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X Home Duplex
Commercial Industrial
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Dryer Range
"X" above the work covered b
REQUEST FOR ELECTRICAL INSPECTION ��
Minnesota State Board of Electricity 3
1821 University Ave., Rm. S-128, St. Paul, MN 55104 �
�
Phone (612) 642-0800 �'�
Apt. Bldg. Other: New Addn
Farm Remod Re air
Water Htr. Load Mgmt. Other:
Elec. Heat Temp. Service
request. Enter remarks in this space and on the back of /he white copy only.
Calculate Inspeciion Fee - This Inspection Request will noi be accepted withoui the correcf fee:
Other Fee # Service Entrance Size Fee # Circuits/Feedi
Mobile Home Park Stall 0 to 200 Amps 0 to 100 Amps
Street Ltg./Traffic Sig. Above 200 Am s Above 100
Transformer/Generator INSPECTOR'S USE ONLY TC
Sign/Outline Lig. Xfmr. .
Alarm/Remote Control
the elechical installation described herein on fhe dates sfated
Fee
Speciallnspection J
Final Da
Investigative Fee ' � 2�--'-0�
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFlCE USE ONLV This request void 18 months from validation date printed in fhis box.
III�I�IiII���I�������IIIN�I�IIH�I����a� '� �s�
* 0? 1 3 3 8 1 2* 7�°SJ`�
PLEASE PRINT OR TYPE
Requesf Dafe RougMin inspecfion required$ ❑ Yes �i] No Inspeclion Other Than RougMn: � Ready Now ❑ Will Call
11-3�9H �.� �You musf call the inspecfor when ready) Date Ready:
I, �] licensed contracror ❑ dwner hereby request inspection of the above electrical work at:
Job Address �Street, Box, or Roufe No.) Ciy Zip Code
5840 6th St NE Fridley 55432
Secfion No. Township Name or No. Ranpe No. Fire No. Couny
Occupanf
Reg Costigan
PoWef Suppli¢f
Phone No.
Electrical Contractor (Company Name) Conhacfor License No. Mastei
Total Electric INc. CA02749
Mailing Address �Conhacbr or Owner Pefforming Insfallafion) �
10760 Mankato St NE Blaine MN � �
Authori ignature (Conkactor or Ow Perf ming Insf tion) _I t Phone
A-1 1 8/96 STATE BOARD COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY
572-1076
(Planf
786-8484