P - 80944�5�565 `
.
REQUEST FOR ELECTRICAL INSPECTION
Minnesota State Board of Electricity
1827 University Ave., Rm. 5-128, St. Paul, MN 55104
Phone (s12) 642-0890 _ __
a ve �he work covered by this requesG Enter rej�orks in this space a,�i
d��a/-� i� ��E G� /'RFUiGcl1 /C
,�j�✓�L l�s� �c��`f -
Calwlate Inspeclion Fee - This Inspecfion Reques� wilf ml be accepled win
Other Fee # Service Entrance Size Fee
� Above 200 ,
INSPECTOH'S USE ONLY
ine Ltg. Xfmr.
mofe Conlrol
� Pool
Boom
on !ne bock or me wnite copy only.
�1i �' %'i-�r s is �v�2.
the correct ke:
it Circuifs/Feeders Fei
0 to 100 Amps [
Above 100 Amps
TOTAL/ ` 'S
�
m desri6ed herein on the daks swled
Doie
�Imestigalivehee �� —��'"'� � ��( O�.e--------�' I R�'�—J—L�/
THIS INSTALLATION MAY BE ORUERED pSCONNECTED IF NOT COMPLE7ED WRHIN 18 MONTHS.
I IIII I II I�I II II II I�II IN II III ��1 I I�I OFFICE USE ONLT This r^9uest wid l8 mon� validmion dare�ted i� �`
1/
l
I N l(L��v
� 0 5 3 2�5 6� S 9� p�pSE PRINT OR NPE
a�e�� Da�g ,s �9 Roughin I�spxfion required? ❑ r� ❑ No Inspection Olher Than Rough-In: ❑ Ready Now 0 w�n caii
�� no� m�.� �n �n� ��,�ro,,.ne� ,�a,,� oa� e�dY:
I, ❑ licensed conhoc�or,[a'
lab Address (SVeet, Boz, or Rou�e No:
.� �
Sx�ownshio��
Pawer
hereby reques� inspection of the above elecfrical work at
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Ra�ae
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