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REQUEST FOR ELECTRICAL INSPECTION
Minnesota State Board of Electricity �
1821 University qve., Rm. S-12g, St. Paul, MN 55104
Phone (612) 642-0840
Duplex Apt. Bldg. �
Industriol Farm n �' � �!
Htg. Equip. Wa�r Hh. �Q New Addn
2ange �O°d Mgmt. Other: � Remod Re ir
Elec. Heat Temp. Service
��by is r u si. En
�emorks i� this oce and on the bock of �he white co
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Calculote Inspeciion Fee - This Inspectfon Re
Other quest will not be accepteal without the correct fee:
Mobile Fiome Park Stall F� #�^''ce Entrance Size
Sfreet Lt . �+0 200 Am 5 Fee # Circuits/F�e�
9/��affi� Si9. P 0 to 100 Amps Fee
Transformer/Generator /�bove 200 Am s
5ign/Outline Lt . �NSPE�TOR•s use oN�r Above 1 pp AmPs
� g Xfmr. _
Pool
'A��
���vesngative Fee F��al �ar� --'�
THIS INSTALLqT10N MAY BE ORDERED Dlg ,~ ��`
TED IF NOT COMP EL TED W�THIN 1 ��
-- MONT
OFFICE U$E ONLY This rey --- -� —__ �
IIII�IIIIII r� uest vaid 18 months 6om validation daM printed in this box.
Illlry I�III � C/ ��
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4 5 9 4 8 2 6 * ��14�j'
Request Date PLEASE P �
�� � Rough.in inspection r RINT OR 7ypE
equiredz ❑ Yes
(You musf call the f�S � Inspedion O�{�er
pecror when reody� Than Rough-In: ❑ R�dy Now
�. �licensed confractor �O� R�dy: ill Call
❑ owner hereby re uest ins
Job Address So-e�� �x or Route No.� 9 P�rion of the above electrical work
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Secfion No. Township Name or No. 1 Z�P C�de
Range No. Fire No. �-__ ,
Occupp�.�.�
�'c�es,� f�e*-�
Prnver Sopplier ��
Phon
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� � � �rE �� ` � C� r Licen� N��
��� � Y�L�fr � Masfer Lic. No. �Planf Elect (
�ress (Conh�� � p�,,�er P
Gy erForming InsMlla'
�9�v-�e ConhacYO�rpN,�rPe ��« C /t
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����� � � � _"�j � O Phone No.
18/96 v O �
STATE BOAqD �pPY - �E INSTR ��� �
UC170NS ON BqCK OF YELLOW Cppy