P - 80232REQUEST FOR ELECTRICAL INSPECTION
C� �`rt - 2 41 � Minnesota State Board of Electricity
1821 University Ave., Rm. S-128, St. Paul, MN 55104
f" Phone (612) 642-0800 `'�'
Home Duplex Apt. Bldq. Other: New Addn
� Commercial Industrial Farm Remod Re
Air Cond. Htg. Equip. Water Htr. Load Mgmf. Other:
Dryer Range Elec. Heat Temp. Service
"X" above the work covered by this request. Enter remarks in this space and on ihe back of the white copy only.
Calculate Inspection Fee - This Inspection Request will not be accepted wifhoui the correct fee:
Other Fee # Service Entrance Size Fee # Circuits/Feeders Fee
Mobile Home Park Stall 0 to 200 Amps 0 ro 100 Amps
Street Ltg./Traffic Sig. Above 200 Am s Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY TOTAL
Sign/Outline Ltg. Xfmr. �� ��-��
Alarm/Remote Conhol
Swimming Pool
Irriaation Boom
I herebvi certiN that I insoecled the eleclrical insmllafion described herein on the dates sfated
. . F� �
Investigative ee ' 2% ""�'d
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
... OFFlCE USE ONIY 7his requesf roid 18 months 6om volidafion dofe prinfed in fliis box.
i i i i i i i i il i l i i i i i i i i l i i i i i i i i� i i � i i n i i i i� •�o -�
* D 8 4 4 2 4 I, 0* ��
PLEASE PRINT OR TYPE
Reques� Dife�� � y� Rou h-in ins on r uired?
g pecli eq ❑ Yes specfion O�er Than RougMn: eady Now ❑ Will Call
� v (You must call fhe inspecfor when ready� Dafe Reody:
I, �ensed contractor ❑ owner hereby request inspection of the above electrical work at:
Job Addrezs (Sheet, Box, or Roufe No.� Ci Z'ip Code
��- . ` 5 �3 Z
Section No. Township Name or No. Range No. ire . ounly A �
����. � V �. �' I
Power Supplier
Elechic I Co\ acfor �Company Name) � �^
Mailinct Address onhacror or Owner Performina Installai
2�
ihorized Signature
Own^r Perl
A-11 6/96 STATE BOARD COPY - SEE
Z-Z
��{ Y "� � Q ✓ 1f
/. � Phone N�.
/ �� ssp � �j
BACK OF YELLOW COPY