P - 83218r
REQUEST FOR ELECTRICAL INSPECTION
r P�5 O o/I O 1 Minnesota State Board of Electricity
V it O 1821 University Ave., Rm. S-128, St. Paul, MN 55104
�
Phone (612) 642-0800 "�'
Home Duplex Apt. Bldg. Other: New Addn
Commercial Indusfrial Farm i�b�<<-'E-' i"��m�— Remod Re air
Air Cond. Htg. Equip. Water Htr. Load Mgmt. Other:
Dryer Range Elec. Heat Temp. $ervice
"X" above the work covered by this request. Enter remarks in this space and on the back of the white copy only.
Calculate Inspection Fee - Ihis Inspection Request will not be accepied wifhoui the correct fee:
Other Fee # Service Entrance Size Fee # Circuits/Feeders Fee
Mobile Home Park Stall 0 to 200 Amps 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. � �`S'�
Alarm/Remote Conhol
Swimming Pool
I hereb ceAi that I ins the eleckical installafion described herein on the dates stated
Irrigation Boom RougMn o�
Special Inspecti
Fi,wl D
Investigative Fee i�
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 ON HS.
� OFFICE USE ONLY This request void 18 months from validafion dafe prinfed in this box.
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* 0 6 5 0 4 8 1 5� L��Q9
PLEASE PRINT OR TYPE
Request Dak Rough-in inspecfion required2 ❑ Yes No Inspeclion Olher Than Rough-In: Ready Now ❑ Will Call
<p �,s�p (You must call the inspecfor when ready) Date Ready: 6,�3(� ���+"
I, �licensed contractor ❑ owner hereby request inspection of the above elecfrical work at:
Job Address (Sfreef, Box, or Rou�e No.) City � Zip Code
`74�0/ -�n� esTClRCGE N E. �r � ot l�e
Section No. Township Name or No. Range No. Fire No. County
/4 na k4
Oc�cu nf � Phone No.
Kas� ( i �i�Q Wa r�Qr '7�b -S/7�.
Power $upplier Address
Elechical Co (Company Name) Contracror License No. Master Lic. No. (Plant Elecl. Only�
l27's Fc��r�eic e•4o �y
Mailing Address (Conhacfor or Owner PerForming InstallaKon) ..
�7Z0 -- ._ �ve nit.�J Z� � r� • S33 i�
Aufhorized Signafure (Confroctor or Owner �rforming Installation) - Phone No.
• �%
�y�-9�.0
E&OOOOIA 11 8f96 STA OAR OPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY