P - 83913`' � RE�UEST FOR ELECTRICAL INSPECTION ��-;
�I I I iMinnesota State Board of Electricity L�r
I.�f�) l) �l ll lll I� I9I II II II III II (II II (II I� �II I I�II 1821 University Ave., Rm. S-128, St. Paul, MN 55104 �-. `,?�
. �.,�,�
* 0 2`! 9 4 1, 7 6* Phone (612) 642- 00
Home Dupiex Apt. Bldg. Other: . /I� New Addn
Commercial industrial Farm �i ���' Remod Re air
Air Cond. Htg. Equip. Water Htr. Load Mgmt. Other:
Dryer Ran e Elec. Heat Temp. Service
"k' above the work covered by this request. Enter remarks in this space and on the back of the whits copy only.
Calculate Inspection Fee - This Inspection Request will not be accepted without the correct fee:
Olher Fee # Service Entrance $ae Fee # Circuits/Feeders Fee
Mobile Home Park Stall 0 to 200 Amps 0 to 100 Amps C?.
Street Ltg./Traffic $ig. Above 200 Amps Above 100 Amps
Transformer/Generator INSPECTOR•suseoN�r TOTAL
Sign/Outline Ltg. Xfmr. �A1-I�y2/ �- 5 �C��, �(• ���— �l'S��
Alarm/Remote Control /`�',b ��� �_��
Swimming Pool �'j,(�- � �
I hereb certi thaT I ins eded ihe eledrical installation describ in on }h � tes
Irrigation Bo Rough-In : � �
Special Insp ' ,
Final ,� C
Investigative Fee -
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONT :
2 9 9- 417 � OFFICE USE ONLY Thi: request void 18 monfhs from validation daie printed in this box.
�� ��� �/
PLEASE PRI T OR TYPE �/ �
Request D e Rough-in inspecFion required2 �Yes ❑ No Inspedion Other Than Rough-In: ❑ Ready Now ,�Will Call
`� � ��� (You musf call }he inspedor when ready) Date Ready:
I, ❑ licensed contractor �owner hereby request inspection of the above electrical work at:
Job Address (Sireet, Box, or Route No.) City Zip Code
7 0 �E.� v % � �.� � �o � ,�5�� Z
Sedion No. Township Name or No. Range No. Fire No. County
�S �-s �2d� �.�c�E.��K �8�—c�U81�
Power Supplier � � Address
NS /►'IQLf iVo. A<v�Slv�
Eledrical Contracfor (Company Name) Contractor License No. Master Lic. No. (Plant Eled. Only)
0���%/�
Mailing Address (Conirador or Owner Performing Installation)
��
Autho ' Signa re (Contrado r e o ing Install n) Phone No.
� �- l `Z8� ov �f
EB-00001 -10 6/95 STATE BOARD COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY