P - 838935��-116 �
Home Duplex
REGIUEST FOR ELECTRICAL INSPECTION
Minnesota State Board of Electricity
1821 University Ave., Rm. S-128, S4. Paul, MN 55104 -
Phone(612)642-0800
Other: New Addn
Commercial Industrial Farm Remod
Air Cond. Htg. Equip. Water Htr. Load Mgmt. Other:
Dryer Range Elec. Heat Temp. Service
"X" above the work covered by this requesi. Enter remarks in ihis space and on the back of the white copy only.
�bfo ��L.�u�r� vr `7 � 7- 7�'� S
Calculate Inspection Fee - This Inspection Request will not be accepted without the correct fee:
Other Fee # Service Entrance Size Fee # Circuits/Feeders Fee
Mobile Home Park Stall 0 to 200 Amps 0 to 100 Amps
Street Ltg./Traffic Sig. Above 200 Amps Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY TOTAL
Sign/Outline Ltg. Xfmr.
Alarm/Remote Control
Swimming Pool
I hereb certi that I ins the elxhical installafion described herein on the dates stated
Irrigation Boom RougMn Dare
Soecial Ins�ectio�� L. , M ;
Investigatrve ree - �—Ci� l
THIS INSTALLATION MAY BE ORDERED DISCO ECTED IF NOT COMP�ETED WITHIN 18 MONTHS.
OFFlCE USE ONLV This requesf void 18 months from validaticn date printed in fhis box.
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* � 5 1 9 1 1 6 $�K PLEASE PRINT OR TYPE �✓ '�
Requesf Date Rou h-in ins fion r uired?
��.���� g pec eq ❑ Yes o Inspecfian Ofher Than Rough-In: ❑ Reody Now ill Call
(You must call the inspector when ready) Date Ready:
f, �licensed contractor ❑ owner hereby request inspection of the above electrical work at:
Job Address (Sfreet, Box, or Rqute No.J� Ciy �. �� Zip Code ,
G'
Secfion No. � Township Name or
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Power
Electrical Conhactor (Company Name)
BIAINE HTG. A/C ELECT., INC.
Mailing Address In IJ 'on�
� qAlQt MN 55304
1 A-? 1
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Fire No. Couny '
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Phone No.
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License No.
�l7
255 f .�
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