P - 80608> n REQUEST FOR ELECTRICAL INSPECTION ��'"'�''��
8 0 )� G�� Minnesota State Board of Elec[riciry
� 1821 Universiry Ave., Rm. 5-128, St. Paul, MN 55704 ��
. Phone (612) 642-0800 �!'m�
Home Duplex Apt. Bldg. Other: New Addn
Commercial Industrial Farm Remod Re air
Air Cond. Hfg. Equip. Woter Hfr. Wad Mgml. Ofhec
Dryer Range Elec. Heat Temp. Service
"X" abave tfie work covered by this requesG Enfer remorks in iFiis space and on fhe back of the whi/e co opy nfy.
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Calculote Inspection Fee - This Inspecfion Requesr will no� be accepted wi�houh �he <orred fee:
O[her Pee 71 Service Enh ce Size Fee u Circuits/Peeders Fee
Mobile Home Park Stall D to 200 A (�Q 0 l0 100 Amps • O
er/Genemlor INSPECrOH'S USE oNyLY
ine Llg. Xfmr. � � /� --y --�%�
mote Conhol Ci �
� Pool �'�
1 hese6 <enI tlwt I In 1ed the elecrc�ml �nsalk
Boom e,.,,,.�„
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Investiga}ive Fee � l
� THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This request vold I B manrhs fiom volidofon daie pnnted in �hls bax.
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PLEASE PRINT OR TYPE
Request O�e RougMn inspecnon reqoired? Yes ❑ No Inxpecnon O�her Than RoughAn: ❑ Ready Now WIII Coll
�—� 7' _. Q� �1'ou mos� mll the inspecta when reody� Dote Reody:
I, ❑ licensed mnfractor owner hereby requesl inspection of �he above elecfrical work at:
Job Address ISrveer, Box, or Roule NoJ CiN r., t'„do
2 S ee -�'
Township Nome or No. Rarge Nn Fire No.
� 1 �. JWaf-�Z
er Address
Ce�
ntmc�w �Cwnpa�y Wme) Conhanor Lice
ress �Conrcacror or Owner Performiig Insbllof�an�
ig ure �Con cior ��Pe Ing Insmllmlonl .
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1 8/96 �C STATE BOppD COPY - SEE INS C1pN5 ON BA
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