P - 77198�1 rr,. REQUES� FOR �LECTRICAL INSPECTION --°��..
4 r'r L- 9 6 3 Minnesota State Board of Electricity
1821 University Ave., Rm. S-128, St. Paul, MN 55104
Phone(612)642-0800
Home Duplex Apt.6ldg. Other: �rT /�/'�q New Addn
Commercial Industrial Farm ��� /K�V Remod Re ir
Air Cond. Htg. Equip. Water Hfr. Load Mgmt. Other:
Dryer Range Elec. Heat Temp. Service
"X" above ihe work covered by ihis request. Enier remarks in this space and on the bc�ck of the white copy only.
Calculate Inspection Fee - This Inspection Request will not be accepted without the correci fee:
Other Fee # Service Entrance ' 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� [ TOTAL
� G v N�tlo �T �
�ign/Oudine Ltg. Xfmr. ✓���( � �/'�� '� _
47�/' C'vTs
Alarm/Remote Conh �
Swimming Pool �%v n;,. (�) i�� sc •�f
ITierebvi cerfi(y tlwl I insoected�the elechical insMllafion described herein on the dates stated
Speciol Inspection v '2 y— �� 3
Fiwel Date
Investigative Fee l� Q �
THIS INSTALLATION MAY BE ORDERED DISCONYECTED IF NOT COMPLETED WITHIN 18 MONTHS.
Q
secrio
OFFlCE USE ONLY This request void 18 monfhs 6om validafion daM prinfed in fhis box.
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PLEASE PRINT OR TY E
st Da"^"'G7 Rou h-in ins on r uired? .
9 P� eq ❑ Yes No Inspec6on O�er Than RougMn: ❑ Ready Now ill Coll
���J (You must call the inspecbr when ready) Da1e Ready:
�'licensed contractor ❑ owner hereby request inspection of ihe above elechical work at:
ldress (Street, Box, or Route No.) Cily � Zip Code
—� �� � C� �µ �i:f-e -�—t� S's' 3
n No. Township Name or No. Range No. Fire No. Cou
_3��3��� � �� �� _o_ _
Atidress
A � I l ^
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'� ' /�c�e � ��..�-��7" ,, ,�,., "a,. �,,,;
dreu �Conhac or Owner Performmg Installahon) ^ �
'" �.7 Z}� /2 f � �.� � S c( �
ignafure (Conhocfo or er P r Ins afion) p�,,, � o
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11 8/96 — STATE BOARD COPY - SEE MISTRUCTIpNg pN g/�CK OF YELLOW COPY