P - 80782, _ � 0-854-582 Q
Home Duplex
Commercial 4ndustrial
Air Conditioner Htg. Equip.
Dryer Range
,X" above the work covered by
Ca/cu/ate Inspecti
Other Installations
Mobile Home Park Stall
Street Ltg. / Traffic Sig.
Transformer/Generator
Sign / Outline Ltg. Xfmr
Alarm/Remote Control
REQUEST FOR ELECTRICAL INSPECTION
Minnesota State Board of Electricity
1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104-2993 -
(651) 642-0800 www.e/ectricity.state.mn.us � : '
, Other: New Addn
Farm Aemod RE
Water Htr. Load Mgmt. Other:
Elect. Heat • • Temp. Service
��t�� nv��if ���ack of the white copy on/y.
Fee - This Inspection Request will not be accepted without the correct fee.
�e # Service Entrance Size Fee # Circuits / Feeders Fee
0 to 200 Amps 0 to 100 Amps
Above 200 Amps Above 100 Amp
INSPECTOR'S USE ONLY TOTAL
�0•.S�
I herebvi certiN that I insoected the eledrical installation described herein on the dates stated:
_ � Investigative Fee � � � jl7 � ��
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS
........,,,,,,,,,,,...........- - ,.....�WW........� ......................�.....,��...t.....,..,.._._ --........,..
OFFICE U8E ONLY This request vdd 18 months from validation date printed in this box.
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*08545824* `1�B�R�
PLEASE PRINT TYPE
R�.�� Rough-In inspection required? ❑ Yes ❑ No Inspection Other Than Rough-In: ❑ Re��lill Call
You must call the inspector when ready! Date Ready:
x
I, ❑ licensed contractor ❑ company ❑ owner hereby request inspection of the above electrical work at:
Jo (Street, City Zip C .
Section No. Township Name or No. Range No. Fire No. Counry
Electrical Contractor ( Company Name
Y2�iQT DC�QNC J"11/Z'�,"ba�ti'!C, 1lA�t�'� �
Mailing Address (Contractor, Company ar Owner Perfortning Installati
Authorized Signature (Co or Owner Performing Ir�
6 01A-12 5/1999 STATE BOARD COPY
Contractor License No. j Master Lic. No. (Plant Elect. Ony)
Phane Number
SEE INSTRUCTIONS ON BACK OF YELLOW COPY