P - 8092379;� 777 �
c
Home Duplex
RE�UEST FOR ELECTRICAL INSPECTION �''�°"�.
Minnesota State Board of Electriciry i �S�
1827 University Ave., Rm. S-128, St. Paul, MN 55104
Phone (612) 642-0800 `�'�
. Ofher: New Addn
Commerciol Indusfrial Farm
Air Cond. Hlg. Equip. Water Htr. Load Mgmt Other.
Dryer Range Elec. Heaf Temp. Service
"X" obove the work covered by �his requesG En/er remarks in �his space and on ihe bock oF �f
��i w �.m 0�/�+0 � �"t S f%fr PI 1� C e.
j,,' eb -i°��-ZS8'�
Caiculate InspecYion Fee - ihis inspecfion Request w'ii) no� be accep�ed w'dhou+ 1he correcf fee:
Other Fee # Service En[r e Sizx Fee # Circuits
Mobile Home Park Stail 0 ro 0 A , 0 to 100 A
, Sfreef Llq./TmBic Sig. Above 200_Amps Abave 100
INSPECTOWS USE ONLY
iofe Conlrol
Pool
Do�e
copy
Fee
Investigative Fee �,C b' �-�$ l
THIS INSTALLATION MAY BE ORDERED DISCONNECTEU IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This req�+eslvaid 18 monfhs hom wlidaiion dote prinied in �his box.
1NN IIII IIIIII I f ill Ilf�l ilIiIHIIHN �,s ��� 5��
* 0 7 9 2 7 7 7 5 s
PLEASE PRINT OR TYPE
R ues� Dare Roigh�in inspecrion requiredB ❑ Ves No inspecnan Oiher ihan Rougbin: eady Now 0 Will Call
^' ��� g S �l'ou musl mll the I�spector whe� reodyl Daa Reody:
I, licensed contmcfor ❑ owner hereby requesl inspecfion of the abave electricol work at
Job Address (S�ree1, Box, or R Na ) Ciy Zip Code
6 ���st n� � r���. 5'y3�
Section No. Township Name or No. Ronge No. Fire No. ounq-
Occupanf
'3c9�nv� Z u
ol Commcbr I�mpony Name�
� �n �p= �
Addren �Conhacior or Ownrr
zed�gnaNre (�pnrvact �r
� VMne No.
i J>- �/:
Address
� -aoo r
� Commcror license No. Maner Lic No.
_ z"/;�� IS�c't—
STATE BOAPU COPY - SEE INSTFUCTIONS ON BACK OF YELLOW COPY