P - 80661r � REQUEST FOR E�ECTRICAL INSPECTION °'�
7(�•� _ 8 9 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 Industrial Farm Remod Re air
Air Con Htg. Equip. Water Htr. Load Mgmt. Other:
Dryer Range Elec. Heat Temp. Service
"X" obove the work covered by this request. Enter remarks in this space and on the back of the white copy only.
P..�b �I,r�,u� t�S �-l�1 � ��s
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 to 200 Amps 0 to 100 Amps
Street Ltg./Tra(fic Sig. Above 200 Am s Above 100 Amps
Transformer/Generator INSPECTOR�s uSE ON�Y TOTAL '�/,
Sign/Outline Lig. Xfmr. V
Alarm/Remote Control
Swimming Pool
I hereb certi that I ins ted the elechical installation deuribed herein on ihe dates stated
Irrigation Boom RougMn Dare
Special Inspection
Final
Investigative F ' �_—
THIS INSTAL E ORDERED DISCQNNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
� OFFICE USE ONLY This request void 18 monfhs from validafion date printed in fhis box.
i�iii ii {�I ii i�i ii lil ii iil ii iia�i iii ii iii i{nl . a° "�
* 0 7 9 9 8 9 4 1* � g V�
PLEASE PRINT OR TYPE
Request Dafe Rough-in inspecfion required$ ❑ Yes � o Inspecfion Ofher Than Rough-In: ❑ Ready Now ill Call
� �You musf call fhe inspecfor when ready) Dote Ready: ��
I, licensed contractor ❑ owner hereby request inspection of the above electrical work at:
1ob Address (Sheet, Box, or Roufe No.) Ciy � Zip Code �
!4 '�u�� i ��n �rtd� Ssy�L
$ection No. Township Name or No. Range No. . Fire No. Counfy �� �
Occupant Phone No. �
�au..r s� �f -v7 � �
Power Sopplier Address
Elecirical Conhactor (Company Name) Conkac/fo�r Lyice�n�se No. /�, Masfer Lic. No. �Planf Elect. Only)
SlA1�iE FffO. AiC ELECT.� {NC. \,1 ' U I 1 1(e
.,.�.,...'..�.,.. ..� .� �
�(:onracfoT ner Pertormi� Inslallofion) � Rij f�, V tJ I Pho��
� �P.�,1J�J��s 7-(O ZaD
•,, ., .�TATE BOARD. COPY - SEE INSTRLCTIONS ON BACK OF YELLOW COPY