant Elect. Onty�
lC ��e ��z C G�D/? 0
Maili Address ( ontractor r ner Performing Installation
/ �G�Jl� C �1
Authonzed Sign re ntract r Owner Performi Installation) Phor�gN� '
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EB-OOOOtA-17 8/95 STATE BOARD COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY