P - 83633i '� � �
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Home Duplex
Commercial Industrial
"X" above th
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RE(�UEST FOR ELECTRICAL iNSPECTION --
Minnesota State Board of Electricity
1821 University Ave., Rm. S-128, St. Paul, MN 55104
� Phone (612) 642-0800 '
Apt. Bldq. Other: New Addn
Farm
Water Htr. Load Mgmt. Other:
Elec. Heat Temp. Service
request. Enter remarks in this space and on
copy
Calculate Inspection Fee - This Inspection Request will not be accepted without the correci fee:
Other Fee # Service Entrance Size Fee # Circuits/Feeders
Mobile Home Park Stall 0 to 200 Amps 0 to 100 Amps
Street Ltg./Traffic Sig. Above 200 Am s Above 100 Ar
Transformer/Generator INSPECTOR'S USE ONLY TOT�
$ign/Outline Ltg. Xfmr. `
Alarm/Remote Control
Swimming Pool
I hereb certi fhat I ins ted the elechical installafion described herein on the dak
Irri9ation Boom Rough-In Dore
Special inspectio •
Fee
. ��
Finol D �
Investigative fee '�
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This request void 18 months from validation dafe prinfed in this box.
,�, SSv
I IIII II III II III II III II III �� III Ii lll !I III I IIII �- ��a�
* � 4 6 8 7 5 9 �� PLEASE PRINT OR TYPE�
Request Dafe Rou h-in ins ction re uired?
g pe q ❑ Yes No Inspection Other Than Rough-In: ❑ Ready Now Will Call
��` � l� �' � �You must call ihe inspector when ready) Dafe Ready:
I, �licensed contractor ❑ owner hereby request inspection of the above electrical work at:
Job Address (Sheet, Box, or Route No.� City Zip Code
' 1' �r� 1"� .. � � �-�-��� !� � ����i` �.3-
$ecfio� No. Township Name or No. Range No., Fire No. County
Phon�No.
�� ��� 0,� ��. _� 7�- ` ��`�l 3 �
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Elechi�al Contr cfor �Company � Contractor license No. Master Lic. No. �Nanf Elecf. Only)
S�c�-,Y�E,W- —�–�� `�}–►- c�c:.. i � � . ��- �'%17 l I
Mailing Address (Conhacfor or Owner Performing Insfallafio
�1._�`'i�� �-i �� � `�-f�. `�lC� CC�`'�� `'�1"A,' ��110
Authorized Sig�afu hacror or Owner Performin atio � 5 3�� P� n No.
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&OOOOIA- 8/96 STATE BOARD COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY