P - 81715.
802-248 �
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REQUEST FOR ELECTRICAL INSPECTION
Minnesota State Board of Electricity
1821 University Ave., Rm. S-128, St. Paul, MN 55104 �;
Phone(612) 642-080
Apt. Bldg. Other �O c�p New Addn
Farm �� �'`'� Remod Re air
Water Htr. Load Mgmt. Other:
Elec. Heat Temp. Service
request. Enter remarks in this space and on the back of the white copy only.
Calculate Inspection Fee - This Inspection Requestwill not be
Other Fee # Service Entrance
Mobile Home Park $tall 0 to 00.�4mps
Street Ltq./Traffic Siq. Above 200
Alarm/Remote Confrol
INSPECTOR'S USE 9NL1
I hereby ceAiry that I inspec4
without the correct fee:
Fee # Circuits/Feeders
0 to 100 Amps
Above 100 Ai
TOT
fhe eleckical installation described herein on ihe dales slafed
Date
Fee
Investigative Fee `4j'" �T4r C/
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This roquest void 18 months from validation date pvjnted in this box.
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PLEASE PRINT OR TYPE J
Requesf Dafe Rou h-in ins fion r uired?
� � � 9 P� eq � ❑ Yes No Inspection Other Than RougMn: ❑ Ready Now � Will Call
(You mus+ call the inspector when ready) Date Ready:
I, �licensed contractor ❑ owner hereby request inspection of the above electrical work at:
Job Address �Sheet, Box, or Route No.) . Ciy Zip Code
/ 7 � /� ' �a
Secfion No. Township Name or No. Ranpe No. fire No. C unN _
� � -� Phone No.
� � �� 37a 8 �
pplier Address
' �s � o -C �1�
Conhacfor (Company Name) nhacror Lice�se No. Master Lic. No. �Plant Ele�
,d8ress �Conhactor or Owner Performing Insfallafion)
� /�l� Z7� (.� ��1�' • J� /��G ,
�d nature (Conh cror or Owner Performing Installafion) Phone N.
..L 71�3 �5�,=
'�l 1 8/96 STATE BOARD COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY