P - 80728REQUEST FOR ELECTRICAL INSPECTION
�`F �° 119 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
ommercial Industrial Farm Remod Re air
Air Cond. Htg. Equip. Water Htr. Load Mgmt. Other:
Dryer ange Elec. Heat Temp. Service
"X" above the work covered by ihis request. Enier remarks in this space and on the back of the white copy only.
C.�GiJ�'v
Calcula►e Inspection Fee - This Inspe on equest will not be accepied 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
Street Ltg./Traffic Sig. Above 200 Am s Above 100 Amps
Transformer/Generator INSPECTOR's usE oN�v TOTAL , F�
Sign/Outline Ltg. Xfmr. .�'� v�-�
Alarm/Remote Confrol
Swimming Pool
I here certi that I ins the elechical instailation described herein on the dates stated
Irrigation Bo � RougMn Do�e
Speciallnsp o
Fipal Da
Investigative Fee �- � 2-O — °
THIS INSTALLATION MAY BE ORDERED DISC CTED IF NOT COMPLETED WITHIN 18 MOhTHS.
OFFICE USE ONLY This requesf void 18 mon alidafion dafe prinfed in this box.
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* 0 8 4 5 1 1 9 7�c ���P �
PLEASE PRINT OR TYPE
Requcrst Dafe Rough-in inspection required? ❑ Yes ❑ No InspecYOn Olher Than RougMn: Ready Now 0 Will Call
' (You must call Il�e inspeclor when ready) Date Ready:
I, icensed contractor ❑ owner hereby requesf inspection of the above electrical work at:
Job Add�eu �Sheet, Box, or Route No.) City Zip Code
O � �' � ' 3
Secfion No. Township Name or No. Range o. Fire No. County
Occupant Phone N� I
Power Supplier Address
V
E��DEPENDABLEYELE�CTRIC.�tNG. �° �O �censeNo. MasterLic.No.�PlaniElecf.Onyi
� c
��Cvon feRapids, MN 55433 5 Ilafion�
Authorized Signafure (Conk r Own n I Phone No.
�S7 -S� �'6
EB-00001 A-11 8/96 g BO D C PY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY