P - 83440RE(IUEST FOR ELECTRICAL INSPECTION
6,8 y� o�� � Minnesota State Board of Electricity
< 1821 University Ave., Rm. S-128, St. Paul, MN 55104
� ' Phone(612)642-0800
' Home Duplex Apt. Bldg. Other. New Addn
Commercial Industrial Farm '—�i}i`�4 °�-� Remod Re air
Air Cond. Htg. Equip. Water Htr. Lead Mgmt. Other.
Dryer Range Elec. Heat Temp. Service
"X" obove the work covered by this request. Enter remarks in this space and on the back of the white copy only.
Calculaie Inspection Fee - This Inspection Request will not 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 �
Sheet Ltg�/Traffic Sig. Above 200 Amps Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY TOTAL
Sign/Outline Ltg. Xfmr. �
Alarm/Remofe Conhol
Swimming Pool
I hereb certi thaf I ins the electrical installation described herein on the dates stated
Irriqation Boom e�,,,,i,.i., oo�
Investigative , F� C v ���- ����Z -- ��
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE Of�Y This requesl void 18 monfhs from validation date printed in fhis box.
I N�I (I ��� II �II II I�I I��� �� III II I�I �� I�I 15' � 5�0 ��2#d'ob�
* 0 6 8 9 0 3 8 8*
P EASE PRINT OR TYPE
Requesf Dafe Rou h-in ins ion r uired?
.�_�„' � g pacf eq ❑ Yes No InspecKon Other Than RougMn: ❑ Ready Now ill Call
� j (You must call the inspector when ready) Date Ready:
I,�licensed contractor ❑ owner hereby request inspection of the above electrical work at:
Job Address (Sheet, Box,pr�oute No.) _ � Ciry n __ Zip Code
�
Seclion No. Township N� orONo. Range N: Fire No. Counly
a{
Occupant Phone No.
� �A� • �.. �1/ M[� r� Srt�ti�
�
_��.� .,.,.. � C.� ! v�/C� ! / � ����Ul�
Eleckical Contracror (Company Name� /� � Conhacror License No. Master Lic. No. (Mant Elecf. Or
�
Mailing Address (Conhac r o Owner erfomi stallation)
�3 � � .� , �s- ��"�4�3
Authorized Sign onha Owner i tal 'on Phone No.
� � � �`l �` � -�/�
B 00001 A-1 1 8/96 STATE BOARD COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY