P - 82150� � REGIUEST FOR ELECTRICAL INSPECTION ;twue�:-<...
: J��— S 2 0� Minnesota State Board of Electricity
1821 University Ave., Rm. S-128, St. Paul, MN 55104
Phone(612)642-0800 " '
ome Duplex Apt. Bldg. Other: New Addn
Commercial Industrial Farm Remod Re air
Air Cond. Htg. Equip. Water Htr. Load Mgmf. Other:
Dryer Range Elec. Heat Temp. Service
"X" pbove the work covered by this quest. Enter remarks in this space and on the back of ihe white copy only.
�`��' �'�/�, �`d ,��5.�`— ,�-i�.
Calculate lnspection fee - This lnspection Request will nof be accepted without )he correct fee:
Other Fee # Service Entrance Size Fee # Circuits/Feeders Fee
Mobile Home Park Stall 0 to 200 Amps 0 to 100 Amps ro�
Sfreet Ltg./Traffic Sig. Above 200 Am s Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY T `��
Sign/Outline Ltg. Xfmr.
Alarm/Remote Control
Swimming P (
I hereb certi thaf I ins ted the elechical insfallafion described herein on the dales stated
Irrigation B Roo9h-I� Da�e
Special Inspection
Final Dar�-
Investigative Fee �—t. (� '��
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
__. OFFICE USE ONLY This requesf void I B months from validation date prinfed in fhis box.
Il�lllllilllllllillllllll�lll�llill�lll � a�-�
III
* 0 6 6 2 8 2 0 0* �Q7a
P ASE PRINT OR TYPE
R uesf Date Rough-in inspecfion required? ❑ Yes No Inspection Other Than Rough-In: Ready Now Will Call
� � �/�60 (You musf call the inspecfor when ready) Dafe Ready:
I, icensed eontractor ❑ owner hereby request inspection of the above electrical work at:
Job Addreu �Strcet, Box, or Route No.) City / Zip Code
0 � Q�� i/ c'�l �7 �.r�
Secfion No. Township Nome w No. Ronge No. Fire No. ounfy
(� �
Occ nf Phone No.
� OrJ '"7(�'� '� �l�'
Power Suppl' r � � Address .
�%5�' - �'�'
Elechical Conhactor (Company Name) Conhacfor License No. Master lic. No. (Plant Elecf. Only)
�-��'�'� .� �7
Mailing Address (Conhactor or Owner Performing Instal ation)
�' 7� y rt,v�' G.r� 1�OuJ' 7�. '.�e.�'�52�,
Authorized Sig r Confractor or wner Pe 'ng,�sfallation) Phone N.
. c . �..!/�%
/
E&0000 A-1 1 8/96 STATE BOARD COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY