P - 82267� RE(1UEST FOR ELECTRICAL INSPECTION
C:�' V�- 212 � Minnesota State Board of Electricity `:3
� 1821 University Ave., Rm. S-128, St. Paul, MN 55104 =
• Phone(612) 642-0800
Home Duplex t. Bldg. Other: New Addn
Commercial Industrial Farm Remod Re air
Air Cond. Htg. Equip. Water Htr. Load Mgmt. Oth r• �
Dryer Range Elec. Heat Temp. Service f•� �
"X" above the work covered by this request. Enter remarks in this space and on the back of the white copy only.
c�ui•�� -7 ,4/L .
Calculate Inspection Fee - This Inspec►ion Request will nof 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 TOTAJS �
Sign/Outline Ltg. Xfmr. 7 �
Alarm/Remote Control
Swimming Pool
I hereb certi fhaf I ins fhe elecfrical insfallafion described herein on the dafes sta�ed
Irrigafion Boom Rouglrin Dafe
$pecial Inspectiorl - �
. - Final Date
Investigative Fee
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
,_ OFFICE USE ONLY This roquesf void 18 months from validation date printed in fhis box.
I III) II �II I) III II III II III II III� ��� I(�I �
* 0 8 0 2 2 1 2 1* ��' S� �� �/
PLEASE PRINT OR TYPE
Reques� Rou h-in ins on r uired? .
O' g pecli eq ' ❑ Yes �lo Inzpection Other Than Rough-In: ❑ Ready Now ifl Call
� Z (`/ou musf call the inspector when ready) � Dafe Ready:
I, [��iCensed contractor ❑ owner hereby request inspection of the above electrical work at:
Job Addresi S eet�r Rou� ��� � iy � Zip r--y _�
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Section No. Township Name or No. Range No. Fire No. County //,,w /�L�/`+
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Occupanf /� Phone No.
�di��j C'�/[�A/j'J.�
Power Supplier �� � Address �
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Electrical Conhacfo ompany Name) '� . ' Conhacfor License No. Masfer Lic. No. (Planf Elecf. Only)
�,c'��'.�.�.o ��cr, sr�s c�Z 2 yZ
Mailing d ess (Confracfor or Owner Performing Installafion)
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Authorize � ature (CorJqacf r ner Performing Insfallafion� PhoY3 ./
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EB00001 A-11 8/96 STATE BOARD COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY