P - 83977REGIUEST FOR ELECTRICAL INSPECTION �-_�..
����� 0 O Minnesota State Board of Electriciry
1821 University Ave., Rm. S-128, St. Paul, MN 55104
Phone (612) 642-0800
Home Duplex Apt. Bidg. Other: � y j'/ New Addn
Commercial Industrial Farm (,O' � uL � Remod Re air
Air Cond. Htg. Equip. Water Htr. Load Mgmt. Other:
Dryer Range Elec. Heat Temp. Service
"X" above the work covered by this request. Enter remarks in this space and on the back of ihe white copy only.
Calculate Inspection Fee - This Inspection Request will not be accepted without the correct fee:
Other Fee # Service Entrance Size Fee # Circuits/Feeders Fee
Mobile Home Park Stall 0 to 200 Amps 0 to 100 Amps
Sfreet Ltg./Traffic Sig. Above 200 Amps Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONI.Y TOTAL �/s o
Sign/Outline Ltg. Xfmr. CJl "
Alarm/Remote Conhol
Swimming Pool
I hereb certi that I ins ted the electrical installation described herein on the dates stated
Irrigation Boom �- RougMn Dare
Special Inspecti � j
Final � Ddte^ �Z�� T(`/
Imestigative Fee -1�--C_�--------- � C S
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This request void 1 S months from validation daie printed in this box.
I IIII II III II III II III II III II III III �����
II III I IIN 1�
* 0 5 3 1 7 � � 3* PLEASE PRINT OR TYPE ���"
Requesf Date Rough-in inspecfion required? ❑ Yes o Inspecfion Other Than RougMn: dy Now ❑ Will Call
;�/ �"l �. -�j` (You must mll the inspecfor when ready) Date Ready:
I, ❑ licensed confractor ❑ owner hereby request inspection of the a ve lecfr' I work at:
Job Address (Street, Box, or Route No.) Cify Zi��
r��'� :3 �
Secii No. T nship ame or o. Range No. Fire No. County �
.3�� � >,�-�}'
Occupant Phone No. ^ /�
� � SGh��,� f- -���fs�� «
Power up� /"� � � � � Ad ress �/ ` / , �� �� r ��
;/f � ln .ls,' z/.'
/! /f.'
Elecfri Conhacfor (Compa�y Name) Conhacfor License No. � Master Lic. No. (Planf Elecf. Only
�� �„� � �.- � . ' �I' � �'//'C� ,� .S�
Maili Addr Cont��clor or ner Per4orming Ins afio
�' r�i �� l� �c� r�����
Authorized Si nature (Conhacfor or ner PerForming Installafion) �.� Phone No �/^
i � l�� � �'(�
. "' , .`� . . . , (
EB-OOOOlA-11 8/96 ATE BOARD COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY