P - 84220REQUEST FOR ELECTRICAL INSPECTION
5���/I O A � Minnesota State Board of Electricity
�f 0`+ 1821 University Ave., Rm. S-128, St. Paul, MN 55104
- Phone (612) 642-0800 �,� '�'
Home Duplex Apt. Bldg. Other: New Addn
Commercial Industrial Farm S� ""° Remod
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 whi►e copy only.
Calculate Inspeciion 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 'rj 0 to 100 Amps
Street Ltg./Traffic Sig. Above 200 Amps Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY J� TOTAL ��/ S�
Sign/Outline Ltg. Xfmr. — ZC= �'� ����{
Alarm/Remote Control
Swimming Pool
_ I hereby certify fhaf I inspe,rJqd fhe elecfricaLnstallafion described herein on ihe dafes stated „
0
Irnestigative Fee S^ ` - � ^ l
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
----- — -- — --. — _ _ _ _ _ — -- - - -- -�
OFFICE USE ONLY This request void 18 months from validation dafe printed in ihis box.
� ��. ��
I IIII II II) II II) II (II I II II II) I) III II III I IIII ���
* 0 5 3 2 4 8 4 3* PLEASE PRINT OR TYPE
Requesf Daie Rough-in inspecfion required? �Yes ❑ No Inspection Ofher Than Rough-In: ❑ Ready Now ❑ Wili Call
�+ 3 Q ��� �You must call ihe inspecior when ready) Date Ready:
I, ❑ licensed contractor � owner hereby request inspection of the above electrical work at:
lob Address �Sheef, Box, or Route No.) City Zip Code
� t 3�� �a c•,re �1. �. �r, a�� s s
Section No. Township Name or No. Range No. Fire No. County
�c� -2 i��►o °(�.
Occupant . Phone No.
� �,.9 d�C c� �-Q �C" 2 � N 5 � \ (o i 'Z '1 t "1 � \ �i1'\ �j
Power Supplier Address
(Conkoctor or Owner
V � � �
�
Elect. Only�
I G � � �-t t -� - � �yg
E&OOOOIA-1 1 8/96 STATE BOARD COP UCTIONS ON BACK OF YELLOW COPY