P - 80365REQUEST FOR ELECTRICAL INSPECTION �e°'E
�p��q � p /� �� Minnesota State Board of Electricity �'
O a �� �t 1621 University Avenue Suite S-128, Saint Paul, Minnesota 55104-2993 �
(651) 642-0800 www.electricity.state.mn.us �� '
Home Duplex Apt. Bldg. Other: New Addn
Commercial Indusirial Farm Remod Repair
Air Conditioner 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 s ace and on the back of the white copy only.
Po�el' Suppl� �� �a6`e T V• Cyc��
U-t-� l►�es n�ee�l �� be C�on�ec�-er./
Calculate Inspection Fee - This Inspection Request will not be accepted without ►he correct fee:
Other Installations 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 5�
Sig� / Outline Ltg. Xfmr. —"
Alarm/Remofe Control � I � � (��
Swimming Pool ��
I hereb certi that I ins ted the elechical installation described herein on the dafes stated:
Irrigation Boom Rough-In Dare
$pecial Inspection _
Final Da
Investigative Fee ` � — 00
THIS INSTALLATION MAY BE ORDEREO DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONIY This requesf void 18 months (rom validafion date printed in this�box.
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* 0 8 9 9 4 4 6 9* '
PLEASE PRINT OR TYPE
Requesf Dafe Rough-in inspecfion required$ ❑ Yes ❑ No Inspection Ofher Than Rough-In: Ready Now ❑ Will Call
� �. � You must call the inspecfor when ready Date Ready: � �
I,�licensed contractor ❑ company ❑ owner hereby request inspection of the above electrical work at:
Job Address �Sireet, Boz, or No.) Ciy . Zip Code
�. � � ,
Section No. Township N or No. Range No. Fire No. ty
�g�< f�Cr�z�} �}'�k �...
Occu n Phone No.
J�l�e d�4, O e_
Power Sup ier Address
� �
Elechical Controctor / Compa y Name Contracfor license No. Master tic. No. (Plant Elect. Only)
I'�'l �� b ro�.� � 1�e -f-r� " � o t�3 �
Mailing Address �Confractor, Company or Owner Performing Insfallation)
a 3 B i r � � D/'- � �� �.0 c�"'t° f' /YI n1 SSo 8a-
AWhori d Si fure (Confracfor, Co n or Owner Pe ing Insfallation) Phone Number �
(�57� ��fs- 9030
E 1A-12 5/1999 STATE BOARD COPY SEE INSTRUCTIONS ON BACK OF YELLOW COPY