P - 81424'��2-552
Home Duplex
Commercial Induslri
Air Cond. Hig. Ec
Dryer Range
"X" above the work c�vered
REQUEST FOR ELECTRICAL INSPECTION
Minnesota State Board of Electricity
1827 University Ave., Rm. 5-128, St. Paul, MN 55104
Phone (612) 642-0800
Apf. Bld . Other: � C� New Addn
Form d Remod Re air
Waler Hir. Load Mgmt O�her:
Elec. Heaf Temp. Service
�equest. En�er remarks in fhis spoce and on rhe back of rhe whi�e copy only.
Cakulate lnspecfion Fee - This Inspec�ion Request will nof be a«epted wifhout fhe correct fee:
Other Fee 8 Service Entrance Size Pee k Circuits
Mobile Home Park Stall 0 to 200 Amps 0 ro 100 A
Street Lig./Tmffic Sig. Above 200_ Am s Above 100
Transformer/Generator INSPECTOF'S USE ONLY
Sign/Oulline Lfg. Xfinr.
Alarm/Remole Control
Swimming Pool � �
Fee I
i he,a ��� �nm i ��, red *e ei�.��ai m,�ooer�, aex��sea n�� o� me ao� sro�aa
Irrigofion Boom Roogh-m .
Speciallnspection '✓ ^
F� �� �
Imes�igalive Fee —t
THIS INSTALLATION MAY BE ORDERED DISCO D IF NOT COMPLETED WRNIN 18 MONTHS.
OFFICE USE ONLY This req�ast wid 18 monihs frwn wlidotion date printed in ihis 6ox
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* � 5 3 2 5 5 2 7 �K PLEASE PRINT OR TYPE
�� �� Rough-in inspecnon req�ired? �Yes ❑ No Inspenion qher Thon RougMn: ❑ Ready Now�Will Cdl
(Yau mustmllthe inspeciorw en ready� Do1e Reody:
I, Ikensed conhaclor ❑ owner hereby request inspection of fhe above electrical work at:
Job Address (Srvcet Bon or kauh No.) Ciy Zip Coda
j 7S� �.� rlS�-e.ns�r, �,RT �"� �x.
Senlon No. Twmship Name NQ� Ran�� Fire No. Couny ^
�' �1. o K�
o«���, Bo d� P s���— ��eNo.
av�-e,r
a�,e� s��.;�. � . nda.
� s �Ua � �
� Electrical Conhadar �Cap� Namel �� � Con�rorWcense�JO. �� hbsrer Lic. Na (Plom Elal. Only)
��i � �c, rre r��� i �
Ma�i��9 naa,e, �fgY"4` T 1 � re� 9 i���mo�� C$ U I
� 7 S r- r'a Yl � �
Aulliarized Signm onhactar « x Performing Insmllanop� �� Phone No. '� �
� /,� 6
EB00001 A-11 8/9 �pTE BOAHD COPY - SEE MSTHUCl10N5 ON BACK OF YELLOW GOPV