P - 80699RE(�UEST FOR ELECTRICAL INSPECTION ��
'7'� � � 9 � � � Minnesota State Board of Electricity ' -� � --" �
E 1821 University Ave., Rm. S-128, St. Paul, MN 55104
� Phone(612)642-0800
Home Duplex Apt. Bldg. Other. So�C ��1C o%+�Lt 3;�'D New Addn
5 Commerciol Industrial Farm w�ek o F 6`- 7-�'r� Remod Re air
Air Cond. Htg. E uip. Water Htr. Load Mgmt. Other:
Dryer Range Elec. Heat Temp. Service
"X" above the work covered by this requesi. Enter remarks in this space and on the back of the white copy only.
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Calculate Inspeciion Fee - This Inspection Request will not be accepted without the correct fee:
Ofher 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 TOTAL
Sign/Outline Ltg. Xfmr. /
Alarm/Remote Control �Q � �'d
Swimming Pool
I hereb certi that I ins fed the elechical installafion described herein on the dates sfated
Irrigation Boom RougMln Dare
Speciallns ct
Investigative Fee F��� DO� —�C's "CJ�
THlS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFflCE USE ONLY This requesf void 18 months from validafion dafe printed in this box.
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PLEASE PRINT OR TYPE
Requesf Date � Rou h-in ins ion r uired?
g pecl' eq ❑ Yes o Inspection.Other Than RougMn: ❑ Ready Now I Call
i+ �� (You must call the inspecfor when ready) Dafe Ready: �
I, licensed contractor ❑ owner hereby request inspection of the above electrical work at:
Job Address (Sheet, Box, or Route No.) Ciy f Zip Code
G�I o � C �u /.�� d /�
$ecfion No. Township Name or No. Range o. Fire No. ounty . �
��U� �
Phone No.
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Elec ical Con acfor (Company Name) � Conhactor License No. Master Lic. No. �Planf Elect. Only�
S��e �Le�T��c ,��►C C ao/�'t.Z
Mailing Address Contractor or Owner PerForming Installafion) �
o� hr�a v� /V, �= su,�r �' �,�i Lr ot ,. s'sY.�
Au riz Si ature (Conhacfor or Owner Performin Ins lation� Phone No.
� � � 2 � 6�� %�o- ,S 6,zS,
E $ 9 STATE BOARD PY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY