P - 84643REQUEST FOR ELECTRICAL INSPECTION �.
� 8 Q, �. g O 5 Minnesota State Board of Electricity '-��
. 1821 University Ave., Rm. S-128, St. Paul, MN 55104 �:
Phone (612) 642-0800
Home Duplex Apt. Bldg. Other: � New Addn
Commercial Industrial Farm %�����-e Remod Re ir
ir Cond. Htg. Equip. Woter Htr. Load Mgmf. Other:
Dryer Range Elec. Heat Temp. Service
"X" above the work covered by this request. Enter remarks in fhis space and on the back of the white copy only.
fao ce�� l-����+c C�<�<< ec�`ro ��- � G.
,
Calculate Inspection Fee - This Inspection Request will not be occe
Other Fee # Service Entrance Size
Mobile Home Park Stall 0 to 200 Amps
Sfreet Ltg./Traffic Sig. Above 200 Am
Transformer/Generator INSPECTOR'S USE ONLY
Sign/Outline ltg. Xfmr.
Alarm/Remote Confrol
Swimming Pool
I hereb certi }haf I ins d the i
Irrigation Boom Rough-In
$p@CIO� �f15DEC}1BI1� _
without the correci fee:
Fee # Circuits/Feeders Fee
0 to 100 Amps p, o�
Above 100 Amps , 5 L
TOTAL
�5��
ol installafion described herein on the dofes staled
Dafe
� _' _ _
-- . c. _ .._�._'_�__.
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 IUONTHS.
i---------------- --�—_
OFFICE USE ONLY This requesf void 18 months From validation date printed in fhis box.
I�II II III II III II III II III I �1
�m�l���������������� �s,S�
� �3
� 0 4 8 4 8 0 5 7� //9
PLEASE PRINT OR TYPE
Request Dafe Rough-in inspection r uired?
eq ❑ Yes o Inspxfion Other Than Rough-In: eady Now 0 Wi11 Call
�� 7�' �7 �`!ou must call the inspector when ready� Date Ready:� —�
I, �Yi"censed controctor ❑ owner hereby request inspection of the above electrical work at:
Job Address (Sheef, Box, or Roufe No.) City
Zip Code
��� �,� C%��% �iP�/� T �� ��Pi c� e
Secfion No. Township Name or No. Range No. Fire No. Cn„�n,
Occupant C10 KG�
� J�� //%�%O � �`� Phone No.
/ // �/'/ % 6.3`0 �/}3
PoWef $UpD�IBf . � �
s'o �/ / S!
�ecT��"c Z'�, c
:for or Owner PerForming Installafi
� �U� /�, �� �
nhacfor or Owner Performing Insf
�7
%,.- �• ��
STATE BpppD COF
Conhaclor License No. Muster Lic. No. (Plant Elecf. O
C �Q`oo�� a
��rd h - /�'l�, 5.���z
Phone No.
�-, 7�o--,So,2S-
BACK OF YELLOW CpPY