P - 80344U-���9�-388 �
REQUEST FOR ELECTRICAL INSPECTION
Minnesota State Board of Electricity
1821 University Avenue Suite S-126, Saint Paul, Minnesota 55104-2993 ���:
(651) 642-0800 www.electricity.state.mn.us " `
Home Duplex Apt. Bldg. Other: New
Commercial Industrial Farm Remod
Air Conditioner Htg. Equip. Water Htr. Load Mgmf. Other:
Dryer Range Elec. Heat Temp. Service
"X" above the work covered by this request. Enter remarks in this space and on the back of the white copy
�ol,t��i� Sc,c_�c,, -�� ca(o(e� �Tv C� .
L�eG�c� -�v t�-h l � Co�-,v�.e�-� en
Calculate Inspection Fee - This Inspection R uest will not be accepted wi►hout the correc► fee:
Other Insfallations Fee # Service Enkance Size Fee # Circuits / Feeders Fce
Mobile Home Park Stall 0 to 200 Amps 0 to 100 Amps
Street Ltg. / Traffic Sig. Above 200 Amps Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY TOTAL
Sign / Outline Ltg. Xfmr. � L
Pool
— I hereby certify that I inspected the electrical installation described herein on the dates stated:
�� . i K �i �i RouqMn Dafe
Repair
�
Investigative Fee F10O� ('� �_ I Datg �+ �`r,,�
��-
THIS INSTALLATION MAY BE ORDERED DiSC D IF NOT COMPLETED WITHIN 18 MONTHS.
OFFlCE USE ONLY This request void 18 months (rom validation daM printed in this box.
I�I�������������I����u���� • a�.�
�
* 0 8 9 9 3'8 8 3* % 7C��
PLEASE PRINT OR TYPE
Requesf Dafe Rough-in inspection required? ❑ Yes ❑ No Inspection Ofher Than Rough-In: Ready Now ❑ Will Call
� p �') ��.� You musf call fhe inspecfor when ready Dafe Ready:
�y"'r-�v
I, ' licensed contractor ❑ company ❑ owner hereby request inspection of the above electrical work at:
Job Address �Street, x, or oufe No.� City � Zip Code
�� U� � �
$ection No. Township Name or No. Range No. Fire.No. Cou
Vccupant " �
���1 � ��
�
Powe Supplier �
` J
Electrical �onfracfor / Company Name
(Yi 1 �I�arr� �'(.�
Mailing Address �Conhacror, Company or Owner
, Company or Owner
2 5/1999
Phone No.
f/h�--G�JaNr�..�
Address
Conhacfor License No.
� G�4 o a-
Installation)
`�v • � ,�-I--, I I (,��c
Master Lic. No. �Plant Ele
Phone Number
��'
)NS ON BACK OF YEI