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Minnesota State�Boald oCTRICq� ►NSP
1821 University Ave., Electricity ECTIOIV
Phone (612) 642-080pRm. S-128, -'° `�
Apr. Bld , St. Paul, MN 5510q
Farm 9 Other:
Water Htr. �oad M ;......:
req'� En t TefryP• Service �ther: Re od Redan�
ues� ter rernarks in this spaCe and on
Jfre bock of y/�e �vhite copy on/v.
non Request will not
# Service be occepted wifhou� the
Entrance g�Ze correct f�:
0 to 2pp Fee f�
Amps # Circuits/F�e�
Above 200
INSPECTOR• � Am S 0 ro 100 qmPs Fee
S USE ONLY Above l00 .
l�S'.�O
7'HIS II�ST ' ce v �•• ��r'� herein
— _—_�, q<_LATIOf� MAy • F��w1 /,�i - on thDa�ore5 sm,ed
--___ _ BE ORDERED
- -- —�I�ONNECTED IF �'—�
- __ _NOT COMP �-�c� --� --
�I"�il °�ce use oN�r �ETEp yy1THIN
"�I�i� This r�uest void 18 momhs fr '$ M�NrHS.
"II�' � °m validafion da
* �I'I'I I � , fe prin � .
o dl �"���� -� �,^ �,s �
4 y I�'�'� SS� x.
p '�I�i �
Request �ate 5 6 4 9�r
�� 7 �9 %� Rough-in insPecfion r '7����
l (1'ou must call �he ins�uired; PLEqSE pRINT
�� Iice ❑ Yes L� No OR TYPE
nsed contrpctor � �Of when ready) �nsp��;o�
�Iher Tha� RougMn:
Job Address (Str�r, gox, or °�'�er hereb �te Reudy:
�,�` — Route No.) Y �e4uest ins ReOdr Now �W�II Call
G 7�r.�'. � Pection of
Section No. Uto /j�F' C�ry the above electrical work at: �
TownshiP Name or No. �J/
Occupont Range No. F. ���GZ `'Ly Z'P Code
PoWer Su plir l e
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Nailir �� c i
9 Addreu �Conhc
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foror Qq,ner pe
r� dormim
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Address S � / ���
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Controctor License No.
rtion) ����f/� M°sler Lic. N
4l '
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bllatio f%�ry ' �����p..
f � • V
COPy _ �none No.
SEE Iryg�V�OMS ON
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