P - 78640w REQUEST FOFi ELECTRICAL INSPECTION --_
' Q o����� � Minnesota State Board of Electricity
U 1821 University Ave., Rm. S-128, St. Paul, MN 55104
Phone(612)642- 800
X Home Duplex Apt. Bldg. Othe� o� (`� New Addn
Commercial Industrial Farm < e�k� 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. En►er remarks in this space and on the back of the white copy only.
Calculate Inspection Fee - This Inspection Request will not be accepted wi�hout the correct fee:
Other Fee # Service Entrance Size Fee # Circuits/Feeders Fee
Mobile Home Park Stall 0 to 200 Amps 0 to 100 Amps
Street Ltg./Traf�ic Sig. Above 200 Am s Above 100 Amps
Transformer/Generator� INSPECTOR'S USE ONLY����!/� TO�L 5�
Sign/Oudine Ltg. Xfmr. � �'�� � �
Alarm/Remote �
Swimming Pool
Irriqation Boom
described herein on the dates stated
-, �-�/ a
� Investigative Fee V V# ZI 1 � - � I�-�,•L�G3
THIS INSTALLATION MAY BE ORDERED DiSCONNECTED IF NOT'CO�IIPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This roquest void�monlhs from validation date prinfed in this box.
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* 0 8 0 2 3 9 0 5* /jl��
PLEASE PRINT OR TYPE
RequesT Da�e Rou IFin ins fion r uired$ Yes ❑ Rea Now � iIl Call
g pec eq ❑ No Inspeclion Other Than RougMn: dy
%'�G �� (You must call the inspector wh dy) Date Ready: .
I, ❑ licensed confractor � owner hereby request inspection of the above elecfrical work at:
Job Addreu (Sheet, Box, or Roure No.� Ciy Zip Code
7 8 s 7 �}C.rJ � N r,v,� y �,� r o c. � �S"�'� 3y
Section No. Township Name w No. Ranpe No. Fire No. CounN w
Occupanf / i � Phone No �
� t G Gt � � �►�l �e rL. 7G 3-S7/ - SS"� S
Power Supplier Address
1cc� Ls �-I �v
Eleckical Conhac�or ( ny Name� ConMacfor License No. Master lic. No. (Planf Elecf. Only)
Maili�g Address (Contrafor or er PerForming Installafion�
Authorized Signalure �Confrac Own Pe ing InsMll n� Phone No.
. S�/� ?
BOOOOIA-11 8/96 STATE BOARD PY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY