P - 80539�02-277 �
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Home Duplex
Commercial Industr'
Air Cond. Htg. E<
Dryer Range
"X" above the work covered
REGIUEST FOR ELECTRICAL INSPECTION
Minnesota State Board of Electricity
1821 University Ave., Rm. S-128, St. Paul, MN 55104
Phone (612) 642- 00
Apt. Bldg. Othe�:� c�'Y Ne Addn
e
�I Farm �� ` �� emod Re air
oip. Water Htr. Load Mgmt. Other:
Elec. Heat Temp. Service
by this request. Enter remarks in this space and on the back of the white copy only.
-- ��.,� � � _
Calculate Inspection Fee - This Inspection Request will not be accepted withou► Ihe correct fee:
Other Fee # Service Entrance Size Fee # Circuits/Feeders Fee
Mobile Home Park Sroll 0 to 200 Amps 0 to 100 Amps
Sheet Ltg./TrafFic Sig. Above 200 Am s Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY TOTAL, /� �
Sign/Oudine Ltg. Xfmr. ,� /%` 7 � o O
Alarm/Remote Control
Swimming Pool
ereb certi that I ins the el ' al installafion dexri her ' on the dates staAed
Irrigation Boom Ro„9M„ pa�9
Speciol Inspection ` �� rt� /
Fino! Dare � n r
Imestigative Fee � - - v3 �/L26�-
THIS INSTALLATION MAY BE ORDERED DISCONNECTED iF NOT COMPLETED WITHIN 1 MONTHS.
OFFlCE USE ONLY This request void I S months from validation date printed in this box.
I IfIP II Iff II III II fil 11 i11 II Ilf I! Ifl II I� II I� I INI
* 0 8 0 2 2 7 7 4* ������ ,�9,��
I, ❑ licensed contractor
Job Address �Sheef, Box, or Route
�i32 �r�,�
Section No. Township Name or
��
oc�upa�r
Power
�xce (
co�n«ro. �c
Mailing Address (Conhactor w
PLEASE PRINT OR TYPE
Rough-in inspection required? Yes ❑ No Inspeclion Other Thon Rough-In: ❑ Ready Now ill Call .
�Yo� musf call fhe inspecfor n ready) Dafe Ready:
�wner hereby request inspection of the above electrical work at:
Ciry Zip Code
� e� v e �r: �e �54 Z
Ra�ge Na. Fire No. County
29��_ 24 ��_
Phone No.
'7t�3 - 5�i- y78o
Mots N�� �� v � s��
Conhador License No. Master Lic. No. (Plani Elect. Only)
It�orized SignaNre (Conhacror or Owner Performing Instollalion) P
��w�`►\�((",,�JJ����'` rY'lc�'o�Mo�
b00�'4_� � 8�96 � ATE BOARD COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY