P - 83290REGIUEST FOR ELECTRICAL INSPECTION
/� ��' p p� Minnesota State Board of Electricity
•'Lf O O 1821 University Ave., Rm. 5-128, St. Paul, MN 55104
Phone(612)642-0800
Duplex Apt. Bldg. Other: New Addn
Commercial Industrial Farm Remod Re air
Air Cond. Htg. Equip. Water Htr. Load Mgmt. OFher:
Dryer Range Elec. Heat Temp. Service
"X" above the work covered by ihis request. Enter remarks in this space and on the back of the white copy only.
Calculate lnspection Fee - This lnspection Requesi wil! not be accepied wiihoui /he correct fee:
Other Fee # Service Entrance Size Fee # Circuits/Feeders Fee
Mobile Home Park Stall 0 ro 200 Amps � 0 to 100 Amps
Street Ltg./Tra�Fic Sig. Above 200 Am s Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY TOTAL
Sign/Oudine Ltg. Xfmr. Q ����� ay �(,� ��� 5�
Alarm/Remote Control � / �
Swimming Pooi
I herebvi cerfi(v Ihat 1 ins e eleclrical installalion described herein on the dates stated
Investigative Fee � s .._. �? —� ,–jAG�
THlS INSTALLATION MAY BE ORDERED qSCONNECTED IF NOT COMPLETED WI HIN 18 MONTHS.
OFFICE USE ONLY This request void 18 months from validafion date printed in this box.
� ����-(�,�1' �'
IIIII!lllllllllll lllllllllllll!lIIIIIIIIII � ,
* � 4 3 7 8 8 5 7* PLEASE PRINT OR TYPE
Request Date Rough-in inspection required8 ❑ Yes No Inspection 01her Than Rough-In: eady Now � Will Coll
� 8 (You must call the inspector when ready) DaM Ready:
I, licensed contractor ❑ owner hereby request inspection of ifie above elecirical work at:
Job Address (Streef, Box, w RouFe No.( _ Cily Zip Code
�'�e 2` �' � f� -� il�' � �' 4L( D L�
Secfion No. Township Nome or No. Ranpe No. Fire No. Coun
Occupanf
/7/+r� �'u �crZ�
Phone No.
��hacfor �Company Name) Conkactor License No. Master Lic. No.
G��� L� �`�l�-' � ��40 o cr C(�
dress �Conkacfor or Owner Per �
t� %�r4 X.C�I`l� � U Iri .�.. 0 MC3+ � l� �'.1-'�
Jignature �l,ontrocror of Vwner Yertolm�ll9 InStOIWIIOn� Yhpne No.
r.►�-- a. o� � 73 3� r
11 96 STATE BOARD COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY