P - 81501REGIUEST FOR ELECTRICAL INSPECTION -: ��.
5 3� 2- 5 5 7 Minnesota State Board of Electricity
� 1821 University Ave., Rm. S-128, St. Paul, MN 55104
Phone(612)642-0800
ome Duplex Apt. Bldg. Other: New Addn
Commercial Indushial Farm Remod e air
Air Cond. Htg. Equip. Water Hh. Load Mgmt. Other:
Dryer Range Elec. Heat Temp. Service
"X" above ihe work covered by this request. Enter remarks in this space and on the back of the white copy only.
Calculate Inspection Fee - This Inspection Request will not be accepted without the correct ke:
Other Fee #�rvice Entranc ize Fee # Circuits/Feeders Fee
Mobile Home Park $tall 0 t 00 mps 0 to 100 Amps `—
$heet Ltg./Traffic Sig. Above 200 Am s Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY TO �
Sign/Oudine Ltg. Xfmr. ,5 v
Alarm/Remote Conhol
Swimming Pcol
I hereb certi that I ins the electrical inslallation described herein on the dates stated
Irriaation Boom o,.....��.. �_�
Invesfigative Fee - � �.� V _ � - U
THIS INSTALLA710N MAY BE ORDERED NECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This requasf voi��'18 months (rom validafion dafe printed in ihis box.
�� i
� `"'� �t �,` Jv
�� �� � �� ��� �� N� � ��r II III �� �� �� ��� � ��� ��)
* 0 5 3 2 5 5 7 6* �`3°? 7
PLEASE PRINT OR TYPE
R��� �O� Rou h-in ins on r uired?
n Q g pecfi eq ❑ Yes o Inspeclion Ofher Than RougMn: ❑ Ready Now �Nill Call
3--�t,2'7' 9 (You must call the inspec�or when ready) Dale Ready:
I, ❑ licensed conhacror �'owner hereby request inspection of the above elechical work at:
Job Addreu (Sheet, Box, a Roufe No.) Ciy ZiP C�
���Y,2 �vd �''i . �r: �C`e � � Y 21
Seclion No. Township Name or o. Range No. , Fire No. County
�� � � HNV�C�.
Occupant Phone No.
D n, b� D, rr n�� 1Q /:t-Si(-j loo
Power Supplier Address :
NSP %�L,S � � � _
Elechical Conh«for�(d�ny Name) A ConhacTar license No. Masfer Lic. No. �Planf Eleci. Only�
Mailing Address (Conka�.tor � Owner Performing Installafion)
or er Yertorming Insipl�i�i _y.� /'� Phone No.
V�J�
_ �%l-JLiO
STATE BOARD COPY - SEE INSTRUCTioNS oN aacK eF vF� i nw r.nav