P - 82624� -
REQUEST FOR ELECTRICAL INSPECTION
8 O.� � 210 � Minnesota State Board of Electricity ;
1821 University Ave., Rm. S-128, St. Paul, MN 55104
, Phone (612) 64 80 �.r;��:.<-
Home Duplex Apt. Bldg. Oth�F: � New Addn
Commercial Industrial Farm �° Remod e air
Air Cond. Htg. Equip. Water Htr. Load Mgmt. Other:
Dryer Range Elec. Heat Temp. Service
"X" above ihe work covered by this request. Enter remarks in this space and on the back of the white copy only.
Calculate Inspection Fee - This Inspection Request will rot be accepted without the correct fee:
Other Fee # Service Entranc � e Fee # Circuits/Feeders
Mobile Home Park Stall t 200 Am 0 to 100 Amps
Street Ltg./Traffic Sig. Above 200 Am s Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY TOTAL
Sign/Outline Ltg. Xfmr.
Alarm/Remote Control
Swimming Pool
I hereb certi fhat I ins the electrical ' Ilation described herein on the dates stated
Irrigation Boom Rough-In Date
$na � �%r}i�v�� . 2.+�
Fee
�a
�d0
� THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
IIII� II�II IIIII II �II OFFICE USE ONLY This request void 18 months from validation date printed in this box.
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PLEASE PRINT OR TYPE
Request Date Rough-in inspection required2 ❑ Yes o
/�_ �O � Inspection Ofher Than Rough-In: ❑ Ready Now Will Call
ou must call fhe inspector when ready� Date Read
Y
I, ❑ licensed contractor�owner hereby request inspection of the above electrical work at:
1ob Address (Sheet, Box, or Route No.) C�y
�1 Zip Code
`T5u 3 � o �'�L.� �-r� c( l� Ss`i 3�
Secfion No. Township Name r No. Range No. Fire No.
Couny
_ � �' � �i .�.n �J� ,,,�
Power Supplier
N�P
Elechical Confracfbr �Company Name)
Ov� r,^
Mailing Address (Con c � r farming Installation�
�" � `��_
Aufhorized $ignature �Conhacfor or Owner PerFormina �nsmll�
Phone No.
4 G: J
License No. Master Lic. No. (Plant Eled. Only)
tu-U�( p 1 A-1 1 8/96
__ ATE BOARD COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPV