P - 8357753�-549
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Home Duplex
Commercial Industr
Air Cond. Htg. E�
Dryer Range
"X" above the work coverec
REQUEST FOR ELECTRICAL INSPECTION � -w�.
Minnesota State Board of Electricity
1821 University Ave., Rm. S-128, St. Paul, MN 55104
Phone (612) 642-0800 `ffi'
Apt. Bldg. Other: n, New Addn
Farm �V Remod Re air
Water Hfr. Load Mgmt. Other:
Elec. Heat Temp. Service
request. Enter remorks in this spoce and on the back of the white copy only.
Calculafe Inspecfion fee - This lnspection Request will noi be accepted withouF the corcecr ke:
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
Tronsformer/Generator INSPECTOR'S USE ONLY , TOTAL �
. Sign/Oudine Ltg. Xfmr. C i t9 - n��''� a" !'�-�' ��"��
Alarm/Remote Control
Swimming Pool
I herebvi certifv �hat I insoecled the eleulC�al ins�allation described herein on the do�es staled
Investigative fee � � V --'L-7—�
THIS INSTALLATION MAY BE ORDERED dSCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This request void 18 months from validation dafe prinfed in this box.
, ���������I��������������I�O�������I��������� • �' �
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* � 5 3 2 5 4 9 3 * PLEASE PRINT OR TYPE
��5� Rough-in inspecfion required? `�Yes ❑ No Inspeclion Other Than Rough-In: ❑ Ready Now Will Call
Da�e
1'— �—�� (You must call the inspector when ready) Date Ready: ��s �
I,�licensed contractor ❑ owner hereby request inspection of the above elechical work at:
Job Addreu �Streef. Bmc, w Rou�e No.) Ciry Zip Code
Id032 2 i ST N E T�2.IbU� 55�-13 Z
Seclion No. Township Name or No. Range No. Fire No. County
3a z y �10,�
o«���� w� r•�.
5 coT T 1--t�L Gt�
Power Supplier � � � � Addreas ��� � � �D � � �
Eleclriwl Contracbr (Company Name) Conhacror License No. Masler lic. No. (Plant Elecl. Only�
S�1 h�15E� —LEU�IC.. �i.0 � N C. �� 6 I� o�i
Mailing Address (Conhac�or w Owner Performing Inslallation)
7� r S 4'7 ST E � G 1-F n�t � S�Z� "1%
Authwized SignaNre (Conhaclor or Owner P ing Installa " � � Phone No.
..�'�'%�' (0�2 �7�f�1 /D8�
EBOOOOIArt l 8/96 y�ATE BOARD COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY