P - 84142560-272 ���
/ Home
Commercial
Air Cond.
Dryer
"X" above the �
REGIUEST 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
Industrial Farm
Htg. Equip. Water Htr. Load M
Range Elec. Heot Temp. :
covered by ►his request. Enter remarks in
����� C�rn� �
Other:
spac and on the back
��l�'
Remod
copy
Calculate Inspection Fee - This Inspection Requesf will not be accepied without the correci fee:
Other Fee # Service Entrance Size Fee # Circuits/Feeders Fee
Mobile Home Park Stall 0 to 200 Amps 0 to 100 Amps
Street Ltg./Traffic Sig. Above 200 Amps Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY TOTA��`�
Sign/Outline Ltg. Xfmr. � � � � ; 1 �
Alarm/Remote Control ��
Swimming Pool
I hereb certi that I ins the electrical installation described herein on the dates stated
Irriqation Boom Rouqhln �}e
� Investigative Fee � � ' �y ' +' -� `J
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFlCE USE ONLY 'fhis request void 18 months from validation dafe printed in this box.
II � /�l�D
I ���� �) �I� �� ��� �� I�� (���� �� (�� �� ��� u�I � ��I� 2 5��`� ��3�
* � 5 6 � 2� 2 7* PLEASE PRINT OR TYPE ��0 lO
Requesf�% ,•y / � Rough-in inspecfion required? ❑ Yes o Inspection Ofher Than Rough-In: Ready Now � Will Call
/�/ ��� �� �You musf call the inspector when ready) Date Ready:
I, �k"censed contractor ❑ owner hereby request inspection of the above electrical work at:
1ob Address (S eet Box, or Route { - � City �� ' Zip Code
��( � /�.�1 ��i''� ,.,-^� f ei�� e�0 f� �.�/ � c /
Secfion No. Township Name or o. Range No. Fire No. ounty /
i
" 6:�`r�
Occupant
���r,���
d: or Owner Performin�
/
�i�f;!�� /
Phone No.
5 � ' ��
��� � ����
co cror Lice s o.
-',�° / '? � .
� ���. �
� _ ���;�,
��,
t��. No.
Pho � �
� /�� a�
�J
Y