P - 82881REQUEST FOR ELECTRICAL INSPECTION -�� �
6'J J= 3 6 5� 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
Commercial Industrial Farm Remod e 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 ihe white copy only.
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Calculate Inspection Fee - This Inspection Request will not be accepied without fhe correct fee:
Other Fee # Service Entra Size Fee # Circuits/Feeders Fee
Mobile Home Park Stall 0 to 00 Amp 0 to 100 Amps
Street Ltg./Traffic Sig. Above 200 Am s S, � Above 100 Amps
Transformer/Generator INSPECTOR�s use oN�v TOTAL
Sign/Outline Ltg. Xfmr.
Alarm/Remote Control a r
Swimming Pool
I hereb certi that I ins ihe elecirical installafion described he�ein on ihe dates stafed
Irrigation Boom RougMn Da1e
Special Inspect' n . _ � i
Final �p�a �
Investigative Fee ' -' (��—
THIS INSTALLATIOhI MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This requeaf vad 18 moMhs kom validafion date printed in ihis box.
I IIII II III II III II III II li� II III II III II II) I IIII • as��
* 0 6 0 9 3 6 5 2* ��a�
PLEASE PRINT OR TYPE
Request Date � Rough-in inspection required$ ❑ Yes ❑ No Inspecfion Ofher Than Rough-In: �Ready Now ❑ Will Call .
r'ou must call ihe inspectcr when ready� Date Ready:
I, �licensed contractor ❑ owner hereby request inspection of the above electrical work at:
1ob Address (Sheet, Box, or Route No.) City Zip Code
� SS �5 S Z_
Secfion No. Township Name or No. Range No. Fire No. nty
Occupanf Phone No.
12 lC,ti � � � G�
Power Supplier Address �
Elechical Contmcfor (Company Name) Conhacfor License No. Masfer Lic. No. (Planf Ele
fh� �12ciwi c� �e�v"1 c.st, �c.-. CI� OO\�tc�
Mailing Address �Conhactor or Owner Performing Installafion) .
�ZIO� (� 1� �'1-t, � �I��
Aufhorized Signafure � o mctor or Owner Performi Insfallafion 5. � Phone No.
� � . . S?(-7].Co
EB-0OOOlA-1 1 8/96 STATE BOARD COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY