P - 77865-r
REQUEST FOR ELECTRICAL INSPECTION EB-00001-04
' See i�atructions for completing this form on back of yellow copy.
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-X Be���r��o�red by This Request
ladd Rep. Type of Building Applitfnces Wired Equipment Wire�!
Home Range Temporary Service
Duplex Water Heater Lightin,y Fixtures
Api. Building Dryer Electric Heatin
Commercial Bldg. Fumace Silo Unloader
Industrial Bidg. Air Conditioner Bulk Milk Tank
Farm ocne� pec� v tne� Isve��ty)
' t er Speci y Ot er pth�r
ompuie lnspection fee Be/ow
# Fee ServiceEntranceSize # Fee Feeders/Subfeeders tt Fee Circuits
Uto200Am s Oto30Am s Oto30Am s
Above 200 Am �si 31 to 100 Amps 31 to 100 A s
Swimmin Pool Above 100_Am s Above 100_Am s
Transt'ormers Irrigation Booms Partial,'Other Fee
Signs Special Inspection S � �. r�Q TOTAL FEE
Remarks ne room a i ion e in ouse
Final � 1
C ,�� y/�t��,.
This nquest void 18 months fiom
�--- — ---� —
Thfs request void
18 monjhs from
V��080852^
Request Date
6/�4/83
Licensed Electrical Contractor
❑ Owner
Street Address, Box or Route No.
272 El
ection o. Township Name or No.
/ Date
(.$, ' " { I, the Electrical
' "" t' � � Inspector, hereby .
certify that the above
Date inspection has been
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��,;�� � �i�� made.
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� � �� .�� .� � � q7G�/
Fire No. Rough-in Inspect
Required? 9� eady Now �Will Notify, Inspec-
�QYes ❑ tor When Ready
1 hereby request inspection of above
electrical work installed at:
nge rvo. County -
Anoka
Occupant IPRINT) Phone No.
Kenneth Brustad 784 4358
Power Supplier Address
N S P
Electrical Contractor (Company Name)
Cnx F1P..ric n
Mailing Address (Contractor or Owner Making Instailation)
1725 reen Ave. Anoka� Mn. 55303
Authori ed Si natu e(Cont ct Owner Making Installation)
1 ESOTA STATE BOARD Of ELECTRICITY
riggs-Midway Bldg. — Room N-197
1827 University Ave., St. Paul, MN 55104
P6..r.e IR191 997_9771 .
Contractor's License No.
Phone Number
427 3048
THIS INSPECTION REQUEST WILL NOT
BE ACCEPTED BY THE STATE BOARD
UNLESS PROPER INSPECTION FEE IS
ENCLQSED_