P - 81618, _ � — ._
(� REQUEST FOR ELECTR�!:;AL INSPECTION � H
� ,—" � �'��� � Minnesota State Board of Electricity � �
F;-
� 1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104-2993
(651) 642-0800 www.electricity.state.mn.us
Home Duplex Apt. Bldg. Other: New Adtln
Commercial Industrial Farm Remod Repair
Air Conditioner Htg. Equip. Water Htr. ._ Load Mgmt. �ther:
Dryer Range Elect. Heat `� Temp. Service
X" above the work covered by this request Enter remarks in this space and on the back of the white copy on/y.
��i'� �'JfA itr!��"��J J��{ � t.��"1 � ��,.�.i { �.Lr�� � � {J��i
Ca/cu�ate inspecti�
Other Installations
Mobile Home Park Stall
Street Ltg. / Traffic Sig.
Transformer/Generator
Sign / Outline Ltg. Xfmr.
Alarm/Remote Control
Fee - This inspection Request wiii not be
ae # Service Entrance Size Fee
0 to 200 Amps
Above 200 Amps
INSPECTOR'S USE ONLY
Rough In
without the correct tee.
Circuits / Feeders Fee
0 to 100 Amps
Above 100 Amps
TOTAL
��.'�JQ
n on
Date
�`�� Investigative Fee �'�`'.'"'' �•"R• ���^ �-�•'� — 2. f^°"'�-
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
....,.1....-. _.. ........,_,.., ...�:::s:_ ;w,;�;vr•ra:n�:s�:�:ir:�:r::a:t:a��s:1:::�:s:......... y �.
................... ......... ._.................... . .. __
/ I III��I �I�I� IIIII �IIII IIII� III �II� I�I) I�/I OFFICE USE ONI� �ueat vad 1B months from validation date printed in this box.
I' ��
* 1 0 � 67 5 * ,�j'�� � �
� PLEASE PRINT OR TYPE
Request Date Rough-In inspection required? ❑ Yes ❑ No Inspection -. e II Call
You must call the inspector when ready!,� Date Ready:
���.7�?�� ����i�Q
I, ❑ licensed contractor ❑ company ❑ owner hereby request inspection of the above electrical wor a:
X
Job Address (Street, Box, or Route No.) City Zip Code:
�5 �r} ; �
Section No. Township Name or No. Range No. Fire No. County
�{��'�l
Occupant
�"'��Q�.7�.�
Power Supplier A
NSF' �� 85��
/
Electrical Contractor / Company Name
���� ������ � �
Mailing Address (Contrador, Company
o �, 8�, nr ; m
Phone No.
F(�t� C'j 6 i 7 574-9315
Address
R�lti"�.5 pFPi GE
Contractor License No. Master Lic. No. (Plant Elect. Only)
�}7l�}�{ �� ��
or Owner Performing Installation)
7P.,� �3-(�Q3AI 95� E3SQ-3a55
�~ y o �'P In a I on) Phone Number
\ /
STATE BOARD COPY SEE INSTRUCTIONS ON BACK OF YELLOW COPY