P - 80690• • • �
. . •
REQUEST FOR ELECTRICAL INSPECTION
Minnesota State Board of Electricity
1821 University Ave., Rm. S-128, St. Paul, MN 55104
Phone(612)642-0800
Home Duplex Apt. Bldg.
Commercial Industrial Farm
Air Cond. Htg. Equip. Water Htr.
Dryer Range Elec. Heat
"X" bove the work cov red by this request. Enter
-�� ��i�
�1�����- �<<
New
Remod
Mgmt. Other:
Service
in this space and on the back of the whiie copy
� a�,�.z' _
`''�, ="'1°
� '�
Calculale lnspection fee - This Inspection Request wrll not be accepied without ihe correc/ 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 Amps Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY TOT
Sign/�utli�e Ltg. Xfmr. z6 ' � �
Alarm/Remote Control � � ��� � ^
Swimming Pool �� ��
I hereb certi that I ins the elecfrical installafion described herein on the dates stated
Irriqation Boom o,,,,,,�„ n..b
Investigative Fe �) F��I �� I � ! � �� ° �
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This request void 18 months from validation daie prinfed in fhis box.
IHIIIIIIII�f�IN��IIII��IIIII�I�I�II�������III + �'/�5�
* 0 7 8 7 8 7 8 A* 3%p`t�
PLEASE PRINT OR TYPE
Requesf D te Rouglfin inspecfion required$ ❑ Y o Inspection Other Than Roug�eady Now ❑�II Call
� (You must call fhe inspecfor when ready� � DaTe Ready: �
I, licensed contractor ❑ owner hereby request inspection of the above electrical work at:
Jo� Address�Sheet, �ox, or Roirte No.) � Cily,, �, Zip Code
or No. � Range No. � Fire No.
�� � Conhactor
b..
or Owner
Phone
or VWner YertOrmin9 Insfallofion� J I Yho�o. ,�
Y
STATE BOARD COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY