P - 84328i:��.,
REf�UEST FOR ELECTRICAL INSPECTION Ee-0000�-os
� �, _,,, �� l ' See instructions for completing this form on back of yellow copy.
� ��S �`?�'�`Q X Below Work Covered by This Request 'll��,�"
New Add Rep. Type of Building . Appliances Wired Equipment Wired
Home Range Temporary Service
Apt. Building
Comm./Industrial
Farm
Other (specify)
Compute Inspection Fee Below:
# Other Fee
Swimming Pool
Transformers
Signs
Irrigation Booms
Water Heater
Dryer
Furnace
Air Conditioner
ContractoGs Remarks:
(,c.i t V`t�
Service
� � Above 200 _
Inspector's Use Only:
Electric Heating
Load Management
Other (Specify)
E( (� (,�/1-Q�
Fee # Circuits/Feeders Fee
0 to 100 Amps
Above 100 Amps
TOTAL _
Alarm/Commu ' t�o °< � THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT .
Other Fee COMPLETED WITHIN 18 MONTHS.
I, the Electrical Inspector, hereby Rough-in �li oa �.�
certify that the above inspection has "` p
been made. ��- � ���
OFFICE USE ONLY (/' G
This reques[ void 18 months from � \. a_�-7�
0-155-88� 5��s_� ���
F3epu t Dat Fire No. Rough-In Inspection Required Inspection ha Rough-In
..�L (YOU must call inspector hen ready) � Ready Now � Will Notify Inspector
❑ Yes No Date Ready
I�I licensed contractor ❑ owner hereby request inspection of above electrical work at:
Jo�re�Street, Box or Route No.) j � � City �� ))
S r C�. �� i �
�� v�,
Section No. Township Name or No. Range No. CoyqtS)
Supplier
Elecjrical Contractor (Company ame� ' /
W !�% °L " �� .0
Mail' Address (C ntractor or Owner Making Installation)
�� r.l��x �27� S? �
Address
� � irs� L � C��— � - —.
MINNESOTA STATE BOARD OF ELECTRIC6ITY I�I
G 299Unive sity Ave., St�. P uISMN�IB� t� CJ `�.��IlI,II�, fIIIRlIIII (III) (IIII III�I IIII7.IIIII IIIlI
Phone (672) 642 0800
36 � %�
Contractor's License No.
C o �
�.�z
Phone Number
�7 ���
THIS INSPECTION REQUEST WILL NOT
8E ACCEPTED BY THE STATE BOARD
UNLESS PROPER INSPECTION FEE IS
ENCLOSED.