P - 79680$Q��304 �
Home Duplex
Commercial Industri
Air Cond. Htg. Ec
Dryer Range
REQUEST FOR ELECTRICAL INSPECTION �
Minnesota State Board of Electricity 3
1821 University Ave., Rm. S-128, St. Paul, MN 55104 =
Phone (612) 642-0800 " '
Apt. Bldg. Other: l v G��� New Addn
Farm l� � d Remod Re air
Water Htr. Load Mgmt. Other:
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 only.
� " ""—'
/��4
Calculate Inspection Fee - This Inspeciion Request will nof be accepted without 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 ONLY TOTALr // � O
Sign/Outline Ltg. Xfmr. �` � �-���( Cc�vt.'� %� � `
Alarm/Remote I
Swimming Pool
I her cerfi tfiaf I in fhe eleckical insfallafion described herein on the dafes sfafed
Irrigation Boom RougMn Dar
Special Inspection � � �
Final - te . 'L .�
Investigative Fee
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTFiS.
OFFICE USE ONLY This request void 18 months from validation dafe prinfed in this box.
I Illf II III il iil I! III II III II III II III II IN II Iil I I�I
� U 8 0 2 3 0 4�n � �° � �CIH % ,�/�� �b
PLEASE PRINT OR TYPE
Request Date Rough-in inspecfion required? ❑ Yes ❑ No Inspection Other Than Rough-In: ❑ Ready Now ❑ Will Call
� M� (You musf call }he inspector when ready) Dafe Ready:
I, ❑ licensed contractor ❑ owner hereby request inspection of the above electrical work ah
Job Address �Shcet, Box, or Route No.) Ciy Zip Code
� Z� B�ri' rvtoKE ��2 �'R � 7C� S SY3Y
Section No. Township Name or No. Rarge No. Fire No. Couny
3 4 � ��70 ��
Ocw nt � Phone No.
�r�a,n �f11`es-�ave�r'���� S7/_Z3 �2�
Pow $upplier AdMdress n� T
�i�� /'! �s � /VO� �/%JI`Si0✓)
Electrical Conha for (Company Name) Conhacfor License No. Master Lic. No. (Plant Elect. Only�
d w►�e,r
Mailinp Address IConhacfor or Owner Performirm Installafiool
%�11:1.�. � � �3'S� �-23
1 1 /96 STATE BOARD COPY - SEE INSTRUC710NS ON BACK OP YELLOW COPY