P - 82511REQUEST FOR ELECTRICAL INSPECTION
������- 2 5 5� Minnesota State Board of Electricity 3
' 1821 University Avenue Suite 5-128, Saint Paul, Minnesota 55104-2993 -
(651) 642-0800 www.electricity.state.mn.us "ffi'
Home Duplex Apt. Bldg. Other: _c, j � 1y�� ew Addn
ommercial Indusirial Farm '� �"�'�'� �rTR�
� Remod Repair
Air Conditioner Htg. Equip. Wafer Htr. Load Mgmt. Other:
Dryer Range Elec. Heat Temp. Service
�"X" ab ve the work covere y this request. Enter remarks in this space and on t e back of e white copy only.
G;�S� ��1-l� �'�' 6' �?� ���7�/�-�,
�.Q ���` �.
Calculate Inspection Fee - This Inspection Request will not be accepted without the correct fee:
Other Installations Fee # rvice Enhance Size Fee # Circuifs / Feeders fee
Mobile Home Park Stall 0 to 200 Amps � 0 to 100 Amps �,QO
Street ltg. / Traffic Sig. Above 200 Amps Above 100 Amps
Transformer/Generator INSPECTOR'S USE QNLY TOTAL ` �
Sign / Oudine Ltg. Xfmr. ,()
Alarm/Remote Control
Swimming Pool
I hereb certi that I ins ted the elechical installation described herein on the dates stated:
Irrigation Boom �'%"'s Roogh-In • Da
Special Inspection ����
Investigafive Fee F��a' D�� ( -U (
THIS INSTALLATION MAY BE ORDERED DISCO CTED IF NOT COMPLETED WITHIN 18 MONTHS.
'1� I�������� 1���1117�IIf II III I IIII �4 � O v 1
* 0 9 9 5 2 5 5 7* %,, �
�� "'� �D PLEASE PRINT OR TYPE
RequeSf ate Rough-in inspection required$ Yes ❑ No Inspection Other Than Rougfi-In: ❑ Ready Now Will Call
1�� �� You must cal) the inspector when ready Date Ready:
1, � licensed contractor ❑ company ❑ owner hereby request inspection of the above electrical work at:
1ob Address trcet, Bo�c, or Route No.) Zip Code �
da �P�� L� f
Sec n No. Township Name o. Range No. Fire o. County
� � ���1� / � V � ��
Occu � � � � .,�.�i%�/�/'�� �L:� � PhoneN� 6 �� �'^'����
f^
PowerSupplier �� Address
�y o.,
EI 'cal Contmdor / Company Name Conkacfor License No. � Master Lia Na �Plant Elect. Only�
Y � �� �13�
Mailing�Addreu (Conhacfor, Company or Owner �P�er ?r�mi�ng Insfallation) � Q
f� 1 2 N�C7 /�'� /U� r d cl-� ft,, f�l/✓
ature (Contmcror or Owner Performing Installation) Phone Number
1�6� 3-��
E A-72 5/199 STATE BOARD COPY SEE INSTRUCTIONS ON BACK OF YELLOW COPY