P - 83788REQUEST FOR ELECTRICAL INSPECTION �«
� � Minnesota State Board of Electricity
5� J- 5 2 0 1g21 University Ave., Rm. S-128, St. Paul, MN 55104
, _ .�:
Phone(612)642-0800
Home Duplex Apt. Bldg. Other: New Addn
Commercial Industrial Farm Remod Re air
Air Cond. Htg. Equip. Water Htr. Load Mgmt. Other:
Dryer Range Elec. Heat Temp. Service
"X" above the work covered b�y is request. Enter remar 'n thjy�space and on the back of the white copy only.
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Calculate Inspection Fee - This Inspection R quest will not be accepted withouf the correcf fee:
Other Fee # Service Entrance Size Fee # Circuits/Feeders Fee
Mobile Home Park Stall 0 to 200 Amps ,�'� Z 0 to 100 Amps L�,(,�
Street Ltg./Traffic Sig. Above 200 Amps Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY TOT
$ign/Outline Ltg. Xfmr. ���
Alarm/Remote Control
Swimming Pool
I hereb certi fhat I ins fed the elecfrical insfallation described herein on the dates sfated
Irri9ation Boom Rough-In pa�
Speciallnspect , �
Irnesti9ative Fee � Final - �1-' ef�„ �
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THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This request void 1 S months from validaticn date printed in fhis box.
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* O 5 2 5 5 2 0 �� PLEASE PRINT OR TYPE �� �
Request Daf Rou h-in ins tion re uired?
'��i iy "") 9 P� q ❑ Yes No Inspection Other Than Rough-In�eady Now � Will Call
y/ (You must call the inspector when ready Date Ready:
f, icensed contractor ❑ owner hereby request inspection of the above electrical work at:
Jo`�b Ad�dr/e�s treet, Box, o Roufe /oJ� City ' Zip Code
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Section No. Township Name or N. Range No. Fire No. Counry A /
Occupanf
Phone No.
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Powe� Suppli Address �
J�i`� �/�3` ��'��� �i<�
Elecfric onh c r Com�° me) Contr9,ctor License No. Master Lic. No. (Plant Elect. Only�
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Address �Confractor or Owner P rmii
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ed gnafur ontractor or er e
I -11 8/96 STAT 0
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YELLOW COPY