P - 84176REQUEST FOR ELECTRICAL INSPECTION ��_.
5�'� w/� Q� � Minnesota State Board of Electricity
`+ V 1821 University Ave., Rm. S-128, St. Paul, MN 55104
� Phone (612) 642-0
;...._--
- . ., � /i1
Home Duplex Apt. Bldg. Other: �� j=r! New Addn
ommercial Industrial farm `� Remod Re air
Air Cond. Htg. Equip. Water Htc Load Mgmt. Other: i
Dryer Range Elec. Heat Temp. Service
"X" above the work covered by this request. Enter remarks in this space and on the back of the white copy only.
Calculate Inspec►ion Fee - This Inspection Request will not be accepted withoui the correct fee:
Other Fee # Service Entrance Size Fee # Circuits/Feeders Fee
Mobile Home Park Stall 0 to 200 Amps to 100 Amps
Street Ltg./Traffic Sig. Above 200 Am s Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY TOTAL '
Sign/Outline Ltg. Xfmr. � �t �$'�'�zrs'�""' �/ �
Alarm/Remote Control ��, C � rLCC�,,��
Swimming Pool
I hereb certi thaf I ins ed the elecfrical " fallafion dexribed herein on the dafes stated
Irrigation Boom RougMn � � �
Special Inspecti ` "
Final , � n �
Imestigative Fee �
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFlCE USE ONLY This request void 16 monihs �rom validation daTe printed in fhis box.
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* 0 5 3 2 4 8 2 i* PLEASE PRINT OR TYPE �`� �
Request Date Rou h-in ins tion r uired?
C g pec eq Yes ❑ No Inspection Other Than RougMn: ❑ Ready Now Will Call
b� Z (You must call the inspeclor whe rea � Date Ready:
I, ❑ licensed contractor owner hereby request inspection of the above electrical work at:
Job Address (Skeef, Box, or Route No.) City Zip Code
�/ ���' � e °d1 S�Ll3L
ection No. Township Name or No. Rarige No. Fire No. C nty
_ Id�
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OccupanT Phone No.
E,f 1 �1 ' ,�,-'i- .5��- 6�3'
Power Supplier �� � ddress
Elechi�tracfor (Company Name) Confracfor License No. Master Lic. No. (Planf Elecf. Only)
iX �C.. � � �_
(� . �j v�► iGt- 1
Mailing Address (Co hacfor or Owner PerForming Inst I ion�
��.N.�� �( QA+C� /� GI N
Authori Si a re �Co acfor or Ow r Performing Installation� Phone No.
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E&OOOOIA-11 8 STATE AFiD COPY - SEE IN RUCTIONS QN BACK OF YELLOW COPY