P - 83529REQUEST FOR ELECTRICAL INSPECTION � e.
5 3 L��'-} 1 � Minnesota State Board of Electricity
1821 University Ave., Rm. S-128, St. Paul, MN 55104
Phone (612) 642-0800 �
Home Duplex Apt. B�dg. Other: ' � New Addn
Commercial Indushia) Farm Remod Re air
Air Cond. Htg. Equip. Water Hh. Load Mgmt. Other:
Dryer Range Elec. Heat Temp. Service
"X" above ihe work covered by this request. Enter remarks in this space and on ►he back of the white copy only.
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Calculaie Inspecfion Fee - This InspecFion Request will not be accepted without the correcf fee:
Other Fee # Service Entrance Size Fee # Circuifs/Feeders Fee
Mobile Home Park Stall 0 to 200 Amps 0 ro 100 Amps
Street Ltg./7raffic Sig. Above 200 Am s Above 100 Amps
Transformer/Generator INSPECTOR'S USE WiLY 3 w TOTA
Sign/Oudine Ltg. X�rnr. � � � �'`� �
Alarm/Remote Control
Swimming Pool
1 ' IFw1 I in lhe elec�rical inspllo�ion described herein on the da�es stated
e rca
Irrigafion Boom Ro„9�,.i„ F� _
Special Inspection
Invesfigafive Fee � -�^�
THIS INSTALLATION MAY BE ORDERED DISC ECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE OI�ILY This requesf void 18 months from validafion date printed in this box.
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Re9ueN Da�e Rough-in inspecfion required$ ❑ Yes ❑ No Inspeclion Olher Than RougMn: �- �Reody Now ��II CaH
�L n, �� 9 g (You musf ml) the inspacror when reody) Da�e Reody:
I, ❑ licensed contractor � owner hereby request inspection of the above elechical work at:
Job Addreu �Sheer, Box, or Roula No.) Ciy � Zip Code
p 2 I?c r,�+ a N , A �ce, t, � N►N .ss �f z. r
Section No. Township Name w No. Range No. Fire No. County
K
o«���r � r� No.
w4.� SI��eLs 7Z-$7�
r�. s�� ndd�u
M�N � � ws c,
Electrical Conhacror (Company Name� Contracror license No. Master Lic. No. (Plant Elect. Only�
Mailing Address (Contractw w Owner Perfiormirg Installation) .
Authorized Signalure (Conhocior or er Performing Insfollation) Phone No.
.
E&OWOI A-11 /96 g7A7E BOARD COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY