P - 82784RE(IUEST FOR ELECTRICAL INSPECTION �
�'t �- 313 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 ddn
Commercial Industrial Farm Remod Re 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.
�M�L.Y R.�M /��oM
Calculate lnspection Fee - This Inspection Request will noi 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
Street Ltg./Traffic Sig. Above 200 Am s Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY TQTAL� �
Sign/Oudine Ltg. Xfmr. Jti�
Alarm/Remote Conhol
Swimming Pool
I hereb certi t}wt I in hd the elechical insrollation described herein on the dates sfaFed
Irrigation B 4- : Ra,gMo Da
Speciai Ins o % '-�
Final
Investigative Fee �
THIS INSTALLATION MAY BE ORDEREO DISCONNECTED IF NOT COMPLETED W HIN 18 M THS.
OFFICE USE ONLY This roquest void 18 months from validation date printed in this box.
I�II���INIIIII�IIIIllllillh�ll� � y�
� 0 6 4 3 1 * Lf l q�
3 3 0
PLEASE PRINT OR TYPE
Reque Dafe � Ro h-in ins ion r uired2 es .
ug pecY eq ❑ No Inspecfion Other Than RougMn: ❑ Ready Now �DO'ill Call
(You musf call the inspeclor when ready) Dafe Ready:
I, icensed confractor ❑ owner hereby request inspection of the above elechical work at:
Job Address (Skeet, Box, or Roufe No.) Ci Zip Code
M� �� 2 (,E u�a--
Section No. Township Name or No. Ranpe No. Fire No. C4unN
Power Supplier Address
�
Elechical Contractor (Company Name) Conhaclor license No. Masler Lic.
IN� � c I N C C�O �
Mailing Addreu �Contracror or Owner Performing Insrollation�
O C I�Cc� tN
A or' ed Sign e(Conhacror or Owner Performing Installafion) �"°j � q Phone No.
c� , �+ �.i
E&00001 A-11 6 STATE BOARD COPY - S�E 11�87RUCTIONS ON BACK OF YELLOW COPY