P - 84577REQUEST FOR ELECTRICAL INSPECTION
'-F �v�' 7- 0 5 4 Minnesota State Board of Electricity
, 1821 University Ave., Rm. S-128, St. Paul, MN 55104 �.
Phone (612) 642-0800
Home Duplex Apt. Bldg. Other: New Addn
Commercial Indusfrial Form Remod Re ir
Air Cond. Htg. Equip. Water Htr. Load Mgmt. Other:
Dryer Range Elec. Heat Temp. Service
"X" above the work cove by this reques . Enter remarks in this space and on the back of the white copy only.
�% ► r : G � �� 11 �� � �, �t �
C ld�, �; G E S e,� � �c� �;,� �c�; �� �� i.� c� ��/
� 2 �;P� �Tt e �. y
Calculate Inspection Fee - This Inspection Request will not be accepted without the correct fee:
Other Fee # Service Entrance Size Fee # Circuits/Feeders Fee
Mobile Home Park Stall 0 f mp j c1, � 0 to 100 Amps 4�
Sfreet Ltg./Traffic Sig. Above 200 Am s Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY TOTA
Sign/Oudine Lfg. Xfmr. �'� a a�
Alarm/Remote Confrol
Swimming Pool
I hereb certi fhat I ins fed the elecfrical installation described herein on fhe dafes sMted
Irrigation Boom RougMn . pa�
Special Inspecti � j *��_ — _
Final pa�
Invesfigative Fee r? -�
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This requesf void 18 monfhs 6om validation dafe prinfed in fhis box.
���������������������� I �
I��I ������������������ -
� o �/ �=s� � �9
4 5 i O 5 4 S* PLEASE PRINT OR TYPE
R � �O� RouglFin inspecfion required? es ❑ No Ins ion Olher Than Rou Mn:
� p�' g ❑ Ready Now Will Call
i~" ! C? Cj (l•ou must cali ihe inspecfor when ready) Date Ready:
!
I, � licensed confractor ❑ owner hereby request inspection of the above elecfrical work at:
Job Addrea (Sh x, or Rou1e .) Cily �� Zip Code
1 � � � �� ��E-� �: I`--p_, .� s����
on No. Township Name a No. Range No. Fire No. County ,7
1 �
='��� �`� � ff�L��fi
' Phone No.
( � ,� �,
pplier / - Ad �ess '; �
J �
-S � ��� ��_S ��� ��%G��f/C�r�-��
Conhac�or �Canpany Name� Confraclor License No. Master Lic. No. (Planf Elecf. Onh�)
I i� C� r'V C� � E l� �' /� �%Z;1 ��
�ddreu �Conhacfor or Owner Performing InsfallaKon _ t
�`- •c • r'1 L1�1 � � � N v� ,� �� �� �
d Signoture �Con w r Performing Installafion) A�� �� ^ Ph ne No. /
IV . - �� � ��3 �
41 � 8�9 STATE 80ARD COPY - SEE INSTRUCT1pNS ON BACK OF YELLOW COPY