P - 83284631-��204 �
Home Duplex
Commercial Industriol
Air Cond. Htg. Equi
Dryer onge
"X" above the work covered
REQUEST FOR ELECTRICAL INSPECTION
Minnesota State Board of Electricity
1821 University Ave., Rm. S-128, St. Paul, MN 55104
Phone (612) 642-0800 `' '
Other: New Addn
Farm
Water Htr. Load Mgmt. Other:
Elec. Heat Temp. Service
request. Enter remarks in this space and on
ite copy
Calculate Inspection Fee - This Inspection Request will not be accepted withoui the correct fee:
Other Fee # Service Entrance 'ze Fee # Circuits/Feeders Fee
Mobile Home Park Stall � 0 to 00 Amps � � 0 to 100 Amps 7�
Sireet Ltg./Traffic Sig. Above 200 Am s Above 100 Amps
Tronsformer/Generator �NSPECTOR'S uSE ON�v TOTA��' �D
Sign/O,udine Ltg. Xfmr. ��,Z Ga�-�y �
Alarm/Remote Control
Swimming Pool I hereb certi lhaf I in ed the electrical instollafion described herein on the dates stated
Irriaation Boom a�....�., n,.b
� Investigative Fee �`� }-' -i L C � C-- � J� jj " z"T
THIS INSTALLATION MAY BE ORDERED DISCONNECTED iF NOT COMPLETED WITHIN 18 RAONTliS. _
OFFICE (1SE ONLY This request v�oid 18 months from validation date prin in this box.
� I�I I� I�I N �I� II ��I�i�� ��I I� I�� �� ��� • �� �
II�III�I
� 0 6 3 Z 2 0 4 5� ���
PLEASE PRINT OR TYPE
Re uest Dafe Rou h-in ins fion r uired2 ❑ Yes
�_ 2 g pec eq �No Inspection O�er Than RougMn: ❑ Ready Now 0 Will Call
�� 9$ �You must call the inspector when ready) Dafe Ready:
I, ❑ licensed cantractor ❑ owner hereby request inspection of the above elechical work at:
Job Address �Sfrcef, Box, or Roufe No.) City Zip Code
(014� S��9Rt���lT' LVb �'�rD�� �
$ection No. Township Name or No. Range No. Fire No. � Counly
�--- +____. �-- �} N� K �f
Occupant Phone No.
D o R, 5 /✓� L So^/ S 7/ - sZa f
Power upplier Address �
SP
!or (Company Name) Conhacfor license No. Masfef Lic. No. (Plant Elect. OnF,
'Jc�+�✓ �'�crRlc c,9 ool�oZ
(Confractor or Owner Performing Installafion�aRQQ�L�/ / .
' i✓m y?h� S>' CE�✓ri /'1 �i✓n/ SSr`�3Q
f re �Conhacfo r Owner Performing InsTallation) phone No. �"
:1 c- ' ' � �C/ 7Y���.7
9 STATE BOARD COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY