P - 80679� RE(�UEST FOR ELECTRICAL INSPECTION -
5��-- 5 81 Minnesota State Board of Electricity
1821 University Ave., Rm. S-128, St. Paul, MN 55104
" Phone (612) 642- 00
me Duplex Apt. Bldg. Other: �f� / % New Addn
Commercial Industrial Farm ��° � �L�63- c- Remod Re ir
Air Cond. Htg. Equip. Water Htr. Load Mgmt. Other:
Dryer Range Elec. Heat Temp. Service
"X" above the work covered by this request. Enter remarks in this space and on the back of ihe white copy only.
Calculate Inspection Fee - This Inspecfion Request will not be accepted wifhoui the correct fee:
Other Fee # Service Entrance Size Fee # Circuits/Feeders Fee
Mobile Home Park Stall 0 ro 0 to 100 Amps
Sfreef Lig./Traffic Sig. Above 200 Am s Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY TOTAL ���
Sign/Oudine Ltg. Xfmr.
'�` " Alarm/Remote Control
Swimming Pool
I here certi thc�t I ins fhe electrical insfallation describad herein on the dates staled
t
Irrigation Boom RougMn ^��
Special Ins �
Final ��e QR'
Investigafive t �a
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This request void 18 monfhs (rom validafion date printed in this box.
� 374q�3�00
III�IIIIIIIIIIIIIillllill lllllllllilllllll �/�
* � 5 3 2 5 8 L(� 7k PLEASE PRINT OR TYPE
R est Date/� /� Rough-in inspecfion required? es ❑ No Inspeclion O�er Than RougMrr.. ❑ Ready Now �II Call
�� l%�� —J (You must call the inspeclor when ready) Date Ready:
I, ❑ licensed contractor ,�owner hereby request inspection of the above electrical work at:
Job Addreu (StreN, Box, or Route No.) Ci � Zip Cade
�jc�o ' T�.�w . � 5�43 a—
Secfion No. Township Name or N Range No. Fire No. Coun
�O � n� �
����� �-�-�Ic� S-i✓�e,cfi-� P�%Z -��2, —1�i o
Power Suppl er Addreu �
I'VI �LS N� . D � J ���
Elechical Contracror (Company Name) Contractor ticense No. Master Lic. No. (Plant Elacf. Only)
V •' �
Mailing Address (Conhactor or Owner PerForming Insfallalion)
Sc%v�
Au 'zed Sigrwiu Con or Ow PerForming I ��� � P1 �- ��D �
�
E 1 A-11 8/96 ST TE BOARD COPY - SEE INSTRUCiIONS ON BACK OF YELLOW COPY