P - 83373RE(�UEST FOR ELECTRICAL INSPECTION �°�.
7 l_J `J�- 5 6 8� Minnesota State Board of Electricity '3
1821 University Ave., Rm. S-128, St. Paul, MN 55104
, Phone (612) 642-OS00 `'�'
Home
New
ommercial Industrial Farm Remo � Re
ir Con tg. Equip. Water Htr. Load Mgmt. Other.
Dryer Range Elec. Heat Temp. Service
"X" above,t(�e �rk covered by this request. Enter remarks in this space and on the bock of the whi►e copy only.
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Calculate Inspection Fee - This Inspection Request� b� acce ed� out the correcf fee:
Other Fee # Service Entrance Size Fee # Circuits/Feeders Fee
Mobile Home Park Stall 0 to 200 Amps 0 to 100 Amps
Street Ltg./Traffic Sig. Above 200 Am s Above 100 Amps
Transformer/Generator INSPECTOR'S use oN�r TOTAL �.. ;
Sign/Outline Ltg. Xfmr. �
Alarm/Remote Control
Swimming Pool
I hereb certi rhat I ins ted the elechical insfallafion desaibed herein on the dafes stated
Irriaation Boom p,,,,,,k�., n„b
invesngarrv� r�e — �— -� 6 —.
THIS INSTALLATION MAY BE ORDERED DISCON ECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFlCE USE ONLY This requesf void 18 monihs (rom validation date prinTed in this box.
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PLEASE PRINT OR TYPE
�quesf � Rou h-in ins fion � uired?
�/7 (`� _� g pec eq ❑ Yes No Inspection Other Than RougMn. eady Now ❑�II Call
���1 (You must call fhe inspector when ready) Da1e Ready:
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licensed contractor ❑ owner hereby request inspection of the above electrical work at:
lAddreu ( h t, Bo Route o.) _ Ciy Zip Code
i�
cfion No. Township Name or No. Ranqe No. Fire No. Coun
Phone
Elech'ca Conhactor (Company Name) , Confr or License Masfer Lic. No. �Plant Elecf. Only)
ailing Address (Conhactor r er Perfor ing Installatio
(/ �`-���Z
Aufhoriz SignaNre Contr r Performin sfallafion) Phone No�_ , '
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EB-00001 A-11 8/96 STATE BOARD COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY