P - 80676.ir REQUEST FOR ELECTRICAL INSPECTfON ��
C���� O� Minnesota State Board of Electricity -
3'� O 1821 University Ave., Rm. S-128, St. Paul, MN 55104
Phone(612)642-0800
Home Duplex Apt. Bldg. Other: '/� �� New Addn
Commercial Industrial Farm Remod Re ir
Air Cond. Ht . Equip. Water Htr. Load Mgmt. Other:
Dryer Range Elec. Heat Temp. Service
"X" above the work covered by ihis request. Enter remarks in this space and on the back of the white copy only.
Calculate Inspection Fee - This Inspection Requesf will not be accepied without the correct fee:
Other Fee # Service Entrance Size Fee Circtirts/F Fee
Mobile Home Park Stall 0 to 200 Amps 0 ro 100 Amps
Street Ltg./Traffic Sig. Above 200 Am s Above 100 mps
Transformer/Generator INSPECTOR'S USE ONLY / TOTAL
Sign/Oudine ltg. Xfmr. ��y�, �� ' QC� � S�
Alarm/Remote Control
Swimming Pool
I her certi t{w11 in the elechi installation described herein on Ihe dates stated
Irrigation Boom Ro„gM„ /
Special Inspect' 3
� Fi�wl c. ._ /i�
Investigative , s. • —�v
THIS tNSTALL'A� MAY BE ORDERED DISCONNECTED IF NOT COMPLETED IN 18 MON �';
OFFICE l�E ONLY This request void 18 months from validation date printed in this box.
(�(` `( (`N` • �jI �
I�III IIII) II III I� I�� �I II) II I I� II� I�III I��I) 3�3 /
* 0 5 3 2 5 8 2 4�K PLEASE PRINT OR TYPE
Requesf te Rou h-in ins on uired� � Yes specli g ❑ Ready Now � wll Call
g pecli req ❑ No In on Other Than Rou Mn:
"p�r. (You must call Ifie inspecror when ready) � Dafe Ready: .
I, ❑ licensed conhactor ❑ owner hereby request inspecFion of the above elechical work at:
Job Address �Sheet, Box, or Route No.� � Ciry Zip Code
3 S-t u,'n S t F'.�, �� SS'
Section No. Township Name a No. Range No. Fire No. C ny
3� � �
oa�pa�r Pha�e o:
i r �
�. � V
Power Sup�l'ier Add S' oT /� � f'�•
S �
Elechical Conhactor (Company Name) Conhacror License No. Masfer lic. No. �Planf Elecl. I�
Y^i
Nbiling Address (Contractor or Owner PerForming Installafion)
S �� �, °
AutFarized Signature (ConhacTOr w Owner Performi InsAOlbtion) � P1ane No.
� 7 � � � �
EB-00001 A-11 96 �7pTE BOARD COPY - INSTRUCTIO CK OF YELLOW COPY