P - 828246��i-�35 �
REQUEST FOR ELECTRICAL INSPECTION
Minnesota State Board of Electricity
1821 Universiry Ave., Rm. S-128, St. Paul, MN 55104
Phone (612) 642-0800
Home Duplex Apt. Bldg. Other: New
Commercia{ Industrial Farm Remod
Air Cond. Htg. Equip. Water Htr. Load Mgmt. Other:
Dryer Range Elec. Heat Temp. Service
"X" above the work covered by this request. En►er remarks in this space and on the back of the white copy only
ConueaT Gas I�sTLAmp ro E/ecr,eiC
.1'NSr�u�o GFr our�eT oti /�,sr� `ph� � on� a� � ^k�TiR o � /�ou.s�
.LtisT,�//�,o � �i` �cr,e�s-,o ��eacc�� /�� h t f ,'�tru a� .
Calculate Inspection Fee - This inspection Request will noi be accepted without the correct fee:
Qther Fee # Service Entrance Size Fee # Circuits/Feeders
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 TOTAL
Sign/Outline Ltg. Xfmr.
Alarm/Remote Control
Swimming Pool
Irriqation Boom
Addn
Fee
O.
/c� . �O
instollafion described herein on the dafes stated
Dare
Investigative Fee F10O� ��,�..�- I Dore G`/ � G� C/
a O
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WiTNIN 18 MONT�i$. _
OPFlCE USE ONLY This requesf void 18 monihs from validation date printed in fhis box.
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* 0 6 6 1 6 3 5 3* �-�5-3
PLEASE PRINT OR TYPE
Requesf Dafe Rough-in inspecfion required? ❑ Yes � No Inspection Other Than Rough-In:
�—/� -� /n g (You must call rhe inspector when ready� Date Ready: �.. �� r,sf 8'
I, � licensed contractor ❑ owner hereby request inspection of the above eiectrica{ work at:
Job Address �Streef, Box, or Route No.� Ciry
73yo C'onc�Qro (�uac�e /I�C Fa��
Section No. Township Name or No. Range No. Fire No. Couny
Occupanf
Tom -� am ��m
�Confractor w Owne�
,�/l�O�i4
Phone No.
7sy-'�'io3
No. i rna5t�
�ConhacTor or Owner P� ing Insf n) `� A� A� Phone No.
� �� V ` �
STATE BOARD COPY - SEE INST ON O BACK OF YELLOW COPY
Now ❑ Will Call
Zip Code
J'.?y3�