P - 82916RE(�UEST FOR ELECTRfCAL INSPECTION �.
5���� 0� Minnesota State Board of Electricity
1821 University Ave., Rm. S-128, St. Paul, MN 55104 �:
� Phone (612) 642-OS00
ome Duplex Apt. Bldg. Other. New Addn..
Commercial Indushial Farm Remod Re air
Air Cond. Htg. Equip. Water Htr. Load Mgmt. Other:
Dryer Range Elec. Heat Temp. Service
"X" above the work covered by is r uest. Enter remarks i is space and on the back of the white copy only.
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Calculate Inspection Fee - This Inspection Request will not be accepied without fhe correcF fee:
Other Fee # Service Entrance ize Fee # Circtirts/Feeders Fee
Mobile Home Park Stall 0 to 00 Amps 0 to 100 Amps
$treet Lig./Traffic $ig. Above 200 Am s Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY TOTAI�.� �-��
Sign/Oudine Ltg. Xfmr. o��
AlarmjRemote Conhol
Swimming Pool
I hereb cefi tfwl I in the elechical installation described herein on Ihe dales staled
Irrigafion Boom RougMn Daoe
Special Ins
Final Date
Investigative --, t.y i' a
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WIT1iIN 18 MONTHS.
OfACE USE OfILY This raquast wid 18 months (rom validation date priMed in this box.
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* 0 5 3 2 5 � �a 3* PLEASE PRINT OR TYPE
Re9uest �°�e Rough-in inspecfion required? ❑ Yes ❑ No Inspection Other Than RougMn- ❑ Ready Now �'Will Call
�j I I aQ �You must call the inspecror when ready) Dafe R�dy:
I, ❑ lice�sed contractor [y'owner hereby request inspection of the above elechical work at:
hb Address (Street, Box, « Roufe No.) Ciy Zip Code
�(�i�l �I {J' u�2E1� �t' nr£ �tD� �5`�32
Secfion No. Township Name or No. Range No. Fire No. County �
� a y o+cA-
Occupam � Phone No. %3p�-f� —7� % �
Da�Nr� �cay � z�s aqa� c.� �
Power Supplier Addreu
(��v ��5 ►�a� NI P�-S N o2rtk � � �� SC b�J
Eleclricol Conhacror �Company Name) Contractor License No. Master Lic. No. �PIaM Elect. Only)
OI�N �.K
Mailing Addreu (Contrac�or a Owner PerForming Installafion)
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AWhoriz Si aNre (Confracfor w Owner Perfw ing Instal � C. � � Phone No. .
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E A-11 8/96 � BOARD COPY - SEE INSTRUCTIONS ON BACK OF YELIOW [�PY