P - 84170REQUEST FOR ELECTRICAL INSPECTION I
C�J9 ��: 7 g 6 Minnesota State Board of Electricity
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1821 University Ave., Rm. S-128, St. Paul, MN 55104
� r Phone (612) 642-0800
Home Duplex Apt. Bldg. Other: / New Addn I
Commercial Industrial Farm —`-�(�,.' Remod air
Air Cond. Htg. Equip. Water Htr. load Mgmt. Other:
Dryer Range Elec. Heat Temp. Service
"X" above the work covered by his request. Enter remarks in this,space and on the back of t e white copy only.
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Cblculafe Inspection Fee - This Inspection Request will not be accepted without the correci 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 Amps Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY TOTAL
Sign/Outline Ltg. Xfmr. ��
Alarm/Remote Control
Swimming Pool �
I hereb certi that I ins the elechical installation deuribed herein on the dates stafed
Irri9ation Boom RougMn � Dore
Special Inspec'
Final te
Investigative F --
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED W HIN MONTHS.
Y?� (� � OPFICE USE ONLY This requesf void 18 monfhs kom validafion dafe printed in fhis box.
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* � 5 4 3 7 9 6 ?�K PLEASE PRINT OR TYPE ����
Request Date Rou h-in ins fion r uired2 p y y ❑ Will Call
g pec eq ❑ Yes o Ins ecfion Ofher Than Rou h-In: ead Now
— -- �You musf call fhe inspecfor when ready� Date Ready:
I, icensed contractor ❑ owner hereby request inspection of the above electrical work at:
1ob Address (Streef, Box, or Route No.) City Zip Code
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Section No. Towns ip Name or No. Ran e No. Fire No. Counfy '
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Occupantp Phone No.
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Power Supplier � Address
Elechica tractor (Compan,� me� Contracfor License No. Master Lic. No. �Plant Elect. Only)
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Mailing �AS ess (Contractor or Ow r Perfor "ng Insfallation) �
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Authoriz � Signatu� to� or Owner Per(nrming Insfallation) ') Phone No.
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E&00001 A-1 1 S/96 STATE BOARD COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY