P - 84644� REQUEST FOR ELECTRICAL INSPECTION -
�b F v Q�� ^� Minnesota State Board of Electricity
' o Q' �� ,� V� 1821 University Ave., Rm. S-128, St. Paul, MN 55104
` > Phone (612) 642-0800
Home Duplex Apt. Bldg. Other: New Addn
ommercial dushial Farm Remod Re ir
Air Cond. Htg. Equip. Water Hfr. Load Mgmt. Other:
Dryer Range Elec. Heat Temp. Service
"X" above the work covered by this request. Enter remarks in this space and on the back of the white copy only.
Calculate Inspection Fee - This Inspection Request will not be accepted withou► fhe correct fee:
Other Fee # Service Entrance Size Fee # Circuits/Feeders Fee
Mobile Home Park Stall 0 to 200 Amps 0 to 100 Amps
Sheet Ltg./Traffic Sig. Above 200 Am s Above 100 ps
Transformer/Generator INSPECTOR'S USE ONLY T L
Sign/Outline Ltg. Xfmr. � �
Alarm/Remote Control
Swimming Pool
I hereb certi thaf I ins cfed the elechical insfollation dexribed herein on fhe dafes stated
Irrigation Boom Rougffln ��
$pecial Inspection
Final �. - .�, �C � �,J--
Investigafive fee '
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFlCE USE ONLY This request void 18 months from validation date printed in fhis box.
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I IIII II III II III �I �I � III Ir�� ���II II III ��I I I��I � fs-� �i��
* � 4 8 4 8 6 3 6* PLEASE PRINT OR TYPE
Request Dyte Rough�n inspecfion required? ❑ Yes No Inspection O�er Than RougMn: Ready Now ❑ Will Cal)
(Vou musf call ihe inspector When ready�� Dafe Ready: •
I, licensed contractor ❑ owner hereby request inspection of the above elech-ical work at:
ob Addr s(5 « Route�J / 17 , �, w,,,.., _ J Ciry �� � Z� ode �
Ul�-�"►' T� �I �
Seclion o. ownship Name w No. Range No. Fire No. County
Occupant �/ , �°� � Phor�.li� A
AM '���'/
�l� I I% �� �' l �
Power Supplier Address
Electrirnl Conh r o N e ConhacMr 'ce se No% Master Lic. No. (Plant Elect. Only)
g.T�'��`� � �ONS ELEC. INC. C
. ''.'?:'� i�ALLEY �I'C'. & AIR J
AAailing Address �onhotfor�mr� � t t� �
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d. cas�� l/
Au1F�wized Signature (Conh r n I s� I i � / Phone No. _
EBOOOOIA-11 S/96 MS7� p(�SQp (.(�DV _ SFF IFISTRIIf`TflNS nN FIACK nF YEI LI1W COVY