P - 82726T� REGIUEST FOR ELECTRICAL INSPECTION
J O�-17 4 Minnesota State Board of Electricity
1821 University Ave., Rm. S-128, St. Paul, MN 55104
Phone (612)642-0800
Home Duplex Apt. Bldq. Other: New Addn
Commercial Industrial Farm Remod Re air
Air Cond. Htg. Equip. Water Htr. Load Mgmt. Other:
Dryer Range Elec. Heat Temp. Service
"X" obove Ihe work covered by this reques►. Enter remarks in this sppce and on the back of the white copy only.
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Calculate Inspection Fee - This Inspection Request will noi be accepted without the correct fee:
Other Fee # Service Entrance Size Fee # Circuits/Feeders Fee
Mobile Home Park Stall 0 to 200 Amps Z 0 to 100 Amps a. �v
Sheet Ltg./Traffic Sig. Above 200 Am s Above 100 Amps
Transformer/Generator INSPECTOp'S USE ONLY T TAL
Sign/Oudine Ltg. Xfmr. ot ��
Alarm/Remote Control
Swimming Pool
I here certi Ihat I ins the eleclrical installafion described herein on Ihe da�es sfated
Irrigation Boom RougMn Da�e / Z
Special Inspectio °p���,
Investigative Fee �— 7C.�--�� �
THIS INSTALLATION MAY BE ORDERED DISCO CTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFRCE USE ONLY This requesf void 18 months kom validaTion dake printed in this box.
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* O 5 O L 1� 4 7* PLEASE PRINT OR TYPE
Request Date Rou h-in ins on r uired$ es
. g pecti eq ❑ No Inspeclion OIF�er Than RougMn: ❑ Ready Now �11 CaN
a.� /i (You must call ihe inspeclor when ready) Da�e Ready:
I, icensed conhactor ❑ owner hereby request inspection of the above elecFricol work at:
�ob Ada.ess �stree�, soX, o� eoute rJo.� cy ziP cade
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Secfion No. Township Name or No. Ranpe No. Fire No. ounN
/�-itJa �i�
Oau t Phone No.
6 �. s-��- /� �
Power Supplier Address
S/° /!a � � � �
E 'cal Contracror (Compa�ry Name) � Contracror license No. Masrer lic. No. �Plant Elec1. Onl�
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Mailing Address (Conhacfor or Owner PerForming Installafion
O C,o�,3� l ��-.��'r/��✓ �',�✓ ,�r �
Authorized 'gnature (Contracfor Owne rforming InsfallaKon) one No.
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E 1 Arl 1 8/96 STATE BOARD COPY - SEE INSTRUCTIONS ON BACK OF Y�LLOW COPY