P - 81001802�160 �
Home
Commerc
Air Cond
Dryer
"X" above tl�
REGIUEST FOR ELECTRICAL INSPECTION
Minnesota State Board of Electricity
182i University Ave., Rm. S-128, St. Paul, MN 55104
Phone(612)642-0800
Farm `T�L /`C(p
ip. Water Htr. Load Mgmt. Other:
Elec. Heat Temp. Service
y this request. Enter remarks in ti�is space and on the back
Calculate Inspection Fee - This Inspection Request will not be accepted wiihout the correct fee:
Other Fee # Service Entrance Size Fee # Circuits
Mobile Home Park Stall 0 to 200 Amps 0 to 100 A
Street Ltg./Traffic Sig. Above 200 Am s Above 100
Transformer/Generator INSPECTOR•s use oN�v
Sign/Outline Ltg. Xfmr. �L' �g'kt �-
Alarm/Remote Control
Swimming Pool
copy
� �"•�'
'�:�. �-
� •..
Fee
TOTAL, �ls.�
,y
I hereb certi fhai I ins the elecfrical insfallafion described herein on the dates sfated
Irrigation Boom Rooyh-I� Da
Special I r �� '�� ,
Final Date -.��_G
Investigati F e �
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This request void 18 months from validafion date prinYed in fhis box.
� �II� �� I�I �� ��� �� ��� �I ��� I� ��� I��� � III ��II •�c" �
� 0 8 0 2 1 6 0 2* � d� 3�
PLEASE PRINT OR TYPE
Request Dafe Rou h-in ins tion r uired? es
g pec eq ❑ No Inspection Olher Than Rough-In: ❑ Ready Now Will Call .
�Q �` � � g (You must call the inspecYor whe ready� Date Ready:
I, ❑ licensed contractor owner hereby request inspection of the above elecfrical work at:
Job Address (Shce�, Box, or Route No.J Ciy Zip Code
1� P U� � F�tCi �LL S
Secfion No. Township Name or No. Ranpe No. Fire No. County
o«opa�r
Si'c
Power Supp�ier
Name)
Address �on�acror or Owner PerForming
� ANO (�A
Phone No.
�� 6/ Z- 5 7 ho�i73
Conhacror License No. Masler Lic. No. (Plant Ele
��� � �/Z �S`
A-11 8/96 STATE BOARD COPY - SEE INSTftUCT10NS ON BACK OF YELLOW �'-"�` ----