P - 83375REGIUEST FOR ELECTRICAL INSPECTION
���"` " Minnesota State Board of Eiectricity
��- 8 5 6 1821 University Ave., Rm. S-128, St. Paul, MN 55104
Phone(612)642-0800 " '
Home Duplex Apt. Bidg. Other: New Addn
Commercial Industrial Farm Remod Re
Air Cond. Htg. Equip. Water Htr. Load Mgmt. Other:
Dryer Range Elec. Heat Temp. Service
"X" above the work covered by this request. Enier remorks in this space and on the back of the w}�'►e copy only.
�.�YY10�D 1Q�9�i+� ! GOI��T t�1121�(S l� 11'ttitJEL�.
�� � aD��� N'� � �Qa' fl�� 6�.Z
1 ��1} �l�W� �'r�f9'�i�t� (� �L..��l_��— � �/� f��o� �
Calcu aP ie7�n Fe��This' Ins�tio�Reques" t �vil�not be acc�ied wit out i e correc 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 INSPEC70R�S USE ONLY TQTAL__ �f �
ie Ltg. Xfinr.
iote Confrol
Pool
�
I herebvi certifv Ihaf I insoecfed the eleclrical installation described herein on the dales stafed
Investigative Fee ��� c�
THIS INSTALLATION MAY BE ORDERED NECTED IF NOT COMPLETED WITHIN 18 MONTHS.
, OFFICE USE ONLY This �equesf void 1 B months from validatian date printed in this box.
� �'�
I�I� �p Ilt �1 �I� II III �� II I I� II III ��1 (�
* � 5 2 3 8 5 6 3� PLEASE PRINT OR TYPE �� ��
RequesT Dafe Rough-in inspection required$ ❑ Yes ❑ No Inspeclion Other Than RougMn: eady r�,. 0 wn can
'' —/ �� �You must call ihe i�spector when ready) Date Ready:
� �.
f, licensed contracror ❑ owner hereby request inspection of the above elechical work at:
Job Addreu (Sfreet, Box, or Route No.) Ciy Zip Code
�'J�S �� p►'r►'1 I/1� ST; A}�� -� 1
No. Township Name or No. Rance No. Fire N�—
L
(Cono-acrw «
...,_...���
i
Phone No.
No.
�cror w Owner P ing Ins ry'pn) P
�_ e
STA7E RD COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY
Lic. No.
�
�