P - 83841REf�UEST FOR ELECTRICAL INSPECTION ��,�
� Minnesota State Board of Electricity `����u .. �
' I IIII II �� II I�I (I I�) I) III II III II III II III �I �II I II�) 1g21 Universi Ave., Rm. S-128, St. Paul, MN 55104 �- -�% ¢
`* 0 2 9 9 4 � 8 5 * Phone (612) 642- 00 �'���
Home Duplex Apt. Bldg. Other: New Addn
Commercial Industrial Farm ��� Remod Re air
Air Cond. Htg. Equip. Water Htr. Load Mgmt. Oth /�
D er Ran e Elec. Heat Temp. Service �L�/Lr�'���
"k' above the work covered by this request. Enter remarks in this space and on the back of the whits copy only.
Calculate Inspection Fee - 7his Inspection Request will not be accepted without the correct fee:
Other Fee # Service Entrance $ize Fee # Circuils/Feeders Fee
Mobile Home Park Stall 0 to 200 Amps 0 to 100 Amps
$treet Ltg./Traffic Sig. Above 200 Amps Above 100 Amps
Transformer/Generator INSPECTOR'SUSEONLY TOTAL� ) (��
Sign/Outline Ltg. Xfmr. F'
!� --� g 7
Alarm/Remote Control IY�
Swimming Pool
I hereb ceAi that I ins eded fhe eledriml installation described herein on }he dates stated
�ffigafion BOO Rough-In �O�
Special (nsped� ^ � � �i_�
F��I � � ,-C6
Investigative Fee
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
2 9 9�"} 0 8 OFFICE USE ONLY This requesf void 18 monihs from validation date printed in fhis box.
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PLEASE PRINT OR TYPE
Request Date ) Rough-in inspedion required2 ❑ Yes No Inspection Other Than Rough-In: � Ready Now Will Call
���} '�� 7C -� (You mus} call }he inspedor when reody) Date Ready:
I, licensed contractor ❑ owner hereby request inspection of the above electrical work at:
Job Address (Sireet, Box, or Route No.) City Zip Code
�o� ✓` ( �S l�'l'�r� �(LI �0 L� �/ SS�J 3 2-
$edion No. Township Name or No. Range�. Fire No. Coun
3t� Z � o (,�4-
Occupan Phone No.
�<<�- G� r�1k�Fr 5� �- 555 5
Power Supplier Address
�I S" � ��L.S /� u�-f !'t� �r �/,
Eledrical Conirador (Company Name) Coniractor License No. Master Lic. No. (Plant Eled. Only)
C.��� ri�l� �S� F��: �. C►��' 2� S 3
Mailing Address (Confrador or Owner Peho/ming Installation)
Z-7�o6 2tEGL t' 1��TI I/11r�1 55�`(°
�ignatur Confradoror ne�P o ing Instollafi � Phone No.
c� /Yi� Q�� �l��r - 3`7 5
10 6/95 STATE BOARD COPY - SEE INSTRUCTIONS ON BACKOF YELLOW COPY