P - 80817- I�II�IIIIIIIIII�IIIIIIII�IIIIIIIII�I�I�If�IIII�II R8 Q UE�Se sFORve.LRm. SRiC8, StN aPfEMNION04 ����
Minnesota State Board of Electnaty �
* 0 3 8 1 1 9 6 5�` Phone (612) 642-0800 �_����
Home Duplex Apt. Bldg. Other: New Addn
Commercial Industrial Farm Remod Repair
Air Cond. Htg. Equip. Water Htr. Load Mgmt. Other:
Dryer Range Elec. Heat emp. Service
"X" above the wor � covered by this request. Ente� remarks in this $oace and on ihe back ot the white copy only.
z ns-f-Q 1/V..e� I oo.,�m p�an�
�'iaX ��'�l u h� F'.�zz
Calculate lnspection Fee - This lnspection Request will not be accepted without the carect fee:
Other Fee # Service Entrance 'ze Fee # Circuits/Feeders Fee
Mobile Home Park Stall 0 00 Amps - 0 to 100 Amps
Street Ltg./Traffic Sig. Abo e 200 Amps Above 100 Amps
Transformer/Generator INSPECTOR�s use NlY TOTAL �
Sign/Outline Ltg. Xfmr. ��;e-�,,"+,4 [ .es�f � p0
Alarm/Remote Control �� t5
Swimming Pool I hereby certiy that I inspected the electrical installation described herein on the dates stated
Irrigation Boom Rough-In Date
Special Inspec ' n Final
Investigative F ��
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN � M9N'[H$, _-_ _
OFFICE USE ONLY This reQuest void 18 months from valldation date printed in this box.
1-196 [� � 7s-. Sa
�7oa
PLEASE PRINT OR TYPE
Request Date Rough-in inspeciion required? ❑ Yes �No Inspection Other Than Rough-In: ❑ Ready Now 6f Will Call
�- � O �� (You must call the inspector when ready) Date Ready: r
I, � licensed contractor ❑ owner hereby request inspection of the above electrical work at:
Job Address (S eet, Box, or Route o.) City Zip Code
5 �O- os or -e � FF�
Sectwn No. Township Name or No. R n e No. Fire No. Co ty
Q�
cupant s� � 1r �� Vln� No.` L� _� ��
�U , '�
Power Supplier Address . � SQ � � �
, $. , � �,e �'.e. ' �. i. i U s
trical Cont a to�ompany Name) Contract r License No. -- Master lic. No. (Plant Elect. Only)
��I^ i G C Gi�o l't� �-
Maili g Addr ss/(�C+ontrac r or Owner Performing Installation) �J /'\ �J �O' I
� ✓ \ /GA' ` � �' / V - c+^ f ! / Q � -e I J T
Au orized Signature (Contra tor or Ow Performin I tallation) �� A ne No.
• v�e9 � � �� ''O
EB-OOOOtA- 5 STATE BOARD COPY - SE STRUCTIONS ON BACK OF YELLOW COPY