P - 81017RE(�UEST FOR ELECTRICAL INSPECTION
8��,� O�� Minnesota State Board of Electricity 'a
1821 University Ave., Rm. S-128, St. Paul, MN 55104
' Phone(612) 642-0800
Home Duplex Apt. Bldg. Other: New Addn
Commercial Induslrial Farm Remod Re air
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.
�/ iI n � ..Y�-i�, 5�.� ��� � �
t/ l.i�L.
Calculate Inspection Fee - This Inspection Request will not be accepted without the correct fee:
Other Fee # Service Entrance Size Fee # Circuits/Feeders
Mobile Home Park Stall 0 to 200 Amps 0 to 100 Amps
Sfreet Ltg./Traffic Si . Above 200 Am s Above 100 Ar
Transformer/Generator INSPECTOR'S USE ONLY TQ�
Sign/Outline Ltg. Xfmr.
Alarm/Remote Control
Swimming Pool
Irrigation Boom
Sp6CIaI IftSp I A /i �
I hereb cerTi ihat I ins ected the elechical installafion described herein on
RougMn � �
Fee
•�J —
THIS INSTALLATION MAY BE ORDERED 91SCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This request void 16 months from validation date printed in this box.
il�lllfl(Iliilllllllillll�lilllfil�lllll� • �°��
* 0 8 3 3 0 2 7 6* ���
PLEASE PRINT OR TYPE
R uesf Date Rou h-in ins ion r uved2 es
�� \�— ^� g pecf' eq ' ❑ No InspecEon Other Than Rough-In: ❑ Ready Now i Call
l `(You musf call the inspector when ready� Date Ready:
I, ❑ licensed conhoctor ❑ owner hereby request inspecfion of the above electrica) work at:
Job Address �Sheet, Box, or Route No.� 1 � Ci i J �� Zip Code ��
132 ��S- � ss
$ection No. Township Name or No. Range No. Fire No. Co�� �
0�� �
V �
ny �am�
or Owner Performing Insfallal
N-�,
icTOr or Oyvn�('�e�qni�p Ins
Phone No.
�t, v� � � �� ��� �.,
��96 STATE BOARD COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY
�4�
I�Z�