P - 83949REQUEST FOR ELECTRICAL INSPECTION —
5 6 0 w�� 1 m Minnesota State Board of Electricity
�r 1821 University Ave., Rm. S-128, St. Paul, MN 55104
" Phone(612)642-0800
Home Duplex Apt. Bldg. Other: New Addn
C mmercial Industrial Farm Remod Re air
ir Cond. Htg. Equip. Water Htr. Load Mgmt. Other:
Dryer Range Elec. Heat Temp. Service
"X" above the work covered by thi request Enter remarks in this space and on the back of the white copy only.
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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 /O --
Street Ltg./Traffic Sig. Above 200 Am s Above 100 Amps
TOT --_..._.-- —
T�ansformer�Cienerato� INSPECTOR'S USE ONLY _
Sign/Oudine Ltg. Xfmr.
Alarm/Remote Control ,� `�5�
Swimming Pool
I hereb certi that I ins ted !he electrical installaiion described herein on the dates sfafed
Irrigafion Boom RougMn Dafe �
Special Inspe � n� _
Final
Investigative �- � �
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This requesf void 18 monfhs from validafion dafe printed in fhis box.
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I IIII II III II III I� �II (I �II (I II�I III �I (�� I(III
* � 5 6 Q�G 5 7 8* P EASE PRINT OR TYPE �� d0
Reques Date /j Rough-in inspection required? ❑ Yes No Inspecfion Other Than Roughan: eady Now � W�11 Call
�� L� �, (You must call the inspector when ready) Date Ready:
I, censed contractor ❑ owner hereby request inspection of the above electrical work at:
Job Address (S� eet, Box, orRT,,ute o.) City Zip Code
7�l(!, s' ����� l. '/ �� �'o���
Section No. Township Name or No. Range No. Fire No. Coun
��v�C�
Occupant � Phone No.
L" � ���
Power Suppli Address � ! •
� �/�.S' �k-�l'�° D� �
Eledr' o tor (Co Name Contr tor License No. Masfer Lic No. (Planf Elecf. Only�
��'`,� ��"��� � �D���'
Ma"n ddress (C ractou or Owner Pe ing Install '
�3�s/ l/r/1 � �.� ,SS�-/ 3
Aufhori �Si ture �C mct or O or Installation) Pho No.
2 5 � .�7�'/�'�.3
EB-0000 -1 1 8 6 ST TE BOARD COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY