P - 80637' REQUEST FOR ELECTRICAL INSPECTION -
5��� C O� Minnesota State Board of Electricity
� J 0 1821 University Ave., Rm. S-128, St. Paul, MN 55104
Phone (612) 642-0800 '�'
Home Duplex Apt. Bldg. Ofher: New Addn
Commercial Industrial Farm Remod Re air
Air Cond. Htg. Equip. Water Hh. Load Mgmt. Other:
Dryer Range Elec. Heat Temp. Service
"X" above ihe work covered by this request. Enter remarks in this space and on the back of the white copy only.
� Ca4 A'+�� �.SG � �� �M� C'��%Gati�/'��'
Calculate Inspection Fee - This Inspection Request will not be accepted wirhout the correct fee:
Other Fee # rvice Entranc ize Fee # CircuiWFeeders Fee
Mobile Home Park Stall to Amps 0 to 100 Amps
Street Ltg./Traffic Sig. Abov 200 Am s Above 100 Amps
Transformer/Generator INSPECTOR•S usE oN�r TOTA_ L __ _
Sian/Oudine Lta. Xfmr. �
� P�' 1 here certi that I i fhe elechical inslallaKon described herein on the dales sfaPed
Boom A �..- o..,�.�.,., n„b
Invesrigative Fee - --� �
THIS INSTALLATION MAY BE ORDERED DISC ED IF NOT COMPLETED WITHIN 18 MONTHS�
OFFlCE USE ONLY This request void 18 mon�s from validation dofe printed in this box.
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4111I II III II I{I II IN II III II II III II III I IIII �
* � 5 3 2 5 8 7 3�C PLEASE PRINT OR TYPE
Request Dat/e'� /� /�� Roug}rin inspeclion required'C ❑ Yes fnspeclion Other Than RougMn: ❑ Ready Now �11 CaN
"/--7'i - y`1 �You must call the inspec�or when ready� Dale Ready:
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I, ❑ licensed conhactor � owner hereby request inspection of the above elecfrical work at:
hb Address (Street, Box, w Roupe No.) Ciy LP CO�
�sa6 �n s�f,�E FR�,oc,r- y s�-�3a
Secfion No. Township Name or No Range No. Fire No. Counly
3 u a alca
Occupanf Phone No.
o �-.�i�k 6�a-�4� •�a
Power Supplier Address
.�i S,�D OLS t�r► a.� ��/
Name) . -� conhaiw license Plo.
Perfo�mi� ImtaNalion) '�i+ � .
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w �,wner'�mnanon,
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ATE BOARD COPY - SEE INS7RUCilONS ON BACK OF YELLOW COPY