P - 82933REQUEST FOR ELECTRICAL INSPECTION = -
5�•� �. � 0 O � Minnesota State Board of Electricity
1821 UniversiTy Ave., Rm. S-128, St. Paul, MN 55104
Phone(612)642-0800
Home Duplex Apt. Bidg. Other. New Addn
Commercial Industrial Farm Remod Re air
Air Cond. Htg. Equip. Water HFc Load Mgmt. Other:
Dryer Range Elec. Heat Temp. Service
"X" above the work covered by this request Enter remarks in this space and on the back of the white copy only.
aa�`�u� G2c��e- rew wlr�nc� _
F�e'MO�.����e1 e)G1S�\t�� �'j�2C�^ �'''�V�1\'(�i�
Cj
Calculate Inspection fee - This Inspection Request will not be accepted without the correct fee:
Other Fee # Service Entrance ize Fee # Circuits/Feeders Fee
Mobile Home Park Stall 0 to 200 Amps �" 0 to 100 Amps
Sfreet Ltg./Traffic Sig. Above 200 Am s Above 100 Amps
Transformer/Generator INSPECTOR'S US� ONLY TOTAL
s s ��� �� �� � �o sfl
Si n/Oudine Lt . XFmr.
Alarm%Remote Control
Swimming Pool l�� ��''�(�
1 her ceAi Ihaf I ins Ihe elecFrical installa6on descri herei� on the dafes stafed
Irrigation Boom Rough-In .— Das. � Q�
Special lnspection ' �/ w� "�eS' o I
Investigoiive Fee F�� � C I
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 1$_MQNTNG
pFf7CE USE ONI.Y This roquesf wid 18 months from validation dafe printed in this box.
{IIHIII�Illlllllllf IINIIIIllfl111l1111lI
,� .� ��a� � ��,��
' �K Q 5 3 2 5 D 0 6�: PLEASE PRINT OR TYPE
Request Date Rough-in inspeclion required? �Yes ❑ No lnspection 01her Than RougMn: ❑ Ready Now �II CaN
�•� �.�� �`/ou must call the inspecSOr when reody� Date Reody:
�i �w
I, ❑ licensed contracror �owner hereby request inspection of the above electrical work at:
Job Address (Sheet, Box, w Roule No.) Ciy Zip Code �
2c� � SY �V -LP�N� 'F ' ��e � 5 �1 z
$eclion No. Township Name w No. Range No. Fire No. Cou
r i c� � Q 't10�a
�� Phone No.
�F,�.;�r �'�-t�v��T _ 'S� 1 • 11 �?
vo��
S :� 6 ` . . ` ►�
. .
Conhacfor (Company Name) � � Conhacfor License No. Masfer c. No. h
lddress (Contractor or Owner Performing Insfallafion)
l�ieflormm�,n�ananon� _
Y� 5�f ^11'1
ST OARD COPY - SEE INSTRUCTIONS ON BACK OF YELLAW COPY