P - 81228�Oz�166 �
Home Duplex
Commercial Industr
Air Cond. Hta. Ec
I "X" above the
REQUEST FOR ELECTRICAL INSPECTION
Minnesota State Board of Electricity a
1821 University Ave., Rm. S-128, St. Paul, MN 55104 =
Phone (612) 642-080 "�'
Apt. Bldg. Oth r: n/j� ',,��(� New Addn
Farm ��� Remod Re air
Water Htr. Load gmt. Other:
Elec. Heat Temp. Service
request. Enter remarks in this space and on the back of the white copy only.
Calculate Inspection Fee - This Inspection Request will rot be accepted withovi 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./Traffic Sig. Above 200 Am s Above 100 Amps
Transformer/Generator INSPECTOR•s use oN�r n TOTAL�/��
Sign/Oudine Ltg. Xhnr. �� �JJIAcc�! 2 � �
Alarm/Remote Control � F10�–� 6/^ —�qQ�r
Swimmi�g Pool
I here6vi ceAifv that I insoecled the elechical insfallation described herein on the daTes sfafed
Special Ins � v u
Final �O !/L'��...
Investigative
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFlCE USE ONLY This request void 18 months from validation dafe prinfed in this box.
Illlllllllllllllllllllllllllil�llllllll�lll� �� ��93
* D 8 Q 2 1 6 6 9�x �, �'J�
PLEASE PRINT OR TYPE
Requesf Dale Rough-in inspeclion required? Yes ❑ No Inspeclion O�er Than RougMn: ❑ Ready Now Will Call
�/�! f 9 (You must call the inspectw en ready) Date Ready:
I, ❑ licensed contractor �owner hereby request inspection of the above elecfrical work at:
Job Address (Sheef, Box, or Roufe No.� City Zip Code
/0381 N S�-, hl„�, • �t2t1DL�Y 5543Z
Seclion No. Township Name or No. Range No. Fire No. CouMy .
-- 30 24 — At3oK�
Occupant , Phone No.
s�o a, �C bTG4-(��tJ ��z- s� �- 8433
Power Supplier - Address .
I�.s , P, MpVS� -�t�4oCZ�d fl�v �s�or.s
Elechiwl Contractor (Company Name� Contracfor License No. Masfer Lic. No. (Plant Elect. Only)
B dW N�2
Mailing Address (Confracfor or Owner Performing Insfallafion) �
`��i h'ti�
Authorized Signature nhac r or er P in n Ila ��� Phone No.
�!Z S?<-8�f 3
EB-00001 A-11 /96 STA BOARD COPY - SEE INSTRUCTIONS ON BACK OP YELLOW COPY