P - 84680448-250
Home Duplex
Commercial Indusfrial
Air C�n Htg. Ec�}ui
Dryer ang �
"X" above the work covere b
RE(IUEST FOR ELECTRICAL INSPECTION -°}-�
Minnesota State Board of Electricity
1821 University Ave., Rm. S-128, St. Paul, MN 55104 =
Phone (612) 642-0800
Other. ew Addn
Farm
Water Hh. Load Mgmt. Other:
Elec. Heat Temp. Service
request. Enier remarks in this space and on
copy only.
Calculate Inspection Fee - This Inspec►ion Request will not be accepted without the correct fee:
Other Fee # Service Entrance Size Fee # Circuits/Feeders Fee
Mobile Home Park Stall 0 to 00 Amps 0 to 100 Amps
Street Ltg./Traffic Sig. Above 200 Am s Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY TOTAL
+A�
Sign/Oudine Ltg. Xfmr. S
Alarm/Remote Confrol
Swimming Pool
I hereb certi that I ins d fhe electrical installafion described herein on the dales stoted
Ir�i9atiOn Boom Ro�9�� � _ � � � � � �
$pecial Inspecti
Final
Investigative Fee
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS_
OFFlCE USE ONLY This requesf void 1 R months 6om validation date printed in fhis box.
II��IIIII) Illi��l�ll�l) IIIIII I�IIIII�) II 7�',s'd ��
I I� IIIII ��
* 0 4 4 8 2 5 0 1* � PLEASE PRINT OR TYPE
R uesf Dafe Rough-in inspecfion required$ Yes ❑ No Inspection Other Than RougMn: ❑ Ready Now ill Call
�p � p� �9 �You must call the inspector when ready) Date Ready:
I, ' ensed conhactor � owner hereby request inspection of the above elecfrical work at:
Job Address (Sheef, Box, or Roufe No.) Ci � Zip Code
3o i T s�n . ����c..�e
Seclion No. Township Name or No. Range No. Fire No. Coun ����� �
1Ld�i" Lwv��
Po� s��i��
dV c��
Eleclrical Conhactor �Company Name�
Conhactor
Inslallaf���'
N�_MN 5502�
Phone No.
Masfer
� I�IBtallafion) *% _ 1('� � C� I P
�� s� y
COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY