P - 80668'� � REQUEST FOR ELECTR)CAL INSPECTION
5� L- 5 8 3 Minnesota State Board of Electricity
1821 University Ave., Rm. S-128, St. Paul, MN 55104
Phone (612) 642-0800
e Duplex Apt. Bldg. Other: New Addn
Commercial indushial Farm Remod Re air
Air Cond. Htg. E uip. Water Htr. Load Mgmt. Other.
Dryer Range Elec. Heat Temp. Service
"X" above the work covered by this request. Enter remorks in this space and on the back of tiie white copy on1y.
Ad� � �� SO�-�- p��s � �� � C�SIt ��G�J ��� ��O �
n � u c��� �
�ti�- �S — !'� �� ''.r �� '''` -�, c e � ( <-.S /-` "� f7 (� �
aci
�oS � {� X��v�
Cakula�e Inspectio� Fee - 7his Inspection Request will not be accepted without the cor ect fee:
Other Fee # Service Entrance Size Fee # � Fee
Mobile Home Park Stall 0 to 200 Amps 0 to 100 Amps
Street Ltg./Traffic Sig. Above 200 Am s Above 100 Amps
Transformer/Generator INSPECTOR•s use oN�r TOTAL i^}� /I(
� Pool � ���eby cerny rhar i
�W� P..��../J..
Investigative Fee - �j
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED IN 18 MONTHS.
OFFICE USE ONLY Thia request void 18 mailhs from validation dale printed in this box.
.� �� ��� g:
IIII!!lIINII(IIIIIIII(II11 IlIIIIMIfIiN!( �
* � 5 3 2 5 8 3 2 * PLEASE PRINT OR TYPE
R��t DOTQ � Rougf�in inspection required$ ❑ Yes ❑ No Inapedion Olher Than Rough�ln: ❑ Ready Now ��d CaN
����" q� (You musf call the inspector when ready) ,� a Dote Ready:
!, ❑ licensed confrocror�owner hereby request inspection of the above ' I work ot
1ob Address (Street, Box, w Ro No.) City Zip Code
�O��a %�w /V_ �. �r� � � „SS /3Z
Seclion No. Township Name w No. Range No. Fire No. Couny
Occupant
a c .�-�
�S�° � --
ia (Com ny Name�
►c..1 �
�Contracror or Pefforming Installation)
�3�b A1��. w�� � ,�,
�c��«�m. a o,�,�.
�
STATE BOARD COPY - SEE INSTRUCTIONS ON BACK
Phone No.
SS��.-�Z
�� r�.
��� �7 �
I�l COPY