P - 81000REQUEST FOR ELECTRICAL INSPECTION �
4! �� -15 4 Minnesota State Board of Electriciry
r 1821 University Ave., Rm. S-128, St. Paul, MN 55104 �:
Phone (612) 642-0800
Home Duplex Apt.Bldg. Other. ,�wj,�+� )- �•t.re�v,�tt��� New Addn
Commercial Industrial farm �Q N� 1- I'9C � t" Remod Re oir
Air Cond. tg. Equip. Water Htr. Load Mgmt. Other.
ryer Range Elec. Heat Temp. Service
"X" above the work covered by this request. Enter remarks in this space and on the back of "`�vhite copy only.
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Calculaie Inspection Fee - This Inspection Request will not be accepted without ►he correc► fCe;� �t`
Other Fee # Service Entrance Size Fee # Cireui' ers Fee
Mobile Home Park Stall 0 to 200 Amps 0 to 10�' "s
Street Ltg./Traffic Sig. Above 200 Am s Above i: Amps
Transformer/Generator INSPECTOR•s use oN�v ' TOTAL
Sign/Outline Ltg. Xfmr. �� - S�
Alarm/Remote Conhol
Swimming Pool I her certi that I ins the elechical insMllafion described ` i 1he dates stated
Irrigation Boom r RougMn " Date
Special lnspection
Investigative Fee F`�� � ��� . 3
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THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLET HIN 18 MONTHS.
OFFICE USE ONLY This requesT void 1 B months_6an'� �� �- .._ ion dafe printed in this box.
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PLEASE PRINT OR TYP
Request Dafe Rouglrin inspection required$ ❑ Yes ❑ No Inspection Ofher Thon R .,�;� Ready N ill Call
�.. �— gi (You musf cali the inspecfor when ready) Date Ready: _ �S" -�� �
I icensed confractor ❑ owner hereby request inspection of the above electrical worF� �-�'
Job Address �Sheet, Box, or Route No.) Ciy : Zip Code
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Secfion No. Township Name or No. Range No. Fire No. ty . :-:'�
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Occupanf Phone No. - �
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Power Supplier - Address ��...
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Electrical Contractor (Company Name) Conhodor License No. �ic. No. (Plant Elecf. Only)
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Mailing Address �ConhacTor or Owner Performing Insfallafion) ' � ��
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Aufhorized Sig re (Conkacbr r ner Perform' g Insfall � � ��. � a.
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001 A 1 8/96 �p7E gOARD COPY - SEE INSTAUCTONS ON BACK OF YELLOW COPY