P - 83576REQUEST FIaR ELECTRICAL INSPECTION -:�
��('� �� p/� � Minnesota State Board of Electricity
., f) O�f ` 1821 University Ave., Rm. S-128, St. Paul, MN 55104 -
CI / `% /� Phone (612) 642-0800 '� �
J `C [ LJ
Home Duplex Apt. Bldg. Other: New ddn
ommercial Industrial Farm Remod Re air
Air �. Htg. Equip. Water Htr. Load Mgmt. Other:
Dryer Range Elec. Heat Temp. Service
"X" above the work covered by this request. Enter remprks in this space and on the back of the white copy only.
���c�� A,�1r G�v►G� i i�i.��.�w
Calculate Inspection Fee - This Inspection Requesf will not be accepted without the correct fee:
Other Fee # Service Entrance Size Fee # Circuits/Feeders Fee
Mobile Home Park Stall 0 to 200 Amps 0 to 100 Amps
SMeet Ltg./Traffic Sig. Above 200 Am s Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY TOT�L ���
Sign/Oudine Ltg. Xfmr.
Alarm/Remofe Confrol
Swimming Pool
I hereb certi thaf I ins ted fhe elechical installation dexribed herein on the dafes stafed
Irrigotion Boom RougMn Dare
$pecial inspecti �-
Final Da
Investigative Fee . —��—p
THIS INSTALLATION MAY BE ORDERED DISCO CTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This requeaf void 18 months from validation dafe printed in this box.
I�IIiIIIIIIIIIIIIIIIIIINMI��llllllll��ll� • l���/
* 0 7 3 6 2 8 4 1* ��� `f'
EASE PRINT OR TYPE
Request Dat'�� � Rough-in inspeclion required2 ❑ Yes No Inspection Other Than Rough•In: eady Now ❑ Will Call
e7
(� (You must call the inspecfor when ready) Date Ready:
I, licensed contractor ❑ owner hereby request inspection of the above electrical work at:
lob Address �Sheet, Bq�c, or Route No.� Ci1 � Zip Code �_
Section No. Township Name or No.
Oc ant
Power Supplier
Elechical Contractor (Company Nome)
Mailing Addre (Conhacfor or ner
�
A(Ilfery7�ed SignaNre �Conhoctor or O�
' Ran�s No. Fire No. C�u ly
Phone No.
^ ` V�
reu
Co acror License No. Moster Lic. No. (Plant E
. I
6.t(i
'ng Installa'o � �
�
'erforming Insfol afion) i r}. ��'*- - � Phone No.
2 � s � � C�cZ°� �
BOARD COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY