P - 80450REQUEST FOR ELECTRICAL INSPECTION �
�(� � e� Q� � Minnesota State Board of Electricity
,� v 1821 University Ave., Rm. S-128, St. Paul, MN 55104
Phone (612) 642- 8 0 '�'
� Home Duplex Apt. Bldg. Other: •� � Addn
Commercial Industrial Farm � S� � Remod Re air
Air Cond. Htg. Equip. Water Htr. Load Mgmt. Other:
Dryer Range Elec. Heat Temp. Service L��["�+�� r�p/� e
"X" above the work covered by ►his request. Enter remarks in this space and on the back of th white copy only.
Galculaie Inspection Fee - This Inspection Reqvesf will not be accepted without the correct fee:
Other Fee # Servi e Entran e Fee # Circuits/Feeders Fee
Mobile Home Park StaN 0 to p 0 to 100 Amps �
Street Ltg./Traffic Sig. Above 200 Am s Above 100 Amps
Transformer/Generafor INSPECTOR'S USE ONLY TOTAL LC C�
Sign/Outline Ltg. Xfmr. �` �" - a-3c /r� �`( JJ � .7
Alarm/Remofe Control /v�^ �%— / `%�(/j�
Swimming Pool �. �ff - ��_ � �
I here certi ihati ins ihe electrical insMllafion desc i erem o fhe daMt s
Irrigation Boom _ RougMn Dare
$pecial Inspection '�` � 1
Final Da
Investigative Fee 2,- 3 -O
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This request void I S months irom wlidafion date printed in fhis box.
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* 0 8 0 2 2 8 4 0* �,5�
PLEASE PRINT OR TYPE
Requesf Dafe Rou h-in ins on r uired$ 0 Yes
g pecli eq ❑ No Inspecfion Other Than Rough-In: ❑ Ready Now � Will Call
v. �(,i� l (`(ou must call the inspecror when ready) Date Ready:
I, b licensed conhactor � owner hereby request inspection of the above electrical work at:
Job Address �Sfreet, Box, or Route No.� City Zip Code
o ; ry 5�3a
Secfion No. Township Name or No. Ranee No. Fire No. Counly
3 � 'd �I-nok
Occupant Phone No.
C�� K►�nko � 5oa �1�4�0
Power Sup ' r Address
�xc�. 2 �9 n�
Electrical Conhacror �Company Name) -j� Conhactor License No. Master Lic. No. (Hant Elecf. Only�
lAi
Mai ing Address �Conhacfor or Owner Perlorming InstallMion�
SQrne
Aufhorized Signature (Conhactof or Owner Performing Installafion) Phone No.
7� - �va ^�9l00
EB-00001 A-1 /96 S TE BOARD COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY