P - 82791. RE(�UEST FOR ELECTRICAL INSPECTION � �w�..
�� S�, O� 0 m Minnesota State Board of Electricity
. 1821 University Ave., Rm. S-128, St. Paul, MN 55104
Phone (612) 642-0800 `�'
� Home Duplex Apt. Bldg. Other: New Addn
Commercial Industrial farm Remod Re ir
Air Cond. Htg. Equip. Water Htr. Load Mgmt. Other:
Dryer Range Elec. Heat Temp. Service
"X" above the work covered by this request. Enter remarks in this space and on the back of the white copy only.
Calculate Inspection Fee - This Inspection Request will not be accepted wiihout ihe correct fee:
Other Fee # Service Entrance Size Fee # Circuits/Feeders Fee
Mobile Home Park Stall 0 to 200 Amps 0 ro 100 Amps
Sfreet Lig./Traffic Sig. Above 200 Am s Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY TOTAL2 �y
Sign/Outline Ltg. Xfinr. d�"-"''
Alarm/Remote Control
that I
�
/�,; L
� Investigative Fee Z—o0
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFlCE USE ONLY This request void 18 months hom validation date prinfed in this box.
. ,� .50
IIIII�IIIIIIIIIIIII IIIIIIIIII�I�I�II�I � ��3�
* � 4 3 6 � 9 �$�k P�EASE PRINT OR TYPE
Requesf Rou h-in ins on r uired? �(es
��_^� g pecti eq ❑ No Inspection OTher Than RougMn: ❑ Ready No��H Call
�`� (You musf call IF�e inspecbr when ready) Date Ready:
/
I, �licensed conhactor ❑ owner hereby request inspection of the above electrical work at:
bb Addreu (� , Box, or Route No.) Ciy �� Zip Code��� �
� S
Seclion No. Township Name or�N�� Rang� . Fire No. ounty .
� �
Oaupant � Phone No. `
��L, l.is_r., (VGcis_�rTG, /bYi//7Lr_� �Siy .i—y�i�
Name�
r • l �'L„�
(Coniracfor or er Pe rming Installafion) � ... ,� `� �� P{wne No.
_ � . y� 3
STATE BOARD COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY