P - 83192REQUEST FOR ELECTRICAL INSPECTION �A:�
6� g���� � Minnesota State Board of Electricity � .,
1821 University Ave., Rm. S-128, St. Paul, MN 55104
. Phone(612)642-0800 " '
Home Duolex A�t. Blda. Other: New Addn
Commercial Industrial Farm
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
u�a y��de S�.e��e e To �oa �c��
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Calculaie Inspection Fee - This Inspection Request will not be accepted wifhoui the correct fee:
Other Fee # Service Entrance ize Fee # Circuits/feeders Fee
Mobile Home Park Stall 0 to 00 Amp ,'� �- 0 to 100 Amps ,S',o�
Street Ltg./Traffic Sig. Abo 200 Am s Above 100 Amps
Transformer/Generator INSPECTOR�s use oN�v TDTAL �_
$ign/Oudine Ltg. Xfmr.
Alarm/Remote Conhol
Swimminq Pool
herein on the dates stafed
Dafe
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Investigative Fee r���� � �,��; _� I uO��� �Z ^—[ p
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFRCE USE ONLY This roquesf void 18 months from validafion dafe printed in this box.
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PLEASE PRINT OR TYPE
Requesf Dafe p� Rough-in inspection required2 ❑ Yes No lnspecfion Olher Than Rough-In: eady Now 0 Will Cal)
�%^� p (You musf call fhe inspedor when ready) Dute Ready: r��
1, icensed conhactor ❑ owner hereby request inspection of the above electrical work at:
Job Address (Skeef, Box, or Roufe No.� City Zip Code
f 3�lwas�<ti 70 � 5�r Fi.�<�le
Section No. Township Name o. Range No. Fire No. County
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Elec ical Co1n racfor (Company Name)
�S�/e E'LecT/1ic �hc..
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Mailing Address (Confractor or Owner Performing Installafio
8'�o/C�hT,�al �'ie �/,f, .S,
Aufhorized Sign re �Contractor or Owner Performing I fal
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E&OOOOIA- 8/96 STATE BOARD C
INSTRUCTIONS
Phone No.
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br license No. Master Lic. No. �Planf Elect. Onl
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